[Gobbledock]

From Byron Baileys article;

"The ATSB, described by one of those experts as “the best of the best”,

Indeed they once were. Said in past tense. Until the likes of Jonathan Aleck crafted a ridiculous MOU, and again proved that all things aviation and legal are his 'personal play thing'. Then we have DDDDDDDolan, under the strings of MrDak. It's all down hill from there.

Our ATsB was neutered and then buggered thanks to MrDak, Aleck and Beaker. The rest as they say is history.

Alan Stray's ATSB..... R.I.P

#bringbackalan

[Kharon]

"Toughen up Princesses!"

 Fat chance – Princess Hood is dancing the dance of the seven veils; or should that be fails?  Anyway, the art form of the seven veils is to never, ever really show any tits or bum, but to titillate the audience, with glimpses of forbidden treasures.  The ‘real’ story of Salome is not quite so ‘cute’; much like the ATSB saga, where a ‘head on a plate’ was demanded as the price for the ‘the dance’.  Blood, lust, power, deceit, deception, corruption for political gain; just the usual, run-of-the-mill grist.  

The difference this turn around is that Princess Hood will be the one who looses her head should any glimpse of the scabs, pustules, boils and warts be seen by the audience.  The threat of summary execution will keep the princess on her toes, but what when the music stops?  The dance of Mildura, Norfolk and many other ‘horror’ stories are still waiting in the wings.  Keep dancing, just keep ducking and weaving.  Oh, and make sure the invisible Manning keeps winding the gramophone handle, lest the music stops.

From WIKI:-

The idea that Salome's dance involves "seven veils" originates with Wilde's 1891 play Salomé. Wilde was influenced by earlier French writers who had transformed the image of Salome into an incarnation of female lust. Rachel Shteir writes that,

To the French, Salome was not a woman at all, but a brute, insensible force: Huysmans refers to her as "the symbolic incarnation of undying Lust … the monstrous Beast, indifferent, irresponsible, insensible"; and Mallarmé describes her as being inscrutable: "the veil always remains." Huysmans' hero Des Esseintes characterizes her as a "weird and superhuman figure he had dreamed of. … [I]n her quivering breasts, … heaving belly, … tossing thighs … she was now revealed as the symbol incarnate of old world vice.

#bringbackalan

[P7_TOM]

Wiki – “[the] monstrous Beast, indifferent, irresponsible, insensible"; and Mallarmé describes her as being inscrutable: "the veil always remains."”

It is not too high blown a flight of fancy, is it: not really.  Students of the classics can find many parallels in both history and legend of ‘monstrous’ doings and dangerous dealings. Always with a reckoning at the end.  In legend, (and Hollywood) the ‘good’ always triumphs over the evil doer.  Being a pragmatist at heart, I like to avoid the concept of ‘evil intent’.  Mostly I content myself with the logic of self interest prevailing over conscience; and, ignorance of consequence over malicious intent.  Oh-ho, those elements exist, no doubt of that; world history proves it, repeatedly.  However, the sad demise of the once glorious ATSB begs many questions.  Questions which will haunt the organisation for many years to come, I fear.

Can they all be traced to one source; or, is a more a question of abrogated blame?  If that could ever be traced back to murky political doings; then, it matters not.  If the imperative was politically driven, then actioned by those who could happily (or not) live with the ‘bending’ of circumstance; deflection of fact and to ignore the ‘common good’, then there is little hope for ATSB to be resurrected.  It seems to me, on sober reflection, that there has been, in one form or another, let’s call it a softening of resolve; a willingness to ‘comply’ with the requirements of political nicety and expediency.  

Rather than criticise the people left in the ATSB smog; it seems to me that those who left, even as a matter of principal; or even conscience are as much to blame.  A case could be well argued for more blame.  I am in favour of men standing up for their principals; indeed I encourage it, however.  When there is an opportunity to speak out and defend those principals, particularly when ‘in camera’ protection of the Senate is available, then, to leave Mick Quinn to do all the heavy lifting, alone, seems a bit spineless to me – The infamous “I’m all right Jack and the devil take the hindmost” philosophy of the not truly committed.

Not saying I’m right; not at all, just sharing some stray thoughts provoked by Salome and a couple of pints of ‘Genius’.  All founded on the fear of loosing the integrity of the one agency which should be absolutely fearless and totally reliable for informing us how our friends, colleagues and passengers are at risk; and, importantly -  how to avoid repeating the error.  Well, it’s my round and the ‘lad’ has just bowled in, thirsty as usual no doubt.  

“Two more here please barkeep and keep your thumb out of the glasses”.

[Gobbledock]

Welcome, to Fantasy Island

The ATsB, under law, has some extraordinary powers. Indeed, an independent body with powers that go beyond most government agencies and legal entities. And CAsA knew this, and I might add was sick of this because as we all know, the CAsA don't like having to be anybodies 'bitch'. Ultimate power and freedom from having to answer to anybody is their mantra.

So along comes the master of PNG Witchdoctors and with a prayer to a pagan god he sprinkles some goose blood and donkey semen on the ATsB, chants the lyrics to "Don't fear the reaper" and the rest is history - the Fort Fumble/ATsB marriage is born and consummated. This sets the ground work for later on when the dopey, flaccid, beard wearing accountant Beaker licks his way into the top job. Without so much as a brain cell in his bald head, Dr Voodoo takes advantage of Beakers stupidity (and obsession with beards) in about the same way that I as a 14 year old teen lad took advantage of my 15 year old willing gal cousin!! The ATsB's authority, autonomy, independence and structure was now tainted, soiled and smeared with CAsA DNA.

Thus the CAsA fantasy of full control and unlimited power is turned into a reality by Dr Voodoo. He sets up an arrangement in which the ATsB on paper still appears to be independent, but in reality now answers to CAsA and has lost it's full, hefty testicles. Brilliant Doc brilliant!

Gentlemen, as you were...may the race to the bottom continue.

#bringbackalan

[Kharon]

The boy stood on the burning deck
With crackers he had frolics
Till one went off between his legs
And blew off both his bollocks

[thorn bird]

Thats the Hoody Cap'n Ahab pose..." She rises she rises!!..."Tharrr she blows!!!"

[Gobbledock]

He should've worn the Toga! A gust of wind over the deck of the ship would've blown the toga upwards and revealed his gun turret!

Or was that photo taken of Hoody on top of a float at the Mardi Gras?


"Safe deck scrubbing for all"

[Peetwo]

The boy stood on the burning deck
With crackers he had frolics
Till one went off between his legs
And blew off both his bollocks

Thats the Hoody Cap'n Ahab pose..." She rises she rises!!..."Tharrr she blows!!!"

He should've worn the Toga! A gust of wind over the deck of the ship would've blown the toga upwards and revealed his gun turret!

Or was that photo taken of Hoody on top of a float at the Mardi Gras?


"Safe deck scrubbing for all"

[Peetwo]

Q/ Will the ATSB now be investigating?

From the AAP courtesy SBS two days ago:

8 Aug 2016 - 5:57am
Jetstar Qld flight forced to land in Guam


A Jetstar flight travelling from Japan to the Gold Coast has been forced to land on the Pacific island of Guam.
Source:
AAP
8 Aug 2016 - 5:54 AM  UPDATED YESTERDAY 5:57 AM

A Jetstar flight carrying 309 people bound for the Gold Coast has been forced to land on the Pacific island of Guam due to safety concerns.

Flight JQ12 from Narita, Japan, was diverted to Guam on Sunday after the aircraft displayed an indicator message relating to oil pressure, Jetstar said in a statement.

The pilot turned off one engine after seeing the oil pressure message.

Boeing 787s can fly safely on one engine, Jetstar said.

The Australian Transport Safety Bureau says it's gathering more information on the unplanned landing but is yet to decide if it will investigate.

The discount airline stressed it was a "priority" landing, not an "emergency" landing.
"(This) relates to the urgency with which a flight would have to land, including how the local air traffic control responds," a spokeswoman said.

"In this case the landing was precautionary, it wasn't an emergency."

At least one disgruntled passenger vented on social media.

Teagan Lowe tweeted "Get your s*** together @JetstarAirways ... we have been stranded in Guam for 10 hours w/no updates. What's going on?!?"

Jetstar said alternative travel arrangements are being made for passengers who will arrive on the Gold Coast on Monday morning.

P2 comment: Teagan with all due respect would you rather risk having to swim the rest of the way to the Gold Coast? - UDB

This line...

 "..The Australian Transport Safety Bureau says it's gathering more information on the unplanned landing but is yet to decide if it will investigate.."

Well after just reviewing the ATSB aviation investigation page - see HERE - it would appear that the ATSB is still pondering whether they will investigate??

Maybe Hoody is temporarily distracted with his teams, frankly shambolic, recent PR management of the MH370 SIO search, however after reading Binger's article (in the Oz today) on the Jetstar Guam occurrence, I think he made need to seriously consider opening an investigation:

Fault in new engine sets off Jetstar Guam emergency

Jetstar passengers arrive home from Guam yesterday. Picture: Regi Varghese

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM August 9, 2016
  

Reporter
Sydney
@Mitch_Hell
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
The Jetstar-operated Boeing Dream­liner forced to switch off one of its engines mid-flight and divert to the Pacific ­island of Guam had a new engine installed three months ago.
Flight JQ12 — a one-year-old Boeing 787-9 Dreamliner — was bound for the Gold Coast from Narita, Japan, with about 320 people on board when it was forced to divert to the US island territory on Sunday because of a suspected oil pressure issue with one of its General Electric-manufactured GEnx engines.

The Australian has learnt the engine at fault was fitted to the plane three months ago to replace a nine-month-old version of the same model in need of repair.

“This is a relatively new ­engine so it’s unusual to have an issue like this so soon,” a Jetstar spokesman said.

“We have asked engine manufacturer GE for an explanation. GE has a team which is working with our engineers to understand what occurred.”

The engine issue will be closely watched at Qantas, which is set to take delivery of eight 787-9s also powered by GEnx engines from October next year.

The Dreamliners will progressively replace five of Qantas’s older Boeing 747s and become its flagship aircraft on international routes.

It’s not the first time Boeing’s 787 and the GEnx engine have ­endured mid-flight problems. The Australian has uncovered nine separate incidences in the past 12 months where the engines had in-flight issues.

The most recent occurred in a Qatar Airways 787 flying from Norway to Qatar with 254 people on board that was diverted when one of its engines had to be shut down mid-flight.

In April, another 787, operated by Xiamen Airlines, also had to have an engine shut down because of an oil pressure problem.

And in February, an Air India 787 also switched off one engine after encountering problems.

Despite the problems, Boeing 787s are designed to fly safely on one engine.
A spokeswoman for General Electric declined to comment about the issues with its GEnx ­engine but said the company was working with Jetstar to understand why the aircraft was forced into its unscheduled landing in Guam.

“We … expect to know more in the next 24 hours,” she said.

The incident involving Jetstar comes after the US aviation regulator in April issued an urgent ­directive for operators of as many as 150 Dreamliners to rework or replace at least one engine on 787s that use the General Electric engine.

The Federal Aviation Administration found that certain up­graded models of General Electric’s most advanced engine posed an unacceptable safety risk because internal ice build-up could result in an unexpected ­engine shutdown.

The Jetstar engine replacement and the incident at the weekend, however, are understood not to have been related to this issue.

A spokesman for Boeing could not be reached for comment but Marcus Diamond, a Safety & Technical Consultant at the Australian Federation of Air Pilots, said it was highly unusual that a three-month-old engine would have to be switched off mid-flight because of a mechanical issue.

“That an engine had to be ­replaced within nine months of ­operation on a new aircraft is unusual to begin with but that there’s now been an issue with its three-month old replacement is very unusual indeed,” he said.

The pilots who diverted the Jetstar plane to Guam with only one engine running followed the correct procedure to ensure the safety of crew and passengers on board, Mr Diamond said. “Low or no engine oil pressure can lead to much more severe conditions such as overheating, catastrophic engine failure and fire,’’ he said.

“When this happens, the proper procedure is to verify through another source that the oil ­warning is in fact correct, and then to shut down the engine.

“Once the engine low oil pressure is verified, both a red ‘master caution’ light and low gauge indication may be seen.

“Then you go through the ­engine failure or shutdown ­checklist.

“That is the common engine shutdown procedure for most ­aircraft and, indeed, what it says in the Boeing quick reference ­hand­book.”

Passengers on board the Jetstar flight had a 24-hour delay in Guam but were delivered back to the Gold Coast yesterday at 9.40am on another of Jetstar’s 787 Dreamliners.

“Safety is our highest priority, so our captain diverted the flight to the closest airport en route to the Gold Coast, and it landed ­safely in Guam, where it will be ­inspected by engineers,” the Jetstar spokesman said.

[Gobbledock]

The lead and how to swing it

"The Federal Aviation Administration found  certain up­graded models of General Electric’s most advanced engine posed an unacceptable safety risk because internal ice build-up could result in an unexpected engine shutdown".

That's the difference between the FAA and CAsA - the FAA has the balls (the lead) and are prepared to act (swing it). No issue, let's fix the problem regardless of who the operator is that will be affected. Safety first and all that shit. Unlike the captured CAsA and equally scared ATsB who simply could not bare to do anything that may adversely affect the precious Kangaroo group.

I can see it now (this evening or Wednesday morning) - team Pumpkin Head, Perm boy Chester, Hoodwink, Skid'Mark, Wingnut Carmody all having an emergency confab possibly with Roo representatives in attendance, all discussing how one will manage this 'minor safety blip'.

#bringbackalan

[Gobbledock]

A concencus has been reached!

Slightly off topic but then maybe not - I think the Census debacle is yet ANOTHER example of how inept, incompetent and incapable Governments truly are. My mates and I had literal bets the day before Census on whether it would be successful. As always, being the glass half empty kind of IOS person I bet high that some sort of failure would occur. And fail spectacularly it did!! My pocket is now full (tax free).

A $340m white elephant, failure, clusterf#ck. So here is my point - we should trust the ATsB on what it says about MH370? Trust they know better than anyone else? Trust they are making the right call on abandoning the search? Trust that they have even been searching in the right place(s) all along? For Christ's sake people we are talking about government here. The ATsB couldn't find a cucumber at a lesbian love-in!

Goldman Sachs Turnbull could easily pull out another $340m of our tax money to pay for an independent lead field of experts (not Government drongo's) to complete the search. Give Byron Bailey and some of the other zealous researchers and searchers the money and you will find your MH370!

As for Census, how funny is that. Yet again another bureaucratic steaming pile of shit to go down in the annals of history.

TICK TOCK? Oh hell yes, again....  

#Malcolmisawanker

[Kharon]

Recommended listening. – HERE -.

Well done RNZ and Kathryn Ryan.  No hoop-la, no fuss, no dramatic tear jerking commercialised bullshit.  Just a very well conducted interview, how very refreshing.  Thank you.

When P2 posted the link I thought oh no, not more dribble – duty bound, I gave it my thirty second test; it made it through to the three minute mark and sailed through to the whole 24 minutes. Remarkable in itself.

Right or wrong in the search for 370, the ATSB recovered a lot of my respect during that interview.  Hood was there in support, did the intro, then sat back and let his man do the talking.  I hope this is a sign of things to come; it is significant that Hood allowed his man to speak unhindered, without interruption.  Nicely played.

Which brings us to Foley; who, IMO, did very well for his country and his organisation.  For mine, the point that Australia in not, repeat not, the ‘investigator’ and really only interested in the ‘end-flight’ only as it relates to the search area, is the very best position to take.  In fact it is the only ‘true’ position that may safely be taken.  Speculation answered with reality; theory acknowledged and discounted with ‘known’ fact; exactly what I would expect from an impartial agency.  Foley simply stated that we don’t know, not for certain sure where the aircraft finally met a large ocean; for indeed we do not know.  He also allowed for reasonable doubt and had the right answers to that – he may even hold many of his own, personal doubts; however, as stated he is working within the bounds of his remit and what he believes is the best of ‘probabilities’.

So very nice to be able to say well done ATSB.  The calm, professional, reasoned, reasonable approach has done much to repair the damage inflicted and suspicion raised when Dolan was in charge; putting him anywhere near a highly charged investigation was a serious error; now rectified.

Australia does not have a dog in this fight; we are a near neighbour doing the heavy lifting.  Foley brings that stark reality back to focus.  As said, let us hope that Hood is leading ATSB away from the dreadful mess Beaker left behind; we need and want to have faith in the ATSB.  Any back-sliding from now on will be judged harshly.  Anyway,  just this once, – Choc frogs all round.

Toot toot.

[Peetwo]

ATSB post Beaker: From the sublime to the ridiculous -  

Today the ATSB released a final report that took 1105 days to investigate into a pushback incident, which saw a Virgin B737 collide with the tail cone of a Jetstar A320  - UDB!

Collision during pushback between Boeing B737-8FE, VH-YID and Airbus A320-232, VH-VGR Melbourne Airport, Victoria, on 10 August 2013
 
Investigation number: AO-2013-125
Investigation status: Completed
 

• Final Report
  
• Photo
  

Final Report
Download Final Report
[ Download PDF: 1.35MB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 10.15MB]
 
What happened

On 10 August 2013, an Airbus A320-232, registered VH-VGR (VGR) and operated by Jetstar Airways Pty Ltd was holding short of gate D2 at Melbourne Airport, Victoria. At the same time, a Boeing B737-800, registered VH-YID (YID) and operated by Virgin Australia Airlines Pty Ltd. (Virgin) was approved by air traffic control for a pushback from bay E1 once VGR was on the gate at bay D2. The dispatcher for YID assessed VGR was on the gate and commenced the pushback. During the pushback, the left wingtip of YID collided with the tail cone of VGR, damaging both aircraft. There were no injuries.

What the ATSB found

The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.

What's been done as a result

Virgin advised that following this occurrence, they issued a local instruction to ground staff, mandating the use of wing walkers from certain bays at Melbourne Airport, including bay E1.

Safety message

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.
 
Photo

Download Wing tip damage to the Virgin Australia aircraft VH-YID - Source: ATSB

Download Gates D2 and E1 - Apron diagram of Melbourne Airport. Source: Apron diagram Melbourne Airport, occurrence details by ATSB

Download Figure 3: Damage to the tail cone of VGR aft of the APU, looking from left to right of the aircraft. Source: ATSB

Download Figure 4: Screenshot of YID during pushback, 5 seconds before the collision with VGR and showing the position of the tug and the dispatcher. Source: Melbourne Airport, modified by the ATSB

Download Figure 5: Pushback of the same Virgin flight from bay E1 on the next day. Source: ATSB 

General details

Date: 10 Aug 2013
 
Investigation status: Completed
 
Time: 9:33 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Victoria
 
Occurrence class: Operational
 
Release date: 18 Aug 2016
 
Occurrence category: Accident
 
Report status: Final
 
Highest injury level: None
 
 
Aircraft 1 details

Aircraft manufacturer: Airbus
 
Aircraft model: A320
 
Aircraft registration: VH-VGR
 
Serial number: 4257
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.

Aircraft 2 details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737
 
Aircraft registration: VH-YID
 
Serial number: 38709
 
Operator: Virgin Australia
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.
 
 
 


Last update 18 August 2016

Planetalking has picked up on this report and more than adequately highlights the totally farcical laughing stock that the ATSB has become in the world of ICAO Annex 13 aviation accident/incident investigative authorities:

ATSB takes three years to investigate pushback bingle

Australia's safety investigator exhaustively concludes that airlines need to keep a sharp lookout while reversing their jets. Really? Yes.

Ben Sandilands

This is the Virgin violated tail cone of the Jetstar A320

In what might be an attempt to embarrass Government over lack of resources the ATSB has today published its final report into a low speed terminal area bump and grind between a Virgin 737-800 and a Jetstar A320 at Melbourne Airport three years ago on August 10.

It was a minor incident although it carried the risk of a becoming major had fuel in the wing of the Virgin flight caught fire when it ripped off the tail cone of the Jetstar plane.
After 36 months the ATSB concluded that:

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.

No shit Sherlock. This is really laying it on the line about the under funding of the transport safety investigator. No-one takes three years to investigate the aviation equivalent of a car in a shopping carpark reversing into a stationary vehicle.

The clear message, and it is a genuine safety message, is that the ATSB has been so gutted of resources that this bingle which should have taken less than a month to exhaustively investigate was left to only fitful moments of attention for three years while the safety investigator struggled to sort out more serious matters.

Not that it always succeeds in such efforts. It not only screwed up a compromised investigation into the Pel-Air medivac charter crash of 2009, but seems hopelessly lost in dealing with its past serious errors and coming up with a credible and comprehensive new final report.

It took three years to fail to address the principle safety issue which saw a Virgin and a Qantas 737 both forced to land short on fuel at a fog shrouded airport in Mildura the same year because neither needed to be fuelled under Australia rules to find an alternative to Adelaide airport when it was closed by a deterioration in the weather when neither had anywhere else they could go.

But while there are many valid grounds for criticising or despairing about the ATSB, it hasn’t been given the government support necessary to actually do its job in a timely manner.  It treatment is a reflection on successive governments who have adopted policies of cutting back on spending on public services until they break.

If the ATSB can’t deal with a pushback incident at Melbourne airport in less than three months let alone three years, it is broken.

It may be severely broken but the questions are can it be fixed; is Greg Hood the man to fix it; and/or has he been given a mandate to fix it? If the answer is no to any of those questions, then I am afraid the ATSB is doomed to irrelevance and the eventual scrap heap...

MTF...P2

[Gobbledock]

ATsBollocks hits an all time low

How utterly atrocious! Surely this report is someone taking the piss and pulling a late April fools prank, surely?
If not, this investigation and subsequent report will go down in the annals of history as one of the most embarrassing investigations and reports of all time! 3 effing years!!!! Are they serious?

Oh Beaker, you should hand back your last 5 years salary you worm. I weep for the good ATsB people still working there, and the good ones who have been forced out. What an embarrassing load of shit.

Heads should still roll. Jules Verne? Folly? Hoody? Chester? Barnaby? MrDak? This is a sham. Surely ICAO can no longer sit on it's fat useless hands and accept for one minute that its 'state', Australia, is compliant with annexe 13? And these same muppets are searching for MH370? Christ almighty.
THIS FARCICAL SITUATION CAN NOT BE ALLOWED TO CONTINUE ANYMORE!

I'm shell shocked. Do I cry some more tears or just start laughing?? 3 years for this absolute shit! Unbelievable.
Pull the pin on them now. Shut down the ATsB and contract it out to Zimbabwe or some other chickenshit third world outfit who can produce the same pre-school crap at a tenth of the price.

#bringbackalan

[Peetwo]

ATSB post Beaker: From the sublime to the ridiculous -  

Today the ATSB released a final report that took 1105 days to investigate into a pushback incident, which saw a Virgin B737 collide with the tail cone of a Jetstar A320  - UDB!

Collision during pushback between Boeing B737-8FE, VH-YID and Airbus A320-232, VH-VGR Melbourne Airport, Victoria, on 10 August 2013
 
Investigation number: AO-2013-125
Investigation status: Completed
 

• Final Report
  
• Photo
  

Final Report
Download Final Report
[ Download PDF: 1.35MB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 10.15MB]
 
What happened

On 10 August 2013, an Airbus A320-232, registered VH-VGR (VGR) and operated by Jetstar Airways Pty Ltd was holding short of gate D2 at Melbourne Airport, Victoria. At the same time, a Boeing B737-800, registered VH-YID (YID) and operated by Virgin Australia Airlines Pty Ltd. (Virgin) was approved by air traffic control for a pushback from bay E1 once VGR was on the gate at bay D2. The dispatcher for YID assessed VGR was on the gate and commenced the pushback. During the pushback, the left wingtip of YID collided with the tail cone of VGR, damaging both aircraft. There were no injuries.

What the ATSB found

The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.

What's been done as a result

Virgin advised that following this occurrence, they issued a local instruction to ground staff, mandating the use of wing walkers from certain bays at Melbourne Airport, including bay E1.

Safety message

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.
 
Photo

Download Wing tip damage to the Virgin Australia aircraft VH-YID - Source: ATSB

Download Gates D2 and E1 - Apron diagram of Melbourne Airport. Source: Apron diagram Melbourne Airport, occurrence details by ATSB

Download Figure 3: Damage to the tail cone of VGR aft of the APU, looking from left to right of the aircraft. Source: ATSB

Download Figure 4: Screenshot of YID during pushback, 5 seconds before the collision with VGR and showing the position of the tug and the dispatcher. Source: Melbourne Airport, modified by the ATSB

Download Figure 5: Pushback of the same Virgin flight from bay E1 on the next day. Source: ATSB 

General details

Date: 10 Aug 2013
 
Investigation status: Completed
 
Time: 9:33 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Victoria
 
Occurrence class: Operational
 
Release date: 18 Aug 2016
 
Occurrence category: Accident
 
Report status: Final
 
Highest injury level: None
 
 
Aircraft 1 details

Aircraft manufacturer: Airbus
 
Aircraft model: A320
 
Aircraft registration: VH-VGR
 
Serial number: 4257
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.

Aircraft 2 details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737
 
Aircraft registration: VH-YID
 
Serial number: 38709
 
Operator: Virgin Australia
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.
 
 
 


Last update 18 August 2016

Planetalking has picked up on this report and more than adequately highlights the totally farcical laughing stock that the ATSB has become in the world of ICAO Annex 13 aviation accident/incident investigative authorities:

ATSB takes three years to investigate pushback bingle

Australia's safety investigator exhaustively concludes that airlines need to keep a sharp lookout while reversing their jets. Really? Yes.

Ben Sandilands

This is the Virgin violated tail cone of the Jetstar A320

In what might be an attempt to embarrass Government over lack of resources the ATSB has today published its final report into a low speed terminal area bump and grind between a Virgin 737-800 and a Jetstar A320 at Melbourne Airport three years ago on August 10.

It was a minor incident although it carried the risk of a becoming major had fuel in the wing of the Virgin flight caught fire when it ripped off the tail cone of the Jetstar plane.
After 36 months the ATSB concluded that:

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.

No shit Sherlock. This is really laying it on the line about the under funding of the transport safety investigator. No-one takes three years to investigate the aviation equivalent of a car in a shopping carpark reversing into a stationary vehicle.

The clear message, and it is a genuine safety message, is that the ATSB has been so gutted of resources that this bingle which should have taken less than a month to exhaustively investigate was left to only fitful moments of attention for three years while the safety investigator struggled to sort out more serious matters.

Not that it always succeeds in such efforts. It not only screwed up a compromised investigation into the Pel-Air medivac charter crash of 2009, but seems hopelessly lost in dealing with its past serious errors and coming up with a credible and comprehensive new final report.

It took three years to fail to address the principle safety issue which saw a Virgin and a Qantas 737 both forced to land short on fuel at a fog shrouded airport in Mildura the same year because neither needed to be fuelled under Australia rules to find an alternative to Adelaide airport when it was closed by a deterioration in the weather when neither had anywhere else they could go.

But while there are many valid grounds for criticising or despairing about the ATSB, it hasn’t been given the government support necessary to actually do its job in a timely manner.  It treatment is a reflection on successive governments who have adopted policies of cutting back on spending on public services until they break.

If the ATSB can’t deal with a pushback incident at Melbourne airport in less than three months let alone three years, it is broken.

It may be severely broken but the questions are can it be fixed; is Greg Hood the man to fix it; and/or has he been given a mandate to fix it? If the answer is no to any of those questions, then I am afraid the ATSB is doomed to irrelevance and the eventual scrap heap...

MTF...P2

ATsBollocks hits an all time low

How utterly atrocious! Surely this report is someone taking the piss and pulling a late April fools prank, surely?
If not, this investigation and subsequent report will go down in the annals of history as one of the most embarrassing investigations and reports of all time! 3 effing years!!!! Are they serious?

Oh Beaker, you should hand back your last 5 years salary you worm. I weep for the good ATsB people still working there, and the good ones who have been forced out. What an embarrassing load of shit.

Heads should still roll. Jules Verne? Folly? Hoody? Chester? Barnaby? MrDak? This is a sham. Surely ICAO can no longer sit on it's fat useless hands and accept for one minute that its 'state', Australia, is compliant with annexe 13? And these same muppets are searching for MH370? Christ almighty.
THIS FARCICAL SITUATION CAN NOT BE ALLOWED TO CONTINUE ANYMORE!

I'm shell shocked. Do I cry some more tears or just start laughing?? 3 years for this absolute shit! Unbelievable.
Pull the pin on them now. Shut down the ATsB and contract it out to Zimbabwe or some other chickenshit third world outfit who can produce the same pre-school crap at a tenth of the price.

#bringbackalan

Ps - CF for Gobbles for best summary of the current diabolical state of affairs at the ATSB. 

Pps Perhaps another solid reason why the 'powers to be' (if they were remotely interested in saving the bureau) should seriously consider bringing back Alan:

Tragedy inspires Indonesian investigator to improve safety
Indonesian safety investigator Apib Prayogi can trace his journey to working at the Australian Transport Safety Bureau in Canberra to two tragic aviation accidents.

The first was the loss of Air France Flight 4590 from Paris to New York on 25 July 2000. All 100 passengers and nine crew members aboard the Concorde died when it crashed into a hotel on take-off. On the ground, four people were killed and one was critically injured. It was the only fatal Concorde accident during its 27-year operational history.
A few years later in junior high school, Apib was fascinated by a Discovery Channel documentary on the accident and, more importantly, the investigation that followed.
“I was very curious as to how the investigators did their detective work to uncover the cause of the crash,” Apib said.
It struck a chord in the mind of the young Apib such that when career consultants paid a visit in senior high school, aeronautical engineering was presented as an option that could lead to interesting work.
With (very) solid maths results at school, Apib completed a Bachelor of Aeronautical Engineering (2010) in Adisutjipto College of Technology, Jogjakarta, and then a Master of Aeronautical Engineering (2014) from the prestigious Institute of Technology, Bandung.
This led to Apib becoming a junior investigator with Indonesia’s National Transportation Safety Committee (NTSC).
The second accident was in March 2007 when a Garuda Indonesia Boeing 737 over-ran the runway while attempting to land at Yogyakarta airport in central Java. The accident claimed 21 lives, five of whom were Australian. The accident lead to the development of the Australian government Indonesia Transport Safety Assistance Package (ITSAP).
ATSB Manager International Richard Batt says the main elements of the ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC.
“This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods,” Richard said.
“Our Indonesian colleagues learn much from us. But it’s not all one way. The programs that we develop are mutually beneficial. Cooperation between the ATSB and the NTSC is a key element in ensuring lasting transportation safety for the people of Indonesia and Australian travelers to Indonesia.”
Apib, 28, was selected as the first of two junior investigators who will spend time at the ATSB in Australia this year, thanks largely to his English language skills.
“I started learning English in junior high, where it is compulsory,” Apib said. “I continued into senior high and when I did my tertiary studies, most of the aeronautical engineering texts were in English.”
Apib is delighted with his time at ATSB, working with professional and highly committed staff and expanding his knowledge and experience.
“It’s like on-the-job training, especially with the short level (Level 5) investigations. We don’t have the kind of system and databases that you have here,” he said.
“I am learning how ATSB does its investigations, especially with its more advanced tools and laboratory. I already have a better understanding of how an investigation goes. And from that I can see how we can improve in Indonesia.
“We would like to have a system, such as you have at ATSB, which meets international standards. We will get there, but in my view it may take up to 10 years.”
Perhaps not surprisingly, Apib sees himself as a senior aviation investigator ‘in about 10 years’.
Married with a young daughter, Apib will continue to gain more qualifications, expand his knowledge and undertake more training.
In the meantime, he is grateful for the opportunity to work in Canberra at the ATSB, even if it is the middle of winter.
“I would like to thank Australia, the ATSB and the ITSAP program for this opportunity, and for assisting to improve our investigator qualifications and set up our flight recorder laboratory,” Apib said.
“I especially would like to thank Dr Soerjanto (NTSC Chairman) and Dr Richard Batt and the team in Level 5 investigations at ATSB. Everyone has been helpful and supportive and given me the opportunity to learn.”
Apib said he was also grateful to those who took him “out bush” for a first-hand encounter with kangaroos, koalas and a platypus!
 

 Yes indeed time to #bringbackalan

Update: With tongue in cheek comments from Comet, Dan Dair & Jacob courtesy PT...

comet
August 18, 2016 at 8:35 pm
“This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback.”

Wow. It took the ATSB three years to reach that earth shattering conclusion.
The once proud ATSB can now join the once proud Australian Bureau Of Statistics (ABS) as being modern day basket cases, and the laughing stocks of the entire world.

1. 1. 
      Dan Dair
      August 18, 2016 at 9:02 pm
      Meanwhile the membership of the AABCO* is increasing by the day.!!
      (* Australian association of basket-case organisations)
      

1. 1. 
      Jacob HSR
      August 18, 2016 at 11:50 pm
      I wonder if the pushback driver was on a 457 visa.
      

Dan Dair
August 19, 2016 at 9:00 am
Not that I’m the kind of bloke to kick a man when he’s down………
(or a state-funded organisation)
But,

if they’d asked me, I’d have been quite happy to consult on this matter.
Obviously I’d have wanted first class travel to investigate (where available) but to be honest, I could have been happy to have followed a directive/nod-&-a-wink to deliver that result in under three months.

Now I think about it, I’d have probably asked what systems of assessment the airline or ground handler has in place before pushing-back an aircraft.

 I’d have expected n actual procedure to be in-place, even if it was a formal walk-around or a formal-visual from the cab of the tractor, before an aircraft was moved.????

Next time the ATSB is struggling, you can reach me through these pages & I’ll be happy to offer my services as a consultant.!!!!

  
Choccy frog for Dan Dair's last, pure GOLD! - And Hoody you can count me in for the next hangar rash incursion, except I reckon I can get it done and dusted in < a month...


MTF...P2

[Sandy Reith]

Used to fly students into Ansett and the then Australian Airlines maintenance hangars at Tulla. Both companies were very cooperative taking us in for educational tours. Made a few of these evening flights, one memorable for watching a Fokker Friendship being towed into one of those hangars alongside something with rear engine nacelles, probably a DC9. Must have been a dozen staff able to watch standing around while we looked on and I thought to myself that F27 wingtip will collide with the jet's engine nacelle. It did. Not too serious, screw drivers out and went to work to change the wing tip. I made a mental safety report on the spot, in one third of a second not three years, that goes like this;  "if you don't look you will not see."
 Reminds me of the chief of CASA who has asked AOPA for the facts regarding the decline of GA and is then shown the CASA figures which do show the disastrous decline that's been obvious for years. Yes you might have your eyes open but if you can't be bothered, or don't want to see, then mind blanking will prevail.

[Peetwo]

Ben Sandilands getting up a head of steam -

Following on closely from the PT Cobham BAE-146 blog piece & the 50 odd comments that followed, Ben Sandilands has yet another 'serious' Jetstar incident to sink his teeth into to again highlight the appalling duplicity & selective bias by the inept, seemingly captured big "R" regulator CASA.

This ATSB investigation will also be interesting in that it could be regarded as the first real test for the soon to be Chief Commissioner Hoody to insure a totally non-PC'd final report is produced, warts & all.       

For background here is a rehash of the 'other' Jetstar incidents that were also covered by AP & PT...  

AAI in a parallel universe - Will Aviation Safety again be the victim of Bureaucratic obfuscation & Political expediency..

Two serious Jetstar incidents under ATSB investigation

From the 'Closing the safety loop' thread & yesterday's ABC radio 'World Today' program:

WILL OCKENDEN: The Australian Transport Safety Bureau (ATSB) isn't the only one looking into this matter.

The aviation regulator, that's the Civil Aviation Safety Authority, or CASA has taken the unusual step of running its own investigation in parallel to the ATSB.

Peter Gibson is from CASA.

PETER GIBSON: We, of course, as the regulator, as the safety regulator need to look at immediate safety issues, be satisfied that they've been dealt with, that the causal factors have been understood by the airline and that the airline has taken the appropriate actions.

So that's why you've got two parallel investigations.

WILL OCKENDEN: What could be the outcome of a CASA investigation?

PETER GIBSON: Well, we're making sure most importantly that Jetstar is putting in place changes that will ensure these sorts of mistakes aren't made again.

Vivid memories of the last high profile 'parallel' investigation and we all know how that turned out -

Wonder if the operator will voluntarily ground all A320 operations until all the safety issues are effectively risk mitigated to the satisfaction of the regulator? - Yeah right & Elephants can fly  (see pic above)

[/url]  
Continued from ABC World Today program:

BEN SANDILANDS: These are really serious investigations.

WILL OCKENDEN: That's Ben Sandilands, an aviation writer and commentator for the crikey.com.au blog, Plane Talking.

He says the other incident, 10 days later on the 29th October, was far more serious.

BEN SANDILANDS: A Jetstar flight to Perth actually really struggled to take off from Melbourne airport at all. It was very nose heavy, clearly had gone too far down the runway to stop and that could have been a very serious incident.

WILL OCKENDEN: The Australian Transport Safety Bureau says it's investigating both incidents to find out how the so-called "aircraft loading event" occurred.

It's classified the incidents as "serious".

Ben Sandilands agrees.

BEN SANDILANDS: They moved people around on the flight so that they could land in the proper configuration in Perth. On the other incident, which was a Brisbane to Melbourne flight, they were out by more than, well, almost two tonnes in the weights and balances on the aircraft and so they had to adjust their landing calculations for Melbourne.

WILL OCKENDEN: They're supposed to do this before they take off. Is there any indication why those checks weren't done?

BEN SANDILANDS: None whatsoever. What is extraordinary and I've been talking to a number of pilots this morning who just cannot believe that something that is fundamental to a small tier country airline service could be messed up so badly by a scheduled airline.

It is beyond belief that an airline in Australia would push back and begin a flight without actually knowing how many people were really on board and indeed the other elements of the calculations as to where they were seated.

That's fundamental. That is the sort of stuff that airlines stopped making a mess of back in the 1950s and 1940s.

Ben Sandilands again with a follow up article:

[url=http://blogs.crikey.com.au/planetalking/2015/12/04/comment-why-action-should-be-taken-against-jetstar/]Comment: Why action should be taken against Jetstar

Ben Sandilands | Dec 04, 2015 5:48PM |

 
P2 comment: The mention of Nick Xenophon is extremely relevant because at a pivotal point in the Pilot training Senate Inquiry, when NX was zoning in on the dodgy safety culture of Jetstar (*1) - somewhat conveniently?? - CASA with very little warning took the bold step of grounding Tiger -

(*1 - Remember "Toughen up Princesses" & Ben Cook Darwin base Fatigue Special Audit report?)  

OK...so one more time round the Mulberry bush..  

&... TICK TOCK goes the Miniscule clock??

Ben S courtesy of Planetalking today:

Why Jetstar's latest incident should alarm flyers
The ATSB says a 'serious incident' is one that could end in a crash, and Jetstar has just had another one

Ben Sandilands
Jetstar’s tail strike incident at Melbourne Airport this week puts another red flag over the Qantas subsidiary’s operations and the unwillingness to date of the supposed safety regulator CASA to ground or restrict its flights.

However the ATSB appears to have fast tracked its inquiry into an incident that imperiled the lives of those on the 180 seat passenger jet bound for Hobart, indicating a final report will be provided by this November...

Update on ATSB Jetstar loading incidents investigation.

From the ATSB today:

Updated: 23 August 2016


Completion of the draft investigation report has been delayed due to competing team member priorities and workload, and to allow additional investigative work to be finalised.

This additional work includes:

• obtaining and consolidating additional evidence
  
• analysis of evidence held and the development and test of investigation findings.
  

When complete, the draft report will be released to directly involved parties (DIP) for comment and on the factual accuracy of the draft report. Feedback from those parties over the 28-day DIP period will be considered for inclusion in the final investigation report...

Yeah I know.."patience grasshopper"...but Hoody mate?? this one has a real smell about it -    


MTF...P2  

[Gobbledock]

Will the real Investigative authority please stand up

Herr Batt said;

"development of the Australian government Indonesia Transport Safety Assistance Package (ITSAP).
ATSB Manager International Richard Batt says the main elements of the ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC. (insert Alan Stray, 2008-2010).
“This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia (insert Alan Stray, 2008-2010), and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods,” Richard said.
“Our Indonesian colleagues learn much from us (insert Alan Stray, 2008-2010). But it’s not all one way. The programs that we develop are mutually beneficial. Cooperation between the ATSB and the NTSC is a key element in ensuring lasting transportation safety for the people of Indonesia and Australian travelers to Indonesia.”

The only reason ITSAP came about is because after the 2007 Garuda crash the Europeans banned the Indo's and so did the FAA. Australia tried to jump on the band wagon but the Indo's threatened to ban us from using their airspace if we put them on our blacklist. Our Government (and Murky) panicked. Can you imagine the political fallout for our then serving Politicians, not to mention the implications for the Red Rat and other international carriers flying to and from Australia? Hence ITSAP was born. In other words, 'if we are lacking the balls to ban them, we better at least provide them with some safety assistance before they kill someone on Aus soil'. The rest as they say, is history, and Garuda continued to fly to Aus and we weren't forced to fly around their airspace. Oh and by the way, you won't read any of this in any online documents and minutes! All out of Gobbledocks collection of secrets.

So, regardless of how the program came about, the fact is that Indonesia's standard of air safety investigations is at the level it is today due to the hard work of one man, Alan Stray. This man found a 'home' amongst the Indo's after being pineappled by hungry political shysters within the ATsB. The result was twofold - the ATsB in Australia basically lost the skills and expertise of the valuable Mr Stray which put a huge dent in its overall ability. But the Indo's gained a gem in Alan Stray and as a result they have seen their investigative capability rise above Australia's now shambolic piss-poor standard!

Can you believe it? Australia gets Beaker and the Indo's get Alan Stray! Unbelievable.
Mention Alan's name amongst many in the DGCA and particularly the NTSC and you will only hear comments such as 'gentleman', 'skilful', 'dedicated and passionate', 'highly respected'.

#bringbackalan ? You got that bloody right!

[Peetwo]

Will the real Investigative authority please stand up

Herr Batt said;

"development of the Australian government Indonesia Transport Safety Assistance Package (ITSAP).
ATSB Manager International Richard Batt says the main elements of the ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC. (insert Alan Stray, 2008-2010).
“This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia (insert Alan Stray, 2008-2010), and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods,” Richard said.
“Our Indonesian colleagues learn much from us (insert Alan Stray, 2008-2010). But it’s not all one way. The programs that we develop are mutually beneficial. Cooperation between the ATSB and the NTSC is a key element in ensuring lasting transportation safety for the people of Indonesia and Australian travelers to Indonesia.”

The only reason ITSAP came about is because after the 2007 Garuda crash the Europeans banned the Indo's and so did the FAA. Australia tried to jump on the band wagon but the Indo's threatened to ban us from using their airspace if we put them on our blacklist. Our Government (and Murky) panicked. Can you imagine the political fallout for our then serving Politicians, not to mention the implications for the Red Rat and other international carriers flying to and from Australia? Hence ITSAP was born. In other words, 'if we are lacking the balls to ban them, we better at least provide them with some safety assistance before they kill someone on Aus soil'. The rest as they say, is history, and Garuda continued to fly to Aus and we weren't forced to fly around their airspace. Oh and by the way, you won't read any of this in any online documents and minutes! All out of Gobbledocks collection of secrets.

So, regardless of how the program came about, the fact is that Indonesia's standard of air safety investigations is at the level it is today due to the hard work of one man, Alan Stray. This man found a 'home' amongst the Indo's after being pineappled by hungry political shysters within the ATsB. The result was twofold - the ATsB in Australia basically lost the skills and expertise of the valuable Mr Stray which put a huge dent in its overall ability. But the Indo's gained a gem in Alan Stray and as a result they have seen their investigative capability rise above Australia's now shambolic piss-poor standard!

Can you believe it? Australia gets Beaker and the Indo's get Alan Stray! Unbelievable.
Mention Alan's name amongst many in the DGCA and particularly the NTSC and you will only hear comments such as 'gentleman', 'skilful', 'dedicated and passionate', 'highly respected'.

#bringbackalan ? You got that bloody right!

AI & SMS in the 21st century - Have we digressed?


Gobbles your excellent post spotlights perfectly the rise and humiliating fall of our ATSB, while the Indon's progress we digress...

This rapid digression I believe can be directly attributed to hiring of Beaker as the CC and to his subsequent role as the top-cover specialist of all potentially embarrassing and revealing inadequacies of the State (ICAO Annex 19) SSP or SMS. Beaker was also responsible for overseeing the ATSB adopted philosophy, contrary to the rest of the World, of BASR (beyond all sensible Reason).

Ironically, as the following excellent blog article will show, the James Reason model is fundamental to the functioning of any successful 'Safety Management System', or in Australia's case the SSP. Therefore if you don't uphold the principles of Reason then the SSP is merely a box ticking exercise to placate our obligations as a signatory to ICAO.

Read & absorb   :  

Light bulbs, red lines and rotten onions
1 September, 2016 Nippin Anand 3 Comments


In January 2015, the pure car and truck carrier (PCTC) Hoegh Osaka developed a severe list on departing from Southampton, and was left stranded outside the port for more than 19 days. The official investigation revealed how decision making became the victim of production pressures. The vessel sailed from port without determining accurately the stability conditions upon completion of cargo. It was a routine practice to leave this task to be carried out once the vessel was out at sea; a practice that appears to be common within the PCTC industry.  The weights of the cargoes declared at the time of loading were significantly different from the actual weights; a practice that extends even beyond the PCTC industry. The port captain never felt the need to involve the chief officer in the preparation of the stowage plan. The chief officer, on the other hand, did not feel he had the authority to question the pre-stowage plan.

The preventive actions that followed from the accident should not surprise anyone. A volley of plans, presentations and questionnaires were sent off to the entire fleet reinforcing the importance of compliance with procedures and checklists, and warning the crew against being influenced by perceived commercial pressure. But would such actions mean anything to improve safety?

Safety Management System

During the 1980s a number of very serious accidents including the Herald of Free Enterprise led to the introduction of the International Safety Management (ISM) Code, based on the principles of the ISO standards, and taking a structured, systematic and documented approach to the management of safety and quality. A key requirement of the Code was for every organisation to formally adopt a safety management system (SMS).  
And what exactly is the purpose of the SMS? It can be illustrated using the ‘Swiss Cheese’ model of accident prevention, where several slices of cheese are lined up against each other. The cheese slices represent organisational barriers to prevent accidents. The barriers typically include crew competence and training, emergency preparedness, maintenance of safety equipment, analysis and reporting of accidents, documentation control, effective control and monitoring from the shore side etc. The holes in the cheese are termed as noncompliances; instances where rules, regulations and procedures are not followed. When an accident happens the conventional explanation is that because rules and procedures were not followed the barriers were holed. The purpose of the SMS is to ensure a systematic identification, detection and follow up of holes so that the organisation is better prepared to manage safety risks.

If the capsize of the Herald for Free Enterprise led to the introduction of safety management system, the stranding of the Hoegh Osaka has surely reaffirmed that we need more of it. More rules, procedures and checklists to plug those holes! But the existing approach to safety management has proven deeply flawed and dangerously misleading. For the rest of this paper I will illustrate some myths about safety management systems, and then debunk these myths by offering a new view about safety management system.

SAFETY MYTHS

Light bulbs and the myth of compliance

Light bulbs either light up or they do not. There is no middle way to determine whether they work or not. The underlying philosophy of a safety management system is similar to the working of light bulbs – bimodal and absolute (yes and no), with the sole aim of establishing whether rules, regulations and industry standards have been complied with or not.

But if we apply this bimodal approach to the Hoegh Osaka, there are not many instances of non-compliance. The vessel complied with all the statutory requirements and was manned by competent crew who were adequately rested at the time of the accident. The loading computer program was ‘approved’ and would have worked accurately if the correct cargo weights had been fed into the computer. The remote gauges for tank sounding were not operational at the time of the accident – but this was not necessarily a non-compliance, as long as tank soundings could be obtained manually. It appears that in the absence of compliance risks, the company  regarded rectifying the fault in the remote gauges as a low priority. The official accident report stated that: ‘In light of the low priority given by the company to repairing the gauges, a similar low priority was assumed by Hoegh Osaka’s chief officer, who resorted to estimating ballast tank quantities.’  A defective ballast sounding system that was otherwise compliant with regulations was encouraging ‘unsafe practices’ onboard.

Crossing the red line

At a maritime symposium on ‘safety culture’, the importance of following the rules and procedures came up, as one would expect. An elderly gentleman stood up and said, ‘Ladies and gentlemen, we are in the business of transporting flammables, remember you must never cross the red line’. What he meant was that the workers should under no circumstances dare to breach rules and procedures. The crew on board the Hoegh Osaka had crossed the red line on numerous occasions. The Master did not hold a pre-load meeting with the deck crew and officers. The chief officer underestimated the importance of accurately calculating the stability condition before departure. Instructions on the use of loading computer were not part of the chief officer’s familiarisation checks. The heavy lift cargoes were not secured in accordance with the CSS Code 2011, IMO Resolution A.489 (XII), IMO Resolution A.533 (13), IMO Resolution A.581 (14), IMO Resolution A.581 (14), as amended by MSC.1/Circ.1355, MCA publication Roll-on/Roll-off Ships:
Stowage and Securing of Vehicles Code of Practice (and add to this a raft of regulations, circulars and industry standards that even the experts specialising in cargo securing plans may be unaware of).

All of this would have played its part in the accident. But pick a routine cargo operation on any PCTC and chances are that you may find an even more comprehensive list of rule violations. A seafarer with whom I recently discussed this issue stated: ‘If you go to this level of detail, you will find problems in everything I do’. A dozen experts analysing split second decisions influenced by intense production pressures will no doubt establish numerous instances where rules were violated and procedures were not followed. But is this approach really effective in managing safety?

The proceduralisation of everything

The accident investigation report into the Hoegh Osaka found that there were a total of 213 checks to be completed by the chief officer for cargo operations alone. This exemplifies a ‘rotten onion’ style of management;   one where multiple layers of procedures and checklists can cover up  the core issues. These procedures (referred to as ‘objective evidences’ in the language of SMS) make it extremely difficult for an outsider (i.e. regulator) to gain insight into the core practices and culture of an organisation. I am reminded of a fire damper that was found fully corroded and inoperable during a survey, despite maintenance management plans indicating fully operational firefighting systems in ‘excellent condition’. No amount of processes, procedures and checklists can solve core problems of this nature. If anything, they only make core issues more inaccessible.

To a large extent the problem lies in how safety audits are conducted. The auditor finds a few non-conformances and the company addresses them by adding a set of procedures and half a dozen checks to the SMS. The quest for paperwork to prove safety generates even more paperwork for managing safety. Everything from starting the main engines to turning on the kettle is ‘proceduralised’ and ‘risk assessed’ and the SMS eventually becomes a monster to manage. There is very little foresight and thinking in this mundane ‘check-do’ process.

The Hoegh Osaka’s two hundred or so checks for cargo operations alone are a true reflection of this contagion. While the company was busy creating the checks, the chief officer was busy ticking the boxes on the checks, the Master was too busy to verify the checks, the regulator was kept busy assessing the checks, the investigator was busy counting the checks –  and with these multiple layers of protection, the safety management system was drifting into failure beneath all these checks. The imaginary world of procedures and checks had drifted too far away from the real world of practice.

“No blame” myth

Most accident investigations reports and safety audits start by stating that the purpose of the exercise is not to apportion blame or find faults with individuals. In practice, this is far from achievable with our current approach to managing safety. Within the 83 page Hoegh Osaka incident report, the term ‘chief officer’ appears  132 times, and Master 89 times. By contrast, the organisation responsible for the safety management system appears in the report only on 60 occasions. Of the two dozen conclusions drawn from the report, sixteen are centred on the vessel and the crew on board. It is obvious that the focus of the report remains on the behaviour and actions of those proximally closer to the scene of accident. Research in accident studies views this tendency of focusing excessively on the actions of those physically closer to the accident as ‘proximity bias’.

It is interesting to see how a highly ambiguous and uncertain situation is captured and presented as a structured and systematic report. In an attempt to present an official narrative, the report illustrates a one-sided construct of the entire ordeal. The report suggests the problem begins with an erroneous stability condition and ends with an extremely tender vessel that capsizes just after departing from the port. There is no mention in the report of the last safety audit, management onboard visit, charterer’s inspection, or QHSE plans and reports. How could so many entities have missed so many unsafe practices that were so common on board? The voices from the control room and wheelhouse are lacking. The inability to calculate final stability conditions prior to departure is considered a ‘drift from fundamental principles of seamanship’. Under these circumstances, how can we preach the mantras of ‘no blame’, ‘just culture’ and ‘safety first’ to anyone involved in an accident?

A new view of safety management system

Having summed up the four popular myths of SMS, there are several questions to be answered.

• First, we place so much faith in compliance with regulations in managing safety  – but is compliance really as straightforward (yes & no) as it appears on its face? And if not, can we still  make effective use of compliance in managing safety?
  
• Second, can we think beyond the punitive language of “rule violations” in managing safety?
  
• Third, can we ever manage safety genuinely without shaming and blaming our workers?  
  
• And finally, if excessive procedures and checklists are taking us away from our core problems, what can we do to bridge this gap?
  

The answers will offer an alternative approach to the safety management system (and hopefully debunk  some myths).

Purposeful compliance

Technology moves far faster than our ability to control and regulate it. When compliance with ‘rigid’ regulations conflicts with operations, owners may seek ‘alternative compliance’ through risk assessments, waivers, and exemptions and even threatening to transfer their vessels to ‘business friendly’ flag states. The bottom line is ‘to comply’ and there is not much incentive in making the system any safer than ensuring minimum compliance. Perhaps, the reason why the management of the Hoegh Osaka had decided not to repair the sounding gauges. What appears a matter of absolutes on the surface is in fact imperfect, convoluted, interpretive, and open to abuse. Many high risk industries have realised the limitations of compliance with rules and regulations and resorted to requiring a duty of care and responsibility from the operators even if this requires undertaking measures beyond compliance. (Of course, this approach is not without its own problems).In the case of the Hoegh Osaka, it surely made sense to use all available Codes, Circulars and IMO Resolutions to verify compliance with cargo securing when compiling the accident report – except that this was undertaken in hindsight and with ample time (the official report took more than a year to publish). The knowledge surely existed when the vessel was being loaded, but could it ever be applied as a means of preventing accidents, rather than just identifying noncompliances in the wake of an accident? This is an important question that we need to ask in designing and implementing our SMS.  Compliance must have a meaning and purpose, not be something demanded for its own sake.

Approximate adjustments

In many societies, even the thought of breaching the rules can be intimidating (just as in other societies it is a way of life). After all, rules and procedures are there to assist us. It is unthinkable for many of us to imagine that a vessel could ever sail from port without obtaining final stability calculations. And how could the chief officer tick off checks that were never really carried out? Why, despite clear instructions in the SMS, were tank soundings not obtained on a daily basis? Is this really a case of unreliable seafarers ‘falsifying records’ and crossing red lines?

Far from unsafe practices and a drift away from seamanship, this is exactly how work is performed. If the chief officer had diligently followed the rules and performed all the two hundred or so checks, the vessel may not have departed from the port in time. In many countries with strong unionised labour workers deliberately follow the rules to the letter as a form of protest to cause delays and disruptions to work. (Note: this behaviour is commonly termed as ‘unofficial’ or ‘zeal’ strike and under international laws workers do not forfeit their pay when they work to rule, unlike when they strike.)

When the chief officer was selective in following the checklist, it could well be that he was indeed applying seamanship (using his professional judgment, prioritising and making adjustments when faced with time constraints) rather than ‘drifting away’ from it. What we consider as ‘red lines crossed’ are approximate adjustments required to succeed at all levels within the organisation. They are approximate because we cannot write precise rules and procedures for every single task, procedures demand certain resources that may not always be available (for example ample time, competencies), procedures involve terms such as ‘apply good seamanship’ that do not specify what is expected from an individual in a given situation, procedures are underspecified and so on. .  Approximate adjustments have to be made to get the job done. This is how we succeed in everyday work despite demanding deadlines and budget constraints.

The equivalence of success and failure

Do we always need someone to blame in the wake of an accident, or is there an alternative? Let us examine the fine details of the Hoegh Osaka accident: a last minute change that made Southampton the first call in the port rotation plan rather than the last; a historical trend of guessing ballast quantities rather than obtaining actual tank soundings; a routine practice of declaring less than the actual weights in cargo manifests; a metacentric height (GM) marginally short of the required stability standards; a mere 0.6 metres bow trim that led to a high rate of turn; and a righting moment that brought the vessel back upright when she developed a heel while turning at a speed of 10 knots, but which became insufficient at a mere two extra knots speed at the next turn in the channel. Note the dynamic nature of certain variables and how the routine practices and approximate adjustments came together. Where is the root cause of the accident? This shows how approximate adjustments and routine practices can sometimes emerge as disproportionate, non-linear outcomes.

Change any one of those variables and there is a good chance that the Hoegh Osaka would have safely exited the channel just as do most PCTCs and many merchant vessels each day. None of us would have noticed the ‘deep rooted’ problems so pervasive within the industry. On the contrary, the management would have rewarded the employees in their next performance review. Who would not wish for a workforce that could balance safety with quality so well? Is this not how competitive organisations are meant to operate in an aggressive market? It does not help to explain why we should blame people who exhibit a ‘can do’ attitude and are willing to go that ‘extra mile’. Granted, there are negligent behaviours and unsafe practices – but the boundaries between what counts as success and failure seem to have diminished.

Business is safety

It does not make much sense to react to ‘unsafe practices’ by replacing a handful of seafarers and introducing more checks, controls and barriers. When something goes wrong, it has usually gone well many, many times before. That is why people do it! So without understanding why it was done in this way and why it went well, we have no hope of understanding why it went wrong. It pays to observe a successful routine operation with an open mind.

Recall the last minute changes to the port schedule of Hoegh Osaka. This is a usual problem for many ships (it was also an issue in the case of the Herald of Free Enterprise). Therefore, we should begin by looking at the usual and normal actions in this case. How do crew members adjust to last minute changes to port schedules? When time is limited, how does the crew meet deadlines when getting their jobs done?  How does the vessel still manage to depart from the port on time despite a late arrival in port?

Pay close attention to whether crucial decisions are made based on incomplete, incomprehensible knowledge and poorly written procedures. Observe how work is performed when not all crew members are adequately experienced in handling key operations. Find out how shortcomings in apparently certified equipment are compensated for in everyday work. It is here that we start to appreciate human performance. It is here that we realise the need to remove the unnecessary checks and barriers that impede rather than facilitate decision making. It is also here that we start to realise that we cannot write procedures and checks for every conceivable situation. And it is here that procedures and checklists start to mesh with the messy world of operations. Here lies an opportunity to genuinely promote a ‘no blame’ culture and reduce the administrative burdens that are helping neither safety nor businesses.

After more than two decades of futile attempts to implement a ‘structured, systematic and documented approach’ in managing safety, it should be clear that it does not exist. The case discussed here was chosen not because it was unique or one-off. It only serves as a recent example available in the public domain to expose the fatal fallacy that we call safety management system. Perhaps the time has come to leave behind the light bulbs, red lines and rotten onions and embrace a new view of safety management system. Safety is not a crime against business. Business is safety.

Effective SMS in the 21st century is a work in progress and our mob are still back in the pack contesting 'Reason' - FDS!   

MTF...P2

Tim Tam quality post.

[Gobbledock]

P2 , you are to kind.
But your follow up post to mine was brilliant! And you really nailed the ATsB's root cause in your following comment;

"This rapid digression I believe can be directly attributed to hiring of Beaker as the CC and to his subsequent role as the top-cover specialist of all potentially embarrassing and revealing inadequacies of the State (ICAO Annex 19) SSP or SMS. Beaker was also responsible for overseeing the ATSB adopted philosophy, contrary to the rest of the World, of BASR (beyond all sensible Reason)".

How bloody good is that! And spot on P2.
The methodology of James Reason still sets the bar, so to speak. There are other sound safety methodologies out there, but the good Professor brought it all home in one system. A methodology that still sits at the foundation of safety today! Had the ATsB maintained this concept it would still be the organisation it was prior to Beakers arrival. But oh no, this career public servant accountant unbelievably thought that 'he' knew better!!! Are you serious you bumbling bearded dipshit! And where did your own personal, ego driven mindset get you numbnuts? Yep, nowhere. You took a reputable investigative bureau and turned it into an inept and embarrassing international spectacle that is no longer 'ahead of the game' and most of the world, but is now 10 years behind our third world neighbours standards.

And well done to you Mr MrDak, you have made some brilliant 'Captains picks' over the years -  Beaker, JMac, Harfwit, Sir An(g)us, Greg Russell, Staib, and so the nauseating list goes.....

'Ring ring, hello who is it'? 'Oh, hi Mr FAA and Mr ICAO, how are you'? "Sorry, what's that, you heard that Australia is thoroughly shambolic and we risk a downgrade of our safety rating after the shenanigans of the past 7 years and counting"? Hello? Hello? Anyone there? Hello??