[Gobbledock]

Glen, just keep an eye on that fax machine every Friday at 16:59 for a while.

Cheers

[Kharon]

WRONG.

Glen should get with the ‘new’ culture:-

Monday 0830 – Fax machine broken, new one needed, due process – 14 days to installation.
Tuesday 0900 – Email down -  tech assist in the Bahamas; no help until Thursday.
Wednesday 0945 – Postal strike – Snail mail out of service.
Thursday 0630 – Stress relief day in lieu.  No action taken today.
Friday 1645 – Adopt the Delay Marco express method.  Letter slipped under door at 1710, start the service clock and enjoy the benefits of Commonwealth Evidence Act – part 160, which says, you actually received it (Friday) and the clock started ticking then.  Not in the office? - no ducking excuse.  It's not CASA’s fault you were receiving a lung transplant.  No Sir; You were ‘duly’, black letter, served.

Aye, that’s the new culture, right there.  Get accustomed and save your pennies for a good lawyer - irrespective - 

Vive la réforme.

[Peetwo]

ATSB investigation: AO-2014-163

This accident final report was published last week and I found it interesting because it actually involved an ATSB rarity these days - the issuing of a safety recommendation to CASA..

First here is the summary:

What happened

On the afternoon of 10 October 2014, the pilot of an amateur-built One Design DR-107 aircraft, registered VH-EGT, was performing low-level aerobatic manoeuvres. The manoeuvres were being performed to the east of Goolwa Airport, South Australia.
Witnesses described the aircraft performing a series of similar manoeuvres. Each involved a vertical climb and tumbling manoeuvre followed by a vertical dive and a low altitude recovery.

Witnesses reported that, during recovery from the last vertical dive, the aircraft collided with terrain. The aircraft was destroyed by the impact and the pilot was fatally injured.

What the ATSB found

The ATSB found no evidence of pilot incapacitation or a mechanical fault with the aircraft that could have contributed to the accident. There was insufficient evidence to determine why the recovery was not accomplished above the pilot’s minimum authorised aerobatics height.

The Civil Aviation Safety Authority (CASA) recommends that pilots performing low-level aerobatics undertake regular peer reviews due to the high level of skill and fine safety margins involved. The ATSB found no evidence of the pilot undertaking a peer review of their aerobatic performance in the 15 months prior to the accident.

Finally, the ATSB identified a safety issue that CASA does not require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual, the builder, subsequent owners and other pilots do not have reference to the operational and performance data necessary to safely operate the aircraft.

What’s been done as a result

In response to the identified safety issue, the ATSB has issued a safety recommendation to CASA to take action to require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.

Safety message

This accident highlights the risks inherent in performing low-level aerobatics. Applying the recommendations in CASA civil aviation advisory publication CAAP 155-1(0) Aerobatics will reduce these risks. Specifically, pilots are encouraged to always maintain minimum approved heights above the ground when performing aerobatics and to engage in regular peer reviews.

Owners of amateur built experimental aircraft are also encouraged to ensure a comprehensive and accurate flight manual, or equivalent, is available for reference by themselves, subsequent owners and other pilots who may fly the aircraft.

Amateur-built One Design DR-107 aircraft, registered VH-EGT

 
This was the ATSB identified safety issue, the response from CASA and finally the safety recommendation issued:

Flight manual requirements for amateur-built experimental aircraft

Issue number: AO-2014-163-SI-01
Who it affects: Operators of amateur-built experimental aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Background: Investigation Report AO-2014-163
Date: 14 April 2016

Safety issue description

The Civil Aviation Safety Authority did not require builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate the aircraft.

Proactive Action

Action organisation: Civil Aviation Safety Authority records
Date: 14 April 2016
Action status: Monitor

In response to this safety issue, the Civil Aviation Safety Authority (CASA) advised that:
CASA would like to note that an experimental aircraft must be placarded accordingly to ensure occupants are aware that they fly at their own risk, and that CASA does not set airworthiness standards for experimental aircraft (see Civil Aviation Regulation 1988 (CAR) subregulations 262AP(8) and (9)).

The experimental certificate regulations provide for this level of safety with as much flexibility as possible. The experimental certificate, including conditions specified on or attached to the certificate, is the primary means of maintaining these minimum standards. In the case of experimental amateur built aircraft, the necessary flight restrictions and information about the aircraft, such as weight and balance, are established as part of the flight test program and included on the experimental certificate, or other appropriate method such as placards or an Aircraft Flight Manual (AFM).

The regulations clearly provide that the experimental certificate system is only intended to establish minimum safety standards for other airspace users and people on the ground (see Civil Aviation Safety Regulation 1998 (CASR) subregulation 11.055(1C)). An AFM is not required under the regulations for experimental amateur built aircraft however CASA recommends an AFM be developed (see Advisory Circular (AC) 21.4, section 17).

CASA does not fully understand the rationale behind the ATSB recommendation about mandating, rather than recommending the production of AFM for these experimentally operated aircraft given the non-existence of an AFM for this aircraft had no effect on the incident (as acknowledged in the report on page 10).

CAR 138 states that if a flight manual has been issued then the pilot must comply with it. CASA acknowledges that mandating an AFM for experimental amateur built aircraft may improve safety for subsequent owners and other pilots than the original owner/builder/pilot. However, the experimental certificate system functions as intended by the current regulations (ie. to ensure the safety of other airspace users and people on the ground).

CASA currently recommends an AFM be produced for experimental amateur built aircraft, but changing this to a mandatory requirement would incur a significant cost to the owners/operators. CASA does not believe this incident in isolation provides sufficient justification this change to the legislation given the other safety protections that are already established.

It is noted that the Sports Aircraft Association of Australia (SAAA) Maintenance Procedures Course at Topic 4 (attached) on pages 14–16 recommends how to prepare a Pilots Operating Handbook (POH) for an amateur built using the General Aviation Manufacturer’s Association (GAMA) standards specification 1, this is available from the GAMA website: www.gama.aero/industry-standards.

CASA does not believe there needs to be a regulatory requirement for a POH, it is an SAAA recommended practice to develop one during flight testing and this should form the basis of educational information that could be sent through to all registered owners of these types of aircraft.

ATSB response:

The ATSB acknowledges that CASA and the SAAA recommend that an AFM/POH is produced as part of the flight test program required for experimental amateur‑built aircraft. However, the ATSB remains of the view that, while the absence of a flight manual, or equivalent, did not influence this accident, such a document should be mandatory for the following reasons:

• Without a flight manual the builder, other pilots and especially subsequent owners do not have sufficient reference to operational and performance data necessary to safely operate the aircraft.
  
• Accidents involving amateur‑built aircraft occur at a significantly higher rate than comparable factory‑built aircraft. A requirement to document important operational information would provide a valuable safety enhancement at minimal cost.
  
  

Recommendation

Action organisation: Civil Aviation Safety Authority records
Action number: AO-2014-163-SR-008
Date: 14 April 2016
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to address the lack of a requirement for builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.
 
Current issue status: Safety action pending
 



Last update 14 April 2016

 
From the CASA initial response, in particular this bit...

"..CASA does not fully understand the rationale behind the ATSB recommendation about mandating, rather than recommending the production of AFM for these experimentally operated aircraft given the non-existence of an AFM for this aircraft had no effect on the incident (as acknowledged in the report on page 10).."

...I don't get the impression that the regulator will be rushing to proactively address this SR anytime soon, however kudos for the IIC (backed by Commissioner Manning I would assume) for having the balls to challenge CASA on this..

MTF...P2   

[Kharon]

ATSB – NFI – again.

After the pathetic VMC – IMC report, has ATSB got it’s collective panties in a bunch over nothing, in a vainglorious attempt be seen as ‘significant’?  It seems so, from the effort above. While I’m ‘at-it’, it’s  pedantic I know; but, the English in the recent ATSB reports has been bloody awful.  I keep finding references to “them” or “they” or “their”, when the context is singular; a bit like an annoying noise, once noticed cannot be ignored (like the something ‘buzzing’ in the cockpit), drive you nuts.  

CASA would like to note that an experimental aircraft must be placarded accordingly to ensure occupants are aware that they fly at their own risk, and that CASA does not set airworthiness standards for experimental aircraft (see Civil Aviation Regulation 1988 (CAR) sub-regulations 262AP(8) and (9)).

In the case of experimental amateur built aircraft, the necessary flight restrictions and information about the aircraft, such as weight and balance, are established as part of the flight test program and included on the experimental certificate, or other appropriate method such as placards or an Aircraft Flight Manual (AFM).

The regulations clearly provide that the experimental certificate system is only intended to establish minimum safety standards for other airspace users and people on the ground (see Civil Aviation Safety Regulation 1998 (CASR) sub-regulation 11.055(1C)).

So, quite legally, properly; and IMO, quite rightly CASA disown the ‘experimental’ class.  I’ll own that if I wanted to build and fly my own aircraft, the latitude afforded by the regulations would be welcome and I’ve no quarrel with the CASA approach to managing the task; it seems both reasonable and fair to me.  Good to see sensible regulation at work and, as CASA point out:-

CASA does not believe there needs to be a regulatory requirement for a POH, it is an SAAA recommended practice to develop one during flight testing and this should form the basis of educational information that could be sent through to all registered owners of these types of aircraft.

So I’m left wondering what ATSB is seeking to have changed.  If, as CASA indicate there is a POH and general ‘operating’ notes available, what’s the fuss?  No one is going to allow a ‘stranger’ off the street to operate their aircraft; and, I dare say that before anyone is allowed to fly an ‘E’ aircraft, there would be much reading, briefing and ‘chatting’ about how to handle the aircraft. These aircraft are not ‘line’ or fleet aircraft, to be used and abused by several crew a week, they are usually the darling child, product of a serious love affair, doted on and spoiled rotten by loving owners.

CASA 1 – ATSB 0.  Well played CASA...

[Kharon]

A non accident and a balanced investigation from ATSB on a technical matter makes for a pleasant change.  Ben Sandilands has somewhat to say on the wash up.  Posted a discussion starter – HERE – FWIW.

[Peetwo]

Not an accident but a good news incident - In amongst the endless depressing news reel loops of the political election campaign and the evolving parasitic MSM speculation of the tragic accident of Egypt Air flight MS804, there happened to be an aviation incident that had a good outcome   :

Hot air balloon passengers jump from stricken craft over Port Phillip Bay

Updated yesterday at 3:18pmSat 21 May 2016, 3:18pm

Video: Hot air balloon offloads passengers at Port Phillip Bay (ABC News)

Photo: The Melbourne Coast Guard said all those onboard the balloon were safe. (Twitter: Melbourne Coast Guard)

Nine passengers have jumped from a hot air balloon hovering over Melbourne's Port Phillip Bay onto a police boat below following fears the balloon, which was low on fuel, would ditch into the water.

The balloon was hovering about 500 metres offshore around Black Rock and low on fuel, the Metropolitan Fire Brigade (MFB) said.

Fireboat crews and water police travelled to the scene about 8:30am, while a number of nearby fishing boats trailed the balloon.

The balloon floated over the police boat and each time it began to lose altitude, passengers climbed out of the basket and jumped onto the deck below.
The passengers were taken to the Beaumaris motor yacht squadron to be checked by paramedics.

The loss of passengers reduced the weight of the basket, allowing the pilot to return to shore. The balloon then landed at Mount Martha.

'Occasionally we land in strange spots'

Pilot Peter Wright, who has been flying for 20 years, said he had earlier tried to land in a park in Brighton.

"As I approached the park, my flight path was taking me towards a tall light pole, so I obviously had to go over the light pole but with the speed that I had I was unable to get the balloon into the park ... safely," he said.

"I saw on my map I had a parkland near the beach ... and when I got there it was all full of trees. That was when I realised I needed a bit of luck to go my way."

He said he then climbed back up to try and use the wind to get the balloon back, but given its speed and direction, decided to contact authorities as a precaution to help land safely.

Mr Wright said the whole situation went "smoothly" and the passengers were "fabulous, very cooperative and calm".

He said they never ran out of fuel, but given he had been in the air for about two hours, supplies were running low.

"Ballooning is one of those things. Occasionally we do land in strange spots. Apart from taking up the time of the fabulous water police, it's all been OK," he said.

"I followed our procedures, they worked perfectly."

Photo: The passengers were taken to Beaumaris for medical checks. (ABC News: James Hancock)

MTF...P2

[P7_TOM]

Not really and accident; but, it speaks volumes about how our unique system operates.  The story – HERE - broke cover just before August; we have all been waiting, patiently, for some form of ‘official’ word; alas.  The joining of dots I will leave to your own native intelligence and knowledge of the way things are really done.

[Kharon]

From ATSB – the final report Air ASIA X incident in March 2015 at Sydney – HERE.

No comment required, but I seem to recall an Estimates session which was relevant.

[Peetwo]

From ATSB – the final report Air ASIA X incident in March 2015 at Sydney – HERE.

No comment required, but I seem to recall an Estimates session which was relevant.

Do you mean this session "K"...

Holy hell ! – Yes Senator, indeed.

One of the more intriguing documents read lately is this one – HERE – from Skidmore to the Estimates committee.  It throws a shroud over some fairly nifty sleight of hand.  The letter, of it's self, is self explanatory.   To an inquiring mind, the rest of the 'bumf' is 'background noise' until you realise, as Skidmore must have done by now; it don't answer the question; not fully.

When you read Hansard the intent and the purpose of the question was – how come operators which are blacklisted in Europe can operate into Australia?.  What was needed, by way of answer was an explanation of the differences between Australia and Europe: given that ICAO compliance in the real world is the norm, rather than the 1600 odd differences package which keeps Australia off the real compliance radar, using stealth and technical lip service.

I wonder how long ICAO will sit still, when the world is blatantly taking the Mickey out of Annexe 13.  Perhaps they will start to hunt down a fat, juicy high roller for to make an example of?

Well, poor old Skidmore was lured into a velvet lined trap, foiled by smoke, dazzled by mirrors and succumbing to the oldest trap in the world – the whispered "trust me".

You know the old gag – "I'll only pop it in a little way, if you don't like it, I'll take it out; trust me"..... ......

Tower Chair are we clear to backtrack?

Although personally I was much more interested in other passages of play at the time, I did find that Air Asia ......? (fill out on the dotted line.. ) & EU blacklist thing intriguing and now with Skates 1st Estimates retraction, even more so???

Anyway for those interested here is the "exchange" in pictures - fascinating how Hoodoo Voodoo seems to know in almost intimate detail the previous (prior to December 2014) EU blacklist??

Another point of interest in this whole "exchange" and "retraction" was the Murky Mandarin's constant interference into the fray...

1st example:

Senator STERLE: Why don't we just talk about all AirAsia that fly out of any port in Australia to overseas? Does that make it easier?


Mr Skidmore : To a certain degree it does.

Senator STERLE: It might be your first one, but you learnt pretty quickly.
 
Mr Mrdak : It is an important distinction, because we have AirAsia, which has a significantly longer operational history than the company that was involved in the accident, as opposed to AirAsia Indonesia.

Senator STERLE: Sure. Yes.

Mr Mrdak : The company has various stages of maturity and operations, so it is hard for us to give you a generic answer on AirAsia because there are multiple operators. AirAsia is a Malaysian company. There are various subsidiaries which are—

Senator STERLE: I am aware. The Philippines and Indonesia—

Mr Mrdak : at different stages of operation and have different business patterns to AirAsia's. That is why I cannot give you a—

Senator STERLE: Mr Mrdak, in all fairness to AirAsia, I asked the question and we should answer the whole lot. Mr Skidmore should tell us what CASA are thinking. Because out there in travel land people see AirAsia and go 'ooh'—let me tell you. Ask my mate here. In Perth there was a lot of conversation around that time. A lot of people use AirAsia out of Perth, as I said, to Bali. So you can put our minds at rest without starting an absolute fear campaign.

Mr Mrdak : Perhaps if we start with the business entity which is seeking regulatory approval to commence operations.

Senator STERLE: Spot on. Mr Mrdak, I am sorry to interrupt—while I am being nice and on my best behaviour—but as Senator Back did just say to me, that particular plane had been in service between Perth and Bali. So I think it is a fair question for us to put on the table. Let us have a go.

Mr Mrdak : All I was trying to do was assist you by saying that perhaps if Mr Skidmore starts with the progress on the application for new operations, which are AirAsia Indonesia, we can then talk from there about broader surveillance. But perhaps we could start from where the media focus has been, which is new start-up carriers. Does that assist, Mark?

Mr Skidmore : That will help, thank you. Indonesia AirAsia Extra is the operator who was asking for a Foreign Aircraft Air Operator's Certificate to operate from Melbourne to Denpasar.

Senator STERLE: Oh, have they?...

2nd example:

CHAIR: How did we allow them? Did they apply, or we have not bothered to inspect? How come they are banned in flying in Europe, but we say, 'She'll be right here'?


Mr Mrdak : Can I just jump in. I think we should clarify. Firstly, Garuda does operate to Europe and operates to here. Australia does look at issues like the European black list, but the European black list is not a black list as you might imagine. As Dr Aleck has indicated, the European authorities take certain presumptions in relation to carriers from certain states—

Senator STERLE: Ban the whole lot.

Mr Mrdak : and carriers then can apply to operate. With Garuda international there were some issues a few years ago. They have been satisfied. They are now regarded as a—

Mr Skidmore : Very safe.

Mr Mrdak : very safe and very credible airline. I would not want to leave the committee with the impression, on the evidence that has been given today, that there are any suggestions around Garuda Indonesia. In relation to those matters, we do look at issuing international airline licences and foreign AOCs. As to the status of those carriers on the European listing, they are taken into account. Australia does—and I am sure CASA will outline it for you—its own checks in relation to foreign AOCs and also undertakes its own ramp assessments and—

CHAIR: But there are still two airlines flying into Australia, as I understand it, that do not have the rights to fly into Europe?

Mr Mrdak : Before we are definitive, let me go and check that and give you an accurate piece of information on that evidence so far. Let us take that on notice and come back to you.

& at the end...

Mr Mrdak : I think probably the best way is if we—


Senator STERLE: What are you laughing at, Mr Farquharson? Did I tickle your sense of humour? Are you picking on my mate Mr Quinlivan?

Mr Farquharson : I used to be the regional manager in Perth and I know Mr Quinlivan quite well.

Senator STERLE: Don't worry; I know he knows you. Anyway keep going. You look a bit like him from here.

Mr Mrdak : Perhaps if we come back to the committee with some advice in relation to, firstly, foreign air operators certificate requirements and then our safety surveillance program in relation to foreign carriers. If necessary, we can happily provide a briefing to the committee on those matters.

CHAIR: I was just going to suggest that it may be appropriate to prepare a set of documents to brief this committee.

Mr Mrdak : I think that would be the best way forward, so we do not mislead the committee or the general community about the status of airlines or the way in which this safety surveillance takes place. It is probably better if we do it that way.

Senator STERLE: I agree.

Dr Aleck : Can I just add quickly that, in 2009, we amended our legislation specifically to enable us to look at these issues more closely. We exercised those powers in connection with any operator who draws our attention to their activities, and an accident would be a flag.

CHAIR: It is a long time since I learned to fly. You may be captured by an area that has been black listed, but generally what goes wrong when an airline gets black listed in Europe?

Mr Mrdak : Generally, it starts with a concern about the safety regulator in that country in which the airline is based.

CHAIR: The skill of the pilot, the servicing of the plane?

Mr Mrdak : Generally, it starts with concerns about the quality of the safety assurance process in the country in which the airline is based, and the safety regulatory record of the jurisdiction before it gets to the individual aircraft operator. It is much more complex than simply the operator itself.

CHAIR: Anyhow, you will organise a briefing?

Mr Mrdak : I think that is the best way to handle it.

CHAIR: I agree.

Senator STERLE: In that case, I am finished.

CHAIR: I am pleased they asked the question. Senator Xenophon?

How very strange for M&M in Estimates no less?? M&M is not known for offering up so many words on a subject that should be totally within the remit of CASA. Further to this - strange display of disharmony between the Department and agency - is the fact that M&M then goes onto table the same EU Airline blacklist that CASA does within the Skidmore retraction correspondence, minus the EU legislation:

 3.) Document outlining a list of air carriers of which all operations are subject to a ban within the EU. Tabled by Mr Mike Mrdak, Secretary, Department of Infrastructure and Regional Development.

(PDF 2204KB)

How very bizarre??

Oh & for the record here is the indexed QON on this matter.. :

171
086
CASA
HEFFERNAN
European blacklist of Airlines

CHAIR: Could you table to this committee the documents that backed up the black listing of those places that fly into Australia that are black listed in Europe?

…
CHAIR: But there are still two airlines flying into Australia, as I understand it, that do not have the rights to fly into Europe?

Mr Mrdak: Before we are definitive, let me go and check that and give you an accurate piece of information on that evidence so far. Let us take that on notice and come back to you.

Mr Skidmore: We can take it on notice and confirm to you exactly the numbers there, but Australia still conducts its own assessment in regards to the application put forward to it.
…
Mr Mrdak: Perhaps if we come back to the committee with some advice in relation to, firstly, foreign air operators certificate requirements and then our safety surveillance program in relation to foreign carriers. If necessary, we can happily provide a briefing to the committee on those matters.

CHAIR: I was just going to suggest that it may be appropriate to prepare a set of documents to brief this committee.

 
Hmm...kind of interesting timing of that hearing when you consider this post off the Mount NCN thread... Uh'mm -I’ll have two bob’s worth. Part II - The reply

In particular:

P2 - To confirm to myself that Senator Fawcett on a mission to 'lance the boil', I decided to review the SCOT reports after the 139 report (i.e. the Serbia & Vanuatu air services agreement).

I discovered that there was indeed one more air services agreement that
the Joint treaties committee reviewed in the 44th Parliament: Agreement between the Government of Australia and the Government of the Lao People’s Democratic Republic Relating to Air Services .

The following was from the recorded Hansard from the brief public hearing:

ACTING CHAIR: During the inquiry into air services agreements between Australia and Serbia and Vanuatu last year, the committee was told that, as well as having an agreement in place, foreign airlines need to satisfy safety standards as assessed by the Civil Aviation Safety Authority, CASA. This includes considering how their practices differ from International Civil Aviation Organization standards. In our report, the committee suggested that the DFAT negotiators should consult with CASA as to whether potential agreement parties are meeting the International Civil Aviation Organization standards or whether there are safety concerns. So the question is: did the department consult with CASA about Laos's performance against the International Civil Aviation Organization standards during the negotiations for this agreement?

Mr Smith : There was consultation with CASA for the negotiation of this agreement. Just looking at the time frame of the two agreements that you referred to that were before the committee last time, there was not that specific additional level of consultation that was mentioned with Serbia and Vanuatu. Discussions have taken place with CASA about expanding the level of consultations prior to future negotiations.

Senator FAWCETT: Clearly before you came to this committee you had the previous reports. I accept the fact that this was negotiated a year ago, but you have had the report since then. Have you gone back to CASA to ask them, for example, what the latest IATA, ICAO or FAA audits were on Laos?

Mr Smith : In September 2015, ICAO published its report on the most recent audit evaluation, undertaken in April 2015, of the Lao PDR. The audit was a targeted review of the 224 unsatisfactory findings made by ICAO during an earlier full audit undertaken in 2010 and it intended to find an update of the assessed safety oversight of the status of Laos. No significant safety concerns were identified during the audit. ICAO uses the 'effective implementation' terminology as a measure of a state's safety oversight capability, and a higher 'effective implementation' indicates that a state's safety oversight system has a greater degree of compliance with ICAO provisions. In 2010, Lao PDR was assessed as having an EI of 65.31 per cent and, following the April 2015 audit, the Lao PDR has improved its score to 73.03.

Senator FAWCETT: I hear that, and that has been in the media recently. Laos are very proud of that—and so they should be—but you did not answer my question. Having had that gap between the issue of our last report and this appearance, have you gone back to CASA to ask them for their opinion? For example, Laos is not registered with IATA. They do not have the IOSA audit, which is kind of the benchmark for international airlines. Generally speaking, the perception is that if you have not had an IOSA audit then perhaps you do not think you are ready for it. It is kind of the gold standard for international airlines. The majority of airlines are; Laos is not. Have you gone back and asked CASA their opinion on what may be lacking that has caused Laos to not actually pursue the IATA accreditation?

Mr Smith : CASA were consulted on the text before it was finalised, but we did not specifically ask the sorts of questions that you have outlined. Part of the rationale surrounds the likelihood of Lao Airlines serving the Australian market with their own aircraft. The agreement was settled to provide both for own-operated services and, primarily, for code-share services. In the event that the operation into Australia of Lao carriers with Lao-registered aircraft becomes more likely, I think that issue would become more topical and would certainly interest and exercise CASA's attention. Certainly, the air services agreement we are discussing today includes the standard safety clause that is included in our air services agreements, which provides CASA with the scope and ability to enforce the minimum ICAO standards, as well as applying the domestic standards that they would apply before issuing FAAOCs and the like.

Senator FAWCETT: I still just make the note that, having issued a report recommending a particular course of action, I am a little disappointed that that has not been followed through prior to this hearing so that we have an assurance. Taking on board what you are saying—that, at this stage, you do not anticipate a Lao-registered aircraft to operate here—and noting also the recent ICAO evaluation, I still think that is a loop that should be closed before the committee actually considers the report.

Hmm...them ICAO breadcrumbs are lining up me thinks...
MTF...P2

[Peetwo]

From ATSB – the final report Air ASIA X incident in March 2015 at Sydney – HERE.

No comment required, but I seem to recall an Estimates session which was relevant.

More on this incident via the ABC... :

AirAsia captain entered wrong coordinates before aborted flight, ATSB finds

Updated Thu at 3:41pmThu 8 Sep 2016, 3:41pm


Photo: An Airbus A330 like this one was accidentally told it was near Cape Town. (Supplied: Wikimedia Commons)

A flight from Sydney to Malaysia ended up in Melbourne after the captain entered the wrong coordinates into the plane's navigation system just before take-off, a safety investigation has found.

The AirAsia X Airbus A300, registration number 9M-XXM, took off from Sydney on March 10, 2015, bound for Kuala Lumpur but had entered the wrong departure flight path, the Air Transport Safety Bureau (ATSB) found.

After being alerted by air traffic control, the flight crew found a problem with the onboard navigation systems, a report released on Wednesday said, with a loss of GPS data and route directions.

Attempts by the first officer to troubleshoot the problem, as the captain took over piloting the aircraft, resulted in further problems of the navigation system as well as the flight guidance and flight control systems.

The flight was cancelled but deteriorating weather in Sydney meant the aircraft, which was now limited to visual conditions, had to be directed south to Melbourne — more than 6,000 kilometres from its intended destination.

The errors were fixed in Melbourne and the flight resumed four hours after landing.
The ATSB said that effective monitoring and assistance by air traffic control reduced the risk to the AirAsia X aircraft, and other aircraft in the area.

Heavy workload contributed to further errors

The ATSB investigation found the captain had entered the wrong longitudinal position — 01519.8 (15 degrees) east instead of 15109.8 (151 degrees) east — a misplaced zero which put the aircraft 11,000 kilometres away, off the coast of Cape Town in South Africa.

This "adversely affected the aircraft's navigation systems and some alerting systems", the ATSB report noted, and was not detected despite "a number of opportunities to identify and correct the error".

Pre-flight checks were not carried out in accordance with the manual and it is likely some checks were either omitted or carried out with the navigation display set inappropriately, the ATSB said.

"The flight crew attempted to troubleshoot and rectify the situation while under heavy workload. Combined with limited guidance from the available checklists, this resulted in further errors by the flight crew in the diagnosis and actioning of flight deck switches," the report said.

"This occurrence highlights that even experienced flight crew are not immune from data entry errors."

Manufacturer Airbus had released a service bulletin in 2013 recommending an upgrade to the air data and inertial reference systems on A330 and other aircraft, however it was not mandatory and had not been carried out on 9M-XXM.

AirAsia X released a statement on Wednesday saying they had taken several corrective actions immediately following the incident, and prior to the publication of the ATSB's report.

These include upgrading the flight management systems since the incident, developing a training bulletin and package for flight crew, and briefing all pilots on AirAsia's internal investigation findings.

"AirAsia X would like to stress that we have in place robust management systems to monitor and prevent similar incidents from reoccurring," the statement said.

"We also wish to reiterate that we have regularly passed safety and security audits conducted by various international regulators, including the IATA Operational Safety Audit (IOSA).

"We remain committed to ensuring our compliance to all safety and security regulations."
From other news sites:

• Australian Aviation: AirAsia X flight radar vectored to Melbourne after Sydney data entry error
  
• Daily Mail: AirAsia flight from Sydney to Malaysia mistakenly ended up in MELBOURNE after the pilot entered the wrong details and accidentally turned left
  

MTF...P2

[Gobbledock]

Hot off the press from the Simply Marvellous Horse Pooh;

"Qantas warns of fire risk after device combusts on New York trip"

http://www.smh.com.au/business/qantas-wa...rqou0.html

Tick tock goes these pieces of shit technological marvels! Will it be a drone or on IPhone that brings down the first A380?

[Kharon]

ATSB on the 717 incident - HERE.

[Peetwo]

ATSB on the 717 incident - HERE.

From the ASIB report:

Safety message

Inaccurate take-off reference data has potentially serious consequences. ATSB Aviation Research and Analysis Report AR-2009-052 (Take-off performance calculation and entry errors: A global perspective) documents a number of accidents and incidents where take-off performance data was inaccurate. The report analyses those accidents and incidents, and concludes:

… it is imperative that the aviation industry continues to explore solutions to firstly minimise the opportunities for take-off performance parameter errors from occurring and secondly, maximise the chance that any errors that do occur are detected and/or do not lead to negative consequences.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to data input errors.

 
Reference ATSB desktop ASIB report - Issue 52

MTF...P2

[Peetwo]

ATSB on the 717 incident - HERE.

From the ASIB report:

Safety message

Inaccurate take-off reference data has potentially serious consequences. ATSB Aviation Research and Analysis Report AR-2009-052 (Take-off performance calculation and entry errors: A global perspective) documents a number of accidents and incidents where take-off performance data was inaccurate. The report analyses those accidents and incidents, and concludes:

… it is imperative that the aviation industry continues to explore solutions to firstly minimise the opportunities for take-off performance parameter errors from occurring and secondly, maximise the chance that any errors that do occur are detected and/or do not lead to negative consequences.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to data input errors.

 
Reference ATSB desktop ASIB report - Issue 52

Update: Binger in the Oz today...

QantasLink flight ‘used incorrect weight and temperature data’

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM October 4, 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]
A QantasLink plane avoided a potentially serious incident after it completed a trip from Canberra to Sydney using incorrect data about the plane’s weight and temperature.

An investigation by the Australian Transport Safety Bureau into the June 20 incident has found that a tired crew and last-minute changes to the aeroplane’s passenger numbers meant the wrong takeoff data was used for the flight.

The incident involved a Cob­ham-operated Boeing 717-200 that was flying to Sydney with 91 passengers and five crew on board. The captain had prepared for a “flex” takeoff based on an assumed outside temperature of 39C. Flex allows pilots to use reduced thrust to take off, which reduces the wear and tear on plane engines.

However, that flex temperature was revised down to 34C when 22 additional passengers were loaded on to the plane after the cockpit checklist had been completed. While the captain recorded the new temperature, it was scribbled over the initial 39C figure, which was then used to calculate the engine’s required thrust.

Despite the error, the flight continued to Sydney and landed without incident.

In its investigation into the incident, the ATSB found that both members of the flight crew assessed that tiredness because of their early morning start may have contributed to the flex temperature error, but that they were fit to continue to operate for the rest of the day’s duty.

“The flight crew commented that a combination of distraction by cabin crew and ground personnel while re-entering data, a reduced state of arousal following a high workload instrument ­approach, and possibly tiredness from an early start may have contributed to their omitting to enter the correct flex temperature,” the ATSB said. In its official report into the incident, the bureau said the use of inaccurate takeoff reference data could have potentially serious consequences.

In a 2011 report, the ATSB highlighted the consequences of failing to use correct data for flight calculations, saying that tail strikes, runway overruns and degraded handling qualities could all occur.

“It is imperative that the aviation industry continues to explore solutions to, firstly, minimise the opportunities for takeoff performance parameter errors from occurring and, secondly, maximise the chance that any errors that do occur are ­detected and/or do not lead to negative consequences,” it said.

Cobham Aviation Services, which hires the crew, said they would ensure their pilots used a new takeoff and landing data collection card if new information needed to be added or updated.

[Kharon]

Just having a look at the media offerings on the storm damage at Brisbane airport.  There is one picture of (I think) an Air Nauru 73 which has been damaged by the portable stairs; there are reports of other large-ish items being blown about the place.  Is this perhaps where OH&S need a rethink. I have no quarrel with getting the ‘troops’ off the apron when a storm approaches, I really don’t, but with radar and the rest of it, adequate warning can be given that the ‘storm’ will arrive within the next 30 minutes or so. Surely, that amount of warning time could be used to get both crew and ‘ancillary’ equipment off the ramp and out of harms way, at least far enough away from parked aircraft and other potential targets. I just wonder how the insurance companies would view this, if push came to shove? The storm is an ‘act of the gods’, but leaving portable, unsecured equipment behind and watching it beat an aircraft to death could, possibly, be construed as ‘negligent’.

Dunno – just my two bob’s worth.

[Gobbledock]

Virgin Australia planes clip wings on tarmac at Hobart Airport

Probably a bit early for assumptions as well as accurate details but it will be interesting to monitor developments. However ground related incidents to seem to be becoming the norm in recent years. Tick Tock perhaps?

https://au.news.yahoo.com/a/33438134/vir...ort/#page1

Virgin Australia planes clip wings on tarmac at Hobart Airport

Two Virgin Australia planes have clipped wings on the tarmac at Hobart Airport.
A witness, who chose to remain anonymous, told 7 News Online that the planes were both on the runway when they collided.
He said only minor damage was caused.
Both planes were carrying passengers at the time, with one plane headed to Melbourne and the other scheduled to fly to Sydney this morning.
"Both aircraft taxied back to the gates to let passengers disembark," the witness said, adding that the passengers were directed back inside the terminal to continue waiting.
"Lots (of passengers) are annoyed because there is no update/timeframe for a new aircraft/departure. Most people were told to collect their luggage from baggage collection, so most have left the terminal now, but a few still remain."
No injuries have been reported.

7 News Online has reached out to Virgin Australia, Hobart Airport and the Civil Aviation Safety Authority for comment.

As P2 would say, definitely MTF

[Peetwo]

Virgin Australia planes clip wings on tarmac at Hobart Airport

Probably a bit early for assumptions as well as accurate details but it will be interesting to monitor developments. However ground related incidents to seem to be becoming the norm in recent years. Tick Tock perhaps?

https://au.news.yahoo.com/a/33438134/vir...ort/#page1

Virgin Australia planes clip wings on tarmac at Hobart Airport

Two Virgin Australia planes have clipped wings on the tarmac at Hobart Airport.
A witness, who chose to remain anonymous, told 7 News Online that the planes were both on the runway when they collided.
He said only minor damage was caused.
Both planes were carrying passengers at the time, with one plane headed to Melbourne and the other scheduled to fly to Sydney this morning.
"Both aircraft taxied back to the gates to let passengers disembark," the witness said, adding that the passengers were directed back inside the terminal to continue waiting.
"Lots (of passengers) are annoyed because there is no update/timeframe for a new aircraft/departure. Most people were told to collect their luggage from baggage collection, so most have left the terminal now, but a few still remain."
No injuries have been reported.

7 News Online has reached out to Virgin Australia, Hobart Airport and the Civil Aviation Safety Authority for comment.

As P2 would say, definitely MTF

Also from Binger via the Oz:

Virgin jets in prang
12:00amMITCHELL BINGEMANN
Two Virgin planes collided on the tarmac at Hobart and another veered off the runway at Darwin.

Virgin Australia has been forced to ground three aircraft after two collided on the tarmac at Hobart and another veered off the runway at Darwin.

The Australian Transport Safety Bureau immediately launched an investigation into the Darwin incident, which saw a Virgin-operated Boeing 737 veer off the runway as it landed in gusty conditions.

“Guests were able to disembark as normal,” said a Virgin spokesman. “We will work closely with the ATSB during their ­investigation.”

The plane sustained minor damage. Two ATSB investigators were dispatched to Darwin to conduct an examination of the runway, surrounding area and the aircraft to determine the cause of the incident.

On a bad day for Virgin’s ­safety record, two other of the airline’s Boeing 737s collided on the tarmac at Hobart yesterday morning. The collision occurred when one of the planes was pulling away from the gate. Its wing clipped the tail of a 737 as passengers were boarding.

The planes were scheduled to fly to Sydney and Melbourne but were pulled from service.

Passengers boarding the Melbourne-bound flight reported an “almighty shudder” when the collision occurred but no one was injured. “(It) visibly rocked the plane — people were almost knocked off their feet,” one passenger told the ABC.
Virgin said the aircraft made “light contact”. “There was no safety risk during this time and engineers are currently inspecting the aircraft,’’ a spokesman said. “We apologise for the delay to passengers and are working hard to have them on their way as quickly as possible.”

The spokesman said the “knock-on” effect to other flights in the Virgin network would be minimal as replacement aircraft were available.

Here is the ATSB occurrence report/investigation summary for the Darwin incident:

Summary

During landing on runway 29, the aircraft encountered gusty wind conditions and veered off the runway, resulting in minor damage.

The ATSB has sent two investigators from the Brisbane office to Darwin, arriving the afternoon of 7 December 2016. They are from engineering and air traffic control disciplines and will conduct examination of the runway, surrounding area and aircraft as necessary. It is anticipated they will return to Brisbane on Friday 9 December. Further investigation work will centre around gathering operationally relevant information, including weather, landing data, air traffic control data and aircraft information.
The investigation is continuing.
 
General details

Date: 06 Dec 2016
 
Investigation status: Active
 
Time: 23:03 CDT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Darwin Airport
 
Occurrence type: Runway excursion
 
State: Northern Territory
 
Occurrence category: Serious Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Sep 2017 
 
Aircraft details
Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737-8FE
 
Aircraft registration: VH-VUI
 
Serial number: 34441
 
Operator: VIRGIN AUSTRALIA AIRLINES PTY LTD
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Minor
 
Departure point: Melbourne Vic.
Destination: Darwin NT
 
 
 


Last update 07 December 2016

MTF...P2

[Peetwo]

Virgin Australia planes clip wings on tarmac at Hobart Airport

Probably a bit early for assumptions as well as accurate details but it will be interesting to monitor developments. However ground related incidents to seem to be becoming the norm in recent years. Tick Tock perhaps?

https://au.news.yahoo.com/a/33438134/vir...ort/#page1

Virgin Australia planes clip wings on tarmac at Hobart Airport

Two Virgin Australia planes have clipped wings on the tarmac at Hobart Airport.
A witness, who chose to remain anonymous, told 7 News Online that the planes were both on the runway when they collided.
He said only minor damage was caused.
Both planes were carrying passengers at the time, with one plane headed to Melbourne and the other scheduled to fly to Sydney this morning.
"Both aircraft taxied back to the gates to let passengers disembark," the witness said, adding that the passengers were directed back inside the terminal to continue waiting.
"Lots (of passengers) are annoyed because there is no update/timeframe for a new aircraft/departure. Most people were told to collect their luggage from baggage collection, so most have left the terminal now, but a few still remain."
No injuries have been reported.

7 News Online has reached out to Virgin Australia, Hobart Airport and the Civil Aviation Safety Authority for comment.

As P2 would say, definitely MTF

Also from Binger via the Oz:

Virgin jets in prang
12:00amMITCHELL BINGEMANN
Two Virgin planes collided on the tarmac at Hobart and another veered off the runway at Darwin.

Virgin Australia has been forced to ground three aircraft after two collided on the tarmac at Hobart and another veered off the runway at Darwin.

The Australian Transport Safety Bureau immediately launched an investigation into the Darwin incident, which saw a Virgin-operated Boeing 737 veer off the runway as it landed in gusty conditions.

“Guests were able to disembark as normal,” said a Virgin spokesman. “We will work closely with the ATSB during their ­investigation.”

The plane sustained minor damage. Two ATSB investigators were dispatched to Darwin to conduct an examination of the runway, surrounding area and the aircraft to determine the cause of the incident.

On a bad day for Virgin’s ­safety record, two other of the airline’s Boeing 737s collided on the tarmac at Hobart yesterday morning. The collision occurred when one of the planes was pulling away from the gate. Its wing clipped the tail of a 737 as passengers were boarding.

The planes were scheduled to fly to Sydney and Melbourne but were pulled from service.

Passengers boarding the Melbourne-bound flight reported an “almighty shudder” when the collision occurred but no one was injured. “(It) visibly rocked the plane — people were almost knocked off their feet,” one passenger told the ABC.
Virgin said the aircraft made “light contact”. “There was no safety risk during this time and engineers are currently inspecting the aircraft,’’ a spokesman said. “We apologise for the delay to passengers and are working hard to have them on their way as quickly as possible.”

The spokesman said the “knock-on” effect to other flights in the Virgin network would be minimal as replacement aircraft were available.

Here is the ATSB occurrence report/investigation summary for the Darwin incident:

Summary

During landing on runway 29, the aircraft encountered gusty wind conditions and veered off the runway, resulting in minor damage.

The ATSB has sent two investigators from the Brisbane office to Darwin, arriving the afternoon of 7 December 2016. They are from engineering and air traffic control disciplines and will conduct examination of the runway, surrounding area and aircraft as necessary. It is anticipated they will return to Brisbane on Friday 9 December. Further investigation work will centre around gathering operationally relevant information, including weather, landing data, air traffic control data and aircraft information.
The investigation is continuing.
 
General details

Date: 06 Dec 2016
 
Investigation status: Active
 
Time: 23:03 CDT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Darwin Airport
 
Occurrence type: Runway excursion
 
State: Northern Territory
 
Occurrence category: Serious Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Sep 2017 
 
Aircraft details
Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737-8FE
 
Aircraft registration: VH-VUI
 
Serial number: 34441
 
Operator: VIRGIN AUSTRALIA AIRLINES PTY LTD
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Minor
 
Departure point: Melbourne Vic.
Destination: Darwin NT
 
 
 


Last update 07 December 2016

Update: ATSB confirm Hobart occurrence will be investigated .

Summary

The ATSB is investigating a taxiing collision involving Virgin Australia Boeing 737s, VH-YFT and VH-VUP, at Hobart Airport, Tasmania, on 7 December 2016.

While taxiing from the parking bay, VH-YFT collided with VH-VUP which was stationary.

The damage to both aircraft is still being assessed and no one was injured.

As part of the investigation, the ATSB will interview the flight and ground crew and gather additional information.

A report will be released within several months.
 
General details
Date: 07 Dec 2016
 
Investigation status: Active
 
Time: 10:13 EDT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Hobart Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Tasmania
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Feb 2017 
 
Aircraft 1 details
Aircraft 1 detailsAircraft manufacturer: The Boeing Company
 
Aircraft model: 737-8FE
 
Aircraft registration: VH-VUP
 
Serial number: 36604
 
Operator: Virgin Australia Airlines PTY LTD
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Altitude: Surface
 
Departure point: Hobart Tas.
Aircraft 2 details
Aircraft 2 detailsAircraft manufacturer: The Boeing Company
 
Aircraft model: 737-8FE
 
Aircraft registration: VH-YFT
 
Serial number: 41028
 
Operator: Virgin Australia Airlines PTY LTD
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Minor
 
Altitude:Surface 
Departure point: Hobart Tas.
Destination: Sydney NSW
 
 
 


Last update 08 December 2016

MTF...P2

[Gobbledock]

And so the ATsB should investigate the wing strike. Although Virgin used its typical watered down weasel words and said there was no safety risk to passengers, that is complete bullshit. It turned out to be minor damage, but it could have been a very different outcome. Fires have started from such contact in the past with other airlines.

[Peetwo]

And so the ATsB should investigate the wing strike. Although Virgin used its typical watered down weasel words and said there was no safety risk to passengers, that is complete bullshit. It turned out to be minor damage, but it could have been a very different outcome. Fires have started from such contact in the past with other airlines.

Excellent point you make Gobbles, these taxiing rash occurrences have the potential for far more calamity and mayhem than you will ever read about in a dodgy half-assed & pc'd ATSB report.

Take for example the following off the ATSB - 'search for IP thread': 

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...

Then reflect on the Ferryman's thoughts off the blog on this incident:

Three strikes.

• Posted by admin
  
• on August 20, 2016
  
• • Accidents and Inquiry, Senate Estimates - Unplugged
  

20Aug

“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.”

The Sandilands article – HERE – begins by describing the ground collision between two aircraft as a super market car park bingle, then, after skipping several essential omissions in the ATSB report, takes a shotgun approach to the wide range of problems ATSB have, hitting the odd one or two, while the flock escapes. Missing an opportunity for a defining snap shot of where the ATSB is utterly failing the nations travellers.

ATSB – “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.”

The ATSB statement above, properly analysed, is terrifying.  It clearly defines the utter ineffectiveness of the agency, at all levels.  It also clearly defines the willing emasculation of the ATSB under Dolan.  I shall try, in my clumsy way, to make this simple for the politicians who need to get off their collective beam ends and make sure that either (a) this report is the tool used to close down the ATSB, disband it and save a fortune; or (b) return the ATSB to its proper role as the primary, independent arbiter of ‘safety’.  ATSB  cannot be allowed to wallow along as an ineffective, toothless, captive waste of time and money.  Australia is now so far away from true ICAO compliance that, if we were honest, a token ‘investigator’ parked in an office at the rear of the CASA building would suffice and be on a par with the other ‘token’ ICAO compliance requirements we need to be ‘seen’ to meet.

A good question; but not the first from ‘Dan Dair’ – “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.”

Anyone who has suffered through a crowded shopping centre car park will understand what a busy air-side parking area – Ramp – is like when it is busy.  Arriving and departing a ramp (or gate) is probably one of the most dangerous parts of the entire journey.  Think on – a vehicle, about half the size of a football pitch, without rear view mirrors needs to be reversed about 100 meters into traffic.  The typical 737 is 12+/- meters high, wing span in the 30 meter range and some 35 meters long and weighs in somewhere between 65,000 and 85,000 kg.  I’ll leave the Kinetic energy calculation and the calorific potential in the fuel tanks to you; but it’s a big number.

To get this aircraft ‘pushed-back’ onto a live taxi way requires the coordinated effort of every safety agency we have and the company ‘system’.  It is a massive effort; laws need to be in place through parliament; CASA must turn that law into a rule set which define responsibility, procedure and method. The company must transmogrify that rule into practical, workable solutions, develop a system which ensures legal and operational safety; train staff within that system and maintain the machinery which completes the act.  Flight crew need to be trained to comply with their end of the story and provide the essential link between traffic control and ground crew.  The ATCO managing the ‘ground control’ station has to coordinate traffic all over the aerodrome; from newly landed off the runway, those moving to designated parking areas and those pushing back to begin a journey.  Why is the fool rambling on about this? – well, consider the amount of links in that chain; the potential for an incident is huge.

The point I am labouring to make that somewhere, somehow a link in that safety chain failed and an incident occurred. But which link and why?  It is for this answer we must depend on an impartial ATSB.

Were the company procedures robust, did they comply?
Was the ATC sufficiently trained?
Did the CASA approval of the procedure comply with safety rules?
Did the tug driver make an error.
Were the sight lines obstructed?
Was fatigue an issue?
Was lighting a problem?
Were the push back lines clearly defined?
Who is to make the adjustments to procedure to prevent a reoccurrence?
Who is to approve those adjustments?
What new procedures have been initiated?

I could, if pushed, develop a page of questions which should have been answered.  I would bet a beer or even two, that the companies involved Safety Management Systems (SMS) asked and provided answers to those questions, and more.  I have no doubt of that; but I cannot prove it as fact.  The findings of the ‘internal’ investigations will, quite rightly, remain private.

The ATSB public findings will not assist in the prevention of a reoccurrence; why?  Well there ain’t any; well, not any that are worth a good god damn.

I have no quarrel with SMS.  What I object to is that there may have been a slackening of requirements which allow a company to legitimately reduce (for example) say the number of personnel required to effect a simple push-back; which increases the risk of a repeat.  We don’t know and no one else is telling the tale,
Perhaps it’s just my curiosity curse, I like to know what happened and what was done to prevent it happening again.  For this I rely on the ATSB; if the ATSB cannot provide those answers; then what is the purpose of them?

Long ramble over, but it seems to me there was a little more to consider than a simple ‘beg-your-pardon’ in a carpark.

“Just be careful crossing the road kids” – last words ever heard by young Jimmy as he chased the bouncing ball.

Toot – knitting? – toot.  Apologies to 737 type specialists.

 
Hmm..do I get some sort of a premonition of a common link here (read causal chain... ), nah couldn't be - or could it??

MTF...P2