[Peetwo]

HVH record on prelims, interims & Final Reports -  

Credit where credit is due and it would appear that since HVH has been in charge that prelim reports have been delivered mostly on time and within the prescribed Annex 13 SARPs.

E.g. AO-2017-118 (see AD thread post #264) 

Ongoing investigation

The ATSB investigation is continuing and will include consideration of the following:

• engine, propeller and aircraft component examinations
  
• flight and engine control positions
  
• aircraft maintenance history
  
• obtaining and evaluating witness information
  
• pilot qualifications, experience and medical information
  
• impact sequence
  
• survivability
  
• aircraft performance and handling characteristics
  
• aircraft weight and balance
  
• operator policies and procedures
  
• stall warning systems
  
• nature of seaplane operations
  
• environmental influences
  
• sources of recorded information
  
• similar occurrences in Australia and internationally.
  

While the extensive media coverage etc. died down I noted that the anniversary for another high profile ATSB AAI - AO-2017-013 - came and went without so much as a squeak; a whistle; or even an interim statement coming out of the HVH PR machine. However towards the end of 2017 there was a typical 'no fanfare' update that would seem to indicate that a final report may still be a long way off : 

Updated: 22 December 2017

The investigation into the collision with water involving a Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 is continuing. The investigation has completed the information-gathering phase and the team is engaged in detailed analysis of material. This involves a substantial amount of review, as well as consultation with external parties.

On completion of the draft report and internal review, the report will be sent to directly involved parties for comment before the report is finalised and published.

Should any safety issues be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

So HVH is not big on keeping with the Annex 13 'interim statement' protocol.

Therefore there is no guarantee that we will receive any public statements as we approach a couple more high profile accident investigation anniversaries:

In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014 - https://www.atsb.gov.au/publications/inv...-2014-032/

---

Collision with terrain involving B200 King Air VH-ZCR at Essendon Airport, Victoria on 21 February 2017 - https://www.atsb.gov.au/publications/inv...-2017-024/

As the VARA (now Virgin) ATR accident investigation is approaching the 4th anniversary, I was trolling the internet records for previous years and came across the following article headline from the 'late & great' aviation blogger Ben Sandilands (may he RIP ) - Nothing can excuse the Albury Virgin ATR safety fiasco, not even this recycled piece of ATSB fluff.

This at first made me smile but then I reflected on the post and the first comment from P9 and I began to despair on how serious matters of aviation safety appear to be stuck in a deeply troubling timewarp:

PT - ..The then minister, Warren Truss, was presumably told nothing by his department because he said nothing, and being an upright champion of aviation safety  transparency, undoubtedly would have been concerned by its contents.

Now we have a new minister, Darren Chester, and it is too early to determine whether he does what his department tells him to do, or even asks whether it tells him what he really should be told... P2 - Well at least that Q/ has been comprehensively answered...  

And from Sam (aka P9)... :

Sam Jackson
April 13, 2016 at 7:03 pm

Mountains to Molehills – ATSB style.

When this ‘incident’ first came to light there were serious questions raised, to which ATSB has not deigned to investigate or answer. The aftermath – 13 passenger flights – are not the aberration, but a resultant of the first in a series of events which remain firmly ignored, unmentioned and; not, as yet addressed.

In short; the root cause of the initial ‘problem’ remains unresolved. The ATR has a facility which allows the two normally interconnected flight control systems (yokes) to be disconnected and operate independently. This in case a manual flight control channel is lost. With a significant amount of opposite direction pressure from the other yoke, (e.g. one pulls up, ‘tuther pushes down) the two flight control systems may be separated. This event occurred during a ‘routine’ descent to approach at Sydney, with no noted flight control problem. The potential for stress and damage caused by opposing control inputs, from two viable systems should have engineering alarm bells ringing, demanding serious, in depth inspection. It did not. The controls were simply reconnected, a cursory inspection conducted and the aircraft returned to service; for the remaining 13 flights.

In other accident events ATSB have played the accompaniment to the CASA preconceived notion, Canley Vale and Pel-Air for example. Where ATSB report supported a stern, rapid prosecution of pilots and operators, through to Coroners court, where required. There are some very serious incidents still on the books at the moment related to turbo-prop powered aircraft – Moranbah and the Newcastle coal loader incident for example; there are some serious, outstanding heavy jet transport incidents, such as Perth and Mildura which are still patiently awaiting their ATSB final report.

If we are serious about ‘safety’ the minister, the government and travelling public need to get over the bi-partisan system of relying on ATSB and CASA to ‘sort it’ and start demanding changes to the way our ‘aviation watchdogs’ set about doing their expensive business. But, enough said it. All been said before, and precious little changes. But gods help the government in power when the unthinkable happens and a Royal Commission is demanded. The time is now, to get our aviation safety house in order, before we run out of dumb luck. (E&OE, can’t do it properly on the small screen).

Hmm...see what I mean -

Which brings me to the 1st anniversary of the tragic YMEN B200 DFO prang...

According to the webpage there was a recorded update/revisit on the 12th December 2017 but there is no accompanying update statement. This would suggest that the FR is still a long way (years) from completion. The question now is whether the good Senators will accept a now normalised ATSB delay on this particular AAI. Especially considering the fact that we are fast approaching the Senate Inquiry due date for reporting on the proposed 'Airports Amendment Bill 2016' : Interim Report

---

Recent aviation incidents

1.12      On 21 February, soon after the initiation of this inquiry, a Beechcraft B200 Super King Air VH-ZCR crashed at Essendon Airport. The aircraft impacted the DFO shopping centre alongside the airport resulting in a major fire. An Australian pilot and four American tourists on board died in the crash. 

1.13      These tragic events brought into stark relief the importance of appropriate airport planning regulation and processes. 

1.14      Evidence received by the committee at Additional Estimates on 27 February detailed the accident investigations currently underway by the Australian Transport Safety Bureau. In addition, the Department of Infrastructure and Regional Development (the Department) noted that it was examining 'development approval processes involved in the land‑use planning at the airport'.[11] Departmental Secretary, Mr Mike Mrdak informed the committee that the Department had provided advice to the Minister on the accident investigation process as well as the development approval process for buildings allocated at the DFO site.[12]

1.15      The committee was also advised that the National Airports Safeguarding Advisory Group (NASAG) was considering the adoption of draft national guidelines, regarding runway public safety zones around airports, and runway end safety zones. Queensland is currently the only Australian jurisdiction to have public safety zone legislation.[13]

1.16      On 2 March, correspondence was received from Minister Chester requesting that the committee consider extending its inquiry in light of the tragic accident and subsequent investigations underway (at Appendix 1).

1.17      The committee recognises that the findings and recommendations of the investigations into this tragedy, and the work of NASAG, may have implications for the bill. It takes the view that sufficient time should be provided to allow the investigations to proceed and for the committee to then properly consider their findings.

1.18      Therefore, the committee recommends that its inquiry on the bill be extended to allow consideration of the investigations and any other relevant aviation regulation developments.

1.19      Submissions already received and published by the committee (at Appendix 2) will be considered as part of the inquiry following the outcome of the investigations.

Recommendation 1

1.20      The committee recommends that the Senate grant an extension of time for the committee to report to the first sitting day of March 2018.


Senator Barry O'Sullivan

Chair

---

 TICK..TOCK HVH & BJ - you now own this...


MTF...P2


Ps Looks like it is not just the good Senators that have an interest in the outcome of ATSB investigation AO-2017-024: BJ's airport conundrums: All woes lead to CASA

[Kharon]

A national sport – no less.

‘Throwing sports’ have been around since the cave; but, ASA and it’s highly remunerated sportsmen have reclaimed the game

“On 21 June 1982, Julian Critchley of The Times (London) wrote "President Galtieri had pushed her under the bus which the gossips had said was the only means of her removal.”

Which is scandalous, as the origins of the ‘sport’ were not mentioned. Yes, the game began here. Along with ‘dwarf tossing’.  Australian trough dwellers have devolved the sport to a ‘political’ standard response. The ‘dwarf’ may well be of normal physical stature; which is quite politically correct. The latest craze in Canberra is to ‘throw’ a mental midget – to win the beers. Or; so it was until the ‘bus’ wrinkle was introduced. Now, not only are mental bantamweights lobbed - for laughs; there are extra points to be garnered for getting one ‘under a bus’.  

Physically Halfwit is no light weight – but; with a head so full of hot air (i.e. brain fart gas) there will be a scramble to ensure which of the ‘tossers’ will get to pitch him under the # 9 bus from capitol hill to the local cat house.

I do hope they televise it.

Wall street – eat your heart out; all the greatest scams and the ‘best’ games of all are (dontcha know)  Australian mate (or, perhaps made?) Who knows.

Toot - toot.............

[Peetwo]

HVH's magic O&O minions -

In the course of backing up another one of Mr Peabody's enlightening posts - see Airports thread post: Safety Case????? - I just so happened to bear witness to the magical skills of Hoody's O&O fairies...

Let me explain: -

To begin I was pleasantly surprised that Hitch managed to trump me on the discovery of the 'investigation within an investigation' - choccy frog to Hitch...

As is now SOP for the ATSB there was no media release/announcement, nor was the investigation reference AI-2018-010 immediately transparent when referencing the Aviation investigation webpage: Reference pg 4 - HERE.

When I first clicked on the AI-2018-010 link I noted that this investigation (within an investigation) had been initiated/updated 11 days before on the 08 February 2018. It was also stated that the expected completion date was August 2018:
 

General details
Date: 21 February 2017
Investigation status: Active
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
Investigation type: Safety Issue Investigation
State: Victoria
Report status: Pending

Expected completion: August 2018 
 


Last update 08 February 2018

Some scant 5 minutes after completing my airport thread post I revisited the investigation webpage link and that was when I discovered that the O&O fairies had done their magic...

Here is what the webpage now reads:

---

Summary

On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.

The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.
 
General details

Date: 21 February 2017
 
Investigation status: Active
 
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
 
Investigation type: Safety Issue Investigation
 
State: Victoria
 
Report status: Pending
 
Expected completion: February 2019 
 


Last update 19 February 2018

---

So in the space of 11 days this 'investigation within an investigation' has had it's expected completion date put back by a further 6 months - UDB!  

Considering this is the 3rd active high profile investigation (which I am aware of ) that the HVH crew have initiated within the last 12 months - see search 4 IP post #203 & 4 above: ATSB update on Mallard investigation (which again was captured by Hitch ) - one has to wonder is this the new top-cover obfuscation tactic being deployed by Hoody and his O&O minions?? 


MTF...P2

[Peetwo]

HVH reckons ATSB will be more transparent -

From the ATSB spokesperson HVH: 

ATSB provides increased visibility into investigations
The ATSB is providing further insight into its investigation processes with the release of real-time investigation status information for all of its active investigations.


In addition to releasing the status of an investigation on its dedicated investigation web pages, the ATSB has also made available detailed information about its investigation phases and methodology.

ATSB Chief Commissioner Greg Hood said the changes were designed to provide a greater level of transparency into the work of the national transport safety investigator.

'The ATSB is a world class transport safety investigator and all of our investigations are undertaken in a meticulous and thorough manner, in accordance with both national and international legislation and standards. While our legislative obligations prohibit the release of restricted information during an active investigation, we strive to provide as much transparency as possible during an investigation.'

Mr Hood noted that the ATSB has traditionally provided more insight into its investigations than many international counterparts, particularly regarding the provision of estimated timeframes for each investigation.

'The dynamic and multifaceted nature of investigations can affect timeframes, which are always provided as an estimation.

'We understand that the length of time it takes to conduct a thorough investigation can sometimes generate frustration and uncertainty for directly involved parties such as next-of-kin, and for the interested general public.

'Australia actually performs very well against international investigation timeframes, particularly with  aviation investigations where our overall completion timeframes were assessed by the International Civil Aviation Organization as being around half of the global average.'[/url]

Mr Hood said investigation timeframes are impacted by two primary factors—available resourcing and the unpredictable and often complicated nature of serious incidents and accidents.

'It is important to note that, even if the timeframe of an investigation is extended, if the ATSB discovers a critical safety issue during an investigation we immediately bring it to the attention of relevant parties to be addressed.'

To better reflect the dynamic and multifaceted nature of investigations, the ATSB has now amended its web pages to reflect an expected completion date as a quarter, rather than a month.

Those who would like to be kept informed of ATSB releases can subscribe via [url=https://www.atsb.gov.au/subscriptions/]the ATSB website.
 



Last update 28 February 2018 

Note that this revelation was revealed 2 days after HVH got very sensitive and defensive at Senate Estimates when questioned about one of the world's longest aviation accident investigations where initially all the occupants survived and the aircraft and black-boxes were eventually recovered...

Mr Hood : I wouldn't mind making a few overarching statements about the report, if I can, and then I might hand over to Mr Hornby, who has a much greater and more detailed knowledge of the report.

Senator PATRICK: Sure.

Mr Hood : The report was released on 23 November 2017. It's the largest and most thorough report ever undertaken by the ATSB—in excess of 500 pages. We're very cognisant of the fact of the history. Obviously, the first time round, it led to a Senate inquiry, which led to David Forsyth's regulatory and safety review of ATSB and CASA and to a review of the ATSB's methodologies by the Transport Safety Board of Canada. It reopened investigation of where we went back to Norfolk Island and recovered the cockpit voice recorder and flight data recorder, at the cost of some $500,000 to $600,000. And then, of course, the reopened report includes an additional 30 interviews et cetera the second time round.

Like all of the investigations, the findings in the report are not meant to apportion blame or liability to anybody or any particular organisation or individual. The captain's individual actions with respect to flight planning and fuel management are included in the report as some of the contributing factors. The actions of the captain and other parties are explained in an organisational context, examining the risk controls of the operator and the regulatory framework. So we went to great pains to have a look at the whole chain of events, from regulatory oversight to the ownership of the company and the processes and procedures in the company and then, of course, to the individual factors. So we think it's a thorough report.

In terms of the detail, I don't think anybody at this table or at the back has been involved in the investigation team. The investigator in charge is based in Brisbane. I'll refer to Mr Hornby for specifics on any of your questions....

...Senator PATRICK: We're looking at a number of incidents now that are dealing with weather related concerns. Surely that's something you might turn your mind to in the context of that.

Mr Hood : In the Pel-Air accident report we devoted two full appendixes—H and J—to remote island weather and to Norfolk Island weather. I think out of the 500-odd-page report about 10 per cent, about 50 pages, are devoted specifically to weather. We certainly did have a pretty good look in the report at the weather factors. The other point you make is about general Australian weather. We do have a pretty good look at what we're seeing in Australia in relation to weather events. In most years we have around 12 to 15 reports of unforecast weather where aircraft have been faced with decision-making in relation to diversion because of unforecast weather. That reduced in 2017. We had eight of those. So we are actually looking very carefully. We don't think there's a systemic issue in Australia in relation to weather events currently, but it is certainly under watch.

 
Seems as if Commissioner Manning has thrown on his invisibility cloak once again...

For the record the following is an appraisal of the PelAir MKII final report from a bona fide expert whose specialty lies in Human factors:

---

Systemic Observations – Pel Air Report

There are many observations, which contribute to a less than adequate first and second Pel Air investigation report.

Bottom Line Up Front: If you don’t collect the right data and information in a timely manner as part of the preliminary investigation process then you have significant barriers in ever being able to produce a quality report aligned with the standards expected of an aviation investigatory organisation.

Furthermore, if you are aware of many shortcomings in the investigation process then you need to ensure other factors such as the influence of organisational culture have also been carefully considered prior to making recommendations specific to the active failures of the aircraft captain. In many respects, shortfalls are identified within the investigation report, yet the report continues to use incomplete ‘systemic’ evidence to make final decisions specific to the aircraft captain. Most of these issues are also identified in the Transport Canada (TC) Independent Review. Observations, including TC and final report extracts as follows:

• [b]Quality of the investigation process:[/b]
  • [i]The analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight were not effective because insufficient data was collected.[/i]
    
  • Poor data collection hampered the analysis of specific safety issues, particularly fuel management, company and regulatory oversight, and fatigue. A comprehensive sleep-wake history going back at least 72 hours and to the last two adequate periods of restorative sleep was not immediately obtained. [It should be noted in June 2008, the ATSB sent human performance representatives to attend a CASA run NTSB Fatigue Factors training course as well as an exchange of fatigue related investigation lessons. This included copies of the NTSB fatigue investigation checklist and provided an overview of effective fatigue investigation techniques and NTSB case studies.]
    
  • [i]Weakness in the application of the ATSB analysis framework. Analysis tools were not effectively used.[/i]
    
  • [i]Ineffective ATSB oversight of the investigation.[/i]
    
  • Inadequate data collection e.g. an informal survey of ATPL candidates regarding their understanding of decision making with forecast weather below alternate minima is not strictly valid i.e. what you learn at school can be significantly different to what actually occurs in practice based on company culture and norms. The sample of the survey was small (not valid) and did not include Pel Air pilots other than the occurrence crew. Yet, there was evidence suggesting the company practices (culture) involved a number of fuel planning deficiencies, including a lack of formal consideration to emergency scenarios (depressurization, single engine operations), which were specific normal practices for the majority of aircrew. The survey of operators, while not helpful in determining how widespread the practices observed in the occurrence were within Pel Air (clear limitations due to a lack of interviews with other Pel Air pilots).
    
  • The IIC concluded that pilots did not use a consistent approach to gathering weather information and making decisions in these circumstances (a systemic problem).
    
  • [i]Inadequate consideration to the CASA special audit report.[/i]
    
  • [i]Critical reviews were conducted periodically but did not identify specific shortcomings in the data collection or analysis.[/i]
    

 

• [b]Communication-misunderstandings:[/b]
  • The responsibilities of CASA and the ATSB were never resolved, even though the ATSB had become a separate statutory agency in July 2009. As a result the ATSB did not collect sufficient information from Pel Air.
    
  • The IIC understood that the investigation should not cover the same areas as CASA, which persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots at Pel Air. [A clear lack of evidence with considering the culture of Pel Air, which must be considered prior to casting punitive action towards the aircraft Captain – see next section].
    
  • In May 2010 a critical investigation review was held and an analysis coach was appointed. The IIC felt that the coach’s focus on the performance of the flight crew (cognitive bias) prevented the coach from seeing the systemic issues that the IIC considered important. The coach felt that insufficient data had been collected to identify systemic issues. Coaching broke down and the data quality issues were not resolved.
    
  • November 2010, a peer review identified concerns with the factual information presented, the safety factors analysis, the findings and the readability of the report. The team leader assigned a second peer review, which was not known by the IIC.
    
  • May 2011, GM review – a team leader raised concerns to the GM about the adequacy of the data and analysis to support the draft safety issues. The GM directed a third peer review, which identified the organizational issue within CASA’s investigation report were significant and needed to be developed further in the ATSB report.
    
  • July 2012, Commissioner review and concern there was insufficient factual information and analysis, including concern as to why the CASA special audit report had not been relied upon more extensively.
    
  • Inadequate communication between the IIC, the team leader and the GM, including a GM personally editing the report (ongoing pressure due to a backlog of other reports).
    
  • Some pilots noted they were aware of tensions between the chief pilot and the Westwind standards manager…..a Westwind check pilot reported there was a lack of clarity regarding the role standards manager.
     
    
• [b]A potential ongoing bias towards the captain (punitive approach) with inadequate consideration of the evidence (organisational culture, norms, routine versus exceptional violations, justification of the decision-making process of the ATSB investigators (e.g. just culture culpability chart)) to substantiate the actions of the accident captain:[/b]
  • While the investigation report and the TC independent review highlight many systemic issues, there is inadequate evidence to continue to provide such a direct focus on the aircraft captain. In many sections of the report there are inconsistencies with making an evidence based approach to the analysis.
    
  • For example, the report states ‘contrary to the consistent practice of the operator’s Westwind fleet for such flights, the flight departed with full main tanks rather than full main tanks and tip tanks. Yet the report highlights the accident captain in the past has regularly taken a more conservative approach i.e. carried more fuel. So the critical question – what was happening on this particular day, what were the observed behaviours and what could be eroding the normally conservative decision making of the captain? The obvious consideration from a human factors perspective is fatigue. Furthermore, the culture of Pel Air also remains a key area that warrants investigation but with such a limited number of interviews with other Pel Air pilots the ATSB does not have adequate evidence to draw further conclusions.
    
  • Many organisational issues are identified (inadequate risk controls from the operator including fatigue risk management, crew resource management and flight crew training; limitations with Australian regulatory requirements; a critical breakdown of communication between Air Traffic Services and the flight crew). Hence, there is inadequate evidence and visibility of the process utilised to continue attribute direct blame to the actions of the aircraft captain.
    
  • P9, there were no regulatory or operator specific requirements to carry sufficient fuel for a divert or hold for an extended period…However there was a requirement to carry sufficient fuel to allow for aircraft systems failures…The report due to the inadequacy of the investigation process, namely further interviews with Pel Air personnel, did not gather adequate evidence to determine whether this was a routine (normalised) practice from a whole of company perspective. If yes, within a just culpability framework this could be described as a routine violation that warrants a recommendation for the organisation, not the accident captain.
    
  • Further evidence of lax company processes, in this case crew resource management are identified in the report…the first officer did not participate in the flight planning or fuel planning, nor did the operator’s procedures require her to participate. Again, examples of less than adequate professional practices linked to the culture of the organisation, which is heavily influenced by senior leaders e.g. the fleet standards manager. Further evidence of internal issues with organisational culture that have not been discussed.
    
  • The operators OM did not provide any guidance to flight crew for flight or fuel planning in non RVSM equipped aircraft in RVSM airspace.
    
  • The OM did not provide any figures to use for speed or fuel flow from the CP for the remainder of the flight for a loss of pressurisation. Some Westwind pilots reported they did CP calculations…other pilots reported they did not. [organisational culture – behavioural; norms] – most carried additional discretionary fuel. It is not reasonable to consider an adhoc practice of carrying extra fuel as adequate in this accident to apportion blame to the pilot for the decision made this time.
    
  • The OM contained no specific fuel planning requirements for flights to remote islands.
    
  • There was no formal guidance in the OM about what to do if a pilot was having difficulties obtaining the required weather or briefing material.
    
  • All the above having been identified even though the Westwind standards manager had been exposed to a divert to Auckland due to adverse weather – more signs of a lack of corporate learning through enhanced OM policy and guidance. It was also known that a requirement to depart within two hours could make it difficult to do the fuel and flight planning, prepare the aircraft, and complete the relevant paperwork. This has the potential to create a culture where such attention to detail is routinely bypassed and considered acceptable behaviour to get the job done.
    
  • Some pilots reported that occasionally they had perceived subtle or implied pressure from the air ambulance provider or the operator to conduct a flight when they were not comfortable doing so (organisational pressure).
    
  • Accepting the guidance that most pilots carried extra fuel negates a necessary requirement for professional planning and the calculation of emergency CP’s, yet the investigation elects to focus on the method used by the accident captain. The report should stay focused on what is required and center their findings around those fuel figures. For example, if depressurised CP’s are necessary then this should be the focus, including investigation as to the root causes as to why aircrew were not routinely performing this activity (cultural norms).
    
  • There is a mixed response regarding the practices of the accident captain…The first officer of the accident flight said that, in her experience, the captain of the accident flight normally conducted thorough flight planning. She recalled a previous flight they had undertaken together to a remote aerodrome neither of them had been to before, and the captain made significant preparations prior to the flight. Some other pilots who flew with the captain reported they did not notice any significant differences between the captain of the accident flight and other captains in terms of their flight planning. However, some pilots stated the captain appeared to conduct flight planning tasks in a less thorough manner than some of the other captains employed by the operator. [Given the previously identified limitations of the first report i.e. a lack of interviews with Pel Air pilots, this information contradicts itself and is not adequate evidence to apportion as much attention to the inactions of the accident captain.]
    
  • There is an excessive focus on the data regarding fuel loading (p158) and flight times, which is too focused on the company norms and not what would be expected of an operator IAW the regulations. This is not evidence based but does have an emphasis to discredit the one of decision of the accident captain for this accident. Yet, the paragraph on p159 finds evidence that the accident captain has a history most of the time to depart with full fuel. Hence, the focus must by what influenced the aircraft captain this time to do something that is not consistent with his previous practices and norms.
    
  • 2009, a Westwind check pilot conducted a proficiency check on the Westwind standards manager – base check, line check and instrument rating renewal in 0.7 hours without a flight to another airport. Evidence of a culture of minimal compliance – in this case non-compliance including waivers. Again, the report must consider leadership, company culture and organisation norms to fully appreciate the behaviour of crews and use appropriate just culture frameworks in making decisions when apportioning blame.
    
  • No formal training for captains to cover the unique requirements of operating to remote aerodromes (again, indicative of lax standards).
     
    
• [b]Organisational and reporting culture:[/b]
  • There was evidence of information not being reported by Pel Air to the ATSB – why was this not reported. Warrants further investigation into the organisational culture and the role/influence of the Westwind standards manager.
    
  • Management and safety personnel stated the reporting culture within the operator had been problematic for many years. Why? What was driving these problems?
    
  • …other pilots stated they had never declined a duty, and some of these pilots stated they would have been reluctant to report they were fatigued.
    
  • …several Westwind pilots stated that at times they had been tired or fatigued….however, most of these events did not result in a fatigue occurrence report.
    
  • Sydney-based pilots stated there were no pilot meetings where they could raise issues of concern.
    
  • ..staff had not been receiving feedback regarding closed investigations.
    
  • The company’s executive management relied upon the Westwind Standards manager to apply company policy and procedures to ensure the standard of operations were conducted to the appropriate regulatory and safety levels. It was evident that this had not taken place to the regulatory or safety standard required.
     
    
• [b]Inadequate oversight:[/b]
  • Communications amongst commissioners indicated there was concern with the lack of analysis of the adequacy of the company and regulatory oversight, especially in light of the CASA special audit report, yet this concern did not result in changes to the report.
    
  • Limitations in CASA oversight and regulations for operations to remote aerodromes.
    
  • Westwind standards manager – most pilots, including the Captain of the accident flight, reported they did not use how-goes-it charts and had not been taught how to use them. There was no standard way to calculate PNRs and other captains could not recall how they did that task. There was no requirement in the OM for PNR’s to be cross-checked.
    
  • CASA audit May 2006, although the audit team (including the fatigue management specialist) intended to interview some pilots, this was not conducted given the advice of the (turboprop) chief pilot that this would not be productive given the current lack of faith that exists with an open and honest reporting system.
     
    
• [b]The importance of culture: The investigation fails to consider the impact of culture on the normal behaviour of PelAir aircrew. For example, extracts from the ICAO safety management systems manual clearly highlight the relevance of culture and organisational performance:[/b]
  • Latent conditions are those that exist in the aviation system well before a damaging outcome is experienced. The consequences of latent conditions may remain dormant for a long time. Initially, these latent conditions are not perceived as harmful, but will become evident once the system’s defences have been breached. These conditions are generally created by people far removed in time and space from the event. Latent conditions in the system may include those created by a lack of safety culture; poor equipment or procedural design; conflicting organizational goals; defective organizational systems or management decisions. The perspective underlying the organizational accident aims to identify and mitigate these latent conditions on a system-wide basis, rather than through localized efforts to minimize active failures by individuals.
    
  • A safety culture encompasses the commonly held perceptions and beliefs of an organization’s members pertaining to the public’s safety and can be a determinant of the behaviour of the members.
    
  • Organizational culture sets the boundaries for accepted executive and operational performance by establishing the norms and limits. Thus, organizational culture provides a cornerstone for managerial and employee decision making.
    
  • Through personnel selection, education, training, on-the-job experience and peer pressure, etc., professionals tend to adopt the value system and develop behaviour patterns consistent with their peers or predecessors.
    
• Furthermore, many aviation investigatory bodies have checklists for their investigators (e.g. NTSB) that provide relevant questions and guidance to ensure cultural issues, including the influence of senior leaders/executive are considered, particularly given their direct influence on individual and team performance (what is considered normal and expected behaviour regardless of the policy and procedures that exist).
  

In general, the final report is too long, contains too much extraneous information not directly related to the contributory factors, and lacks consideration of the impact of the Pel Air leadership and organisational culture and crew behaviour with consideration to norms and actual (rather than documented) corporate practices. Hence, there is limited discussion regarding how decisions were made with respect to routine (it’s what everyone does) versus exceptional violations (the person should know better). It is also the opinion of myself and an independent and former NTSN human performance investigator that fatigue did contribute to the accident (see the next section).


 
Fatigue and fatigue management section
This section has been reviewed by myself and independently by a former NTSB Human Performance Specialist who also served as the Chief of the NTSB Human Performance Division.
 
Some key findings:
 

• While there were clear failings to collect adequate fatigue related information in the early investigation the report fails to adequately consider the changes to the accident captain’s behaviour on the day of the accident. Hence, while there may not be adequate evidence to include, there is also a lack of analysis to not include fatigue as a factor.
  

 

• TC Review: In February 2010, an industry stakeholder contacted the ATSB GM suggesting the possibility fatigue should be considered. This was forwarded to the IIC, who in turn communicated with the human factors investigator. No fatigue analysis was prepared at this time. An analysis of fatigue data was not attempted until late in the investigation. By then, it was too late to address shortcomings in the available data.
   
  
• The ATSB examined alternative roster scenarios using FAID. What scores did they use to accommodate the identified limitations of FAID? Why are the results not discussed, including providing the FAID outputs used as part of the updated ATSB report? Why were other biomathematical models not considered for use (e.g. FAST, SAFE) that are known to have some advantages over FAID, particularly the use of aviation data and research. FAID was built using rail data.
   
  
• A culture of minimum compliance rather than applying the FRMS to achieve practical outcomes:
   
  • The Westwind operations manager had been shown how to use the extension of duty checklist and calculate an IFLS during her training. However, she had never applied it when assigning duties for the Westwind Fleet. Clear reliance on a FAID score of 75, which the ATSB report identifies as representing ‘extreme fatigue’ based on the US railroad report.
    
  • Pel Air pilots reported the FAID scores as being inconsistent with their perceptions of their own fatigue levels. The ATSB cannot underestimate or fail to consider the organisational cultural issues – pilots exposed to a system they don’t trust, that does not match their operational judgements but allowing the processes to become the accepted norm. This is a systemic process that allows inadequate FRMS processes to normalise (normalisation of deviance) with the resultant outcome and erosion of professional practices and standards.
    
  • There were unexplained breaches of the Pel Air policy – the operations manager reported the time off duty should have been 10 hours.
    
  • In march 2008, a CASA audit found the operator had not provided flight crew with annual FRMS training.
    
  • As far as could be determined, the operator never conducted a study or analysis to review the suitability of using a default FAID score of 75 for its operations.
     
    
• The ATSB report notes FAID scores between 70 to 80 can be associated with extreme fatigue. Yet, they use FAID to conduct their own analysis.
  

 

• It is considered that adequate evidence exists to substantiate fatigue as a factor. In particular, recent sleep is very low (the report states 3.5-4 hours, although applied sleep science indicates a poor ability for personnel to sleep during the day, which could put actual sleep as low as a couple of hours); the decision regarding the refuel occurred near the afternoon window of circadian low; total time awake remains high hence fatigue would be increasing during the duration of the flight; and there are clear behavioural signs associated with fatigue. For example, the report suggests in the past the Captain normally fills to full fuel. The investigation team should be asking what factors could be influencing the Captains decision-making on this flight? Some of the behavioural factors IAW the NTSB fatigue factors checklist:
  

 

• • Did the operator overlook or skip tasks or parts of tasks? Yes. For example, the captain subsequently reported that he did not recall hearing the words SPECI or special weather, or that there was overcast cloud at 1,100 ft.
    
  • Was there steering or speed variability? No
    
  • Did the operator focus on one task to the exclusion of more important information? Yes. Furthermore, fatigue and expectation bias (a belief from the previous night’s flight to Norfolk that actual conditions would not be as bad as what was being reported bt the AWS) has not been considered or discussed.
    
  • Was there evidence of delayed responses to stimuli or unresponsiveness? Yes
    
  • Was there evidence of impaired decision-making or an inability to adapt behaviour to accommodate new information? Yes
    

 
With consideration to the ATSB listed adverse influences on human performance:
 

• • Slowed reaction time: No
    
  • Decreased work efficiency? Yes
    
  • Reduced motivational drive? Yes
    
  • Increased variability in work performance? Yes
    
  • More lapses or errors of omission? Yes
    
  • Is something influencing decision making in a negative way? Yes
    
  • Is there a greater acceptance of increased risk? Yes
    
  • Obtaining less than 5 hours sleep in the previous 24 hours is inconsistent with a safe system of work.
    
  • Other research has indicated less than 6 hours sleep in the previous 24 hours can increase risk.
    

 
Lack of fatigue systemic recommendations
 

• The report identifies ongoing issues with the use of biomathematical fatigue models yet makes no recommendations on how to address.
  
• The report fails to consider the planned flight beyond the accident – a systemic review should be considering the fatigue risk profiles had the flight continued from Norfolk to Melbourne. This remains relevant to the limitations and systemic failings of the company FRMS and regulatory oversight. This remains relevant to many operators across the Australian aviation industry.
  

---

And the following is a response from a former NTSB fatigue specialist regarding the above summary report:

Basically I agree with everything you say, especially in fatigue (where I have some claim of expertise).  I think the NTSB could reasonably conclude that fatigue was likely in the case of the captain, given that he only had an estimated 4.5 to 5 hours sleep maximum (where as little as 2 hours less sleep than normal can be associated with impairment), where the quality of sleep would likely have been limited based on the available time of day, and where critical trip planning occurred during a circadian low in the afternoon 1500-1700 period. Further, NTSB would conclude that fatigue likely affected the accident as shown in factors such as the captain's uncharacteristic failure to load extra fuel and failure to review options as they approached the point of no return.  I think that fatigue or likely fatigue on the part of the captain should be cited as part of the probable cause.  Certainly, it raises questions about the company FRMS program and corporate culture.


I was also struck by a footnote that the captain, in his initial interview with the ATSB, claimed misleadingly that he slept well (and only changed his story later).  Similarly, the first officer claimed that the fact she took a controlled rest on the flight (and yawned on the CVR) is simply part of operational procedure and does not indicate she was tired.  My understanding is that she would have been unable to sleep if she was actually well rested.  Finally, I find it disturbing that ATSB reports that the company was unable to explain why scheduled crew rest was less than 10 hours but the ATSB says nothing further about this shortcoming.  This type of avoiding fatigue issues is more unusual in the US, where our regulation of duty time is less stringent.  We respect Australia as a leader in FRMS, and it seems unfortunate to think that careful regulation might also bring about a tendency to ignore or misrepresent discussion of fatigue in practical investigation.

MTF...P2

Ps From Hansard:

---

Senator PATRICK: Will you be presenting this particular report at the International Society of Air Safety Investigators conference this year?

Mr Hood : Not to my understanding.

Senator PATRICK: Normally you present significant reports to that conference. My understanding is the ATSB turns up and often makes presentations there.

Mr Hood : I'm looking at my budget currently in terms of whether we can send someone to the ISASI conference. But from time to time the ATSB presents detailed reports. It is not to my knowledge that we're preparing to present this one.

---

So despite Hoody's statement...

"..It's the largest and most thorough report ever undertaken by the ATSB.."

...it doesn't appear that he wants to put it on display to the world as an example of excellence in aviation accident investigation reporting...

[Peetwo]

O&O investigation No: AO-2015-066

This one was published yesterday exactly 2 years, 9 months and 5 days after this serious incident occurred...

---

 
What happened

On 12 June 2015, the crew of a Boeing B737-300, registered VH-NLK, were conducting a non-directional beacon/distance measuring equipment (NDB/DME) approach into Kosrae Airport in the Federated States of Micronesia. The flight was the inaugural regular public transport (RPT) flight for Nauru Airlines into Kosrae. During the approach, at night and in instrument meteorological conditions, the aircraft descended below the minimum descent altitude and three enhanced ground proximity warning system (EGPWS) ‘too low terrain’ alerts were triggered. A go-around was performed prior to the aircraft reaching the missed approach point. During the go-around, the airspeed decayed and required the pilot to use full thrust. The flight crew identified and corrected the barometric pressure setting and the subsequent approach and landing into Kosrae were uneventful.

What the ATSB found

The flight crew did not complete the approach checklist before commencing the non-precision NDB approach into Kosrae, resulting in the barometric pressure setting on the altimeters not being set to the local barometric pressure. This resulted in the aircraft’s altitude being lower than what the pressure altimeter was indicating to the pilots. The aircraft descended below the EGPWS terrain clearance floor profile for the Kosrae runway, resulting in three separate EGPWS alerts.

Terrain clearance assurance was eroded further after receiving the first two EGPWS alerts by the flight crew not correcting the flight profile. The crew's belief that the EGPWS alerts were due to a decreased navigational performance and not terrain proximity led to the crew’s decision to inhibit the first EGPWS alert and not correct the flight path.

The flight crew initiated a missed approach when they lost visual contact with the runway. The captain was experiencing fatigue and the flight crew had an increased workload and stress due to the inaugural RPT flight into Kosrae at night in rapidly deteriorating weather. As a result, the crew’s decision making and task execution on the missed approach were affected, and the aircraft state, airspeed and attitude were not effectively monitored by either crew member.

The ATSB also found that there were established risk factors associated with Kosrae at the time the operator commenced regular public transport operations into Kosrae. The only instrument approach available for use was an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead of a stable approach path, and that it required low level circling manoeuvring from the instrument approach to align the aircraft with the runway. Furthermore, there was very high terrain in close proximity to the runway and the airport did not have a manned air traffic control tower.

What's been done as a result

Following this occurrence, the operator has reviewed and changed procedures relating to:
•increased time for flight crew on non-standard/non-routine activities during their cyclic training program
•reviewed and included control column checklists, which includes the descent and approach checklist, with tactile indicators
•included two-engine go-arounds in simulator sessions
•reviewed and improved awareness of QNH setting procedures and human factors aspects of briefings and line checks.

Safety message

This occurrence highlights the importance of flight crews declaring any instances of acute fatigue and stress-inducing circumstances that may have an impact on their flying performance. Operators also need to remind flight crew of the importance of their decisions with regards to their fitness to fly. For flight crews, the importance of completing approach checklists and monitoring the approach at safety critical times is emphasised. For operators, the occurrence highlights the importance of incorporating dual-engine go-arounds into simulator training sessions.

---

This occurrence was considered significant enough that HVH's minions were prompted to write up - not a safety recommendation - but a 'safety issue' notice:

---

Safety issue description

The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead of a stable approach path, and that it required low level circling manoeuvring from the instrument approach to align the aircraft with the runway. Furthermore, there was very high terrain in close proximity to the runway and the airport did not have a manned air traffic control tower. For this occurrence, the risk was further elevated as a result of the approach being conducted at night-time in poor weather conditions.

Proactive Action

Action organisation: Nauru Airlines

Action number: AO-2015-066-NSA-005

Date: 16 March 2018

Action status: Closed


GPS navigation equipment has been fitted to all aircraft, flight crews have been trained in the use of GPS type instrument approaches and regulatory authorisation to conduct these types of approaches has been obtained.

Flight crews have also been instructed to use runway aligned approaches. 

Current issue status: Adequately addressed

Status justification: The fitment of GPS navigation equipment and the training of flight crew in its use, as well as obtaining regulatory authorisation for the use of GPS based instrument approach procedures, has enabled the operator to conduct runway aligned stabilised approaches into Kosrae.
 
 


Last update 16 March 2018  

---

Err WTD?  - I would have thought the greater 'safety issue' was the fact the crew missed resetting the altimeters to actual local QNH - Just saying...


MTF...P2

[Kharon]

A Totally Substandard Beat-up.  

P2 - Err WTD?  - I would have thought the greater 'safety issue' was the fact the crew missed resetting the altimeters to actual local QNH - Just saying.

Aye, ‘tis a big no-no – however I think this is a ‘classic’ Reason model case and probably a good report to have in the library to demonstrate just how very easy it is, even for experienced crew to fall into a ‘trap’.

My ‘Jepp’ chart series for Kosrae is well out of date, but it will serve for now. One of the first things you note is no ATIS, the next is the rather oblique statement – “ Trans level by ATC” followed by (Trans Alt : by ATC). This may have changed since my chart was published; but ATSB make no mention of the stated ‘transition altitude’ in effect at the time. This is an important ‘trigger’ prompting an almost instant reflex action - write the setting on the TOLD card – set the local barometric reading on the Altimeter and cross check. It’s a curiosity only, but say the crew habitually used F 130 as ‘transition’ from flight levels to barometric altitude, but were obliged to remain on the 1013 datum to almost the beginning of the approach – (traffic separation?) you still must wonder why the approach checks were not complete by then – even if there was a low transition. Has human factors and fatigue played a big role in this little drama?  ATSB make no mention of the duty period or the flight schedule so it’s hard to quantify how much that element of the causal chain is attached to the incident. The ultimate message is clear enough but the bare facts, as presented, fail to provide insight as to why a routine, deeply ingrained almost habitual action was not completed by an experienced crew.

The next item is the approach itself. ATSB cite it as being a ‘dive and drive’ event; this is grossly misleading. The profile chart is drawn using ‘step’ down; but its not flown in the manner depicted – ATSB should know this. D&D was outlawed by serious operators years ago, with bloody good reason. The D&D method is not only potentially lethal, but inefficient and ‘unstable’. ATSB hint that the crew hung about at 1500 feet then ‘dive’ to the next limiting height and ‘drive’ up to the next descent point – Bollocks. Do that in any ‘performance’ aircraft – let alone a swept wing jet and you are looking for trouble. I digress.

On my old chart the NDB approach is ‘tight’ – the approach path points directly at an 800 foot high chunk of terra firma; and, leaves you at 2.9 miles to conduct a visual circling approach; except there is no circling permitted South of runway 05 or 23. A 76 ton aircraft at 130 knots inside of three miles, in the dark, pissing rain with nothing but rising terrain ahead – off a ‘D&D’ style of approach – Nah; don’t think so. Lets’ take a look at my old chart again. At 10 miles almost due West of the hills (797’ terrain @ 7200 [6080’ = ONE nautical mile = 30 seconds at 120 knots] feet ESE of the airport) the NDB approach begins at 1500’ AMSL; that leaves 5 miles to run to the IAF at 900’ – at 140 knots a rate of descent :: to 700 fpm is stable and easily do-able. This fetch’s the aircraft to five miles and enough room to break left or right and join the circuit. So to a visual night circuit, in the rain, think about it for a moment. To land 05 the crew loose sight of the runway – (break right) - left turn to pick up a three mile final – acceptable. To make final leg on the 23 direction is almost unacceptable; a long left turn, followed by a right to base followed by another right hander to final – the runway out of sight until base leg to the FO and out of sight to the Capt. until late base/ final. Not a 'visual approach' at all.- Not too bad in good conditions – but tricky in bad. 

Ah well; at least the GPS approach system and equipment is available to use now. A straight in runway approach to 5/600 feet is right and proper for heavy jet transport in this day and age. Most sensible. What is not acceptable is the ATSB dumbing down and presenting, in bad English, a valuable safety lesson.

ATSB – “This resulted in the aircraft’s altitude being lower than what the pressure altimeter was indicating to the pilots.” – Seriously, who writes and edits this crap?

Right – back to my knitting.

Toot – toot.

[thorn bird]

K, agree with you entirely, but I cant help thinking our system in OZ may set things up somewhat.
 
I remember an incident in Europe some years ago with an Airline I was involved with, where a crew got distracted with workload and ended up on an ILS approach with standard set. All over Europe, transition altitude varies, from 3000Ft in Uk to the ground in Russia.Sop's varied around the place from using QNH to god forbid QFE. Think of SOP, normally approach checks would be completed around 30 miles out, a key gate of around ten thousand feet, or around ten minutes to the FAP. trouble is some transitions at 3000 ft gets a bit cramped for an altimeter set and crosscheck.

It was decided that when cleared to an altitude the Pilot flying would set local QNH, the support pilot would remain on standard until transition, where the call would be made "transition", "set QNH....." from the told card and "crosscheck." The theory being that an error in Altimeter setting would be more likely to be "caught" if there was a split in altimeter readings, and if not at least the pilot flying would have the correct setting on his altimeter for the approach.

Its an easy enough error to make, tired, hassled by ATC, crap weather, the thing I find hard to accept is they ignored several GPWS alerts without having a good look at why? perhaps with split altimeters they may have picked it up. At the end of the day, I can remember years ago when all non precision approaches in OZ were circling, CAsA wouldn't align them because they felt it would encourage pilots to bust minima. A stable approach does not necessarily have to be in a straight line, it can commence from mid down wind or in a turn, Think Hong Kong, 90 degree offset ILS, from the minima a curved turn to final, all nicely stable. Have pilot skills been so eroded by the auto magic that pilots are now incapable of flying a visual stabilised approach?

[Kharon]

Even so.

Some good points made there TB; which is why I made mention of the ‘transition’ notes on the ‘Jepp’ and the lack of information regarding the same in the ATSB report. Whatever SOP the crew used – as you say, 10,000 feet/ 10 minutes is a good place to be ‘set-up’ for an instrument approach – time and space to get the loose ends tidied up – the briefing and TOLD things of the past, nothing to do but fly the approach – routine, done a million times a day all over the world regardless of transition. Same - same a ‘stable’ approach; this crew were clearly capable of conducting the approach – and got it right the second time. There can be little doubt over crew competency – but; we need some in depth information, detail related to just how and why the local pressure was not set.

ATSB – “The flight crew did not complete the approach checklist before commencing the non-precision NDB approach into Kosrae, resulting in the barometric pressure setting on the altimeters not being set to the local barometric pressure.”

Yes – But- Why? I believe we should have been offered a detailed explanation in the ATSB report – an analysis – good enough to use for training. It is a ‘rare’ event this one, the incorrect altimeter setting ‘persuasive’ enough to lead to cancelled EGPWS warning; serious stuff. The NDB approach and circling would be occupying the aircrew – particularly when the crew believe all the checks are complete and consigned to the past – routine again – check complete – forget about it –and, on to the next event. The notion to complete one check list item – out of sequence (later) is fraught with peril, particularly where the next event is a demanding one.

Well, the whole event may well be a rare animal – one we hoped was extinct. It did happen, which opens the door for a repeat – I just think the why’s and wherefores are worthy of examination. It all ended happily this time (nod to the gods) but it should never have happened at all. ATSB should be moving to ensure that it never happens again, through correct, thorough detailed analysis of exactly why the event occurred. That flight came as close to disaster as it is possible to get – remind me again – at what height does the EGPWS kick in with a ‘terrain – to low’ warning?

Oh, don’t mind me; the curiosity curse strikes again; what sequence of events and circumstance could promote a departure from basic routine, SOP and habit – then persuade a crew to cancel a ‘terrain’ warning? Then there’s the Rad Alt to back up the call – more puzzles. Me, I’d be reaching for the taps before the lady had finished saying her piece – right or wrong – we’re out of here – TOGA and horsepower – lots of.

"For want of a nail the shoe was lost " etc…..

Toot - toot.

[P7_TOM]

My two bob’s worth.

Agree with the above – however the following lines from the ATSB put an eccentric spin on what actually happened, and they are arse about face:-

1) - ATSB – “The crew's belief that the EGPWS alerts were due to a decreased navigational performance and not terrain proximity led to the crew’s decision to inhibit the first EGPWS alert and not correct the flight path.”

2) - “The flight crew initiated a missed approach when they lost visual contact with the runway”.

Turn those two statements about, in sequence:-

1) – ATSB - “The flight crew initiated a missed approach when they lost visual contact with the runway”.

2) - ATSB – “The crew's belief that the EGPWS alerts were due to a decreased navigational performance and not terrain proximity led to the crew’s decision to inhibit the first EGPWS alert and not correct the flight path.”

Suddenly, it all starts to make ‘operational’ sense – the crew appear to have been in visual contact with the ‘land’ (one may even guess the runway) when the EGPWS warnings were discarded – fair enough some would say – particularly if the ATSB had dug about a bit to see if spurious EGPWS warnings were a ‘feature’ of the approach conducted. The crew could actually ‘see’ where they were -. The missed approach was initiated when the crew lost ‘visual contact’ and the missed approach procedure was executed. Once again – fair enough – good airmanship – lost visual + EGPWS warnings – no messing about ‘go around’ initiated.

Another small, but troubling item ignored by ATSB is the actual ‘value’ of the islands NDB as a primary navigation tool. From the CPL ground school days any instrument pilot who can’t name the four potential ‘dangers’ to navigation which can be produced by a NDB/ ADF system should not be allowed to fly. We have a coast line + high hills + Sunset /Night + Rain – all of which affect the NDB/ADF system how? ATSB don’t mention the power and range of the NDB or any noted diminished performance due the effects of where it is situated or the time of day.  I wonder, does the operating company mention these old times killers?

Just small points which, IMO the ATSB should have covered – if only to ‘eliminate them from our inquiries’ so to speak. But then, I’ve just read the load of bollocks provided on behalf of Qantas and the 737 into Canberra.

Send that bucket this way when you’re done with it son; meanwhile - I’ll get the beers in. My two bob, spent as pleased me best.

[Kharon]

I solemnly swear I am up to no good…

The bump of curiosity started itching again; Kosrae, the NDB/DME approach and the ATSB report demanding a good scratch. It is the ‘dive and drive' comment (aspersions) which create the irritation – it is just so wrong, you have to wonder why the ATSB set about their work in the manner they adopted. Passing strange I call it. Rough research on a beer coaster follows:-

Lets take it as a given that one way or another – the flight arrived at the ten mile fix at 1500 feet, properly configured for the approach leg. Consider that at 10 nms on an ILS the ‘averaged’ height is around the 2500 foot (AGL) mark (give or take) the Sydney 34 ILS has you at 1600’ @ 5 nms. The approach flown at Kosrae is a laid back affair with 1000 foot advantage and five additional miles – when compared to an ILS approach. The approach profile begins  ‘below’ a standard 3˚ height/distance profile; which excludes any need to be shoving the nose down, trying to slow up and maintain the profile – quite the reverse, you can actually maintain height and 'fly' to intercept the Korsae profile.  If the approach was not off-set that is exactly the way to do it. So why attack the crew with a D&D bull-pooh accusation?

Furthermore, close inspection of the NDB track sets the approach to runway 05 up very nicely; becoming visual anywhere between 5 and 3.5 miles makes for an easy roll onto final – in essence a doddle; however, closer in at 500 feet/2.9 miles is a little tight for a transport jet – with a load of passengers in the back - but you can see why the ground proximity warning would get ‘antsy’. Not a problem if visual.  Landing on the 23 runway is a whole different ball game; but then, when the winds favour the 23 runway – the ‘dry’ season is in – I digress.

Dive and drive approach considerations aside, the real potential threat is the miss-set altimeters (and the vagaries of the NDB). Human factors at work perhaps? Go figure, its an important flight – must be ‘smooth’ and seamless; low transition (5000’?) no SOP for such things and then becoming visual – the temptation to break off early to make a longer, smoother final approach, attention focussed on the landing – that is the next event – the approach is ‘complete’ and forgotten. Then back into IMC – the whole flight deck attitude must change now, from expectation of an easy night landing to potentially an approach to minima, close in and tight. 500 feet @ 2.9 miles ain’t a lot of wriggle room, not in marginal conditions, not with piles of bricks lurking within the cloud, not with the EGPWS bleating; time to go around – and they did. Safe as houses..

I won’t bang on anymore about this – it just annoys me that the ATSB have missed so many of the attending elements to this flight and loaded it all back onto the crew. Not a stellar crew performance I’ll grant you; but the human factors and possibly fatigue played a role in this event – and ATSB dismiss those elements with a totally inaccurate condemnation of ‘dive and drive’; which, by inference is not only technically wrong but most politically incorrect. This from an outfit that claims not to lay blame – Bollocks.

I just hope that a fatal accident which could have been prevented by ATSB doing their job properly and thoroughly never occurs. The smooth, glib, deceptive nature of ‘reports’ disguising the core elements and ignoring the radical causes is becoming a normalized deviance – this, as any safety manager will tell you is not a good thing; not at all.

Save file and close it – forever.

Toot – but then there’s the Canberra incident -  toot.

[Peetwo]

O&O investigation No: AO-2014-032

Not that the average punter, stakeholder or even DIP would know it but the now No1. longest O&O'd ongoing ATSB AAI went past it's 4th Anniversary without so much as an Annex 13 interim statement; or any recognisable update since 05 May 2017. However apparently the investigation webpage was revisited a week after the 4th Anniversary on 28 February 2018 - WTD...

Slightly embarrassed (because I'd missed it before), I noticed that on the AAI webpage a link for a passing strange 'Explanatory Statement', also dated 05 May 2017 (i.e. spot the disconnects ).
 

---

  Media release
ATSB issues second interim ATR report: 5 May 2017

• Media release
  

---

Explanatory Statement
Investigation AO-2014-032 - ATR in flight pitch disconnect

• Explanatory Statement
  

Explanatory Statement - ATSB Investigation AO-2014-032 ATR in flight pitch disconnect
With highly technical investigations, the ATSB considers it appropriate to provide an explanatory statement that describes the nature of the technical investigations in a manner which is more easily understood by readers of this report.

Background

ATR42 and ATR72 aircraft are twin-turboprop, short-haul, regional airliner and cargo aircraft built in France and Italy by ATR, and have been in service around the world since the mid-1980s. They seat between 48 and 78 passengers. The entire fleet of the two aircraft types have operated in excess of 20 million flight hours.

There are currently a small number of both aircraft types operating in Australia.

2014 incident

On 20 February 2014, a Virgin Australia Regional Airlines ATR 72 aircraft, registered VH‑FVR, operating on a scheduled passenger flight from Canberra, Australian Capital Territory to Sydney, New South Wales sustained a pitch disconnect while on descent into Sydney. The pitch disconnect occurred when the crew applied opposite inputs to the elevator controls while attempting to prevent the airspeed from exceeding the maximum permitted airspeed for the aircraft type. The pitch uncoupling mechanism activated and the elevators deflected in opposite directions, resulting in aerodynamic loads above the design strength of the tail structure, causing significant damage. 

The “pitch uncoupling mechanism” (PUM)

The elevator consists of a left and right control surface and is located at the top of the tail structure on ATR aircraft. It is operated by the pilots pushing or pulling on the control column in the cockpit, which raises or lowers the nose of the aircraft (known as pitch). During normal operation, the left and right elevator deflect in the same direction and in equal amounts.

There is also a mechanism called the pitch uncoupling mechanism (PUM), located between the right and left control surfaces in the tail of the aircraft. In the event of one of the elevators becoming jammed, the PUM can be triggered to have the elevators operate independently of each other. The PUM is activated by the pilot (operating the pitch control for the elevator not jammed) applying significant pressure to the control column in either direction. The pilot is then able to operate the elevator on the non-jammed side.

If significant pressure is applied in the opposite direction on each of the control columns, the PUM may also be triggered. An inadvertent activation of the PUM due to opposing control inputs is what occurred in 2014.

Flight crew procedure

Generally, flight crew procedures prohibit the simultaneous inputs by both pilots on the control column. Established handover/takeover communication protocols reduce the risk of any inadvertent dual input.

The Work of the ATSB 

The ATSB has undertaken an extensive investigation into the safety factors and issues behind the incident. The investigation has considered design, engineering and certification aspects of the aircraft, as well as operational, maintenance, training and regulatory aspects.

On 15 June 2016 the ATSB released its first interim investigation report that identified a safety issue concerning the potential for PUM activation to exceed the strength of the aircraft.

During the continued investigation of the occurrence, the ATSB has obtained an increased understanding of the factors behind this previously identified safety issue. This has identified that there are transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads capable of exceeding the design strength of the aircraft structure. The ATSB also identified that these transient elevator deflections were not considered during the certification process. The ATSB considers that the potential consequences are sufficiently important to release a further interim report that expands on the identified safety issue, prior to completion of the final investigation report. Readers are cautioned that new evidence may become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence.

In order to ensure the veracity of the analysis of the evidence leading to the identified safety issue, the ATSB engaged the UK Air Accidents Investigation Branch (AAIB) to conduct a peer review. The AAIB conducted an analysis of the evidence relating to the safety issue and concluded that their findings were consistent with those provided by the ATSB.

Stakeholder engagement and cooperation

The role of the ATSB is to identify safety issues and communicate them to the relevant organisation(s) to address. Since 2014, ATSB has worked closely with ATR (the aircraft manufacturer), the European Aviation Safety Agency (EASA), the French Bureau d’Enquêtes et d’Analyses (BEA), the United Kingdom Aviation Accident Investigation Branch (AAIB), the Civil Aviation Safety Authority (CASA), Toll as the Australian operator of the Australian ATR42 aircraft, and Virgin Australia as the operator of the ATR72 aircraft. Each of these stakeholders has a specific role in relation to the continued safe operation of these aircraft and has taken the following action to address the safety issue:

ATR

ATR has continued to provide data to ATSB and cooperate more broadly to undertake further aeronautical engineering and assurance work to determine if the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. Specifically, ATR has commenced a detailed engineering analysis of the transient elevator deflections that occur during a pitch disconnect. Indications from ATR is that this work will be completed in July 2017.

On 5 February 2016, as a result of this occurrence and a briefing from the ATSB, ATR released an All Operators Message. The message informed operators of ATR 42/72 aircraft of revised maintenance and operational documentation relating to the pitch control system and pitch disconnect occurrences.

EASA

EASA is the issuer of the aircraft’s type certificate and, as such, is the global regulator for the continued safe operation of the word-wide ATR fleet.

While acknowledging the safety issue identified by the ATSB, on 20 December 2016 (and updated on 21 February 2017), EASA issued a related safety information bulletin (SIB) that contained the following statement:

At this time, the safety concern described in this SIB is not considered to be an unsafe condition that would warrant Airworthiness Directive (AD) action ... P2 - So what's the bloody hold up?  

As the global regulator for the aircraft type, EASA is closely monitoring the detailed engineering analysis of the transient elevator deflections being carried out by ATR.

CASA

CASA has advised that they continue to work closely with both EASA and the Australian airline operators of the ATR aircraft, in relation to the continued safe operation of the aircraft type in Australia. ATSB has been advised that this has included both continual dialogue with and specific audits of the airline operators to assure that sufficient pilot training and operational procedures are in place to prevent the recurrence of this event. P2 - Wonder if those audits were conducted in accordance with the recently amended CASA surveillance manual - see Aiding & abetting; or under the busses?? - or as per the McComic black letter regulatory captured days; that brought us strange dichotomies like the PelAir 2009 MAP/SAR vs the Airtex MAP/SAR and AAT embuggerance...     
  
Virgin Australia and Toll

Virgin Australia Airlines advised that, in response to this occurrence, they have taken action to reduce the potential for pitch disconnects and to manage the risk of adverse outcomes from such occurrences. These included:

• reviewing and revising (where necessary) policy and procedures associated with descent speeds, handover and takeover procedures, overspeed recovery and on ground pitch disconnects
  
• incorporation of a number of factors surrounding the event into training material and simulator checks
  
• improved pilot awareness through Flight Crew Operations Notices, manufacturer’s communications (All Operators Messages) and ongoing training and checking
  
• updated maintenance requirements following a pitch disconnect.
  

Toll Aviation and Toll Aviation Engineering advised that, as a result of this occurrence, they issued a safety alert to their flight crew and aviation maintenance engineers, which included copies of ATR and EASA service bulletins. This alert advised that, in the event of a pitch disconnect, the aircraft was to be grounded until the appropriate checks had been carried out.

Toll has also developed and delivered enhanced training to their flight crews focused on handover/takeover procedures, unexpected turbulence and high-speed scenarios, and the pitch uncoupling system. Toll have also conducted detailed inspections associated with major  maintenance procedures.

Safety recommendations

While welcoming the safety action taken to this point, in particular ATR’s engineering analysis, the ATSB retains a level of concern as to whether the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. As a result the ATSB recommends that:

• ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.
  
• EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.
  
• CASA review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect, to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that CASA take immediate action to ensure the ongoing safe operation of Australian‑registered ATR42/72 aircraft. P2 - Funny how for CASA immediate means sometime in the next century...
  

Summary

Readers of this report are encouraged to read this report in conjunction with, the interim report released on 15 June 2016 report and an update on the ATSB website on 10 June 2014.

A final report is expected to be published in August 2017 (P2 - Must be a typo...err maybe HVH 's motley minions meant August 2027... ) and will include the results of the further testing and assurance activity being conducted by ATR, and will also include operational, maintenance, training and regulatory aspects associated with the incident.

 



Last update 05 May 2017

---

Oh well, good to see that HVH and his minions are upholding the Beaker record for making the ATSB the premier international top-cover experts for effective obfuscation of potentially embarrassing aviation accident investigations.

For classic example please refer to the ongoing OI search for MH370:

---

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Oh but that's right.. "nothing to do with us your honour" ...     

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MTF...P2

[Peetwo]

ATCB lining up the ducks on YMEN DFO accident -   

A rehash of where HVH's topcover bureau is currently at with the combined investigations surrounding the tragic Essendon DFO accident: AO-2017-024 & AI-2018-010 

Updated: 9 February 2018

The investigation into this accident has been completed and a draft report is in the final stages of completion. The report will soon undergo a review by the ATSB’s Commission and by Directly Involved Parties (DIPs), which is a process that enables checking of factual accuracy and ensures natural justice. It has been necessary to extend the completion date for this investigation due to a number of factors, including accommodating the involvement of international DIPs, who have up to sixty days to comment under international conventions.

As with any ATSB investigation, if a critical safety issue is identified during the course of an investigation, it is immediately brought to the attention of the relevant parties so that appropriate safety action can be taken.

Last update 28 February 2018

---

• Summary
  

Summary

On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.

The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.
 
General details
General details
Date: 21 February 2017
Investigation status: Active


Investigation phase: Evidence collection
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
Investigation type: Safety Issue Investigation
State: Victoria

Report status: Pending


Expected completion: 3rd Quarter 2018 
 


Last update 20 April 2018

---

And from the Airports thread:

Senate Report released -  

Finally, in the Senate today the RRAT Legislative committee inquiry tabled their report into the Airports Amendment Bill 2016:

---

Report

Airports Amendment Bill 2016 [Provisions]
19 March 2018

© Commonwealth of Australia 2018
ISBN 978-1-76010-747-5

View the report as a single document - (PDF 315KB)

---

And from off the UP, Old Akro & Mr Peabody voice their frustrations:

OA: This accident has been over speculated. We need the ATSB to do its job and publish the report.

In Feb the ATSB put out a media release essentially saying that the report was done but release was delayed because of a requirement to give interested parties time to comment with the inference that this involving international parties was increasing this period to 60 days. This 60 day period has now elapsed by 30 days and still no report.

The exact same update was issued on the same day for the 3 September 2015 incident at Mt Hotham with VH-OWN & VH-LQR- an incident that occurred 32 months ago. .

The list of pending reports has grown to 109.

This is from the ATSB's current strategic plan:

" The Government’s recent Budget measures, and the ATSB’s organisational change program, position the ATSB to reduce its investigation backlog and increase its capacity to complete complex investigations within 12 months, which is a key deliverable of the ATSB."

The ATSB is clearly failing to do its job by any measure.

---

Mr Peabody: I think we will be waiting quite a while for this report to come out; according to the ATSB investigation status the report is still at "Final Report: Internal Review". That means it likely hasn't even gone to the DIPs yet, if it had the status should be "Final Report: External Review".

And yes they do appear to work at a cracking pace!! Snail wise I mean.

In a 'passing strange' coincidence I noted the following addition to the ATCB AAI webpage: 

What happened

In October 2009, the operator of Essendon Airport (now Essendon Fields Airport) received an application from the Hume City Council (HCC) to construct a radio mast on top of the council office building at Broadmeadows, Victoria. The application was made under the Airports (Protection of Airspace) Regulations 1996 (APA Regulations) which was only applicable to leased, federally-owned airports, such as Essendon. The application identified that the building and existing masts had not been approved under the regulations. The regulations required any proposed construction that breached protected airspace around specific airports to be approved by the Secretary of the then Department of Infrastructure and Transport (Department). Protected airspace included airspace above a boundary defined by the Obstacle Limitation Surface (OLS). The Secretary was required to reject the application if the Civil Aviation Safety Authority (CASA) determined that the application would have an ‘unacceptable effect on safety’.

CASA’s initial response to the HCC application stated that the building and existing masts represented a hazard to aircraft and should be marked and lit, while the proposed radio mast represented a further hazard and, as such, would not be supported. The advice was considered inadequate by the Department, who instructed CASA that they required advice that either the application for the mast had an unacceptable effect on safety, or it did not. CASA subsequently determined that the application did not have an unacceptable effect on safety, and in addition, advised the Department of specific lighting and marking requirements to mitigate any risk presented by the mast. The Department approved the HCC application on 28 February 2011 conditional on appropriate marking and lighting being affixed to the radio mast and building. The ATSB has since been advised that the radio mast has been removed due to reasons unrelated to aviation safety.

What the ATSB found

The scope of this investigation was limited to the processes associated with protecting the airspace at leased, federally owned airports, and in particular the application of safety management principles as part of that process. The investigation used the HCC application for examining the APA Regulations processes, and as a result identified an issue specifically associated with that application. However, the investigation did not consider whether or not the aerial on the HCC building was unsafe.

The Airports Act 1996, which was administered by the Department, was the principal airspace safety protection mechanism associated with a leased, federally-owned airport’s OLS. The Australian Government had committed to using a safety management framework in the conduct of aviation safety oversight (that is, a systemic approach to ensuring safety risks to ongoing operations are mitigated or contained). In contrast, the conduct of safety oversight of an airport’s airspace under the Airports Act used a prescriptive approach (that is, the obstacle was either acceptable or unacceptable). This approach met the requirements of the Airports Act, but was not safety management-based. With respect to the assessment of the HCC application under the Airports Act, a safety management approach was not used.

What's been done as a result

The Department, now known as the Department of Infrastructure, Regional Development and Cities, has advised that it will confer with key stakeholders in the APA Regulations process regarding relevant risk management practices. The intent is to implement a more systematic approach to risk management, guided by the Commonwealth Risk Management Policy.

The Department has also identified the need to reform the current airspace protection regime based around the Airports Act. In a paper titled ‘Modernising Airspace Protection’, the Department identifies that current airspace protection regulation under the Civil Aviation Act 1988 and the Airports Act requires improvement, and has initiated public consultation regarding reforms into this particular regulatory system.

Safety message

A safety management system approach is considered ‘best practice’ by the International Civil Aviation Organization and has been adopted by Australia as the core method of aviation safety oversight through the State Aviation Safety Program. The Airports Act processes need to adopt safety management principles to the assessment of construction applications involving breaches of prescribed airspace, but rather, used a prescriptive regulatory approach. Construction proposals can impinge on aviation safety margins, such as those represented by the OLS. A fully informed, safety management-based approach should be used to ensure that safety is not compromised.
 
Background
Context
Safety analysis
Findings
Safety issues and actions
Sources and submissions
Appendices

This bit is IMO simply gob smacking in the observed subservience by CASA to what was then Murky's Department: 

"..CASA’s initial response (sic)...while the proposed radio mast represented a further hazard and, as such, would not be supported. The advice was considered inadequate by the Department, who instructed CASA that they required advice that either the application for the mast had an unacceptable effect on safety, or it did not. CASA subsequently determined that the application did not have an unacceptable effect on safety, and in addition, advised the Department of specific lighting and marking requirements to mitigate any risk presented by the mast..."

Reference safety issue: AI-2013-102-SI-01

The use of risk management principles when considering an application under the Airports (Protected Airspace) Regulations

Issue number: AI-2013-102-SI-01
Who it affects: Airports managing protected airspace associated with their runways
Issue owner: The Department of Infrastructure, Regional Development and Cities
Operation affected: Aviation: Airspace management
Background: Investigation Report AI-2013-102
Date: 03 May 2018

Safety issue description

The Department of Infrastructure, Regional Development and Cities adopted a prescriptive approach to the Hume City Council building application within the obstacle limitation area of Essendon Airport, which was in accordance with the process prescribed under the Airports (Protection of Airspace) Regulations 1996, but did not require the application of risk management principles to the department’s consideration.

Proactive Action

Action organisation: Department of Infrastructure, Regional Development and Cities
Action number: AI-2013-102-NSA-063
Date: 03 May 2018
Action status: Monitor

In response to this safety issue, the Department of Infrastructure, Regional Development and Cities (Department) advised that:

The Department notes the ATSB comments that the approach to the application was in accordance with the relevant applicable regulations i.e. the Airports (Protection of Airspace) Regulations 1996 (APA Regulations). The Department also notes that under APA Regulations r. 14(2) the Secretary must approve applications unless they interfere with the safety, efficiency or regularity of air transport operations.

As outlined in the report, the Department stresses that the primary responsibility for providing safety advice rests with CASA, given that under APA Regulations r. 14(6) the Secretary must not approve a proposal for a controlled activity if CASA has advised the Secretary that carrying out the controlled activity would have an unacceptable effect on the safety of existing or future air transport.

While the Department does consider relevant risks (including to safety, efficiency and regularity) in considering applications under the APA Regulations, the Department agrees that in the future a more systematic approach to risk management should be implemented in relation to applications being assessed under these regulations. To this end, the Department will be guided by its internal 2015 Risk Management Framework, which aligns with the 2014 Commonwealth Risk Management Policy. The Department will document its risk management approach to airspace protection applications during 2018.

The Department will also work with key stakeholders to understand and document relevant risk management practices within those organisations (particularly CASA) that impact on the application processes and advice provided to the Department for the purposes of the regulations.

A significant change since the 2010 incident has been that in October 2015 the Victorian Government amended the Victoria Planning Provisions to include mandatory consideration of National Airports Safeguarding Framework Principles and Guidelines in planning processes around the state’s airports and airfields. This is outlined at: www.dtpli.vic.gov.au/planning/plans-and-policies/planning-for-airports/the-national-airports-safeguarding-framework.

This amendment will assist in early identification of potential airspace intrusions and facilitate communication between the relevant regulators, airports and developers. Further information about the National Airports Safeguarding Framework Principles and Guidelines is available at: www.infrastructure.gov.au/aviation/environmental/airport_safeguarding/nasf/index.aspx

The Department continues to work with industry and State, Territory and local governments to improve awareness of airspace protection issues and planning processes.
The Department is currently reviewing the airspace regulations as they will sunset in April 2019 under the Legislation Act 2003 and will also take into account the ATSB’s findings on this matter.

ATSB response:
The ATSB welcomes the above proposed safety action concerning introducing a risk based approach to decision making. The ATSB will monitor the progress of implementing this safety action in future amendments to airspace regulations.
 
 
Current issue status:
Safety action pending
 


[i]Last update 03 May 2018[/i]

 

The above safety issue response, from the current iteration of the Dept, would appear to suggest that finally we have a Dept Secretary that acknowledges the inherent deficiencies of the regulations surrounding airspace and airport protection in both the CA and Airport Acts. 

However IMO it is still totally unacceptable that this investigation has been O&O'd at HVH HQ for the better part of half a decade, only to be dragged out now when other investigations may potentially draw attention to the ATCB's apparent inability to independently investigate and make safety recommendations to help industry participants proactively mitigate safety risk issues...    


MTF...P2 

[Gobbledock]

CORRECTING THE RECORD, ATSB = ASStsb

The ATSB died the day that Alan Stray left. What was a once highly reputable organisation was then destroyed by the bureaucrats hiring a completely unqualified, moronic, out of his league money counting farkwit called Dolan (Beaker). The moron made a mockery of the ATSB by making smart intelligent Investigators redundant, ignoring proven investigative methodology such as the Reason model, focusing on budgets and absolutely screwing up investigations such as Pel Air and MH 370. Six years of failed leadership under Beaker and his ass licking minions caused irreversible damage. The introduction of lightweight pithy reports containing waffle and complete shite became the norm. Beard on/beard off numpty.

Then along came HiVis Hood (HVH). The ‘bride in waiting’. Lined up as the fall guy for Pel Air by the CAsA’s Screaming Skull and Farkwitson, he never rose above third in the line of command. So he dodged the sword and popped up at the monopoly business that can’t make a profit, ASA. Here he stayed until also realising that he was not to become the new CEO, that role gifted to yet another moron - Electric Blue Harfwit. HVH then heads to the ATSB as chief and commander. His legacy? Another bad joke in which reports have become even more ludicrous, sanitised and dare I say, poofterised, and Hood spends his time blogging and counter-commenting on criticism of his stupid organisation. Emotional fool. So, in short, the ATSB is a worldwide embarrassment.

To have Beaker pop up mi mi mi-ing on 60 Minutes only adds to the embarrassment. He stuttered and stammered as real experts highlighted how Beaker and his Beakerites are clueless fucktards couldnt find a semen stain on a mattress. They should find a smoking hole and disappear down it forever.

“Absolutely unsafe skies for all”

[thorn bird]

Goggles old mate,

God I've missed your succinct Prose.

[Gobbledock]

ASASI Melbourne conference

Hi-vis Hood took the stage early today at the ASASI conference in Melbourne. Very dapper in expensive suit and no sign of the vest. Interesting thing is that Australia has a plethora of skilled and competent investigative guru’s that are part of the organisation, so only god knows why HVH with his ‘correcting the record’ methodology and failures of the Pel Air and MH370 investigations is there? Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???

http://asasi.org/seminar/indexconf.html

‘ASASI - genuinely safer skies for all’

[Peetwo]

ASASI Melbourne conference

Hi-vis Hood took the stage early today at the ASASI conference in Melbourne. Very dapper in expensive suit and no sign of the vest. Interesting thing is that Australia has a plethora of skilled and competent investigative guru’s that are part of the organisation, so only god knows why HVH with his ‘correcting the record’ methodology and failures of the Pel Air and MH370 investigations is there? Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???

http://asasi.org/seminar/indexconf.html

‘ASASI - genuinely safer skies for all’

"..Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???.." - Top shot Gobbles, luv your work...  

If your around tomorrow perhaps you could get us a blow by blow of the Dr A's hoodoo voodoo prezo - 

1130 - 1210 Just Culture from a Regulators perspective - Jonathan Aleck, CASA 

Maybe we can get it on podcast?

MTF...P2   

[Gobbledock]

P2 requested a Sunday update on this hilarious CAsA topic;

1130 - 1210 Just Culture from a Regulators perspective - Jonathan Aleck, CASA

Will see what can be arranged good sir. I imagine Dr Voodoo’s speech will last around 10 seconds, and be something like this;

“All aviators are criminals, lock them up in jail and throw away the key”. Up next, Dr Voodoo’s new inclusion in the Civil Aviation Act; ‘pre recognition’. The art of predicting an aviation offence before it has even been committed and then punishing the yet to offend offender;

[Peetwo]

HVH's 1 in 60 bollocks on O&O'd investigations -   

Resplendent in high viz and fresh from a training session for this year's CEO toga party sleep-out, HVH treads the light fantastic with the latest spin'n'bollocks excuses for investigation backlog...  

From Annabelle in the Oz today :

Air investigator ATSB vows to speed up complex probes. ATSB Chief Commissioner Greg Hood. Picture: Dylan Coker

ATSB vow to speed up probes
ANNABEL HEPWORTH


ATSB chief Greg Hood says the air investigator is ‘actively working’ to finish complex investigations in a ‘timelier manner’.

The nation’s air investigator says it expects to finish its complex investigations in a “timelier manner” after a program aimed at clearing a backlog of reports.

The latest figures show the Australian Transport Safety ­Bureau expects to publish 30 per cent of complex investigations within 12 months in 2017-18, against a target of 90 per cent.

ATSB chief commissioner Greg Hood said the ATSB was finishing complex investigations in an average of 16 months but was “actively working” to improve the timeliness.

The “Back on Track” program, aimed at clearing a backlog of reports, had been “productive”. Some 30 investigations that were behind time were now finished, while a further five to eight were expected to be done by the end of the financial year.

“Back on Track has required a diversion of significant resources away from our business as usual operations and therefore the percentage of complex investigation reports that have been completed remains around 30 per cent for this 2017-18,” Mr Hood said.

“I remain confident that when the Back on Track program is completed and these diverted resources return to business as usual operations, the ATSB will be positioned to complete its investigation reports in a timelier manner.” Mr Hood also pointed to other measures aimed at getting investigations completed more promptly, including moves to hire more transport safety investigators and be more selective in what it investigates.

While the headcount had gone down by about 25 per cent since the ATSB became an independent statutory body in July 2009, a recent budget boost had enabled an extra 17 transport safety investigators to be recruited.

“These investigators are currently being trained and a number have already had the opportunity to deploy to accident sites,” Mr Hood said.

“The process of establishing investigator competencies generally takes 18 months to complete, so we anticipate that we will begin to see the benefits of these additional resources in the next financial year results.”

As well, the ATSB would use its database to pinpoint cases with “the greatest potential for improving transport safety”.

The ATSB had started 120 investigations this financial year, compared with 162 investigations in 2016-17. “There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity. We are also placing emphasis on addressing accidents and incidents that recur through safety education.”

Hmm...no comment - 


MTF...P2 

[Gobbledock]

JUNE 21  - SLEEP WITH HOODY!

HVH has his yearly sleepout for the homeless on June 21. I’m not sure who will be ‘correcting the record’ on his behalf while he is out of the office with other CEO’s sleeping on the street. A noble cause, however it’s just a shame that his compassion for humanity doesn’t extend to the survivors of the Pel Air ditching or the families of the MH370 victims.

I wonder if he will be sleeping in his hi-vis vest, a Toga and a hand knitted blanky? I just hope that whoever he ends up ‘spooning’ with doesn’t get frightened by that pointy object in their back!

“Safe cuddles for all”

[Peetwo]

O&O investigation: AO-2015-108 1029 days to completion - UDB! 

Via the ATSB website today:

• Final Report
  

Final Report
Download final report
[DownloadPDF: 3.16MB]
 
 
Listen to this PDF[img=10x0]https://www.atsb.gov.au/Assets/readspeaker_small_blue.png[/img]
Alternate: [DownloadDOCX: 5.74MB]
 
What happened
On 3 September 2015, several multi-engine turboprop aircraft converged on the airspace above Mount Hotham Airport, Victoria, as part of a multi-day charter involving several operators. While conducting a number of area navigation (RNAV) Global Navigation Satellite System (GNSS) approaches, the pilot of a participating Beech Aircraft Corp B200 (King Air) aircraft, registered VH‑OWN, descended the aircraft below the minimum altitude and exceeded the tracking tolerance of the approach after experiencing GPS/autopilot difficulties. The pilot twice climbed the aircraft without following the prescribed missed approach procedure and manoeuvred in the Mount Hotham area. During this manoeuvring, the aircraft came into close proximity to another King Air, registered VH‑LQR, which had commenced the same approach. Both aircraft were in instrument meteorological conditions and unable to sight each other. Significant manoeuvring was also observed as VH‑OWN was on final approach to the Mount Hotham runway. All aircraft landed safely at Mount Hotham without injury to passengers or crew.

What the ATSB found
Difficulties in operating the GPS/autopilot resulted in the pilot of VH‑OWN experiencing an unexpected reduction in the level of supporting flight automation, and a significant increase in workload, while attempting to conduct RNAV (GNSS) approaches into Mount Hotham Airport. This increased workload affected both the pilot’s ability to follow established tracks such as the published approach and missed approach, and his ability to communicate his position accurately to other aircraft and the air traffic controller.

Although radar coverage in the area was limited, there were opportunities for the air traffic controller to identify when VH‑OWN was having tracking difficulties during all three approaches, and when VH‑OWN tracked towards the expected position of VH‑LQR. However, this position information was not effectively communicated, resulting in a missed opportunity to prevent a potential controlled flight into terrain and/or collision with VH‑LQR.

What's been done as a result
The pilot of VH‑OWN underwent flight testing by both a delegate of the Civil Aviation Safety Authority (CASA), and by a flying operations inspector employed by CASA, who recommended remedial training. Independent of this investigation, in February 2017 it became mandatory for all aircraft operating under instrument flight rules to be fitted with Automatic Dependence Surveillance – Broadcast, further increasing surveillance capability nationally, including in the Mount Hotham area.

Additionally, and independent of this investigation, the Department of Defence radar system, capable of surveillance in the Mount Hotham area, is scheduled for upgrade in late 2018. The radar system upgrade is likely to enhance the national air traffic system through the increased compatibility between that radar and the Airservices Australia surveillance system.

Safety message
Maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced. Additionally, as the responsibility for separation from other airspace users and terrain in Class G airspace lies with aircrew, it is imperative that pilots maintain the skills to navigate accurately, and interpret and utilise traffic information to maintain safe separation. From an air traffic control perspective, the occurrence highlights the safety benefit of communicating any apparent tracking anomalies and/or conflicts to the involved pilots.

Mount Hotham runway
[img=382x0]https://www.atsb.gov.au/media/5774582/ao2015108_picture-4.jpg?width=382&height=286&sharpen=2[/img]

Source: Mount Hotham Airport and Resort

P2 comment: IMO parts of the following extract rings some alarm bells...

The following day, the pilot of OWN, along with a Civil Aviation Safety Authority (CASA)‑approved testing officer, conducted a test flight in OWN which included a practice area navigation RNAV (GNSS) approach in daylight visual meteorological conditions. While the aircraft reportedly did demonstrate a minor tracking anomaly when approaching the final approach fix, this did not replicate the situation of the previous day. Further opportunity to test-fly the aircraft and/or the GPS was hampered when the pilot of OWN destroyed the GPS removable data card before the ATSB had commenced an investigation, making it impossible to replicate the conditions of the occurrence flight. This action was taken after the pilot was reportedly told the data card was likely corrupted.

The pilot of OWN voluntarily suspended RNAV (GNSS) operations until he could undergo independent flight testing by CASA. This testing by CASA then resulted in a recommendation that the pilot complete remedial training before undergoing a further flight test. Following the second flight test, the pilot was deemed proficient and competent to resume operations. At no time during the two test flights were any anomalies with the GPS and/or autopilot recorded by either the occurrence pilot or the CASA-approved testing officers. CASA, however, advised that no formal testing of the aircraft or its equipment was conducted during those two flights beyond observation of functionality.

Also coming out of HVH HQ today...

Via the ATCB twitter guy/gal:

The ATSB is requesting your feedback on the effectiveness of its engagement and communication.   Help us improve transport safety.  Visit the ATSB website to start our stakeholder survey:  http://www.atsb.gov.au/newsroom/news-items/feature-news-items/survey-2018/ …

10:47 AM - 27 Jun 2018

Err...no comments - they're all in the survey...


MTF...P2