Proof of ATSB delays

Popinjay continues to take the PISS on ICAO Annex 13 compliance??

Via ICAO:

Quote:Per Annex 13, the State conducting the investigation of an accident or incident is expected to produce a Preliminary Report within 30 days of the accident. This Preliminary Report may be public or confidential at the discretion of the State in charge.

[Image: SYDEX-media_image001.jpeg]

Courtesy Popinjay HQ, prelim report AO-2023-051 was released 89 days after the fatal accident occurred... Dodgy

Via, PJ's bureaucratic top-cover, load of absolute self-serving (un-interactive) media release bollocks... Angry

Quote:Preliminary report details initial evidence gathered in Hawks Nest R66 helicopter accident

[Image: AO-2023-051%20News%20Item%20image.jpg?itok=zoR-QDEp]
The accident helicopter’s flight path

The Australian Transport Safety Bureau has released a preliminary report from its ongoing investigation into a Robinson R66 helicopter’s in-flight break-up and collision with water near Hawks Nest, NSW on 26 October 2023.

“Today’s preliminary report provides factual information from the initial evidence gathering phase of the investigation, including detailing this tragic accident’s sequence of events,” ATSB Chief Commissioner Angus Mitchell said.

About half an hour before the accident, the helicopter departed Cessnock for Wallis Island, on the NSW north coast, and initially tracked east towards Newcastle, flying close to the cloud base, which was between 500 ft and 1,000 ft above ground level.

Approaching the coast, the pilot received clearance from Williamtown air traffic control to transit Williamtown airspace northbound at 500 ft above mean sea level (AMSL).

As the helicopter reached Anna Bay, Williamtown air traffic control then provided the pilot with a further clearance to follow the coastal VFR route below 2,000 ft AMSL.

“The helicopter’s onboard video camera showed at this time that the helicopter’s autopilot was engaged, with heading hold and altitude mode selected,” ATSB Chief Commissioner Angus Mitchell said.

As it tracked towards Hawks Nest, the helicopter passed over the south shoreline of Yacaaba Headland, to the west of Mount Yacaaba, at about 900 ft AMSL.

Analysis of the onboard video footage showed that the helicopter then experienced a series of initially minor changes in roll, pitch and yaw, and the pilot began to make cyclic inputs, overriding the autopilot.

“As the helicopter passed north of Yacaaba Headland and over Providence Bay it rolled left slightly, then right and left to bank angles of about 10 to 15 degrees. During this time, the nose remained pitched up at about 6 degrees and the helicopter climbed to about 1,100 ft AMSL,” Mr Mitchell said.

“Subsequently the helicopter’s nose pitched down and it rolled to the right, becoming completely inverted, and continuing to roll right to about 270 degrees.”

The ATSB’s subsequent wreckage examination determined that, during the accident sequence, the main rotor likely impacted the cabin and struck and separated the tail boom aft of the engine fairing.

The helicopter impacted the waters of Providence Bay, near Hawks Nest, and the pilot was fatally injured.

Mr Mitchell noted that the helicopter’s onboard camera is proving invaluable to the investigation, as it not only recorded the in-cabin visual and audio environment, but also captured GPS position, acceleration, and rotational speed.

“We were very fortunate that a roof panel to which the camera was mounted washed up on the beach near the accident site and was located by a member of the public who provided it to the NSW Police,” Mr Mitchell said.

“The video files and other recorded data were subsequently extracted from the camera memory module at the ATSB’s technical facilities in Canberra.”

Williamtown air traffic control radar and radio communications between the helicopter have also been retained by the ATSB for analysis.

“As we continue the investigation we will further analyse the onboard video, continue to examine recovered components, and look into flight planning and helicopter performance, amongst other aspects,” Mr Mitchell said.

“Investigators are also closely examining the meteorological conditions at the time of the accident, particularly in the immediate vicinity of Mount Yacaaba.”

The ATSB’s final investigation report will detail findings, any identified safety issues, and safety actions taken to address those.

“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.”

Read the preliminary report: Loss of control and in-flight break-up involving Robinson R66, VH-KFT, near Hawks Nest, New South Wales, on 26 October 2023

Publication Date: 23/01/2024
 
“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.” - Hmm...the funny thing is although this bollocks statement is continuously regurgitated in all ATSB preliminary reports and associated bollocks MRs, there is in fact no longer any 'critical safety issue' definition published on the ATSB website - see previous post... Wink

However a CSI is annually defined (for at least the last 5 years) in the ATSB Annual Report - WTD??

Via ATSB Transparency Portal:

Quote:Formal safety issues and actions

ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:
  • can reasonably be regarded as having the potential to adversely affect the safety of future operations
  • are characteristics of an organisation or a system, rather than of a specific individual, or operational environment at a specific point in time.

Safety issues will usually refer to an organisation's risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.

The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the TSI Act to make a formal safety recommendation either during or at the end of an investigation – depending on the level of risk associated with a safety issue and the extent of corrective action already taken.

When safety recommendations are issued, they clearly describe the safety issue of concern, but they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue, and act appropriately.

When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.

The ATSB can also issue a safety advisory notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.

Safety issues are broadly classified in terms of their level of risk:
  • Critical safety issue – associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.
  • Other safety issue – associated with a risk level regarded as unacceptable unless it is kept as low as reasonably practicable. Where there is a reasonable expectation that safety action could be taken in response to reduce risk, the ATSB will issue a safety recommendation to the appropriate agency when proactive safety action is not forthcoming.

All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.
       
MTF...P2  Tongue
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Popinjay continues to take the PISS on ICAO Annex 13 compliance - Part II

From the 2019 ANAO audit of the ATSB: "Efficiency of the Investigation of Transport Accidents and Safety Occurrences"

Read from CH 2 "Measuring and supporting operational efficiency":

Quote:Areas examined

The ANAO examined whether the ATSB had established efficient processes for the investigation of transport accidents and safety occurrences.

Conclusion

The ATSB has established key elements of an overall framework to promote efficient investigation processes. There is a focus on clearing the backlog of investigations that have been underway for some time, applying sound processes to decide which notifications merit a safety investigation, and adjusting key performance indicators to identify more realistic completion timeframes for the more complex investigations. The ATSB has also taken a number of actions to give greater attention to the efficiency with which it undertakes transport safety investigations.

Areas for improvement

The ANAO has made two recommendations. One relates to short investigations, where recent changed processes have had an adverse impact on completion timeframes.

The second encourages the ATSB to marry its increased focus on timeframe efficiency with greater attention to the resource efficiency of its investigations.

You will even find there is a reference to ICAO -  Rolleyes :

Quote:2.10 In October 2018, the ATSB advised the ANAO that the target of completing 90 per cent of complex investigations within 12 months was driven by the ATSB’s perspective as to what may be considered acceptable to industry and directly involved parties, including the next of kin. The ATSB further advised the ANAO that the 12 month target also took into account the International Civil Aviation Organization’s (ICAO) International Standards and Recommended Practices manual ‘Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Eleventh Edition, July 2016’ (Annex 13). Specifically, section 6.5 of Annex 13 states:

Quote:In the interest of accident prevention, the State conducting the investigation of an accident or incident shall make the Final Report publicly available as soon as possible, and if possible, within twelve months.

However for this post I am more interested the following recommendation for the completion of 'short' investigation:

Quote:Recommendation no.1

2.8 The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

2.9 The ATSB acknowledges the average increase in time taken to complete short investigations since 2016–17. The ATSB plans to address this issue through the allocation of dedicated investigator resources, within the current organisational structure, to short investigations.

Then refer to page 25 'Results against key performance criteria' table of Popinjay's 2022-23 Annual Report

Quote:Median time to complete investigations.

Target - Short 7 months/ Defined 14 months/ Systemic 20 months
Result - Short 10.4 months/ Defined 15.9 months/ Systemic 38.5 months

With all of the above in mind and in stiff competition, has Popinjay taken the record for the longest completion of a short investigation?

Last Wednesday the latest bollocks Media Release with Godlike attributed as the DTS was put out:

Quote:Diversion due to fuel imbalance and engine shutdown emphasises importance of checklist diligence

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A Boeing 737’s crossfeed valve was not closed after a pre-flight fuel transfer, later resulting in a fuel imbalance warning which led to the flight crew unnecessarily shutting down one of the aircraft’s engines, an ATSB investigation report details.

Just after reaching cruise altitude on a Perth to Adelaide flight on 25 October 2021, the captain and first officer of a Qantas 737 were alerted to a fuel imbalance, indicating there were unequal quantities of fuel in the left and right main fuel tanks, located in each wing of the aircraft.

Prior to the flight, the captain had identified extensive cold soaked fuel frost on the wings, due to cold fuel remaining in the main tanks from the aircraft’s previous flight.

“To remedy this, the cold fuel was transferred to the centre tank, and the main tanks were refuelled with additional, warmer fuel,” ATSB Director Transport Safety Dr Stuart Godley said.

“The procedures required the crossfeed valve to be closed when the operation was completed, however, the valve was not closed. This was likely associated with the crew following the maintenance engineer’s verbal instructions rather than referring to the relevant procedure. While this is permissible, referring to procedures is a more reliable method to ensure all steps are carried out.”

During pre-flight checks, and later during the climb and level-off, the pilots did not notice the crossfeed selector in the open position, or the associated dimmed blue indicator light on the fuel panel.

Once the centre fuel tank was exhausted and its pumps were switched off, the open crossfeed valve allowed fuel to be continually pumped from the left main tank to the right engine, as a result of uneven fuel pump pressures.

While the aircraft’s manuals stated this could occur, the flight crew did not recall this, and the Boeing 737 imbalance checklist, worked through by the flight crew, did not provide sufficient guidance for an open crossfeed valve to be identified as the potential reason for a fuel imbalance.

“This led the flight crew to decide there could be a fuel leak and then, partly as a result of confirmation bias, stress and perceived time pressure as the aircraft approached the Great Australian Bight where it would fly over water, they abbreviated the relevant checklists and mistakenly confirmed a fuel leak as the cause for the imbalance.”

The ATSB’s report notes the flight crew, when working through the fuel engine leak checklist, inadvertently performed a step out of sequence, invalidating the process, and contributing to their conclusion that there was a fuel leak.

As a result of this incorrect confirmation, the flight crew unnecessarily shut down the aircraft’s left engine during flight.

After the flight crew diverted to Kalgoorlie and conducted a single-engine landing, a post-flight inspection revealed there was no fuel leak, and the fuel system was serviceable.

Dr Godley noted that, although the presence of information in the checklist about the effect of an open crossfeed valve probably would have led to a different outcome in this case, a fuel imbalance condition is itself usually a minor condition, and the ATSB considered the checklists adequate to address a more serious condition such as a fuel leak.

“This incident highlights the importance to all pilots of being precise when following checklists, especially when under stress,” Dr Godley said.

“Checklists are designed to minimise performance variability under workload and stress, increasing the likelihood that all required actions are successfully carried out.”

Read the report: Fuel imbalance and engine shutdown involving Boeing 737, VH-VZT 135 NM south of Kalgoorlie-Boulder Aerodrome, Western Australia, on 25 October 2021


Publication Date 28/02/2024

Note that in the report there was no safety issues identified and in the 'safety action' section it simply has:

Quote:Safety action by Qantas Airways
After the occurrence, Qantas communicated the factors involved to 737 flight crews.

Presumably the internal investigation and subsequent initiated safety action of Qantas were completed within a relatively short time frame? However this short investigation took 857 days, or more than 4x the target performance (KPI) time to complete?? - UDB! Blush

MTF...P2 Tongue

PS: Wonder why the following contextual information was not mentioned in the Godlike blurb or in the 'contributory factors' section of the report:

Quote:Personnel information

Captain

The captain held an Air Transport Pilot (Aeroplane) Licence (ATPL) and was appropriately qualified and authorised to conduct the flight. The captain had almost 12,000 hours total flying experience with over 5,000 hours on 737 variants. The captain was a check and training pilot for the operator and had flown about 110 hours in the previous 90 days.

As a result of the Qantas response measures to COVID-19[12], the captain was stood down from mid-April 2020 until 23 September 2020. Upon completion of simulator training, they returned to flying duties at the end of September 2020. Although the captain remained stood up after that time, their monthly rostered flying hours were lower than was usual prior to the pandemic. In the 12 months prior to the event, they flew 40% of the hours they had flown in the 12 months prior to stand down. In the 3 months immediately prior to the event flight, their monthly average flying hours were roughly half their pre-pandemic average. The captain reported that while being comfortable to fly, because of the stand down and reduced flying hours, they noted a degradation in their skills.

First officer

The FO held a Commercial Pilot (Aeroplane) Licence and was appropriately qualified and authorised to conduct the flight. The FO had about 1800 hours total flying experience and about 110 hours on the 737. The FO had flown about 24 hours in the previous 90 days. The FO was undergoing line training and was qualified to act as a first officer on revenue flights alongside a check and training captain.

The FO joined Qantas as a second officer on the Boeing 787 fleet. In 2019 they commenced FO promotion and 737 type rating training, however soon after this was delayed. The FO’s training recommenced in May 2021. As a result of Qantas’ COVID-19 response measures, the FO was stood down between September and October 2021, re-commencing flying duties mid-October 2021.
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