[Kharon]

Finally.

At long last; someone on the UP actually see's why the ATSB, under Hood, is drowning in it's own excrement. The following post, from 'Compressor Stall' should be made poster size and nailed up on the wall of the ATSB dream factory walls - as a reality fix; it may remind 'em of what they are supposed to do.  

Coincidentally I am currently on a course with a (foreign) pilot turned investigator who has worked on several high profile accidents that are well known to just about any pilot on the planet.

In discussion it would seem that the good and the bad human factors are to be integral to any report. Rereading this report tonight, it isn't the inclusion of the acknowledgement of the following of SOPs that now is of concern to me. It's the fact that the report has been released without any factual investigative information of the root cause of the event.

Quote:
however the examination was not completed in time for the release of this report.

Quote:
At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.

The crew's following of SOPs would normally have been drowned out in the investigation of the engine and other factors that actually caused the event. i.e. These detailed technical factors caused a situation which (incidentally) was well handled. The primary safety message would be in the reasons for the engine failure.

CS say's it all; summing up what every 'professional' worth the name thinks - neatly, succinctly and accurately.  Tim Tam cupboard key delivered.

Selah.