The search for investigative probity.

Well; seems clear enough to me, CASA’s ‘fatigue ‘ rules ain’t worth the paper they were approved on, by parliament –Minister? Please explain. You do see of course that ‘black-letter’ works both ways – if it is not deemed illegal – we shall comply. CASA written reg’s = BOLLOCKS. Time you understood that simple fact……………
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Ironsider further follow up on snoozing pilot incident -  Shy

via the Oz: https://www.theaustralian.com.au/busines...e184ccc904

Quote:Sleeping pilot couldn’t be raised during freight flight from Devonport to King Island, say air traffic controllers
[Image: e918784e328ec35185ee7e295cf2665f?width=650]This image shows how a Piper PA-31 overflew its destination, King Island, by 46km this month.
  • ROBYN IRONSIDE
    AVIATION WRITER
    @ironsider[img=0x0]https://i1.wp.com/pixel.tcog.cp1.news.com.au/track/component/author/6e7c15929181150836944cea1b4d0979/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/broadsheet/components/article-author/widget&td_bio=false&td_location=none[/img]

  • 6:38PM NOVEMBER 27, 2018

Air traffic controllers complained they could “not raise” a pilot who had fallen asleep during a freight flight from Devonport to King Island.

ATC audio reveals several calls to “Tango Whiskey Uniform”, the call sign of the Piper PA-31-350 Chieftain, operated by Vortex Air.

As The Australian reported yesterday, two investigations are now underway into the flight, which overflew King Island airport by almost 50 kilometresas a result of the sleeping pilot.

The Civil Aviation Safety Authority is investigating whether Vortex Air complied with fatigue management procedures and the Australian Transport Safety Bureau is investigating the “pilot incapacitation” incident.

After refusing to comment, Vortex Air managing director Colin Tucker posted a statement on the company Facebook page.

It said the pilot “unintentionally” fell asleep while in command of the aircraft.

“The issue became apparent when Air Traffic Control was unable to contact the pilot in-flight and the aircraft travelled past the intended destination point while operating on autopilot,” said the statement.

“The pilot safely landed the aircraft at King Island airport.”

It continued on to say the flight was the pilot’s first rostered flight with the company after returning from a period of leave, and “they had declared themselves fit to fly”.

“The pilot was adequately experienced and had previously flown the route a number of times without incident,” the statement said.

“All safety procedures were adhered to and regulatory compliance requirements have been satisfied to date.”

The statement said it was “an extremely rare occurrence as demonstrated by the companies’ excellent safety track record”.

Support was being provided to the pilot to assist them to safely return to full duties, said the statement.

The ATSB’s final report is expected in the first quarter of 2019.


MTF...P2  Tongue
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What will it take to make a Hooded Canary sing?

Reference: http://www.auntypru.com/forum/thread-10-...ml#pid9354

(09-29-2018, 12:39 PM)Peetwo Wrote:  ATSB YMEN DFO FR: More questions than answers -  Dodgy

Not sure how Hoody ever believed that any sane, respecting professional aviator (especially aviators with some time on type) would swallow that bollocks report, is simply beyond me...  Huh

Anyway to add to the "K" curiosities from above, the following is from Sandy off one of the AP email chains:

Quote:Just read the Essendon Kingair report. I did not see any follow up on this strange elevator trim setting. Anyone any thoughts? What would happen if there was a loss of direct elevator control?

Quote from the report:-

Quote:Elevator trim


Both the left and right elevator trim actuators were found in a position that equated to a full nose‑up trim position. “
      
And from Grogmonster off the UP a similar (amongst other) curious OBS: https://www.pprune.org/pacific-general-a...st10261266
Quote:Hi everyone,

I want to stay clear of nasty politics and deal with facts so I have a couple of things to add / ask and I will let you guys carry on.

1. Has anyone looked at the NTSB report on the Wichita, Kansas B200 crash? Its very similar.
2. Has anyone considered that the elevator trim in this incident was found fully nose up but attributed to impact forces and yet impact forces have been discounted with regard to the rudder trim. Why???
3. From personal experience I can tell you that a loose friction nut rollback will leave approximately 600 ft lbs of torque in play hence the ," producing power condition," of the left engine.
4. Systems knowledge here. If you have a failure of the instrument bleed air valve in the "off" position on say the right engine the rudder boost system would sense a lack of reference air from the right engine therefore assuming an engine failure and it would cause the rudder boost to activate and the aircraft would want to veer into the opposite engine. In this scenario the pilot could possibly wind in a heap of rudder trim to compensate or reduce power on a good engine or a combination of both. Confused????
5. A lot of conclusions have been drawn from the state of the wreckage however a lot of change, trim or power lever movements, could have been happening in the cockpit in those short seconds before impact.

I shall leave you guys to it and I look forward to the comments.

Groggy

I also note this (like-minded OBS) post from Propsforever:

Quote:And once again from me:

If you Keep a B200 with 2 Engines running below 160ft, after 5100ft distance you are going the better of 160kts even with the gear down.
If you Keep the Speed below 110kts, which almost no one would do ( read below), the Ship would climb at an insane angle.

In Europe, "Norwegian Air Transport" trains to climb at V2. Everybody else i know, trys to get to Cruiseclimb as fast as possible. To build up some kinetic Energy and to pass 121KT= V2 Flaps up, to raise the flaps (( 1% mor Gradient)), wich happens usually around 50ft AGL

Unfortunatly the B200 i fly is in Maintenance/Repair, otherwise i would try the Scenario at an safe Altitude and Report.

Slighly Off Topic, but related to the Accident:
The reason i dont like to climb with V2 on an 2 Engine Departure is: You are maintaining an Pitch Attitude of give or take 20degr. @ 121KTs clean( Stall Speed 100kt ...). Now one Engine quits and you Need to decrease your pitch to 10degr. while the Aircraft is getting slower and trying to roll on its back. All the Odds are against you in this Scenario.

Every knot of Speed you carry more is just safety! If you climb out with 10degr. you do 160kts, the recommended Cruise climb.

If you loose an Engine above V2se, just maintain Pitch - Keep Directional Control, wich is easier because of reduced Torque effects - Clean up - Check Autofeather in Progress and relax!

I just dont buy the conclusion of this Accident Report. It might even happened that the Pilot has put the trim in the wrong direction while airborne. I have seen this happen with unexperienced Copilots, until it settled into them wich direction to turn. Usually they werent used ( or trained) to work the Ruddertrim and where at first annoyed to get ordered to trim "all the time".

[Image: figure-9.jpg]

Hmm...much like the ATR in picture above, was there any possibility that VH-ZCR was structurally compromised/damaged prior to this accident?

Quote:..At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines[4] before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal...

Wonder if we could get a copy of the CCTV footage of the pilot doing the walkaround?  Rolleyes

Reference: #SBG 16/12/18 - https://auntypru.com/setting-the-odds-and-playing-em/

Quote:Can’t be long now before the Hooded Canary sings?  [Image: rolleyes.gif] 



Quote:“The other point I might add is the ATSB is very much the canary in the mine—and let me tell you, we will sing. But we’re not going to sing prematurely, and we’re not going to sing without the evidence to sing appropriately. You may be aware, from the other committee, of our report on the ATR aircraft. We have formed a strong view in relation to that aircraft. We published two interim reports and we’ve got a third one coming. So, we’re not afraid to exercise that authority and have our say when we think it’s appropriate.”  ―  ATSB Chief Commissioner Greg Hood, 29 August 2017.

Okay so how much would it take for the Hooded Canary to sing on the bollocks ATSB DFO cover-up report where our ATSB Chief Commissioner came out and effectively defamed a dead pilot: ref - https://www.atsb.gov.au/publications/inv...-2017-024/
Quote:[Image: 10297838-3x2-940x627.jpg]
ATSB boss Greg Hood

Posted 24 Sep 2018, 11:11am
Mr Hood said the pilot had five opportunities to pick up the error that led to the crash.
ABC News: James Oaten





After consultation with the BRB, Aunty Pru has tasked the AP editorial team to enlist expert advice and opinion from within the PAIN membership to peer review what appears to be yet another attempt by the Greg Hood led ATSB to slate all blame and liability on a dead pilot in order to shutdown/obfuscate proper scrutiny of the Essendon DFO accident final report.

MTF? - MUCH! P2  Cool
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Strange dissonance in the Hooded Canary's coop? - Part II

References:

1)

(01-18-2019, 09:56 AM)Peetwo Wrote:  ...There is also the fact that the Wichita accident was not even included as a 'related occurrence'. This apparently was because it did not fit the ATSB hypothesis that the sole cause of the DFO accident was the pilot Max Quartermain's lack of checklist discipline which led to him not identifying that the rudder trim was fully deflected to the left prior to take off - UDB!  Dodgy

Okay, even with the total lack of physical evidence/proof that this was the case, if we take the examples used to paint the commonality in lack of 'checklist discipline' causal to these occurrences, why then is not the classic accident for these type of human factor pilot error and lack of SOP discipline included in the accident report related occurrence list? Of course I am referring to, the much publicised and commonly referred to by a multitude of AAI Human factors experts, the Runway Overrun During Rejected Takeoff of G-IV - https://www.ntsb.gov/investigations/Acci...R1503.aspx - on May 31 2014?

Even the CASA Flying Safety publication did an article on this occurrence: https://www.flightsafetyaustralia.com/20...nto-error/

Quote:THE NTSB SAID, ‘ALTHOUGH ONE OF THE PILOTS COULD HAVE COMPLETED ONE OR MORE OF THESE CHECKLISTS SILENTLY, THE PILOTS DID NOT DISCUSS OR CALL FOR ANY OF THESE CHECKLISTS, EXECUTE ANY OF THE CHECKLIST ITEMS USING STANDARD VERBAL CALLOUTS, OR VERBALLY ACKNOWLEDGE THE COMPLETION OF ANY OF THESE CHECKLISTS.’


Also of interest: .... a few terse words revealed the immediate cause of the crash.


At 21.39.59 the pilot said, ‘Steer lock is on,’ a remark he repeated six more times in the remaining 20 seconds of the flight. Fourteen seconds later he said, ‘I can’t stop it’.

There was no other discussion of the situation and the only other words before the recording stops were one of the flight crew saying, ‘Oh no, no’ as the aircraft sped towards the ravine that would trap it. Fire broke out ‘almost instantaneously’, in the words of a witness...
   
 I can only assume that the ATSB regarded the GIV Massachusetts accident as not relevant because it was a multi-crew jet accident and not a single pilot B200 or equivalent turboprop accident? In other words it did not again fit the Hooded Canary's singular causal slice of Swiss cheese. Which is a pity because there is much to take away from the GIV prang especially under the safety recommendation part of the report: https://www.ntsb.gov/investigations/Acci...c=A-15-034

Quote:...The NTSB determines that the probable cause of this accident was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.

Recommendation: TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.
 
Ah yes, unless it is absolutely positively PC and won't have any blow back for the miniscule, the Hooded Canary's flock, unlike the rest of the 1st world AAI organisations, doesn't do safety recommendations and I guess that includes reading the ones from peer organisations like the NTSB? - FDS!  Angry 
 

2)

(01-19-2019, 07:12 AM)Kharon Wrote:  ...The Essendon crash deserved the ATSB’s very best efforts; it could have been a serious disaster, with magnified ramifications. Yet it was quickly concluded that it was all pilot error, nothing to see and the ATSB would concentrate on whether the building measured up to ‘Black letter’ approval. For starters, ATSB are not in the ‘airspace game’ nor are they forensic legal experts on ‘approval’ to build, particularly in light of the convoluted processes used. So why was the aircraft and pilot quickly dismissed in favour of some half-baked ‘investigation into what Hood claims was a ‘life-saving’ building. It’s bollocks – ATSB’s job is to tell us, as best they can, from the charred remains – why this aircraft crashed and claimed five lives; difficult as that maybe... 


&..from this Airports thread post: A duty of care. - Part II

3)

Quote:Patrick Hatch article: ..The Australian Transport Safety Bureau found that pilot error was to blame, but while looking into the crash, decided to launch a separate investigation into how the DFO complex was approved "from an aviation safety perspective".

That probe is nearing completion, with its final report currently out for review by the parties involved ahead of its public release...

A quick check from the ATSB aviation investigation webpage does seem to indicate a recent update to the DFO approval process investigation (AO-2018-010: https://www.atsb.gov.au/publications/inv...-2018-010/

Quote:Investigation number: AI-2018-010
Status: Active  Investigation in progress
Phase: Final report: External review

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
Investigation level: Complex
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre

Investigation phase:
Final report: External review
State: Victoria
Report status: Pending
Expected completion: 1st Quarter 2019

Last update 11 January 2019




Final report: External review phase

To check factual accuracy and ensure natural justice, Directly Involved Parties (DIPs) are given the opportunity to comment on the final report before it is approved to ensure their input has been accurately reflected.

DIPs are individuals or organisations outside the ATSB who possess direct knowledge of the circumstances surrounding the incident or accident. DIPs can only comment on the factual accuracy of an investigation, not its analysis and findings.

This process is consistent with international transport safety investigation conventions, including those published by the International Civil Aviation OrganizationInternational Maritime Organization as well as the Transport Safety Investigation Act 2003. DIPs are provided from five to 28 days to provide their comment and present evidence in support of their comments. This timeframe can be extended to allow DIPs based overseas to provide comment.

Feedback from the DIPs could prompt an investigation to return to the evidence collection, examination and analysis, and report drafting phases of an investigation.

Final report: Approval phase
Following the DIPs process, the report is approved by management before being sent to the ATSB Commission for final approval. Once approved, the final report is prepared for publication and dissemination.

Although the expected completion is quoted as being in the 1st quarter of 2019, to suggest that the investigation is nearing completion is  laughable when you consider the investigation into the VARA ATR broken tail accident has been stuck in the external review process for nearly 2 years (see - https://www.atsb.gov.au/publications/inv...-2014-032/ ). Even then the final report still has to be approved by the ATSB management, PC'd by the commissioners and again run by the DIPs before finally being released for industry and general public dissemination.. Dodgy

Quote:Final report: Dissemination phase
Once an ATSB report is approved, it is released to DIPs prior to its public release and approved safety issues and recommendations are formally communicated to the relevant parties. The report is then released publicly on the ATSB website and communicated on social media channels. The progress of safety action to address ATSB recommendations is tracked and communicated, on an ongoing basis, via the ATSB website.

It is important to note that the ATSB does not wait until its investigations are complete or the final report is published to address critical safety issues. If a critical safety issue is identified during the course of an investigation, it is brought to the attention of the relevant parties immediately so that safety action can be taken.

When you read that last statement in italics and then reflect on how the Hooded Canary's ATSB completely glossed over the significance of the DFO complex to the causal chain of the accident, to the point where they even had the mendacity to suggest the building may have been instrumental in saving lives.

Quote:“In the absence of that building, the aircraft’s flight path would probably have resulted in an uncontrolled collision with a busy freeway, with the potential for increased ground casualties,” the report said. 

It is then very hard to believe the veracity and intent of this investigation to potentially mitigate safety risk. Especially when you consider that despite 60+ years of worldwide experience in mitigating public safety risk with inappropriate urban development encroachment around airports, the Hooded Canary's ATSB apparently and bizarrely can't even see the wood for the trees... Confused 

And it is not like the ATSB can't say they weren't warned:



They even had an opportunity in the context of another ATSB investigation which was ironically entitled Building approval process for structures in the vicinity of Australian airports: references - And the YMEN DFO accident fairy tale grows & https://www.atsb.gov.au/media/5774258/ai...-final.pdf :


Quote:The ATSB carried out an investigation four years later in 2013 into the procedures of these decision-making processes. This was done as a response to a REPCON report received in September 2012(P2 comment - bizarrely the ATSB REPCON database doesn't appear to go back to 2012??) expressing concerns a proper safety case was not conducted on the proposal. The ATSB’s Final Report concluded that whilst the procedure was compliant with the Airports Act 1996 and the Regulations, it “did not require the application of risk management principles to the Department’s consideration”. This was highlighted as a safety issue.
 
Which again brings me back to the QON that I then asked in the context of that post:


Quote:The question there is when was this significant safety issue 1st identified? Another question is - why wasn't the 2013 investigation and final report referred to in either the YMEN DFO accident final report; or in the (AI-2018-010) above summary??  [Image: dodgy.gif] 

Note that even back then the ATSB completely ignores the far greater 60+ year safety issue of public safety zones around airports... Huh 

Yet they do intimate that it is the responsibility of both the Minister, his Dept and agencies to effectively mitigate aviation safety risk around airports through the proper ICAO Annex 19 endorsed Australian State Safety Program.


Hmm...MTF me thinks - P2  Tongue
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YMEN DFO accident - Hooded Canary cover-ups & libelous disconnections?

Off the Airports thread:

(01-23-2019, 08:36 PM)Gobbledock Wrote:  Aeroplanes can ruin your stock....

Spotlight has teamed up with a group of Essendon Airport DFO retailers to sue the owner of a plane that plunged into the shopping centre, killing five people on board and ruining more than $6 million worth of stock. More here;

https://www.theage.com.au/national/victo...50t3z.html

Quote:Spotlight chases crashed DFO plane owner for millions in ruined stock
Tom Cowie


By Tom Cowie
23 January 2019 — 7:40pm


Spotlight has teamed up with a group of Essendon Airport DFO retailers to sue the owner of a plane that plunged into the shopping centre, killing five people on board and ruining more than $6 million worth of stock.

A volley of writs filed in the Supreme Court in the past week continues the legal fallout from the crash, after the families of the four American tourists killed in the disaster said they planned to sue the dead pilot's estate for millions of dollars over the February 2017 tragedy.

[Image: 9f5cfc36b0c16bebda085b979ae08bbe3f6c62ed]

And from off the UP SIUYA makes this prediction: https://www.pprune.org/pacific-general-a...st10368964

Quote:Pinky asked does anyone else hear what appears to be the sound of lawyers sharpening their knives?


There's absolutely no 'appears' about it at all Pinky [Image: icon25.gif]

See:

https://www.theage.com.au/national/v...23-p50t3z.html

which refers back to:

https://www.theage.com.au/national/v...24-p505n0.html


It's going to get VERY VERY ugly (and VERY VERY expensive) I think.

Which all points to some serious, possibly nefarious negotiations going on behind closed doors - this is what's at stake:

Quote:P9: ..CASA are up their collective Hocks in the approval of this building as are the DoIT. Many rice bowls to protect and ‘alliances’ to maintain; not to mention the big money interests. Not one of these outfits can afford the slightest whisper of culpability in allowing this DFO to be built where it is. Hell I can just about hear the insurance legal Eagles sharpening their talons and beaks from here – as a counterpoint to the tramping of politicians feet as they head for the exits, dragging their safety nets and golden parachutes with ‘em...



The Age: ...The companies based at DFO claim in court documents that a lawyer representing BB1544 Pty Ltd had already admitted liability for loss, damage and destruction caused by the accident...




P9: Yet responsibility for the investigation rests on the shoulders of the Hood ATSB. Am I worried? – Oh, you bet I am. I doubt I’d trust Hood as far as I could kick him, given the chance. This is a matter of great importance – Australia trails the world best practice by 60 years; the development around airports since privatisation has been uncontrolled. The Essendon DFO accident was a wake-up call; the investigation needs to be independent, unimpeachable, free from any hint government agency involvement. A Royal Commission working with the USA ‘code’ as a guide would reveal the unprecedented ‘risk’ Australians live with in the vicinity of aerodrome ‘high risk’ areas. 


We were very, very lucky at Essendon – got off very lightly. The worst case scenario at Essendon would have seen Australia’s very worst ever aviation disaster. Is Hood the right man to entrust with this task? 

However putting the legal liability bun fights aside what we here at Aunty Pru are pretty determined to do is to continue to point out the aberrations and disconnections of the Hooded Canary's attempted cover-up report.  

So back to TORs... Shy

Ref: https://www.atsb.gov.au/media/5775076/ao...nal_v2.pdf

Quote:Power lever roll back (creep)

Throughout the investigation, the ATSB spoke with numerous B200 pilots who highlighted the
importance of ensuring power lever frictions were adequately tightened prior to take-off. In their
experience, if inadequate power lever friction was set, the power levers could ‘creep’ back from
the full-power position when the pilot removed their hand from the levers after take-off.
If power lever movement is not noticed, the aircraft may not climb and accelerate normally, and
rudder force may be required to keep the aircraft straight. In addition, the auto-feather system will
be disarmed if either power lever moves back past the ‘90% engine’ speed position (refer to
section titled Autofeather system below).

Having some time on type, I can confirm that the friction nut issue can be a minor trap for new players. In the conduct of any normal take off this should not have been an issue because this is not a multi-crew aircraft, therefore the pilot's right hand should be on or near the power levers until setting climb power. However credit to the ATSB investigators that this aircraft ergonomic deficiency was at least explored in order to try to understand why the aircraft did not accelerate normally for a supposedly 2 engine fully powered take off.

This brings me to the next segment of the Hooded Canary's cover-up report:    

Quote:B250 flight simulator In order to determine the effects of full left rudder trim on take-off and climb performance, a flight was performed in a King Air 250 Level D flight training simulator25. The simulator performance was similar, though not identical to ZCR. The accident weather, airport location and maximum take-off weight were used to make the flight conditions as similar as possible to the accident flight. The pilot who performed the flight commented that:

Quote:The yaw on take-off was manageable but at the limit of any normal control input. Should have rejected the take-off. After take-off the aircraft was manageable but challenging up to about 140 knots at which time because of aerodynamic flow around the rudder it became uncontrollable. Your leg will give out and then you will lose control. It would take an exceptional human to fly the aircraft for any length of time in this condition. The exercise was repeated 3 times with the same result each time. Bear in mind I had knowledge of the event before performing the take-offs.
 
The pilot also stated that it could be possible for a pilot to misinterpret the yaw as being caused by an engine power loss rather than from a mis-set rudder trim.

Besides the fact that the accident aircraft never got anywhere near 140 kts, my first question is, why didn't the ATSB get the simulator pilot to try to fly the sim with a torque rollback scenario? 

Next... "Should have rejected the take-off" ...that statement of fact is IMO a question that is not satisfactorily explored? 

Next... "Your leg will give out and then you will lose control. It would take an exceptional human to fly the aircraft for any length of time in this condition" ...it would appear that there is no appendix report on the findings of the simulator exercise? So how long was it before the pilot's leg gave out?

From here I'll 'hand over' to Old Akro to further highlight the suspect parts of this IMO half-arsed attempt to simulate all possible scenarios that may have been causal to this accident:
Quote:
Quote:I suspect that ATSB policy may not permit them to take a real aircraft outside the envelope. To have done testing with less than full NL trim may not have had sufficient validity - particularly whilst the fin remained unstalled.

Firstly, FGD. I disagree strongly with you, but do respect that you apply intellect & logic. 

But, a) simulators are commonly used to reconstruct accident scenarios. Its clear that the ATSB didn't do this. and b) we don't know what they did because they haven't provided any details in the report (unlike for example the Partenavia report). But the SIM flying they did and the conclusions they reached are from airspeeds outside that flown by the accident aircraft and therefore, invalid. 

You don't need to fly "outside the envelope" to test a hypothesis and I think the 1978 Partenavia report demonstrates this nicely. in this instance, the ATSB took a real aeroplane that was identical to the crashed one and had a pilot experienced on type fly it. The pilot flew a predetermined flight test that consisted of flying a range of different airspeeds at each of the marked trim settings. The control forces were measured at each airspeed / trim combination. When the pilot approached the limit of comfort of control-ability of the aircraft, he stopped and didn't proceed to the next trim setting / airspeed. 

If this testing was possible and warranted for the last trim related fatality, why wouldn't it be now?

A 1 hour flight, 2 brake pedal force transducers, a motec logger and this topic would have been nailed and if it was the smoking gun would have obviated the need for the whole sideslip calculation mess. 

The ATSB has not provided any firm evidence either in terms of statements from the manufacturer, interviews with other B200 pilots or flight test data to support its assertion that the aircraft was not controllable with full left rudder trim. If full left rudder trim can be counteracted by foot application of right rudder, then there is another factor at play (which may better fit the long take-off run which the ATSB has conveniently glossed over). 

The B200 aircraft certification requires that the pilot is able to counteract full elevator trim. There is no similar requirement for rudder trim, although someone pointed to another requirement that infers this. I would question whether full rudder trim leading to loss of control of the aircraft was diligent "fail safe" design. 

The whole premise of the report is therefore based upon speculation.

HEAR!..HEAR! Old Akro... Wink


MTF...P2  Cool
Reply

Old Acro has probably missed the point in using the flight tests following the Essendon PN68 disaster in 1978 as these tests were supposed to prove that the Pilot did it!  The report came out a week or so before the inquest, however the Coroner chose to believe the Pilot over the Departments theory that the Pilot had unknowningly applied nose down trim.

The reality is that the “Department” actually had previously failed to comply with their own requirements for the certification of the Autopilot/Trim system by not obtaining copies of the flight test results as their own Regulations stated! In fact the only authoritative flight test available was not carried out until 17/2/1989 after another PN68 had a trim runaway at Moorabbin!

The department's report also failed to report that the aeroplane actually had a trim setting other than as certified! Even so, FAR 23-143c states that the maximum force required to overcome a trim runaway is 75 lbs. So I can personally testify that the Department has a history of issuing accident reports that try to cover up their own shortcomings
Reply

ICAO - the great bastion of folly

Hood the canary is an embarrassment. A two-bit recreational pilot who worked as an ATCO (nothing wrong with that role by the way) and then climbed the great slippery pole to dizzying heights at CAsA and Airservices before finally being rewarded for his ability to spin, duck, weave and obfuscate - congratulations son, King of the ATsB for you! Enjoy your reward. BOLLOCKS. A mere, queer muppet, who spends his days protecting the Miniscules ass. That’s his role. Prior to the Canary was the nauseating beard on/beard off farkwit accountant, Beaker. A career bureaucrat having never worked in the real world, let alone a complex outfit like the ATsB. Hell, the bearded buffoon actually thought his own version of investigative methodology - Beyond Reason, was more reliable than that of Professor James Reason, the king of root cause and causal investigative methodology. Ha! What an arrogant, narcissistic bucket of pond dross. You need an Alan Stray steering the ATsB ship, an experienced reputable leader who knows his shiznik.

ICAO is a guilty party. Where is their concern over the disgraceful Pel Air investigation? Where is their concern over the disgraceful Lockhart River investigation? Where is their concern over the botched, ridiculous MH370 investigation? Where is their concern over the ludicrous ‘the pilot did it’ investigation of the DFO B200 accident? Nope, all we got was Thor, the trusty ICAO auditor who came to Australia with pen and pencil, lunch box, and strong set of gums for sucking the Australian Governments d#ck.

Absolute pony Pooh for as far as the eye can see. Most days it seems ‘beyond reason’ that the stupidity and folly of the past 30 years is even possible?

Tick Tock
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Flight tests -

P6317 – “Old Akro has probably missed the point in using the flight tests following the Essendon PN68 disaster in 1978 as these tests were supposed to prove that the Pilot did it!”

Alan, I think Old Akro was driving a different nail; your point is valid though – at least the flight tests were carried out ‘in the aircraft’. I’m no expert on how simulators are ‘set-up’ – the ‘top-end’ jobs on the serious aircraft bear some realistic semblance of the aircraft – within the limitations of the data plugged into the boxes. Further down the ladder however, I am informed that ‘realism’ only extends as far as the ‘programmed’ limitations. Which is all well and good for procedures and systems training, great in fact: but it is usually a fair way away from the edges of the ‘envelope’. Once again – fair enough – limitations acknowledged; no harm done. On a purely personal level – I have no use or time for the ‘artificial’ however I can understand and applaud the logic and of using simulator training. Effective and economical – no argument.

My argument begins when the likes of Hood attempt to ‘simulate’ a real life situation – like Essendon in a unit which has probably had the certification data envelope ‘trimmed’ and modified to suit the ultimate purpose of the simulator. Perfectly reasonable for ‘normal’ training operations. But – the conclusions drawn from the DFO ‘simulator’ exercise can only be considered as flawed – within the limitations of the ‘programming’.

It would, operationally, be a simple matter to simulate the Hood scenario in a real aircraft; at a ‘safe’ altitude with zero risk. I’d bet beers that the average pilot could within a few second return the trim control to neutral – remember, the situation become less critical with every turn of the trim knob – the load lessens. Quick glance at the engine gages – Nope all’s well; then a quick check of the trim settings; three rapid half turns on the knob – spend the next 10 minutes cussing your slack checks. The Be20 rudder becomes effective at about 40 knots – you would immediately (in the aircraft) note (a) the off centreline direction of travel and (b) the increased pressure on your boot – tyre blown? (nope No noise) – WTF?- Engines good OK - check trim – fix before 50 knots. Easyology.

This was an experienced on type pilot – fresh out of a retraining session.  

P6317 - “[however] the Coroner chose to believe the Pilot over the Departments theory that the Pilot had unknowingly applied nose down trim.”

Well done that Coroner; I wonder, will the DFO chap (or chapess) be as ‘savvy’. There are a couple of very good questions which, in the spirit of obtaining a fair verdict, should be asked; to wit.

1) Where is the missing part of the control locks?

Traditionally; the three part ‘lock-pins’ are bound together by a stout wire. The ‘rudder lock’ pin is a ‘L” shaped thing which is poked into a hole in the floor, thus locking the rudder. Was this not tethered to it’s sister parts? It is not unknown for this awkward ‘pin’ to be separated from the others. There is a sizable ‘slot’ in the aircraft floor which allows rudder pedal travel. I begs the question – had this item somehow wriggled down the slot and locked a rudder pedal. It has not been found and yet it is, as they say, a ‘thing’ of great interest.

2) Why was the take-off not abandoned as soon as a directional control problem was noted?

Had the directional control problem presented early, then why, unless the reason was known and deemed to be better dealt with airborne, would a pilot continue – with plenty of runway ahead? Don’t make sense – and the ATSB have done little to make sense of it all.

Dangerous muddy waters to be wading through, waist deep. Do we have to force yet another Senate Inquiry to enquire, yet again into the ATSB sliding the facts to suit? I hope not. But, it seems we must, once again, roll the dice.

Sat outdoors; testing the new bench seat (certification and safety check of course) a fresh cold Ale and half a cigar to cheer a cooler evening. Cheers.
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Hooded Canary's search 4 IP in 2019?

References:

(01-31-2019, 11:20 AM)Peetwo Wrote:  ...Given that it is approaching February it should be safe to assume that the Hooded Canary and his minions are all back on deck. Therefore now would be a good time to start trolling through the ATSB Aviation investigation web page records to see where the higher profiled and complex O&O'd investigations are at.

Since it was the last post on here, let's start with the tragic Rossair Conquest training accident. Although the webpage lists a recent update visit - Last update 14 November 2018 -  there does not seem to be any added additional information since the prelim report - see here:  https://www.atsb.gov.au/publications/inv...-2017-057/- and the progress of the investigation is still listed as - Phase: Examination and analysis.

Quote:Examination and analysis phase

The cause of a transport safety occurrence or safety issue is often multilayered and complex. ATSB investigators aim to use the collected evidence to build a detailed understanding of the circumstances surrounding a transport safety occurrence or issue.

During this phase, evidence is reviewed and evaluated to determine its relevance, validity, credibility and relationship to other evidence and to the occurrence. ATSB investigators may:

- undertake detailed data analysis
- create simulations and reconstruct events
- examine company, vehicle, government and other records
- examine selected wreckage in the laboratory and test selected components and system
- research scientific literature related to human factors associated with the evidence
- review specialist reports (such as meteorology, component examination, post-mortem report and toxicology reports)
- conduct further interviews, and
- determine the sequence of events.

Examination and analysis requires reviewing complex sets of data, and available evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined, potentially adding to the length of an investigation.

Not sure what the hold-up could possibly be but unfortunately it is pretty safe to say that this AAI will pass by the 2nd anniversary of this tragic accident.

Quote:[Image: ao2017057_figure-2.jpg?width=463]

..On-site examination of the wreckage and surrounding ground markings indicated that the aircraft impacted terrain in a very steep (almost vertical) nose‑down attitude, and came to rest facing back towards the departure runway...

Note: While the ATSB (for whatever reasons) continues to O&O this accident, I have been informed that there are PAIN associates that are starting to ask serious questions about this accident and in particular what could have caused the aircraft to go from being in stable flight to inverted and diving near vertical from a height of 600ft AMSL.

Ref: Update 09 June 17: Byron Bailey OP.

Quote:P9 - Casa DICTATED ‘Blue line’ fever strikes again?  I know, I know, wait for the details; but this new ‘regime’ of stupidity – V2 + 10 or a nice fat sandwich of wriggle room – all gone.  When will they realise the SIM ain’t real.

10 minutes sin bin? – OK - sounds reasonable M’lud; thank you – bow – exeunt: at a good clip. .
 

There is also the rather large elephant in the sky surrounding the long standing safety issue of CASA FOI dictated procedures for EFATO/V1 cuts in the actual aircraft...think Darwin Brasilia...think Essendon DFO accident etc..etc.

Next on the O&O list another possibly partly CASA induced fatal GA accident which has just been updated with an 2nd anniversary interim statement: see - https://www.atsb.gov.au/publications/inv...-2017-013/

Quote:Updated: 25 January 2019

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 final report has completed the drafting phase and is now undergoing an internal review.

Final ATSB investigation reports undergo a rigorous internal review process to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

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

Currently, the anticipated completion and publication date of the final report is during the first quarter of 2019.

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



Final report: Internal review
Final ATSB investigation reports undergo a rigorous internal review process to ensure the report adequately and accurately reflects the evidence collected, analysis, and agreed findings of the Safety Factor Review. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

If a review identifies any issues with a report, such as information that needs to be expanded or findings that need to be modified, investigators will look to collect new evidence or conduct additional examination and analysis of existing evidence. P2 - code for PC'ing the Final Report Dodgy

Note: I have been reliably informed that there is a lot more than meets the eye and to play out with this accident investigation... Confused    

 Finally from the Hooded Canary's top draw of high profile O&O'd accidents an update to the Birdstrike/broken tail VARA ATR accident, which saw the aircraft flying with a badly bent horizontal stabilizer for 5 days and 13 sectors after the accident flight  Confused : https://www.atsb.gov.au/publications/inv...-2014-032/ 

Again the web page for this AAI was listed as being recently updated - Last update 20 November 2018 - 

Quote:Final report: External review phase

To check factual accuracy and ensure natural justice, Directly Involved Parties (DIPs) are given the opportunity to comment on the final report before it is approved to ensure their input has been accurately reflected.

DIPs are individuals or organisations outside the ATSB who possess direct knowledge of the circumstances surrounding the incident or accident. DIPs can only comment on the factual accuracy of an investigation, not its analysis and findings.

This process is consistent with international transport safety investigation conventions, including those published by the International Civil Aviation OrganizationInternational Maritime Organizationas well as the Transport Safety Investigation Act 2003. DIPs are provided from five to 28 days to provide their comment and present evidence in support of their comments. This timeframe can be extended to allow DIPs based overseas to provide comment.

Feedback from the DIPs could prompt an investigation to return to the evidence collection, examination and analysis, and report drafting phases of an investigation.

However the progress listing for the investigation seems to be eternally stuck in the 'Final report: External review' phase? Therefore, given the 4th anniversary for this accident is less than a month away, it is highly likely this AAI will go well into it's 4th year of being dormant but active at the same time - UDB!  Dodgy 

Ps P2 comment - When you consider that all three of the above investigations have passed (or shortly will pass) their 2 year anniversaries, kind of makes the bollocks, blame the pilot at all costs, YMEN DFO complex investigation final report an aberration and very, very suspect... Huh

&..

(01-31-2019, 07:37 PM)Kharon Wrote:  Is this

“Sadly, it seems that apart from those directly affected by this accident, no one really seems to care. It would appear to be just another statistic for CASA, ATSB and the Australian Government to ponder on, but to do little to avoid such an accident ever happening again,” Mr Scott’s family said.

Very, very un-Australian Minister?

News Flash – it ain’t; it has become the ‘norm’ along with much other pony-pooh associated with government ‘responsibility’ for public safety. Lot’s of ‘genuine’ talk – little in the way of genuine improvement or even accountable investigation. But, I’m so glad you could interrupt a busy schedule to talk to the Essendon 4 – cup of coffee and a reassurance chat. All will be well, never fear, the man from Wagga-Wagga is here. Ah, the words of a genuine honest man; most reassuring. Bet the local kids could write a load of poems about that, to satisfy your desire for poetical, lyrical twiddles, writ by the local kids. You can give 'em an apple as a token of appreciation - then pray they do not go shopping with Mum in a DFO near you. Bloody Muppet.

On the blotter are several fatal accidents - arguably the direct responsibility of CASA' decisions and edicts. Not that you would understand the complex arguments - but; rest assured, the professional aviation world does. No matter, despite your excellent 'advice' on matters aeronautical to the contrary - those incidents will be examined by 'expert' eyes and a full report forwarded to the Senate RRAT committee in time for the election. The 'press' may even get a look-see before that. Won't that be fun?

P7 reckons you need to fix this, before it fixes your lack-luster 'career'  as a transport minuscule for ever. Albo is panting for the 'report' -I do wonder why though? Anyway......

Toot - (with a very Australian - Up your'es)  - Toot.


Of passing interest "K" was the following Ironsider article in today's Oz that references the Mallard Swan River prang investigation: https://www.theaustralian.com.au/busines...89cdb357c5

Quote:Perth Skyworks crash sparks new rules for Avalon airshow


[Image: 3ded920ffd3ad4b026da32de07039356]

Aerial displays conducted at this year’s Australian International Airshow at Avalon will be conducted under new guidelines introduced in the wake of the fatal 2017 Australia Day crash at Perth’s Skyworks event.

Flyovers have been banned from Perth’s Skyworks Australia Day celebrations ever since.

The Australian Transport Safety Bureau expects to release its final report on the crash — in which the pilot and a passenger died — by the end of March following a rigorous internal review. As part of the investigation, the ATSB examined the approval processes the Civil Aviation Safety Authority had in place for air displays and found differences between civil and military displays and between those held in Australia and in other countries.

That information was then analysed to determine whether there were any systemic safety issues in relation to authorised air displays held in Australia.

The ATSB declined to comment further due to the fact their investigation was ongoing

But CASA confirmed its Air Display Administration and Procedures Manual was updated in April last year following an internal review of the Swan River incident and other air display accidents internationally.

“Changes made to the manual include additional information about regulations, the addition of paragliding/hang gliding launch sites, additional information about approvals, rewording the risk assessment guide and additional communications requirements,” a CASA spokeswoman said. “The regulations also state that an air display shall not be conducted without the written approval of CASA.”

She said in the case of larger events such as Avalon, where there was controlled airspace, Airservices Australia provided a safety analysis that was reviewed before the airshow.

City of Perth commissioner Eric Lumsden said the future of flyovers at the annual Skyworks show was riding on the ATSB investigation and the response from federal authorities, including CASA.

“Notwithstanding the investigation still has to be concluded, we would not have any chance of getting approval until they are also satisfied that public safety is assured. At the end of the day it’s not our call,” Mr Lumsden said.

He remained hopeful the flyover component of the Skyworks show would be reinstated for next year’s Australia Day.

“We’re always reviewing activities for the coming year,” said Mr Lumsden, who conceded the ATSB report on the 2017 crash was “taking a while”.

“If it was possible, we wouldn’t close off the option.”

A previous update by the ATSB ruled out pilot incapacitation and aircraft serviceability as contributing to the G-73 crash.

Instead, the investigation was focusing on “further analysis around the aircraft performance and operational factors as well as a review of the planning, approval and oversight of the air display”.

The Australian International Airshow at Avalon runs from February 26 to March 3.

Huh - Spot the disconnections -  Huh 

Standard ATSB bollocks from the investigation page:

Quote:...Should any critical safety issues emerge during the course of the investigation, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations. This will allow those authorities and organisations to consider safety action to address the safety issues. Details of such safety issues and any safety action in response will be published on the ATSB website at www.atsb.gov.au...

And from the Ironsider article:


Quote: ...As part of the investigation, the ATSB examined the approval processes the Civil Aviation Safety Authority had in place for air displays and found differences between civil and military displays and between those held in Australia and in other countries.


That information was then analysed to determine whether there were any systemic safety issues in relation to authorised air displays held in Australia.

The ATSB declined to comment further due to the fact their investigation was ongoing

But CASA confirmed its Air Display Administration and Procedures Manual was updated in April last year following an internal review of the Swan River incident and other air display accidents internationally.

“Changes made to the manual include additional information about regulations, the addition of paragliding/hang gliding launch sites, additional information about approvals, rewording the risk assessment guide and additional communications requirements,” a CASA spokeswoman said. “The regulations also state that an air display shall not be conducted without the written approval of CASA.”


Extract from the (presumably extended? - see para 14.1 pg 8 here: https://www.atsb.gov.au/media/5542380/CA...ch2015.pdf ) 2015 MoU between the ATSB and CASA:

Quote:6 COOPERATION IN RELATION TO COMMENCING AND CONDUCTING
INVESTIGATIONS


6.1 If the ATSB commences an investigation into an aviation transport safety matter
under the TSI Act, with an investigation classification of major, level 1, level 2 or
level 3, it will notify CASA as soon as practicable.

6.2 If the ATSB commences an investigation into an aviation transport safety matter
under the TSI Act, with an investigation classification of level 4 or 5, it will notify
CASA in a weekly report.

6.3 If CASA commences an audit, surveillance operation or investigation that relates
directly to a matter the ATSB is known to be investigating or an unresolved
safety issue identified by the ATSB in an investigation and notified to CASA,
CASA will inform the ATSB as soon as reasonably practicable.

6.4 Where CASA is aware of a matter that has the potential to require compliance
or enforcement action, it will seek to initiate audit, surveillance and
investigation activities under the CA Act to obtain evidence without waiting for
the findings from the ATSB’s investigation into the same matter.

6.5 Both agencies will seek to accommodate requests for assistance from one
another involving the exchange of expert personnel. An agency seeking to
accommodate such a request will take into account the matters in Attachment
2, as well as matters involving the safety benefit, legislative requirements,
available resourcing, internal policies and the manageability of potential
conflicts of interest arising from the exchange of personnel.

6.6 Where assistance of the kind mentioned in 6.5 is provided, each agency will
seek to ensure it does not impose an unreasonable financial impediment on the
other agency providing the assistance.

6.7 Each agency will consult with the other on the development of its policies for
engaging staff from the other agency to provide assistance in the performance
of their statutory functions.

P2 comment: Note how after the ATSB PelAir cover-up report MKI and the subsequent Senate Inquiry, there is not one reference to 'parallel investigations'? Rolleyes

Quote:During the investigation of the occurrence, the ATSB has examined the sequence of events leading up to the occurrence, aspects of the air display coordination, as well as the regulations, procedures and guidance relating to Civil Aviation Safety Authority (CASA)‑authorised air displays. This has included:
  • approval processes for several years of the Perth Australia Day Sky Show air display and for other air display events across Australia

  • the applications to conduct air displays, from this event and others across Australia

  • Air Display Safety and Administrative Arrangements manual (in use at the time of the occurrence) and the revised Air Display Administration and Procedure Manual (published September 2017). This manual provides guidance to CASA and the air display organiser

  • surveillance and oversight of air displays.
The ATSB has also examined the Aircraft Accident Report AAR 1/2017 – G-BXFI, 22 August 2015 that was published by the Air Accidents Investigation Branch United Kingdom.[1] In summary:

At 1222 UTC (1322 BST) on 22 August 2015, Hawker Hunter G-BXFI crashed on to the A27, Shoreham Bypass, while performing at the Shoreham Airshow, fatally injuring eleven road users and bystanders. A further 13 people, including the pilot, sustained other injuries.

Preliminary analysis of this information has identified differences in the approval process within CASA, between civil and military (including combined) displays and between Australia and other countries. The ATSB is continuing to analyse this information, to determine whether there are any systemic safety issues in relation to authorised air displays.


Presumably, not long after the 22 September 2017 update (above) the CASA conducted a parallel...err cooperative investigation and in the process has identified a critical safety issue of it's own totally independent (not parallel -  Shy ) of the ATSB? Which begs the questions; 1) why the ATSB has not identified the same CSI and subsequently issued a safety recommendation to CASA and other affected parties? and; 2) why do we actually need the ATSB?

On a supportive note for QON 2, I note that recently the ATSB discontinued an systemic issue investigation:


Quote:Published: 18 January 2019

Discontinuation notice

Section 21 (2) of the Transport Safety Investigation Act 2003 (the Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 19 November 2015, the ATSB was notified of an occurrence involving an Airbus A321, operated by Jetstar Airways. During take-off on 29 October 2015, the flight crew encountered difficulty rotating the aircraft.[1] A subsequent passenger count found that passengers had not been allocated seats in accordance with the aircraft’s weight and balance requirements, making the aircraft nose heavy.

The ATSB initiated investigation AO-2015-139 on 23 November 2015. Later, the ATSB became aware of three previous events involving the same operator. They were initially investigated as related occurrences as part of AO-2015-139. On 8 September 2017, due to the common factors involved, the ATSB changed the investigation type to a safety issues investigation and it was re‑numbered AI-2015-139. A fifth occurrence, also involving the same operator, was added to the investigation scope in October 2017. A summary of each occurrence is provided at the end of this notice.

On these five separate occasions, and probably others, aircraft were loaded with incorrect passenger distributions or with incorrect passenger numbers used to determine the aircraft's weight and balance. This placed increased operational pressure on flight and cabin crews and, on at least one occasion, adversely affected aircraft performance during take-off. Records show that there were other flights where erroneous passenger loading was discovered before pushback.

Four of the occurrences followed the introduction of a new type of mobile boarding manager (MBM) device used to scan passenger boarding passes and tally the passengers as they boarded. In each case, technical faults and/or erroneous operation of the MBM led to incorrect passenger loading information being provided to flight crews. On two of those occasions, passenger seating allocations were erroneous after a late change of aircraft type.

The ATSB obtained and analysed a large amount of evidence, mostly information from the operator, and interviewed relevant operational personnel during the initial occurrence investigation. However, there were significant and ongoing difficulties in obtaining documentation associated with the project to introduce then new MBM in 2015 and some related matters.

The ATSB strives to use its limited resources for maximum safety benefit and considers that:

- The operator’s organisational context has significantly changed in the 3 years since the investigation began, likely making some of the organisational aspects of the investigation no longer relevant.

- The operator conducted internal safety investigations into the relevant occurrences, and there is significant overlap between the operator’s findings and the ATSB’s provisional findings. The operator has taken action to address those issues in regular consultation with the Civil Aviation Safety Authority.

- The potential safety issues identified to date provide only limited benefit to the greater aviation industry.
Significant further investigation work would be required to obtain sufficient information to develop provisional investigation findings into safety issues that meet the ATSB’s standards for rigour and defensibility.

- Based on the available information, the risk controls currently in place and the operating context, the ATSB considers any undetected passenger loading problem associated with the identified limitations were very unlikely to have a significant operational impact.

- Consequently, the ATSB has discontinued this investigation, and will communicate all additional provisional safety issues and learnings to the operator to reduce future risk. These included limitations in the management of passenger load discrepancies and late aircraft changes, support for concourse staff, management of the then MBM development project,[2] and the framework for operational change. The investigation information collected and analysed to date remains available as reference material for future ATSB investigations.

Summary of occurrences

- On 16 June 2015 an Airbus A321 registered VH‑VWY was being prepared for a flight from Sydney, New South Wales (NSW), to Hobart, Tasmania, after the scheduled Airbus A320 aircraft became unavailable. After the passengers had boarded, the flight crew identified that the aircraft was loaded too nose heavy for take-off, because the passenger distribution in the cabin was too far forward. To balance the aircraft, the captain ordered the underfloor cargo to be rearranged in a manner that contravened the aircraft’s loading requirements and then continued the planned flight. It was later established that passenger seating allocations had been determined using the seat map for an A320 instead of an A321.

- While processing passenger data after an Airbus A320 registered VH‑VFQ departed Brisbane, Queensland for Newcastle, NSW on 6 October 2015, ground staff discovered a passenger count discrepancy between the final boarding report and the central check-in computer. The flight crew were contacted and an in-flight passenger count found that 15 more passengers were aboard than accounted for during pre-flight planning. This affected the flight crew’s weight and performance calculations, but the minor effect of the increased weight had not been noticed by the crew on take-off. The flight crew amended the calculations prior to approach and landing.

- During a flight from Brisbane to Melbourne, Victoria on 19 October 2015, the crew of an Airbus A320 registered VH‑VQG identified a passenger count discrepancy after a cabin crewmember mentioned the large number of passengers on board to the flight crew. They found that 15 more passengers were aboard than accounted for during pre-flight planning. This affected the flight crew’s weight and performance calculations, but the minor effect of the increased weight had not been noticed by the crew on take-off. The flight crew amended the calculations prior to approach and landing.

- On 29 October 2015, an Airbus A321 registered VH‑VWT was being operated from Melbourne to Perth, Western Australia, after the scheduled Airbus A320 aircraft became unavailable. During take-off, the pilot flying needed significantly more control input than normal to rotate the aircraft. After conducting a passenger count, the crew found that the passenger distribution in the cabin was too far forward, making the aircraft nose heavy. The crew moved six passengers to the rear zone for the remainder of the flight, and amended the weight and balance calculations prior to approach and landing. It was later established that passenger seating allocations had been determined using the seat map for an A320 instead of an A321.

- While processing passenger data after an Airbus A320 registered VH‑VGR departed Sydney for Melbourne on 23 October 2017, ground staff discovered an unusual discrepancy between the provisional and final boarding reports. The flight crew were contacted and an in-flight passenger count found that 22 more passengers were on board than accounted for during pre-flight planning. This affected the flight crew’s weight and performance calculations, but the minor effect of the increased weight had not been noticed by the crew on take-off. The flight crew amended the calculations prior to approach and landing.
 
Personally I don't have a problem with the Hooded Canary discontinuing this investigation, after all Jetstar through their SMS would probably have had all their identified deficiencies addressed within months. However I do question why the ATSB even bothered with the AI (safety issues) investigation if they were not going to explore outside of the Operator identified systemic safety issues?

IMO there are much more serious systemic issues here that are related to quick turnarounds and the low cost carrier operating model - TBC

MTF...P2  Cool
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ANAO wet lettuce report? - Not a good look for the Hooded Canary... Blush 



Ref - O&O thread:
(03-14-2019, 08:58 AM)Peetwo Wrote:  [b]O&O AAI: AO-2017-057 -[/b][b] UPDATE[/b]

(03-09-2019, 02:16 AM)Choppagirl Wrote:  Interesting legislation which came out a year after the Rossair crash in which CASA were testing the chief pilot for check and training and the chief pilot was checking an inductee pilot. Which comes first - the chicken or the egg?
https://www.legislation.gov.au/Details/F...ntrol+seat

Via the Adelaide Advertiser: https://www.adelaidenow.com.au/news/sout...405eabe119



Quote:Widow Terri Hutchinson says ATSB has treated families of pilots killed in Renmark Rossair crash as ‘worthless entities’

[Image: 52e72d1564090ea8ab16bfec2520e534?width=1024]


The family of a pilot killed in a plane crash near Renmark says her family has been treated like “worthless entities” by the aviation safety watchdog investigating the incident.



The comments come as the Australian Transport Safety Bureau (ATSB) confirmed the estimated release date for the report into the crash which killed three experienced pilots had been pushed back another six months.

Terri Hutchinson, the widow of Rossair chief pilot Martin Scott, said the ongoing delays and the justifications made by the ATSB were meant to placate the families of the dead pilots.

Mr Scott, 48, was alongside experienced pilot Paul Daw, 65, and Civil Aviation Safety Authority officer Stephen Guerin, 56, in a nine-seat Rossair aircraft when it crashed into scrubland 4km from Renmark Aerodrome on May 30, 2017.

The pilots were completing an evaluation flight for Mr Daw who was planning to join the ranks of Rossair.

The plane was only in the air between 60 and 90 seconds before plummeting into the ground nose first, killing all three occupants on impact.

“To say that I am more than disappointed would be a huge understatement,” Ms Hutchinson told The Advertiser.

“In my opinion, this investigation has been flawed from the outset.”

Mrs Hutchinson said the ATSB had “not bothered to tell those involved” that the publication of the report had been pushed back.

“In fact, the last push-back came after I received an email from the Chief Commissioner of the ATSB saying they would take ‘extra care to keep me informed’.

“That is clearly rubbish and I must say, the latest development has made it seem as though those who lost so much that day are treated as worthless entities.

“To date, Martin’s father and I have been advised that we would receive a draft copy of the final report one month prior to public release.

“(In an email received earlier this week) they have now said that there could be a ‘number of months’ in between the draft report and the final publication.

An ATSB spokesman confirmed the final report is expected to be published in the final quarter of 2019 — more than double the 12 month target for air crash investigations.

“It is important to note that investigations are complex and dynamic, and the priority of the ATSB is always the thoroughness of an investigation to ensure that any systemic safety issues are identified and addressed,” he said.

“This means that complex investigations can take longer, if necessary, in order to ensure a robust investigation with the appropriate third party input and reviews.

“Should a critical safety issue be identified during the course of any investigation, the ATSB immediately notifies relevant parties to ensure safety action is taken.”

With little to no fanfare the ANAO yesterday tabled their audit report into the 'Efficiency of the Investigation of Transport Accidents and Safety Occurrences':  https://www.anao.gov.au/sites/default/fi...019_29.pdf

Quote:[Image: atsb-transport-accident.jpg]

Quote:The objective of this audit was to examine the efficiency of the Australian Transport Safety Bureau’s (ATSB’s) investigation of transport accidents and safety occurrences.

Conclusion

10. The efficiency with which the ATSB investigates transport accidents and safety occurrences has been declining. The ATSB has recently been focussing its attention on reducing the backlog of old investigations, improving investigation timeframes and taking steps to benchmark its performance against transport investigation entities in some other countries.

11. 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.

12. The efficiency of the ATSB’s investigation activities has declined over time both in relation to the length of time taken to complete investigations, and the amount of investigation resources required. The ATSB has recently started taking steps to benchmark its performance against transport safety investigators in some other countries. Analysis of the available data indicates that averaged across the last three years the ATSB has performed well in comparison to the selected countries on a range of efficiency metrics. On an annualised trend basis, the analysis indicates that the ATSB’s efficiency has been declining relative to the selected comparators, particularly in relation to resource efficiency.

Supporting findings


Measuring and supporting operational efficiency

13. The ATSB has performance measures in place addressing time efficiency. Timeframe targets have not been achieved by the ATSB, and work is underway to develop more realistic timeframe targets. The ATSB does not publicly report on its resource efficiency.

14. The ATSB collects a range of information that can be used to inform an assessment of its investigation efficiency. Work is underway within the ATSB to improve its collection and analysis of data for this purpose.

15. The assessment and prioritisation processes support the ATSB focussing its investigation resources in the areas that are most likely to result in safety improvements. Action is underway to enhance the way those processes take into account the extent to which investigator resources are available.

16. Organisational change programs have been initiated and opportunities to improve investigatory processes have been identified and are being pursued.

17. The ATSB has had quality controls and processes in place, however they have not been conducive to the timely completion and review of investigations. Since 2017, the ATSB has implemented key review points earlier in the investigations process. As a result, the ATSB has identified improvements in quality and a reduction in the amount of rework required through the various review stages.

Comparing operational efficiency

18. The ATSB has undertaken limited analysis of changes in its investigation efficiency over time. This analysis has focussed on timeliness and the work effort required to complete an investigation.

19. Efficiency has declined over time. Over the last five years, the time taken and resources required by the ATSB to complete investigations has increased significantly.

20. Prior to 2018, the ATSB had not compared its investigation efficiency to other relevant transport safety investigation organisations. Steps are now being taken to benchmark performance against international comparators.

21. Data obtained in connection with this ANAO performance audit indicates that, averaged across the last three years, the ATSB is performing comparably across a range of efficiency metrics. On an annualised basis, the ATSB’s efficiency has been declining particularly in terms of resource efficiency where it has fallen behind two of the three countries examined for which data was available.



Recommendations


22. Any findings in the report which the audit team feel warrant Executive accountability to remedy should be included as a recommendation.

Recommendation no.1
Paragraph 2.8
The ATSB implement strategies that address the decline in the timely completion of short investigations.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.2
Paragraph 2.18
The ATSB report on the efficiency with which it uses resources in undertaking investigations.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.3
Paragraph 3.5
The ATSB establish more realistic targets for investigation timeframes addressing both calendar and investigator (effort) days.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.4
Paragraph 3.21
The ATSB continue to progress actions that it has recently commenced to benchmark its investigation performance against relevant international comparators and use the results to identify strategies to improve its performance.
Australian Transport Safety Bureau response: Agreed.
     
[Image: dTBCPcmCJ75Cs87Rv0i0MFacxcYJIs2OZFMkVsh0.png]

As expected, with such limited ToR, the ANAO have printed the hard copy on 46 soggy wet lettuce leaves. That said, coupled with the O&O post above, it is still not a glowing assessment of the ATSB Avery under the Hooded Canary's tenure... Dodgy 

  
MTF...P2  Cool
Reply

AO-2017-061: Another PC'd report?Dodgy

After reading the ATSB safety watch media blurb related to the tragic last flight of Cessna 172 VH-FYN...

Quote:'Personal minimums' checklists can help pilots to manage risks

Pilots should avoid deteriorating weather by conducting thorough pre-flight planning, a new ATSB report notes.
[img=216x0]https://www.atsb.gov.au/media/5775759/ao2017061_vh-fyn_news.jpg[/img]
A Cessna 172 was flying from Queensland to New South Wales when it entered an area of reduced visibility, including low cloud, fog and drizzle. The aircraft diverted off the initial track and was last seen disappearing into cloud heading inland. A short time later, the aircraft collided with terrain and the pilot was fatally injured.

The ATSB found that the decision to depart on the flight had placed the pilot at risk of encountering conditions of reduced visibility. On entering those conditions, the pilot likely became spatially disoriented, resulting in a loss of control and a collision with terrain. The ATSB also found that the pilot was likely under some degree of self-imposed pressure to continue with the flight, despite the inclement weather conditions.

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation.

“The ATSB’s safety messages from this investigation are clear: visual flight rules pilots should conduct thorough pre-flight planning to avoid the possibility of flying into bad weather. They should also make alternate plans in case weather deteriorates, and make timely decisions about diverting or turning back,” said ATSB Executive Director Transport Safety Mr Nat Nagy.

“If visual flight rules pilots do find themselves in deteriorating weather and become disoriented or lost, they should seek whatever help is available including contacting air traffic control. This simple action has averted potential disaster in many instances.”

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation. Inflight decision-making is one of the ATSB’s SafetyWatch priorities, particularly regarding pilots flying with reduced visual reference.

Among the advice that SafetyWatch provides, the use of ‘personal minimums’ checklists is key. VFR pilots should use a checklist to help control and manage flight risks by identifying risk factors that include marginal weather conditions and only fly in environments that do not exceed their capabilities.

This report highlights an ongoing safety issue in aviation. Check out our SafetyWatch page, Inflight decision making, for more information on this important subject.

Read the investigation report: VFR into IMC and loss of control involving Cessna 172, VH-FYN, 13 km NNW of Ballina, NSW, on 16 June 2017


 ...your first thought is not another needless VMC into IMC CFIT accident... Angel 

However then you read the 'safety analysis' section of the report under the subheading 'Decision to depart Southport' where it says:


Quote:...The reason for the flight on 16 June 2017 was to deliver the aircraft to a maintenance facility, as the aircraft’s maintenance release was due to expire the following day. The pilot initially had the aircraft maintenance booked for Tuesday 13 June 2017. The pilot then rescheduled the booking twice that week based on the forecast weather conditions. The final booking was scheduled for Friday 16 June 2017. During the course of that week, the pilot had downloaded weather forecasts through his National Aeronautical Information Processing System (NAIPS) account a number of times. Additionally, the pilot had been in contact with the maintenance provider in Ballina to check the weather conditions and reschedule the bookings. The last call the pilot made to the maintenance provider was on Wednesday 14 June 2017. During that call, the maintenance provider told the pilot he could get a special flight permit to allow him to fly the aircraft to Ballina after the expiration of the maintenance release. Instead, the pilot confirmed the booking for Friday...
     
Naturally this led me to the 'findings' section where I discovered, much like the 'safety watch' media blurb, that there was no mention of the above record inside of the 'contributing factors':


Quote:Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 172, VH-FYN 13 km north-north-west of Ballina, NSW, on 16 June 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors
  • The pilot departed Southport, Queensland for Ballina, New South Wales under the Visual Flight Rules with a forecast likelihood of low cloud, fog and showers of rain that reduced conditions below that required for visual flight.
  • It is likely the pilot encountered conditions of reduced visual cues and became spatially disorientated which led to a loss of control and collision with terrain.
    
I guess that part of the of the report, which IMO should normally fall under contributing organisational factors, would have detracted from the 'safety watch' message that team Hooded Canary wanted to convey.
[Image: D0yu7teU0AA9ncD.jpg]
That and the fact that archaic CASA rules that say that an aircraft that is airworthy one day suddenly becomes a ticking safety bomb that could threaten the lives of the Australian public the next could be somewhat embarrassing for the Patron Saint of Australian Aviation Safety and by association our totally captured DPM dummy McDo'Naught... Dodgy 
 [Image: D1F2YVwVAAUpZO2.jpg] 
Addendum: AOPA response to AO-2017-061 


Quote:BAD REGULATIONS AND FATAL AIRCRAFT ACCIDENTS
March 15, 2019 By Benjamin Morgan

AOPA AUSTRALIA EXECUTIVE DIRECTOR BENJAMIN MORGAN DELVES INTO THE LOSS OF CESSNA VH-FYN
[img=705x0]https://aopa.com.au/wp-content/uploads/2019/03/Screen-Shot-2019-03-15-at-10.03.12-pm-1170x500.png[/img]
This week the Australian Transport Safety Bureau (ATSB) released its final report and a warning to pilots about the dangers of continued flight into terrain (CFIT) following the fatal crash of a Cessna 172M (VH-FYN) near Ballina NSW in 2017.

Click to read the full report.

On the surface, the ATSB report reads like so many others, where the pilot in question departed in deteriorating reduced visual conditions, resulting in VFR flight into IMC; by a pilot who was not current on instruments, culminating in a senseless, tragic and entirely avoidable CFIT accident.

And, it’s the word ‘avoidable’ that has been ringing in my head since the day news broke of this accident, and what has angered me after reading the ATSB’s final report.

The sole objective of an aviation accident investigation is to prevent future accidents from happening by clearly identifying the cause or the reason why, so that improvements to aviation safety can be made.  To achieve this, the Australian aviation industry relies on the independence and objectivity of the ATSB to undertake detailed and forensic examinations of all the facts and factors that play a role in the accident chain of events.  More importantly, we rely on the ATSB to make independent recommendations.

But what happens when the ATSB loses its way and produces a report that’s glaringly deficient and fails to embrace the actual cause and need for change?

The simple and inconvenient truth is that the loss of VH-FYM was directly attributable to CASA’s inflexible aircraft maintenance regulations and the inability for aircraft owners or pilots to obtain a simple over the phone approval to ferry an aircraft for the purpose of maintenance.  Had such a facility been in place, the pilot would not have been under any pressure to undertake the accident flight.

Instead of issuing warnings to pilots about continued flight into terrain, the ATSB would be best served issuing a warning to government about bad regulation that has proven to kill pilots, with a call for immediate change.

A totally avoidable accident, yet one that will repeat because the ATSB is failing to play its impartial and independent role in helping improve aviation regulations to drive better safety outcomes for everyone.
  
"..More importantly, we rely on the ATSB to make independent recommendations.."
 
But Ben since Beaker brought in the BASR (beyond all sensible reason AAI philosophy), the ATSB don't make safety recommendations (especially to the regulator), unless they absolutely have to for international diplomacy or political reasons - see from page 3 here: https://auntypru.com/wp-content/uploads/...opin_2.pdf    
  
MTF...P2  Cool
Reply

Devils Advocate? – OK, just this once.

Idle thoughts, time on my hands and no real skin in the game.

Re: VH-FYN. I reckon a cooler head could, with some success argue both sides of this coin and the vote would come out about even. There are things both parties could/should have done to assist – but not to eradicate this type of accident. This is where the ATSB stumbles.

The pilot had a long period of notice that maintenance was due; even if he could not personally deliver the aircraft, then other arrangements could be put in place to ensure timely delivery of the aircraft to maintenance. I understand that the engineering company even offered to ferry the aircraft. Even so, waiting until the last possible moment to deliver the aircraft is not a good idea, particularly when the weather is liquid and lousy. There was a forecast issued, it was probably good enough for an experienced local pilot to at least go and have a look-see – we’ve all done it – if I can squeeze through at Big Hill, I can get down over the coast and weave my way home. Just the nature of VFR flying when the weather is ‘marginal’. I can agree with ‘personal’ margins or, to phrase it better ‘personal no-go’ limits. Clearly, a part of this accident was self induced pressure to get through. That is human nature and there are no rules which can govern that.

CASA could and probably should have a ‘hot-line’ for ‘ferry permits’ and ‘permission to fly’ to maintenance; I’ve operated with several of these; it seemed that during business hours obtaining a ‘permission’ took a little while – paper work backwards and forwards etc; but it did arrive. The one problem I see with a more ‘user friendly’ system is that every man and his dog will be delaying due maintenance and working a system for all it’s worth. That said, it would be great if there was a manned desk, during business hours where a speedy dispensation could be issued – valid for 36 hours; with a fee attached (of course).

The maintenance rules in Australia are bizarre; not a patch on the world leaders edicts; Ken Cannane understands this better than anyone and the rules desperately need to be fixed. That is beyond doubt. But I’d be reluctant to lay blame at the CASA door for this episode. ATSB need a real shakeup and to get back to taws. Start preaching Gospel of Murphey; this type of accident is a recurring killer; has been since day one – and yet it still happens.

I’d start with getting the BoM some credibility for the forecast – 75% of pilots read half of what they see and believe half of that. Remove the temptation; get some plain English into the text – Area 21 suitable for VFR operations West of the divide; marginal to the East. Extensive areas of Low cloud, visibility reduced in Rain. Cloud is. etc. Temperature etc. Dew point etc. Wind etc. Simple stuff forecast accurately – or near enough. It will not stop the determined scud running hooligan; or, those who will go anyway, whatever the forecast; but it may keep honest folk in the shed and alive to fly another day.

The case for a hot-line has merit – aircraft operate 24/7 and an operator can get caught out with an extra hour of two flight time to get an aircraft home – it happens. Good forward planning always helps; but with the cost and hassle of maintenance requirements, people like to get the whole 100 hours as revenue, so things get run to the margin.

Too much regulation creates a tick a box mentality, where everyone is working on staying ‘legal’. Just because it’s legal don’t make it safe; airmanship and common sense do. Time it came back into vogue I think. The ‘kids’ can all quote the regulations at a speed which boggles the mind; ask ‘em to define the flight path weather in operational terms and you get blank looks – “ but, that’s all legal” says young Spotty – “Aye, but is it acceptable” say I.

Toot toot.
Reply

OK? - Over to LB off the UP... Rolleyes  

Ref: For Once I Agree With AOPA



...So we have an average GA aircraft that has an MR that’s about to expire. What actual risk arises in the real world the day after the MR expires, which risk did not exist on the day before the MR expires?

What is it that CASA does, in considering whether to issue a special flight permit or not, that mitigates that risk? How does the turning of some bureaucrat’s mind to the question whether an aircraft should lawfully be allowed to fly, and the decision by that bureaucrat to issue a special flight permit, mitigate any real risk that exists in the real world.

Walk me through the causal links....  Wink



Shy... Tongue
Reply

Why are we (ATPs) paying for the ATCB?

(ATP - Australian Taxpayer, ATCB - Australian Topcover Bureau)

Just read the ATCB AO-2017-044 investigation Final Report -  Huh

Quote:What happened

On 7 April 2017, a Qantas Airways Boeing 747-438, registered VH-OJU, was operated as scheduled passenger flight QF29 from Melbourne, Victoria, to Hong Kong International Airport, in the Hong Kong Special Administrative Region of the People's Republic of China. On board were 17 crew and 347 passengers.

While descending toward Hong Kong International Airport, air traffic control instructed the flight crew to hold at waypoint BETTY.

When entering the holding pattern, the aircraft’s aerodynamic stall warning stick shaker activated a number of times and the aircraft experienced multiple oscillations of pitch angle and vertical acceleration. During the upset, passengers and cabin crewmembers struck the cabin ceiling and furnishings.

A lavatory smoke alarm later activated, however, the cabin crew determined the smoke alarm to be false and silenced the alarm. The aircraft landed at Hong Kong International Airport without further incident. Four cabin crewmembers and two passengers suffered minor injuries during the incident and the aircraft cabin sustained minor damage.

What the ATSB found

The ATSB found that while planning for the descent, the flight crew overwrote the flight management computer provided hold speed. After receiving a higher than expected hold level, the flight crew did not identify the need to re-evaluate the hold speed. This was likely because they were not aware of a need to do so, nor were they aware that there was a higher hold speed requirement above FL 200. Prior to entering the hold, the speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify the low speed as their focus was on other operational matters.

The ATSB also found that due to a desire to remain within the holding pattern and a concern regarding the pitch up moment of a large engine power increase, the pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. In addition, the pilot monitoring did not identify and call out the incomplete actions. This resulted in further stall warning stick shaker activations and pilot induced oscillations that resulted in minor injuries to cabin crewmembers and passengers.

Additionally, the operator provided limited guidance for hold speed calculation and stall recovery techniques at high altitudes or with engine power above idle. This in turn limited the ability of crew to retain the necessary manual handling skills for the recovery.


Quote:Stall prevention and recovery at high altitudes

The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.

Safety issue details

Issue number: AO-2017-044-SI-01
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed


Re-evaluating hold speeds for a change in altitude

The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude.
Safety issue details

Issue number: AO-2017-044-SI-02
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed

& via the Oz:

Quote:Pilots’ role in 2017 Qantas in-flight incident which injured six

[Image: e6bc4bdb75321d25a4b7a60278856bb7?width=320]
MARCH 27, 2019
By ROBYN IRONSIDE

Qantas has been forced to amend training for its pilots following an incident on a Melbourne-Hong Kong flight in which six people were injured in-flight.


The four cabin crew and two passengers, one of whom was in a toilet at the time, hit the ceiling, when the Boeing 747 underwent rapid changes in movement during a flight in April, 2017.

A two-year Australian Transport Safety Bureau investigation found a technical miscalculation by the pilots resulted in the “upset” after flight QF29 was placed into a higher than expected holding pattern (of 22,000 feet) over Hong Kong.

Although the altitude change was entered into the flight management computer, the pilots did not re-evaluate the hold speed.

That meant as the 747 turned to enter the holding pattern, the speed dropped below what was needed, putting the aircraft at risk of aerodynamic stall.

The pilots initially failed to notice until the stall warning stick shaker activated, alerting them to the problem.

The pilot flying responded by starting the stall recovery process but this was not completed, resulting in more stick shaker activations and for a few brief seconds, a very bumpy ride.

A Qantas spokesman said what occurred was essentially a “mismatch between the holding speed and altitude entered into the flight management computer”.

“In correcting the aircraft’s path, the crew was very conscious they were operating in congested airspace and had limited room to manoeuvre, which added to the sense of turbulence in the cabin,” the spokesman said.

The ATSB report said “when entering the holding pattern, the aircraft’s aerodynamic stall warning stick shaker activated a number of times”.

As the pilot went about the stall recovery process, “the aircraft experienced multiple oscillations of pitch angle and vertical acceleration”, the report said.

“During the pilot-induced oscillations, passengers and cabin crew members struck the cabin ceiling and furnishings.”

In the course of the investigation, the ATSB found the Qantas crew had undergone stall recovery training on multiple occasions exposing them to various scenarios, in line with Civil Aviation Safety Authority requirements and industry best practice.

But the ATSB could find no scenarios of stick shaker activation while manoeuvring at altitude, such as that experienced by QF29.

As a result, the ATSB identified the need for specific training which Qantas promptly addressed for not only 747 crews, but those operating 737 and 787 aircraft as well.

“(Qantas) also updated ground school lesson plans and information to ensure standardised flight crew training and ensure holding pattern training was adequately addressed during flight crew training,” the report said.

Now although it reads as a fairly comprehensive report, I have to ask why did this investigation take nearly 2 years to complete for safety issues that were more than likely identified within days and addressed internally, with a proper safety management action plan through the Qantas SMS, within weeks? 

Is this merely just another case of the ATCB providing topcover for in this case our national airline? If we have come to the point where all the ATCB is doing is regurgitating major airline internal investigation reports, then perhaps the Aviation should be omitted from the ATCB's remit -  Huh 

MTF...P2  Dodgy
Reply

RI – “Qantas has been forced to amend training for its pilots following an incident on a Melbourne-Hong Kong flight in which six people were injured in-flight.”

Uhmm – not quite right Robyn. Reality check strongly recommended. Qantas internal safety management would have had this sorted out within a day or two and the solution on the table within a week, revised program up and running within a fortnight. That is what happens in good airlines, when real experts address an operational safety matter. This would have been sorted before the ATSB even Googled the problem to see what the experts where talking about.

The ATSB report apes the expert ‘fix’ – they probably copied the Qantas SMS report, verbatim. I don’t know. But I do know that I’d stand bare arsed, Oxford St on Mardi Gras night the day the ATSB ‘forced’ Qantas to amend anything; it is a ridiculous notion.

P2 – “If we have come to the point where all the ATCB is doing is regurgitating major airline internal investigation reports, then perhaps the Aviation should be omitted from the ATCB's remit.”

Second the motion – save the money.
Reply

Yes, I learned about ‘flying from that.

Hitch – “Visual flight into instrument weather has been resulting in tragedy after tragedy for as long as there have been aeroplanes and bad weather.

True enough – and, as a short precursor to a serious problem, not a bad place to begin a discussion of basic tenets. The question (IMO) is where lays the radical ‘base of error’?

Must we look at human nature – now there’s a puzzle that has confounded both fools and wise folk for millennia. Is it just too hard to quantify? Gods know many have tried to put that particular genie into neatly labelled bottles – and failed; spectacularly. You need look no further than the carnage on roads (worldwide) to realise you simply cannot make a prediction on how any individual will, or will not respond to a given set of circumstance, mind set or even their own and the ‘safety’ of others; well not on a global scale anyway. So, where do we look for a balanced solution to the VFR pilot straying into solid instrument conditions?

Hitch – “And there will be a lot more of it given that it is often the result of a poor decision and pilots are probably going to continue to make poor decisions.”

But is it really that simple? Deciding what to have for breakfast may, or may not be a poor or good decision; the consequences insignificant in the great scheme of things. Deciding to push a small, low performance airframe into high performance weather is an animal of an entirely different colour. I think we can set the psychology aside for a moment (only a moment) and take look at the ‘temptations’; what are they? What creates them – what motives? The modern era has laid many traps: precision navigation tools which can get you to tin can in the middle of the Sahara at midnight, coupled with an auto pilot which performs beautifully for example. This false security is aided and abetted by weather forecast which, despite the science supporting is still, to this day, regarded as purely a guide (+/- 70%).

Even so, we need to understand what possessed the Mt Gambier pilot to believe he could take off into a clear, visible, active and present danger situation.

Back in the day Mack Job published wise articles; retrospective for sure, after the fact; but nonetheless valuable for that. Cautionary tales which were not only read by countless pilots, young and old, when published, but kept and re-read many times. The cautionary tales were written to take you along on the experience; made you think and had real credibility, to all stripes of pilots. A collective, shared experience. You had no need to gain this experience yourself, it was gifted to you. Thus, in my own case least, my first encounter with the known killers, ice, storm, darkness, failing engines etc. was met with at least some previous knowledge of the pitfalls and traps for young players. The ‘experience’ was gained second hand, but it came from the horse’s mouth; so to speak.

The juxtaposition is equally compelling; IMC these days is predicted with some semblance of accuracy – give or take; it is freely available to all – no charge. Not perfect but a good place to begin deliberations - pre departure. No amount of paper can ensure that a pilot will ‘comprehend’ the implications contained within a ‘briefing’ - particularly those who are not familiar with the subtle, cut and dried, abbreviated, often cryptic acronyms. “Looks a bit crook, we’ll go and take a look”. Famous last words?– Yes; in some cases, but not in all. Many more take the punt than do not – and are often proven correct. Often, enough get through and feed the legend that with guile, cunning and a back door, the dire predictions of the BoM are ‘useful’ - but padded. This feeding of the legend is dangerous. Ask any experienced Australian instrument pilot how many approaches they’ve been obliged to fly to published minima and not ‘gotten in’; then ask how many approached they gave away and diverted; then ask how many times they ‘got in’ second try. Believe me, they will remember each and every one; for there will not be many.

So, what’s to be done?

Only my opinion, but I believe there are a couple of things which may be done that would be of great assistance. We need to begin at the beginning – and acknowledge that there will be instances where a VFR Pilot will get ‘trapped’. For it happens and will probably continue to happen.

In the grand scale of expensive ‘safety initiatives’, it would cost ATSB/CASA very little to collate and publish the collection of ‘I learned about flying’ and other educational articles contained in the old ‘Crash Comic’. Make it a mandatory, examinable text for the issue of a PPL, bring the stark reality of the dangers into sharp focus, early in the piece. Education 101.

Secondly, I’d like to see an analysis of the results of an inadvertent entry to IMC, in terms of ‘what happens’. For example – the percentage of ‘spins’, the percentage of significant height loss, the percentage of steep turn/stall/ spin, the percentage of CFIT. From this data training programs could be modified to ensure that when an aircraft is caught out, the PIC has the basic skills to reverse a track, or divert while being aware of the terrain below v cloud base/ turbulence/visibility equation. I don’t know how flying at an ab intio level is taught these days; but I and many of my peers were taught to confirm, on instruments, the ‘attitude’ we were to fly, from lesson one. The transition to IF became simply an extension of first flight, not an entirely new method of operating. – Training 101.

Lastly, I would like to see more emphasis placed on ‘practical’ meteorology. By this I mean the ability to ‘read’ an area or terminal report as a static depiction of a dynamic situation as it will affect the flight path. From this ‘escape’ plans can be developed. An overlay if you like: there on the GPS is the flight path – but in your mind is a picture of the weather situation developing during the flight time. So if the ETA at Kickatinalong becomes the same as the front, the back door is consciously kept open. The BoM (bless ‘em) cannot do this for you, it is part and parcel of a pilot’s tool kit, a skill developed only through education and with conscious practice. Situational awareness 101.

Without a Ouija board we cannot tell what the Mt Gambier pilot was thinking or how he came to make the decisions he did. What we can define is what he should have been thinking; it is probably time for the right thinking to be taught and reinforced, from day one, lesson one.

Was the fatal accident Angel Flights problem? I don’t think so. Has ATSB taken steps to prevent a reoccurrence? Have CASA taken a long hard look at the problem and designed an enhanced safety training program? You know the answer as well as I do.

Aye well, my two bob, spent as pleased me best; a small punt on the ‘Blame game’ race to the bottom.

Toot – toot.
Reply

Hooded Canary opens up yet more investigations into REX -  Dodgy  

Hmm...here we go again??

Quote:ATSB
@atsbinfo

The ATSB is investigating a damaged main wheel landing gear involving a Saab 340 at Adelaide Airport on 20 August.
http://atsb.gov.au/publications/investig...-2019-047/

[Image: EDbMAviUwAA4yH2?format=jpg&name=small]


ATSB
@atsbinfo

The ATSB has commenced an investigation into the in-flight engine shutdown of a Saab 340, registration VH-RXX, near Merimbula, NSW, on 29 August.

http://atsb.gov.au/publications/investig...-2019-046/

[Image: EDbOAadU4AA1wWD?format=jpg&name=small]

Perhaps we could run a tote on how long these investigations will be O&O'd and just what topcover approach will be used this time in order to avoid any unheeded embarrassment or possible liability for REX... Rolleyes

MTF...P2  Tongue
Reply

For the record - off the Senate Estimates thread:

(09-10-2019, 10:54 AM)Peetwo Wrote:  
(09-09-2019, 07:11 PM)P7_TOM Wrote:  ...I read the ‘factual part of the ATSB report into the Mt Gambier accident with some horror; particularly the following paragraph:-

ATSB : At 1003, as YTM passed over the top of runway 36 in a westerly direction, the pilot made a CTAF broadcast ‘lining up for 36’, indicating that he intended to land on runway 36. Witnesses reported that the pilot then conducted a go around after initially touching down on runway 36, and witnesses reported then seeing the aircraft climb back into cloud. The pilot then broadcast on the CTAF ‘going around for runway 24’. After another two low-level turns over the airport, in which the aircraft was captured emerging from the cloud on closed-circuit television (CCTV) at low altitude, the aircraft landed on runway 29 at about 1008.


...And yet, the accident pilot persisted; ducking and weaving around low cloud, whizzing about in low visibility, looking for a sighting of a runway end, eventually landing on R29. I wonder if he realised it was not R 24.

We will never know the reason ‘why’, not really. We can surmise, speculate and reason away all we like; but we will never truly know ‘why’. P2 raised another puzzle; why didn’t he go for a Piddle? He certainly had time. Why didn’t he take off to the East, where the weather conditions were reported better? Why the rush? But the big question is why not cancel. “Sorry folks; but the weather is unsuitable, even the airlines are waiting; we can wait until it improves; or we can go to the Pub”.  

But, the greatest mystery of all is what the hell is ATSB playing at laying all this at the feet of Angel Flight? Did the pilot contact AF for advice? No. Was he pressured or instructed by AF to act in the manner ATSB describe? No. Then WTD is AF doing in the Dock? Individual criminal negligence is on the table here; not the way AF or any CSF do business. It begs a question or two don’t it. There are many causal links in the accident chain – unexamined. Why? While you’re at it, ask why only AF is in the gun, not all CSF operations...

Devil's advocate: Hmm...despite the obvious illegalities involved (see P7 post above) in the maneuverings of the pilot on approach and final landing, followed by the departure into obvious non-VMC conditions, I am somewhat perplexed by the figure 2 to 3 track and aircraft maneuvering depictions??

[Image: fig-2.jpg]

[Image: fig-3.jpg]

Note in figure 2 that there would have presumably been much scud running and even at times penetration of cloud, yet never does the pilot's maneuverings approach any where near uncontrolled, reckless AOB or pitch movements suggestive of a VFR pilot panicking because he has inadvertently entered IMC. 

Now refer to figure 3 and it is the same thing, where except for an initial slight veering to the left of the centreline, followed by a couple of minor deviations to the right, the pilot then appears to make a decision to initiate a turn back to the airfield and sets up standard rate 1 turn to the left until 5 second panel 13, where the pilot IMO inexplicably loses control. Although there is no panel 14 it would appear that in less than 10 seconds the aircraft has gone from being in a standard rate turn and maintaining 200 ft agl (ie controlled flight), to pitching at least 30 degrees nose down and rolling slightly to the right. IMO this would introduce the possibility of a catastrophic event. However nowhere in the report (that I can find) was the possibility/hypothesis even remotely explored. 

Quote:Pilot information

The pilot obtained a Private Pilot (Aeroplane) Licence in December 2014, and held the appropriate aircraft endorsements required to operate YTM. His logbook showed a total aeronautical experience of approximately 530 hours. In the 90 days prior to the accident flight, he had conducted the three take-offs and landings required by Civil Aviation Safety Regulation (CASR) 61.395 to permit the carriage of passengers. At the time of the accident, he held a valid Class 2 Aviation Medical Certificate renewed on 6 June 2017. This included a requirement for reading vision correction to be available while exercising the privileges of the licence.

The pilot commenced training for a Night Visual Flight Rules (VFR) rating in December 2015; this included about 3.5 hours recorded as instrument flight time. The pilot completed a total of 12 hours of training in flight under night VFR between December 2015 and May 2016, however he did not obtain this qualification. The pilot did not hold an instrument rating and his logbook recorded a total of 7 hours of instrument flight time, the latest of which was 0.1 hours in simulated flight conditions during an aeroplane flight review on 29 November 2016.

The ATSB assessed whether the pilot may have been experiencing a level of fatigue known to have an effect on performance. Consideration was made of the pilot’s sleep obtained, time awake at the time of the occurrence, time on task, potential workload and environmental factors. Based on the available evidence, the pilot was very unlikely to have been experiencing a level of fatigue known to affect performance.

Medical and pathological information

The pilot’s medical records, post mortem examination and toxicological analysis identified no acute or pre-existing medical conditions that may have contributed to the accident.

The forensic examination of the pilot doesn't indicate any serious research into the pilot's flight experience and/or logged flights. I would have thought that given the flagrant disregard for the rules surrounding legal VFR flight that there would have been at least a thorough investigation into past flights conducted by this pilot into and out of Mount Gambier (what was obviously a local airport for him). Could it be that there was a pattern of deviance that for this pilot had become very much normalised? 

Hmm...much MTF me thinks?? - P2  Cool

ps Also in regards to the disturbing and unbelievable waffle/weasel worded confection offered up by Dr Chelsea (Godlike) Manning as expert evidence at the Senate public hearing, I note the following off the Dock's self-flagellating linkedin page:

Quote:About

I have worked in transport safety for over two decades, mostly in aviation. With a human factors psychology background, I have applied analytical skills at the ATSB to aviation safety investigations, research and analysis of safety data. My role as Director at the ATSB now also incorporates rail safety as well as aviation. As Director I oversee transport safety investigations of incidents and accidents, safety studies (research), and the overall data strategy at the ATSB. Prior to the ATSB I worked in the safety department of Qantas in both safety analysis and human factors roles. This was from an original grounding of road safety research from a human factors psychology perspective at Monash University Accident Research Centre (including a PhD) and then at the University of Sydney.



Australian Transport Safety Bureau
Total Duration15 yrs


Director Transport Safety
Dates EmployedJun 2017 – Present
Employment Duration2 yrs 4 mos
Canberra, Australia

Director Transport Safety
Dates Employed Oct 2004 – Present
Employment Duration 15 yrs
Canberra, Australia

Assistant General Manager
Dates Employed 2004 – Jun 2017
Employment Duration 13 yrs
Canberra, Australia

Previously:
Senior Transport Safety Investigator
Manager Research
Manager Reporting and Analysis

Currently:
Assistant General Manager, Reporting, Short Investigations and Research

15 years??  Confused  - So that would mean he was involved in/or on the periphery of the Lockhart River tragedy; he was there for the PelAir cover-up and the Beaker adoption of the 'beyond all reason' investigative philosophy; he was there for the MH370 cock-up/cover-up etc..etc..etc - Hmm and Chelsea is not conflicted? FDS! Dodgy

(09-10-2019, 07:08 PM)Kharon Wrote:  Fair Call – However:-

P2 –“Note in figure 2 that there would have presumably been much scud running and even at times penetration of cloud, yet never does the pilot's manoeuvrings approach any where near uncontrolled, reckless AOB or pitch movements suggestive of a VFR pilot panicking because he has inadvertently entered IMC.”

Devils advocate right back atchya. Noted. Discuss; – the aircraft was certified for IFR. Feasible that there was a serviceable auto pilot on board and no doubt GPS. ATSB don’t think it worthwhile to mention how the aircraft was equipped. I can easily see someone at one of the ‘confidence’ benchmarks (500 hours), underestimating the inherent ‘risks’, overestimating their ability, backed up by auto flight and GPS accuracy taking a punt. Those patterns are very, very neat. There are two small clues to this being at least a start point for discussion:-

(1) “ATSB – Witnesses reported that the pilot then conducted a go around after initially touching down on runway 36, and witnesses reported then seeing the aircraft climb back into cloud.

Why? If it had been me, and I’d touched down after an approach like that (unlikely) there’d be no-way I’d go around, back into the murk. More likely I’d be behind the shed having a smoke, trying to sooth agitated nerve endings.

(2) “ATSB - The pilot then broadcast on the CTAF ‘going around for runway 24’. After another two low-level turns over the airport, in which the aircraft was captured emerging from the cloud on closed-circuit television (CCTV) at low altitude, the aircraft landed on runway 29 at about 1008.

Now he’s called for R24 and landed R29. IMO that is a clue to some sort of geographical disorientation – switched on bloke would have called the change – had he been aware of it.

Just saying…. There’s room for speculation on the approach pattern. The departure (as depicted) does appear to indicate a very small time period between what appears to be a controlled, descending left turn and the accident site. Hard to tell from the awful schematic, but; 200 feet a minute (FpM) descent rate is only 3.33 FpS. 600 FpM is 10 feet per second. 1200 FpM is 20 feet per second. So, ten seconds at 1200 FpM = 200 feet. That brings a descent angle of about 60˚+/-. Good-Oh, ATSB reckon 30˚from vertical.

ATSB – “Ground scars and evidence from the wreckage indicated that the aircraft impacted the ground nose down in an inverted attitude, approximately 30° from vertical, and that the engine was producing power at the time of impact.”

For the sake of discussion only: what if the trusty Auto Pilot gave up the ghost, in cloud? Is there enough time lapse for the pilot to not recognise an attitude change, become disoriented and loose control? You can imagine it happening – stressed pilot, believes the AP is running the show, peering out of the window, looking for breaks in weather – then the ‘Oh- crap’ moment when reality dawns – too late.

So glad ATSB didn’t bother to interrupt their hysterical investigator's ‘Air time’ to bother looking into possible causes; after all as she stated in her TV 15 moments of fame, we will be investigating Angel Flight (submission to CASA following) – and they did. I cheered when Rex Patrick pulled the Soppy, so Sympatico Hood up when he dared to blame the Senate for forcing them to look at ‘operators’ rather than flight crew – as they did in the disgraceful Pel-Air investigation. The crazy thing, which clearly demonstrates just how sycophantic ATSB under Hood has become is that they have gone after not once, but twice the wrong Fox. Pel-Air operator deserved a hammering; AF don’t. The Pel--Air pilot got flogged; all of the Mt Gambier pilot’s aberrations have become Angel Flight’s; who, by the way ain't an 'operator'.................

Hood needs to sort his carts and horses out methinks. Aye well, we shall hear what the Senate Committee think of it all in due course. Let’s hope they are not baffled by the Bullshit in another awful report; one of the many we have read lately; or not, depending whether the PR crew and Spin Doctors have finished applying the polish. A No Confidence call in the ATSB would be well justified and supported.

Toot – toot.
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