[Peetwo]

Hooded Canary's search 4 IP in 2019?

References:

...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.

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.

..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.

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/

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

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

 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   : 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 - . 

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 Organization, International 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!   

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...

&..

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

Perth Skyworks crash sparks new rules for Avalon airshow




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.

 - Spot the disconnections -   

Standard ATSB bollocks from the investigation page:

...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:

 ...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:

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'?

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 -   ) 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:

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