[Peetwo]

AAI & the implications of bureaucratic O&O - Part II

Re-hash courtesy of ATSB Aberration thread O&O  :

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

Them holes are aligning

Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering,  aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...



Courtesy the Oz:

Near miss for planes carrying 18 people  

• Too close for comfort. Source: TheAustralian

Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:

Air safety bodies spoke ‘more than once’ on pilot’s near-miss
Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images


...ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.

An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.

“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed...

On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13:

Australia requires reporting of ‘transport safety matters’, which, through definitions
and reporting requirements in the Transport Safety Investigation Act 2003 and Transport
Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of  serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.

  
Okay what I think the ATSB notified difference to ICAO Annex 13 on the definition of a 'serious incident' means, is that the ATSB can (read will) effectively abrogate all responsibility to investigate all 'serious incidents' under the spirit, intent and compliance of the Annex...

Therefore the ATSB practice of O&O'ing some potentially DIP sensitive 'serious incident' investigations has become a normalised SOP.

In the case of the MT Hotham 'near miss' investigation the delay can be (& probably will be) excused because the regulator CASA has conducted proactive safety risk mitigation by testing, re-testing and overseeing the proficiency checks of the incident pilot. The ATSB only need say that safety risk was being effectively mitigated.

However it is 'passing strange' that nowhere within the AO-2015-108 investigation webpage does the ATSB indicate that they have identified a 'safety issue' (i.e pilot proficiency) that they have subsequently sent to CASA to be proactively addressed. Nor is there any indication of any form of Annex 13 required 'interim report' on the 1st anniversary of the ATSB defined 'serious incident' investigation...

On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE.

Dick & 'that man' in the Oz today.. :

Report ‘may have stopped crash’

12:00amEAN HIGGINS

A safety report ‘may have prevented’ tragedy that saw five die when a plane crashed into a Melbourne shopping centre.

An 18-month-old investigation into the pilot involved in February’s Essendon plane crash, which killed five people, will not be made public until June, sparking critic­ism from a former air safety chief that this year’s tragedy may have been avoided had the earlier probe been finalised.

The Australian Transport Safe­ty Bureau is only now in the process of finalising its investig­ation into a near mid-air collision in 2015 which involved pilot Max Quartermain, who died with four passengers near Melbourne’s ­Essendon airport in February.

Dick Smith, a former chairman of the Civil Aviation Safety Authority, said it was “completely ­inexcusable” that the ATSB had still not completed the report of its investig­ation of the September 2015 incident at Mount Hotham.

He told The Australian that had the ATSB completed its investigation and report within a reasonable timeframe, and concluded that pilot Quartermain had engag­ed in poor airmanship endangering­ lives, he might have been grounded.

In that case, Mr Smith said, Quartermain would not have piloted­ February’s flight in which he and four American passengers died when the Beechcraft King Air crashed into a shopping centre nine seconds after it took off from Essendon airport. The ATSB, in its initial determin­ation of the Essendon disaster, could find no evidence of catas­trophic engine failure in the King Air.

• Fatal pilot probed over near-miss Chip Le Grand, PIA AKERMAN, JOHN FERGUSON
  
• Mystery clouds Essendon crash SIMONE FOX KOOB
  

Although aviation experts said this did not exclude the possibility of engine problems due to other causes, such as fuel contamination, it has turned further attention to possible pilot error.

The ATSB launched its Mount Hotham investigation after a pilot claimed that Quartermain, flying a King Air from Melbourne, had confused other pilots in his radio communications and nearly crashed into his aircraft as they both were preparing to land.

Quartermain was flying corpor­ate officials from Audi to an event at the alpine resort when, investigator­s determined, he came within 1.8km horizontally and 90m vertically of a King Air flying from Sydney, transporting passengers to the same function.

At one point, it was alleged, Quartermain radioed to say he was 10 nautical miles west of Mount Hotham, before correcting himself to say he was actually 10 nautical miles east.

Some passengers were so unnerved by the experience they ­refused to fly back to Melbourne with Quartermain, forcing the charter company to send another pilot.

In his complaint to the ATSB, the pilot of the other King Air said: “If this event did result in a mid-air collision, two aircraft would have been destroyed and 18 people would have been killed.” The ATSB report into the Mount Hotham incident has been repeatedly delayed.

An ATSB spokesman said that report was expected­ to be made public in June, and that the delay reflected a large number of fatal accidents and serious incidents over the past six months, which “required re-priorit­isation of limited investig­ator resources.”

The spokesman said the ATSB would always publicly release findings of “critical safety issues” as they were discovered rather than wait for a final report, and added, “it is not a function of the ATSB to apportion blame for transport safety matters”.

That function fell to the Civil Aviation Safety Authority.

..."it is not a function of the ATSB to apportion blame for transport safety matters”... - Nor is it the function of a supposedly ICAO Annex 13 compliant AAI to provide top-cover support for the regulator CASA and/or the ATC service provider ASA...    

Hmm...wonder how long it will be before Hoody again has a sook and makes another addition to the ATSB's BS 'correcting the bollocks' page -  TICK...TOCK indeed...


MTF...P2