[Peetwo]

A timeline of SSP & ICAO obfuscation? - When Senator Fawcett first mentioned the concept of 'closing the safety loop' in Senate estimates, I don't think he envisaged that to mean closing all industry participants out of the loop. Rather I think he meant that all participants, CASA, the ATSB, ASA, Coroners Courts, the Department etc. were actively involved and consulted in the endeavour to plug up all the identified and potential holes in the State SSP (i.e. closing the safety loop).

However reality seems to be vastly different...   Reference post from the safety loop thread:

Closing the safety loop #34 - Gobbles said:

"..What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly..."

Thanks to This Man, Airplanes Don’t Crash Into Mountains Anymore

The wreckage of Alaska Airlines Flight 1866, a Boeing 727, smolders as recovery workers search for the bodies of 111 victims on Sept. 7, 1971, in Juneau, Alaska.
Photographer:AP

Don Bateman’s terrain mapping device has nearly eliminated the largest cause of death in jetliner accidents.

By Alan Levin | August 10, 2016

As Gobbles alludes in his post the introduction of lifesaving risk mitigation technology, like GPWS & TCAS, was due in large part to many findings & safety recommendations from effective AAI (Aviation Accident investigation) as per ICAO Annex 13 throughout the 70s, 80s & early 90s. Since that time we've seen the onset of safety issues revolving around automation dependency. Subsequently there has been many proactive safety recommendations attempting to mitigate this now repetitively identified safety issue.

Unfortunately in Australia our State AAI, the ATSB, is yet to clearly identify 'automation dependency' as a significant safety issue in modern day 'next generation' RPT aircraft.  

Click on a photo for more information.

 

Related: SafetyWatch
 

This is despite the quite disturbing findings in previous Senate Inquiries like:
Pilot training and airline safety; and Consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010
&..
Aviation Accident Investigations
The former inquiry, at Recommendation 9, actually called for the relevant agencies to review the findings & recommendations to come from the AF447 Final Report:

2.299    The committee recommends that the Civil Aviation Safety Authority (CASA), the Australian Transport Safety Bureau (ATSB) and Australian aviation operators review the final findings of France's Bureau of Investigation and Analysis into Air France 447, including consideration of how it may apply in the Australian context. Subject to those findings, the committee may seek the approval of the Senate to conduct a further hearing in relation to the matter.

However like the vast majority of well considered Senate & Government non-partisan review findings, these potential risk mitigation recommendations were completely ignored by CASA, ATSB, Airservices Australia & Murky's department.

Therefore rather than being at the forefront in aviation safety, Australia is now severely lagging behind the rest of the world and in some cases our aviation safety agencies are consistently becoming part of the causal (Reason model) chain...

On data input errors and to a degree 'automation dependency', the recently released final report into a March 2015 Air Asia X A330 incident on departure Sydney is a classic example:
http://www.atsb.gov.au/publications/inve...-2015-029/

What happened

On 10 March 2015 Airbus A330, registered 9M-XXM and operated by Malaysian‑based airline AirAsia X, was conducting a regular passenger service from Sydney, New South Wales to Kuala Lumpur, Malaysia. On departure from runway 16R the aircraft was observed by air traffic control to enter the departure flight path of the parallel runway 16L. Following advice from air traffic control, the flight crew identified a problem with the onboard navigation systems. Attempts to troubleshoot and rectify the problem resulted in further degradation of the navigation system, as well as to the aircraft’s flight guidance and flight control systems. The crew elected to discontinue the flight but were unable to return to Sydney as the weather had deteriorated in the Sydney area and the available systems limited the flight to approaches in visual conditions. The aircraft was instead radar vectored to Melbourne, Victoria and the flight completed in visual conditions.

What the ATSB found

The ATSB found that when setting up the aircraft’s flight management and guidance system, the captain inadvertently entered the wrong longitudinal position of the aircraft. This adversely affected the onboard navigation systems however, despite a number of opportunities to identify and correct the error, it was not noticed until after the aircraft became airborne and started tracking in the wrong direction. The ATSB also found that the aircraft was not fitted with an upgraded flight management system that would have prevented the data entry error via either automated initialisation or automatic correction of manual errors.

The flight crew attempted to troubleshoot and rectify the situation while under heavy workload. Combined with limited guidance from the available checklists, this resulted in further errors by the flight crew in the diagnosis and actioning of flight deck switches.
Finally, the ATSB identified that effective monitoring and assistance by air traffic control reduced the risk to the occurrence aircraft and other aircraft in the area.

What's been done as a result

In response to this occurrence the aircraft operator undertook safety action, including:

• the development of a training bulletin and package for its flight crews that emphasised the correct operation and alignment of the air data and inertial reference system
  
• sharing the lessons learnt from the operator’s internal investigation with all pilots and reviewing the recovery procedures to be undertaken in the form of a flight safety notice.
  

Safety message

This occurrence highlights that even experienced flight crew are not immune from data entry errors. However, carrying out procedures and incorporating equipment upgrades recommended by aircraft manufacturers will assist in preventing or detecting such errors.
Additionally, the airborne management of this occurrence illustrates the importance of effective communication when dealing with an abnormal situation under high workload conditions. This is especially the case when there is limited guidance available to resolve the issue.

Photograph of A330-343 9M-XXM

Source: Airliners.net

 
Our authorities also seem to have this aversion to thoroughly scrutinising certain international operators (like AirAsia & AirAsia X). This is despite numerous incidents/accidents pointing towards serious systemic safety issue deficiencies within these airlines.

Other countries have considered these safety deficiencies serious enough to issue a blanket ban on these airlines and in some cases their affiliates.

However here in Australia we consider 'our' system of oversight of international carriers robust enough to capture any miscreant airlines entering our borders and endangering citizens. Remember this captured on AP from Skidmore's first foray into Senate Estimates?

P7- ...When you read Hansard the intent and the purpose of the question was – how come operators which are blacklisted in Europe can operate into Australia?.  What was needed, by way of answer was an explanation of the differences between Australia and Europe: given that ICAO compliance in the real world is the norm, rather than the 1600 (Edit correction) 4000 odd differences package which keeps Australia off the real compliance radar, using stealth and technical lip service.

I wonder how long ICAO will sit still, when the world is blatantly taking the Mickey out of Annexe 13.  Perhaps they will start to hunt down a fat, juicy high roller for to make an example of?

Well, poor old Skidmore was lured into a velvet lined trap, foiled by smoke, dazzled by mirrors and succumbing to the oldest trap in the world – the whispered "trust me".

You know the old gag – "I'll only pop it in a little way, if you don't like it, I'll take it out; trust me"..... ......

Tower Chair are we clear to backtrack?

Although personally I was much more interested in other passages of play at the time, I did find that Air Asia ......? (fill out on the dotted line.. ) & EU blacklist thing intriguing and now with Skates 1st Estimates retraction, even more so???

Anyway for those interested here is the "exchange" in pictures - fascinating how Hoodoo Voodoo seems to know in almost intimate detail the previous (prior to December 2014) EU blacklist??

 
Later on in that exchange can anyone else see the bizarre contradiction in the spin and weasel words from 1st Dr Aleck and then Mrdak, when compared to the deliberations of Senator Fawcett and the Treaties committee on assessing airservices agreements with Serbia, Vanuatu & Laos?

Dr Aleck : Can I just add quickly that, in 2009, we amended our legislation specifically to enable us to look at these issues more closely. We exercised those powers in connection with any operator who draws our attention to their activities, and an accident would be a flag.

CHAIR: It is a long time since I learned to fly. You may be captured by an area that has been black listed, but generally what goes wrong when an airline gets black listed in Europe?

Mr Mrdak : Generally, it starts with a concern about the safety regulator in that country in which the airline is based.

CHAIR: The skill of the pilot, the servicing of the plane?

Mr Mrdak : Generally, it starts with concerns about the quality of the safety assurance process in the country in which the airline is based, and the safety regulatory record of the jurisdiction before it gets to the individual aircraft operator. It is much more complex than simply the operator itself.

That part in red sounds a lot like the definition, purpose and proper functioning of a State (Annex 19) SSP to me??

Oh but that's right we don't need that, after all we have the indefatigable CASA and their team of flight ops experts, that so effectively oversighted PelAir's international jet operations prior to the 'pilot did it' ditching at Norfolk island - FDS...


MTF...P2