Proof of ATSB delays

As it was in the beginning:-



Find the time; listen, learn and think.

You might want to consider the flight forecast for the ATR flight in question.

The wind in the area was forecast to be from the west to north-west and increase with altitude from 30 kt at 7,000 ft to 60 kt at 14,000 ft. South of Canberra, the winds above 10,000 ft were expected to be up to 20 kt stronger. Turbulence was forecast to be moderate in cumulus cloud and moderate otherwise at all levels throughout the forecast area

 
At 1506, while the crew was en route to Canberra, another area forecast was issued. There was little substantive change to the weather outlook; however, winds were forecast to ease by 5-10 kt and turbulence moderate now above 10,000 ft rather than at all levels.
 
The aerodrome forecast (TAF)20 for Sydney Airport, which was valid from 1100 until 1700,indicated that the winds were 10 kt from the south-east. There was no mention of turbulence in the area.The TAF for Canberra Airport that was in effect for the flight from Sydney to Canberra and the departure from Canberra, indicated that the forecast winds were from the west at 16 kt. There was no mention of turbulence.At the time that the aircraft departed Sydney, the Canberra Airport aerodrome meteorological report (METAR), which had a trend type forecast (TTF) current from 1430, indicated that the winds were 15 kts, gusting to 26 kt from the west-north-west with no significant weather. However, at 1500, 6 minutes after take-off, a revised METAR/TTF for Canberra Airport was issued noting that there was moderate turbulence forecast below 5,000 ft.
 
However, the bureau went on to advise that the balloon flight suggested a relatively strong inversion was developing during the day of the occurrence. The aircraft would have been traversing from a warmer stable atmosphere into a relatively cooler and unstable layer between 7,000 and 10,000 ft. This could account for any reported moderate turbulence.
 
Take a look at Fig.16 in the report. -  05:40:42 to 05:40:57 = 15 seconds with a 22 knots to 8 knots ‘drop’ in wind – 14 knots – for 15 seconds. Hardly 'dramatic'. Anyone ever skipped off the top of inversion - at Red line:?  How many FO's have been advised to back off the speed a bit?  - to be sure - to be sure.
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Twenty five years; four tails; 478 funerals; a birdstrike; and a broken leg - Part III

Reference previous:
(05-28-2019, 07:33 AM)Kharon Wrote:  Find the time; listen, learn and think.

You might want to consider the flight forecast for the ATR flight in question.

The wind in the area was forecast to be from the west to north-west and increase with altitude from 30 kt at 7,000 ft to 60 kt at 14,000 ft. South of Canberra, the winds above 10,000 ft were expected to be up to 20 kt stronger. Turbulence was forecast to be moderate in cumulus cloud and moderate otherwise at all levels throughout the forecast area
 
At 1506, while the crew was en route to Canberra, another area forecast was issued. There was little substantive change to the weather outlook; however, winds were forecast to ease by 5-10 kt and turbulence moderate now above 10,000 ft rather than at all levels.
 
The aerodrome forecast (TAF)20 for Sydney Airport, which was valid from 1100 until 1700,indicated that the winds were 10 kt from the south-east. There was no mention of turbulence in the area.The TAF for Canberra Airport that was in effect for the flight from Sydney to Canberra and the departure from Canberra, indicated that the forecast winds were from the west at 16 kt. There was no mention of turbulence.At the time that the aircraft departed Sydney, the Canberra Airport aerodrome meteorological report (METAR), which had a trend type forecast (TTF) current from 1430, indicated that the winds were 15 kts, gusting to 26 kt from the west-north-west with no significant weather. However, at 1500, 6 minutes after take-off, a revised METAR/TTF for Canberra Airport was issued noting that there was moderate turbulence forecast below 5,000 ft.
 
However, the bureau went on to advise that the balloon flight suggested a relatively strong inversion was developing during the day of the occurrence. The aircraft would have been traversing from a warmer stable atmosphere into a relatively cooler and unstable layer between 7,000 and 10,000 ft. This could account for any reported moderate turbulence.
 
Take a look at Fig.16 in the report. -  05:40:42 to 05:40:57 = 15 seconds with a 22 knots to 8 knots ‘drop’ in wind – 14 knots – for 15 seconds. Hardly 'dramatic'. Anyone ever skipped off the top of inversion - at Red line:?  How many FO's have been advised to back off the speed a bit?  - to be sure - to be sure.

Excellent points you make "K", I would also question why the FDR and associated flight wx forecasts, sig wx reports etc. weren't analysed for the 13 sectors that followed and any recorded data leftover from the flights before the accident flight. This data would surely be invaluable in the analysis of whether the CRM breakdown and flying at VMO (redline fever) in or in the vicinity of forecast and recognised high risk mechanical turbulence areas, was a normalised operating deficiency; and I believe would have helped with the analysis that went into this part of the report:

 
Quote:Operator’s history of VMO exceedances


A search of the VARA occurrence database for overspeed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO overspeed event on descent. In these events, six of which were before the occurrence, the crew cited turbulence and/or distraction as contributing factors. Where target speed was reported, it was 230 or 235 kt and where details were provided about recovery actions, the reported crew actions were reduction of power, disconnection of autopilot, and manual nose-up input. The ATSB noted that there was no significant geographical pattern to the occurrences and that there were 14 reported flap overspeed events during the same period.

A search of the ATSB database also identified one report of a VMO exceedance in an ATR 72, while they were under the Skywest operation in June 2012. In that occurrence, the aircraft was on descent at about 240 kt, when the airspeed rapidly increased due to an atmospheric disturbance. At the time, the pilot monitoring was distracted by another operational task.

VARA also supplied a copy of all incident reports lodged by the flight crew involved in the VH‑FVR occurrence. Neither of those flight crew had lodged reports to the operator of an overspeed event, including flap, gear and maximum operating speed. - (P2#: refer pg 20-21 of the report for crew personnel details and experience  Huh


Extract from ATSB FR 'Safety Message' section:


Quote:...From an operational perspective, the event shows how a flight crew whose intention was to keep the aircraft within the prescribed limitations, can inadvertently expose the aircraft to a higher level of risk. When taking action to address potential aircraft exceedances, flight crew should consider the serious consequence of applying aggressive or large control inputs at high speed relative to the risk posed by the exceedance. Flight crew should also adhere to sterile cockpit procedures to optimise their performance in the higher risk phases of flight and apply the handover/takeover procedures to ensure dual control inputs are avoided or coordinated to maintain effective control.

In terms of continuing airworthiness, the conduct of an inspection may be the sole opportunity to detect aircraft damage. As such, to avoid a single point failure it is imperative that the form of the inspection be fit-for-purpose and for inspections to be effectively coordinated and certified.

For aircraft manufacturers and airworthiness authorities, there can be unforeseen consequences of aircraft design characteristics. It is important that when identified, these are recognised and addressed during operational service of the aircraft type..
   
  From the report under 'safety issues and actions' it states that:


Quote:Proactive safety action by Virgin Australia Regional Airlines and Virgin Australia Airlines 

Action number: AO-2014-032-NSA-051 Virgin Australia Airlines advised that, in response to this occurrence, they had taken action to reduce the potential for pitch disconnects and to manage the risk of adverse outcomes from such occurrences.

These included:

• reviewing and revising (where necessary) policy and procedures associated with descent speeds, handover and takeover procedures, overspeed recovery and on ground pitch disconnects
• incorporation of a number of factors surrounding the event into training material and simulator checks
• improved pilot awareness through Flight Crew Operations Notices, manufacturer’s communications (All Operators Messages) and on-going training and checking
• full induction for ex-VARA crew into the VAA safety management system
• updated maintenance requirements following a pitch disconnect
• compliance with all relevant points in the ATR All Operators Messages with respect to this event. 
 
The date on the proactive action is the 15 June 2016. In reality VARA (now VAA) had probably actioned through their SMS the identified operational safety issues within weeks of the occurrence happening.

However the proof is always in the pudding... Rolleyes 

Quote:https://www.flightglobal.com/news/articles/hard-landing-in-turbulence-damaged-virgin-australia-445098/

A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a 
Virgin Australia ATR 72-600, say investigators in a preliminary report.




https://www.pprune.org/australia-new-zea...rra-2.html

&..

Quote:https://the-riotact.com/probe-launched-i...out/279335

The Australian Transport Safety Bureau said the incident involved an ATR-72-flight from Sydney on 13 December at 7 pm.

The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine.

But for the remainder of the flight and the landing, the crew opted for manual engine ignition.

The ATSB has deemed the incident as serious and has downloaded the flight data recorder and is gathering other information.

Now from a completely left field OBS - in relation to the CBR hard landing occurrence - I noted the following very disturbing update from ASN on the Moscow Superjet accident (my bold): AIOS - & the 21st Century??

Quote:Superjet in fatal Moscow crash had windshear warning on approach and bounced twice on landing
26 May 2019
[Image: 20190505-0-C-1.jpg]

The Russian Ministry of Transport released initial findings on the May 5 accident of a Sukhoi Superjet at Moscow’s Sheremetyevo Airport in Russia.

Aeroflot flight 1492 took off from Sheremetyevo Airport’s runway 24C at 18:03 hours local time on a scheduled service to Murmansk, Russia. Visibility was fine but there were some Cumulonimbus clouds near the airfield at 6000 feet.

The flight crew engaged the autopilot as the aircraft climbed through a height of 700 ft (215 m). At 18:08, as the aircraft was climbing through an altitude of about 8900 ft (2700 m), a failure occurred in the electrical system. At this point, the aircraft was 30 km west-northwest of the airport in an area of thunderstorm activity.

The captain assumed manual control of the aircraft and the crew managed to establish radio contact using UHF. The flight was not able to contact the approach controller and subsequently selected the emergency transponder code 7600 (loss of radio communication).

About 18:17 the aircraft overshot the runway centreline after turning to runway heading. Altitude at that time was about 2400 feet. The aircraft continued the right-hand turn, completed a circle and proceeded on the final approach for runway 24L. Flaps were selected at 25°, which was the recommended setting for landing above maximum landing weight.

At 18:26 the flight crew selected the emergency transponder code 7700 (emergency).

When descending from 335 to 275 m (1100-900 ft) the windshear warning system sounded five times: “Go around. Windshear ahead”.

From a height of 80 m (260 ft) above ground level, the aircraft descended below the glide path and at a height of 55 m (180 ft) the TAWS warning sounded: “Glide Slope.” From that moment on the airspeed increased to 170 knots.

At 18:30 the aircraft overflew the runway threshold and touched down at a distance of 900 m past the threshold at a speed of 158 knots. Touchdown occurred at a g-force of at least 2.55g with a subsequent bounce to a height of about 2 m. After two seconds the aircraft landed again on the nose landing gear with a vertical load 5.85g, and bounced to a height of 6 m. The third landing of the aircraft occurred at a speed of 140 knots with a vertical overload of at least 5g. This caused a rupture of the wing structure and fuel lines. Flames erupted and engulfed the rear of the aircraft. The aircraft slid to a stop on the grass between runway 24L and two taxiways. An emergency evacuation was then carried out while flames quickly engulfed the rear fuselage.

  
Angel  Hmm...no comment but there will be definitely more to follow...  Confused 

In the meantime here is an extract from a 2015 Ventus AP post: 

Quote:My dear Gobbles:

The problem, simply put, is one of discombobulation.
[Image: discombobulation.jpg]

In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).


So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Five years, 3 months and five days to perfectly obfuscate and PC the bejeezus out of what could have been Australia's worst ever aviation disaster - UDB? Nope OPS normal in Oz Aviation's safety circus:

[Image: D2AxoX4U4AAC5Mq.jpg]

&..

 [Image: D1GJV4CU8AArpk2.png]

TBC...P2  Dodgy

Ps I stand corrected on the media coverage of this bollocks report, yesterday Airline Ratings published this by Steve Creedy:
https://www.airlineratings.com/news/auss...atr-upset/
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A hat trick – of warnings.

There are two ‘deep’ elements which ATSB have not deigned to cover off. Esoteric some would say; others would say it belonged to the new generation; some would consider company culture; there are some who would tag the observations as ego and attitude. To me, the elements above weave a pattern where airmanship, training and experience have been lost in the ‘hype’.

One can, and there is evidence supporting (BA for example) where the ‘problem’ begins with the HR folk. A cardboard cut out of the ideal crew – for company purposes – a ‘type’ if you like. You can, with almost 100% accuracy go to a pub and identify the company the individual’s fly for: won many a beer playing this game. There is little in the way of variation; which, for company purposes, is great. Not so much for having the right stuff somewhere on the flight deck. But, IMO it is a flawed philosophy – good pilots ain’t always ‘good’ corporate citizens – compliant and biddable; nor easily intimidated. A small, but important thread in the pattern.

P2 - The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine

To me this is tale is a warning flag; an indicator of pilot training and thinking error. “descending through heavy rain” – Why was the ‘spark’ not selected to manual (ON) before entering ‘heavy rain’. It should be an automatic action to turn the crackers on – long before entering; same as the icing gear – get it hot and working before – basic common sense. Training, corporate or pilot error? It costs maintenance money to replace the ‘crackers’ – but be buggered if I’d sit and wait five seconds for a relight even once – let alone twice. It took two flame outs before the crew selected ‘ON’. Tea and biscuits on my watch for that crew.  

P2 - A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

We have all done it – thumped one on – hard. Quartering crosswind sneaking in behind; strong gusty conditions etc. But you really need to mess it up to damage an inherently tough airframe. You can – even OEI go around from a very low height – you can also ‘feel’ when the aircraft has become a well trimmed manhole cover and take preventative action; maybe you ‘bang’ it on – but you don’t break it.

P2 - A search of the VARA occurrence database for over speed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO over speed event on descent.

Speed excursions happen – not very often – certainly not with this monotonous regularity. Particularly during a descent phase. There is a great deal of difference between a professional assessment of the conditions and the descent profile being ‘worked’ to suit the ambient conditions, than simply programming the Auto to get you to 1500 feet at five mile from Kickinatinalong. Lots of time spent ‘discussing’ and ‘briefing’ the approach plate – but little on the conditions expected throughout the ‘descent’ phase. Over speed is a training and airmanship matter.

Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching in heavy rain. These three known items may not be potential killers – but by Golly, they are man made holes in that famous Swiss cheese. How this becomes a matter for ATR to solve is beyond my ken; this, before we even get to the meat and spuds of how the control channels became separated in fairly routine conditions between Canberra and Sydney; and, how ATR are expected to re-jig their aircraft to prevent terminal stupidity. More to follow – you can bet on it.

Aye well - back to my knitting. Before I do :-

Cute as a button. Or; funny coincidence department? – You pick. Either way it is a classic of ATSB aberrations; all part of being the PR extension for the big guns. I’m rattling on about the exquisite timing of the ATSB release of the long awaited report into the badly damaged ATR. Go figure the odds; five years and change we waited for the release and when does it happen?
 
Apart from Cready and Oz Aviation – the media completely missed this one; and, there is a story there, a scary one to boot. But what with the world watching the Moscow tragedy and the 737 Max brouhaha and some kind of conference; and, a federal election on the boil - ATSB choose this particular time to quietly slip this report into he public arena. Thing’s that make you go Hmm indeed.
 
Coincidence – not a ducking chance 
 
Toot – toot.
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Point of View.

As it happened; I was having a quiet Ale with a few ‘mates’ – nothing serious – just a catch up and a chinwag. One of the fellahin’s had a new fangled I-Pad and was  scanning AP; “read this?” says he: No, so  he read it out.

P9 – “Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching heavy rain.”

These were ‘senior’ experienced men listening; there was quiet for while; then almost simultaneously we all had the same scary thought. Bear with me, there is a point. Standardization – essentially the aircrew across a fleet should be doing pretty much the same thing. – You could, without drawing too long a bow, parlay that into a statement to the effect that they are all operationally at the same standard; one crew pretty much the same as the next (give or take). With a little imagination you could paint a shocking picture where the events mentioned could all not only happen to the ‘same’ crew, but to the majority of crew – standardization; or, normalized deviance, if you prefer. If one lot could do it - etc.

It leaves the impression that any ATR crew could be operating with the regular noted over speed (and the effect this has on air frame integrity) hitting some routine turbulence; disconnecting the control channel through non SOP; entering heavy rain on approach without continuous ignition, then making a heavy landing in an already seriously damaged aircraft. The next step is have the elevator channels reconnected, a quick inspection and the broken  aircraft returned to service for a further 13 sectors. You do realise that another ‘heavy landing’ or another rough ride in turbulence could have led to structural failure.

Us old folk quietly talked it through (as you do) the if’s the ands and the buts’ of it all. Then we applied the oldest test of ‘em all. “Would you let your wife and kids fly with this outfit? “ No prizes for guessing that answer. But the big question of course is – what the hell were ATSB playing at and where was a much self promoted CASA during the five year ‘investigation’. Seems to me some folk should be pulling their socks up, checking their belts and shortening their braces. No matter who drafted the ATSB report; or, more to the point whoever edited and approved the ATSB report should – IMO – be tarred, feathered and run out of Dodge on a rail. The report is even more dangerous than the entire stew of gross aeronautical errors. Scandalous.

Well, so much for old school thinking – a change of subject to happier matters; one for the road then home in time for dinner.
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Fort Fumble White Hats; plus a thread drift? -  Rolleyes  

Was reading the Flight Safety article on this latest abomination of a ATSB topcover report - see HERE - and basically it was like the others (Oz Aviation, Creedy) following the party line - nothing to see here, move along... Dodgy  

Where the CASA White Hats totally lost me was when they included the following Hooded Canary propaganda quote:  


Quote: ‘This serious incident demonstrates aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions. Aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.’
     
Where's the bucket Ol'Tom -  Confused
In my mind this begs the question on why the White Hats even bothered? Then I read some of the comments which included these comments:

Quote:
  1. [img=50x0]https://secure.gravatar.com/avatar/5bac255c958966b36416b873b6726057?s=50&d=mm&r=g[/img]Walter May 29, 2019 at 2:06 pm
    Five years to produce this is a disgrace! We ought to be ashamed of ourselves for being so inept, but I guess this is Australia, a country not known to do anything efficiently or effective !
    Reply


  2. [img=50x0]https://secure.gravatar.com/avatar/71c7b2cc25a3a87f64f9e0f203cbdb55?s=50&d=mm&r=g[/img]Phoenix May 29, 2019 at 2:10 pm
    Interesting that there is so much focus on the mechanical damage, and very little on the management failure that created the situation leading to damage. Surely the need for formal handover of control should have been emphasised? How many times will we keep seeing incidents arising from poor cockpit management and culture?
    Reply

 
And I thought maybe there is a method in their madness and so I included a comment on behalf of P9 - i.e his last post  Rolleyes 
For the record, just in case it gets taken down:  https://www.flightsafetyaustralia.com/20...mment-2274

How things have changed? - NOT!
Now for a bit of a thread drift that I believe underlies the seriousness of this bollocks report.  Sad 
Over on the twitter-sphere yesterday I made the following reply to a tweet thread:  
Quote:2/2...read this 2014 @PlaneTalking (RIP Ben) article: https://blogs.crikey.com.au/planetalking...australia/ … &/or RT https://twitter.com/PAIN_NET1/status/456322171229306880 … then ask yourself what's changed. I would argue that it has only gotten worse: RT https://twitter.com/PAIN_NET1/status/113...1039585280 … & https://auntypru.com/forum/showthread.ph...1#pid10321 … + https://twitter.com/fishonoodle/status/1...5998066688 … #auspol
 
You can backtrack to understand the context if you like: ref - https://twitter.com/PAIN_NET1/status/113...6497699840

Quote:[Image: D7xo9_KU0AEOJvH.jpg]

However my point in rehashing the 5 year old Ben Sandilands article (may he RIP -  Angel ) is very much relevant timeline wise and in context with the point that Ben so clearly made way back then... Wink  
 
Quote:"..The risks of ministerial administrative capture need to be shut down in Australia, before they become the focus of a Royal Commission into a preventable disaster.."

Right then thread drift over...err maybe?  Rolleyes


MTF...P2  Cool
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P2 – “Where's the bucket Ol'Tom?”

That – is (I hope) a tongue in cheek understatement. We need a long drop outdoor dunny to deal with the copious amounts of Canary comment induced vomit from just the fatuous remarks department. I never though we’d miss Beaker, with all his faults even He would not say anything as risible as:-

Hood - “aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions.” (retch).

Seriously? – For Ducks sake. Backtrack the ATR event to weather briefing; fly along until the top of descent and watch as the aircraft is mindlessly configured for a ‘high speed’ descent; no mention of Turbulence penetration speed consideration; just punch the descent into the box and sit back – the turbulence was forecast and; as any pilot who ever flew between Canberra and Sydney will tell you – it can get ‘bumpy’. No ‘wind shear’ warning in any of the weather information – just turbulence and inversion (hint- hint).

"Recommended procedures: A simple rule of thumb would be to split the difference and fly a speed that is approximately half way between Vs1 and Va. However, a slightly faster speed will help improve controllability in very rough conditions. Since airspeed will be varying considerably in turbulence, it is not important that the pilot try to maintain an exact speed, but rather work to maintain near a level attitude and not exceed either the Va or Vs1 limits. The Continental Airlines B-737 Flight Manual offers the following excellent guidance which is also applicable to light aircraft, “The two major concerns when encountering turbulence are minimizing structural loads imposed on the aircraft and avoiding extreme, unrecoverable attitudes.”

So, Ok an experienced crew may not come all the way back to snail speed – but would/should build a ‘buffer’ between two extremes; keeping a few knots off the clock in case the speed picks up toward ‘risky’ and prevent not only ‘over speed’ but potential air-frame damage. Certainly fast enough to keep things ticking over nicely. Not rocket science – Airmanship, professionalism, understanding, due diligence and old fashioned common sense.

So Tweedledee and Tweedledum are bowling along – shock horror – the forecast inversion and the forecast moderate turbulence have caught them out. Too bloody fast mate – over speed approaching. OK – back off the power – ease the nose up - reduce the descent rate and proceed at a reduced speed. No brainer – routine – easiology. Nope, out hero’s elect to not only disregard SOP and manufacturer procedure; but engage in an arm wrestle for control. Can’t remember the number of foot/pounds needed to be deliberately applied to separate the elevator channels - but it is a big one, i.e. you have to mean it. So we have a situation where – at a relatively high speed – one side of the elevator gets an ‘UP’ command – the other a ‘DOWN’ force and, no surprise it breaks. Training error, discipline error, operational error, pilot error – maybe plain old panic and incompetence. Plenty of options there – one option though can easily be ruled out; manufacturer and design error. Hood speaks through his posterior orifice. Disgraceful, deceitful and wrong.

Not content with making a fool of himself in front of aircraft manufacturers and aircrew all over the world – he then tries to ‘piggy-back’ into the Boeing mess to try and give the impression that ‘he’ is a sage, experienced doyen of aircraft systems and their design.

Hood - “Aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.’

It is good thing he can speak through his posterior orifice – because he is full of it. Clown!

Toot – pass the bucket – toot.

Sotto voce – I ain’t done with this yet – not by a long march.
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Catch Up or Ketchup?

One of the worst things that can happen, in almost any field of endeavour is falling behind. The further behind one gets, the harder it is to catch up, much more energy and will power is required and, having expended that energy, getting ahead becomes a very real challenge. It takes a while and some thinking to fully grasp the implications for the Australian 'catchup' emanating from the excellent report into the Air Nuigini 'accident'. (?)

In less than a twelve month, the PNG AIC managed to produce not only a first class analysis, but recommendations which not only have merit, but will stick. Flying operations in PNG are not without risk; almost everyone concerned there has an elevated awareness of ‘real’ risk in ‘real’ time and have a vested interest in finding out what happened, why and how best to fix it to prevent a reoccurrence. There are no faery tales of ‘safety’ told in PNG, no spin to mislead the public into believing that the local CAA is a god like being which, through a myriad of complex rules can sit back and say you are safe. Not in PNG, they understand that terrain, weather, aircraft and pilot can combine in an accident – any tick of the clock – and they do what they may to prevent reality happening, with limited resources and going the extra mile, without fear or influence. They shame Australia.

Despite the spin, bullshit, resources, unlimited power; and, not to mention the minister on a string, Australia has an impressive list of unfinished fatal reports, an even longer list of unpublished recommendations, and a marked reluctance to complete any of the above within a reasonable time frame. If an emerging nation like PNG with limited everything can do a complex, world class report within ten months, why are we in Australia still waiting for results? It also begs the question why did we waste so much time and effort to hold not only a Senate inquiry, but an independent report and an international examination; which, combined produced almost 100 recommendations, to no effective change whatsoever?

P2 - It is also disturbing that despite there being a 2nd inquiry and report by the ATSB into the PelAir VH-NGA ditching that there was no observations/findings in regards to Pacific Island air services agreements etc. like the PNG AIC has been able to do, without fear nor favour, inside of 10 months to an excellent full report...

A good question for the opposition to ask the incumbent Muppet, masquerading as minister methinks.

Perhaps ask why there is such a delay on the final report into the Ross Air fatal for example; another ‘training’ based event which proved lethal. Many would like to hear the ‘official’ ministerial response to that event; or, of any of the serious events which are neatly stacked up in the waiting room, awaiting their final, properly edited turn to be of no practical value.  

How’s this for a response to an enquiry – two years (and counting) down the track of the Ross Air investigation (another sim v aircraft training accident).

ATSB - "The investigation is progressing well, however, the analysis phase is proving to be a complex process due in part to the lack of recorded data from the flight. As a result we now expect to provide you with a copy of the draft report in the 4th quarter of this year. Sincere apologies for the delay however this investigation remains a high priority for the ATSB and the team are working tirelessly to complete the investigation as soon as possible."

Here is one response:-

Anon“but not too busy to try making ATSB keep up with their promise of monthly updates. What utter tosh! Here is a copy of the latest 'update'. As you can see he insults my intelligence by telling me the investigation is progressing well and they are working tirelessly!!! Can you believe the audacity???”

I, for one can, so can many others. Australian aviation ‘safety’ is rapidly becoming little more than a PR exercise for government ministers who just don’t want to address the rapidly growing elephant in the room. Perhaps someone could whisper into the ministerial ear the real opinion of his international peers regarding the pitiful, deceitful state Australian aviation governance has descended into.  Volunteers? No. I wonder why not.

Toot – toot.
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Hooded Canary not singing but still talking bollocks -  Dodgy

[Image: EAMpi7yU0AEm9V5?format=jpg&name=medium]

Via the Yaffa:

Quote:[Image: greg_hood-2.jpg]

ATSB wears Kickback over Angel Flight Report
15 August 2019
    

The Australian Transport Safety Bureau (ATSB) has been roundly condemned by both Angel Flight and the Centre Alliance for its recommendations stemming from the Mount Gambier crash report released on Monday.

The report's recommendations into the VFR-into-IMC accident deliberately focused more on the systems and management behind Angel Flight than the actions of the pilot, suggesting that Angel Flight should consider using regular public transport rather than private pilots (PPL) because it was safer to do so.

Angel Flight CEO Marjorie Pagani slammed the report, saying that the ATSB focus was of no help to general aviation.

"The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather," Pagani said in a statement. "It is regrettable that the Bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions – the cause of the accident.

"It would have been of benefit to the flying community had the ATSB focussed on these aspects of the accident.

"The safety recommendation made was for the charity to book people on airlines for travel. This does not adequately factor in cost (particularly where two or more people are traveling, which is often the case), nor does it properly factor in the infrequent scheduling or non-existence of airline flights into country regions across Australia, the inconvenience and difficulties faced by the elderly and families with young children at major city airports, and the associated ground travel; and appears to work on the assumption that city specialists and hospitals will gear their appointment times around airline timetables.

"Angel Flight does use airline flights where practicable and necessary, and will continue to utilise these services."

Centre Alliance's Senator Rex Patrick was openly critical in a statement released through Angel Flight. Senator Patrick has opposed the CASA-imposed restrictions on community service flights and was behind motions to disallow lodged in the previous parliament.

"The findings in respect of community service flights are intensely bureaucratic in nature and clearly written by people sitting at a desk in Canberra without reference to any of the thousands of families that have been helped by organisations such as Angel Flight," Senator Patrick said.

"Indeed, its hard to take the report’s analysis of Angel Flight seriously. It asserts that many flights can be replaced by commercial services almost blind to the costs of regional flights, their limited routes and their limited schedules. Indeed, the data the ATSB uses to support its claim are based on the very narrowest of data sets.

"The ATSB uses ‘lies, damned lies and statistics’, coupled with predominantly subjective analysis, to portray community service flights as unsafe. Angel Flights use experienced pilots and safe aircraft. There is no difference in the safety case associated with a CASA certified pilot flying a mate to the footy in Melbourne and a CASA certified pilot flying someone to chemo therapy in Melbourne, except the the ill patient is more aware of the qualifications of the pilots and the risks associated with a flight.

"Its Pel-Air (Norfolk Island ditching) all over again - for that particular report the ATSB were found to be grossly incompetent and were ultimately required to redo the report."

ATSB Chief Commissioner Greg Hood defended the investigation report, saying that investigators deliberately shied away from focusing on the pilot.

"If you have a look at the way the ATSB works, we've been broadly criticised, particularly over the Norfolk Island report where we focused on the individual, so with this investigation, given that it was the second triple-fatality, our methodology took us to having a look at organisational factors, and that's why we put in the recommendations we did," he told Australian Flying.

"We went to look at the organisational factors, and one of the problems we encountered is that we didn't have any data. There was no way to have a look at the safety of that particular sector of the industry because the data didn't exist.

"Being private flights they weren't required to state that they were Angel Flights, so what we had to do was ask AF for the schedules and then go back into the flight plan database and then the incident database and match that up to give us some idea of the health of the industry in relation to occurrences and accidents."

On the matter of the recommendation to place clients on RPT, Hood took pains to point out that the ATSB recommended only that Angel Flight consider using commerical flights in the same manner as the Canadian Hope Air, which places 70% of all clients with medical appointments on RPT.

Hood stated that the issue with using PPLs is that Angel Flight missions appeared to impart greater pressures to complete that flight than the ATSB believed are present during general private operations, leading to the conclusion that RPT would be a safer option.

"We did go to great lengths to be balanced," Hood said. "I know that's no everybody's view, but what we were faced with is two triple-fatalities and when we were able to extract the data it was telling us something very clearly in relation to these pressures and so then it was a matter of what recommendations do you make?

"The ATSB has no legislative powers to enforce any of these recommendations; they are there to improve the safety of the traveling public in these particular flights."

Angel Flight also took issue with the data analysis used in the reports, stating that the ATSB didn't use straight comparisons when assessing the levels of reported incidents and accidents.

"The ATSB also chose to compare only the passenger-carrying sectors of flights coordinated by the charity – it disregarded the flights, also coordinated by the charity, where the aircraft flew from home base to the city collection points, the return trips back to base, and the positioning flights to collect passengers from their own home towns," Pagani said

"It did, however, include those flights when reporting ‘occurrences’ against the charity flights. There was, and is, no reason for this failure. To remove up to two-thirds of the coordinated flights in order to make statistical conclusions is unjustifiable. Moreover, when comparing the data with private flights generally, it did not exclude the non-passenger flights for that group – all flights were counted in the general private sector, but not in the charity sector."

Angel Flight is currently contesting the data used by CASA to justify applying restrictions to Angel Flight operations last March, with the matter scheduled to be back before the courts again in September. According to Greg Hood, the ATSB did not rely on the CASA data, but used its own analysis to arrive at a similar conclusion, that Angel Flights were statistically more dangerous than normal private operations.

"We've done everything entirely separately from the regulator," Hood pointed out. "We've been very careful in that space especially after the experience we had with Norfolk [Island] and previous investigations, so we obtained the data from Angel Flight [and] we did our own analysis completely independent from anything that was done by the regulator.

"I'm absolutely confident in the science applied to this. We have a number of data scientists here with PhDs and we had one team developing the science and arriving at conclusions and another team making sure that that was valid.

"The ATSB just wants [Angel Flight] to operate well and for the people who are being carried to medical appointments to have that level of assurance that they're going to get there safely."


Read more at http://www.australianflying.com.au/lates...MDIj7qM.99

& via the Oz:

Quote:ATSB’s warning to pilots on risky flights: ‘Don’t push it, don’t go’

[Image: f434be7ec69e7699c5f5b7f30de9786b?width=650]

A new safety campaign urging ­pilots “don’t push it, don’t go” will be launched next week by the Australian Transport Safety Bureau following this week’s Angel Flight crash report.

That report found pilot Grant Gilbert should never have taken off from Mount Gambier on June 28, 2017, due to low-lying cloud and the fact he was only visually flight-rated. His TB-10 Tobago was airborne for just 70 seconds before the crash that killed him and his passengers, Tracy Redding and daughter Emily.

It was the second fatal Angel Flight crash in six years, with the previous triple-fatality accident in 2011 occurring in similar circumstances.

ATSB chief commissioner Greg Hood said the bureau’s finding that Angel Flight services were seven times more likely to result in a fatality than other private flights showed more needed to be done to improve safety.

“We have absolutely no barrow to push; we’re not anti-Angel Flight, we’re simply saying that the data is telling us something,” Mr Hood told The Australian.

“We’ve got two triple fatalities, you’ve got next of kin who are incredibly upset and we think that better things can be done in the sector.”

He admitted to being “taken aback” by the response from Angel Flight CEO Marjorie Pagani that the final report provided little in the way of useful guidance. She criticised the recommendation that Angel Flight consider booking commercial flights where available as an alternative to using volunteer private pilots, and said there was no advice given to pilots flying in poor weather.

Mr Hood said the best guidance the ATSB could provide was the message of their “don’t push it, don’t go” campaign.

“If the weather’s not suitable, you shouldn’t be flying,” he said.

“I don’t know how many times we’ve run these campaigns over the years, but pilots who are only rated to fly under visual conditions have continued to get themselves in trouble.”

The Australian understands as many as 100 incidents of pilots becoming spatially disoriented in cloud have been reported to the ATSB in the past decade, resulting in 21 fatalities.

Crossbench senator Rex Patrick said he would continue to push for new regulations imposed on Angel Flight by the Civil Aviation Safety Authority to be reversed, despite the finding that the community service operation had a higher fatality risk than other private flights.

“Angel Flight uses experienced pilots and safe aircraft,” Senator Patrick said. “There is no difference in the safety case associated with a CASA-certified pilot flying a mate to the footy in Melbourne and a CASA-certified pilot flying someone to chemotherapy in Melbourne except the ill patient is more aware of the qualifications of the pilot and the risks associated with a flight.”

But the ATSB argued that transporting patients to medical appointments carried greater responsibility and pressure, which had led to pilots taking off in unsuitable conditions.

Transport safety director Stuart Godley said it was important that pilots were trained how to recognise those pressures and deal with them, “rather than leave them alone to make those decisions in the heat of the moment”.

And in regard to O&O'ing reports... Rolleyes 


Quote:ATSB chief Greg Hood: More complex reports take time

[Image: d4607e443259cd8d3141d5915f2cb76a?width=650]

Australian Transport Safety Bureau chief commissioner Greg Hood has defended the increasing time frame for aircraft incident investigations, pointing out the greater depth of recent final reports.

This week’s report on the 2017 Angel Flight crash at Mount Gambier went to great lengths to delve into organisational factors that may have contributed to the accident, and produce the statistics highlighting the risks involved with the not-for-profit operator.

Mr Hood said much of the data had to be sourced from scratch, after the ATSB discovered that what it needed for an examination of the safety of the community service flight sector did not exist.

“What we did is we went back and got more than a decade of schedules from Angel Flight and we matched those flights with data from the Bureau of Infrastructure, Transport and Regional Economics and also from the ATSB database,” he said. “(Statistician) David Wilson wrote the program that matched all that up and for the first time we were able to compare flights in the community service flight sector with private, charter and regular public transport.”

A number of investigations were close to being finalised including the 2017 Sydney Seaplanes crash and the Australia Day crash of a Grumman G-73 Mallard in Perth the same year.
 
Hmm...in the real world the Hooded Canary protestations would be all well and good, however the problem for Herr Hood is that he has a massive  credibility issue in all this because of his checkered past inside of both CASA and ASA. To say the guy is impartial and a SME (subject matter expert) would welcome hilarity from the more credentialed aviation accident investigation professionals throughout the world. 

Remember that this was the guy that as Chief Commissioner saw fit to threaten internally his employees with the possibility of jail time if they were contemplating leaking or having an opinion on the active (at the time) MH370 investigation and search - References:

Joining dots on Hood threat & obfuscation of MH370

Quote:..As witnessed above, currently there is much finger pointing, hand wringing, consternation and condemnation; on the ATSB's 'Hooded' threat to it's employees and attempted obfuscation of the Australian's FOI request for the recorded opinions of the various MH370 SSWG participants...

Well aided and nicely abetted.

Quote:..If the data Australia refuses to release belongs to Malaysia; then why does Hood simply just say so. “Sorry folks, if it were our data, we would release it without hesitation; but, it ain’t”. “If you want it, petition the Malaysian government, it all belongs to them”.  But Hood does not say this – clearly, that’s not case. So, like Higgins and Byron,  I’m left wondering just who is running this country? ..

And remember that this was the guy that was so severely intertwined within the PelAir cover-up (Mark I & II) to suggest a massive conflict of interest with any dealings with the ATSB, let alone being the Chief Commissioner... Dodgy

References: 1. https://auntypru.com/forum/showthread.ph...38#pid8238 & 2. https://auntypru.com/forum/showthread.ph...29#pid8029

Quote:The Iron Ring & the Hooded canary - [Image: confused.gif]  

Quote from this week's SBG: Speak softly; yonder, as I think, he walks.

 "...The opening gambit is readily seen in the media – see: there’s Hood, doing a Geoffrey Thomas (he of Sunrise fame). This is not a top quality act, but ‘twill suffice. Firstly, we must examine the ‘props’ used, the title for a start will impress – ‘top dog in the Australian Transport Safety Bureau (ATSB) and a natural performer. Always seen looking ‘windswept’ and interesting, dressed in his canary yellow vest, wearing his ‘courage’ wrist band. The ‘shrinks’ would have a field day with that little lot, no matter. The long suffering public will not know the lack of qualification, or the association with some of the most disgusting ‘Acts of bastardy’ which hover about the ‘windswept’ visage. They will have no concept of conflicted interest or even ‘departmental’  manipulations. No; they just see the ‘fluff’ and hear the soothing words, reassured; they happily hop on the cheapest flight and toddle off to booze in Bali..."

 &.. from SBG post #95:

"...The main reason being that while HVH was the CASA Executive Officer ultimately overseeing the enforcement actions against both PelAir and Dominic James I also have, on good authority, information that HVH was the designated co-ordinator/liaison officer dealing with the FAA audit team and therefore the consequential cover-up of the actual FAA findings that could have led to the possible Cat II IASA rating..." 

So with interest piqued the BRB have tasked me to re-examine the HVH crumb trail with the intent to join some further chronological dots & dashes on the PelAir cover-up timeline (i.e Pel-Air: A coverup: a litany of lies?)... [Image: huh.gif]

  
MTF...P2  Tongue
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Well. What a surprise. The Rossair investigation report has been delayed until 2020 even though the team are 'working tirelessly'. Makes you wonder what on earth they can be doing!
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Wonder no more….

CG – “Makes you wonder what on earth they can be doing!”

If you get a chance to read the Larry Vance* book on MH 370 (Kindle $8.00), take a little time to study his remarks regarding the ATSB. 
*Larry Vance, who was a senior investigator for the Canadian Transport Safety Boar


There are several passages in the book which draw pretty much the same conclusions as many professional accident investigators and senior aviators have. Vance is quite ‘diplomatic’ but very clear about it, ATSB write reports to a pre determined result. An acceptable conclusion is then supported by carefully managed data.

We have seen this phenomenon several times over the last years; we have also seen ‘time’ used to allow a less palatable result of investigation to drift from active memory. Ross Air a perfect example; the Braz another, Essendon another, the ATR another; all part of an extensive list.

[Image: 3ded920ffd3ad4b026da32de07039356]

There are two ‘classic’ examples – Pel-Air and Angel Flight, where the inherent willingness to oblige with a ‘slanted’ report is clearly apparent. IMO -  the MH 370 story, in professional hands provides the best example of an investigation report being written to fit a pre-determined outcome.

Anyway – FWIW in terms of changing the ATSB the book is probably irrelevant. The sad thing, as the evidence against ATSB piles up is that their reports become worthless, rendered  nugatory, because no one believes 75% of the rubbish presented. The 25% believable is simply the stark fact that there was, in fact, an accident. But we already knew that, didn’t we boys and girls.

Stopping there: before Hell's own ‘Furies’ arrive.

Toot - toot.
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The Hooded Canary takes the ATSB well "Beyond All Sensible Reason" -  Blush

[Image: images?q=tbn%3AANd9GcRQK6U1pRqH2ELk-idMu...gJ1kFIMRPk]

Long post but there is a point (I hope - Rolleyes ) - the chain of disconnection/evidence: 


(05-30-2019, 07:55 AM)Kharon Wrote:  A hat trick – of warnings.

There are two ‘deep’ elements which ATSB have not deigned to cover off. Esoteric some would say; others would say it belonged to the new generation; some would consider company culture; there are some who would tag the observations as ego and attitude. To me, the elements above weave a pattern where airmanship, training and experience have been lost in the ‘hype’.

One can, and there is evidence supporting (BA for example) where the ‘problem’ begins with the HR folk. A cardboard cut out of the ideal crew – for company purposes – a ‘type’ if you like. You can, with almost 100% accuracy go to a pub and identify the company the individual’s fly for: won many a beer playing this game. There is little in the way of variation; which, for company purposes, is great. Not so much for having the right stuff somewhere on the flight deck. But, IMO it is a flawed philosophy – good pilots ain’t always ‘good’ corporate citizens – compliant and biddable; nor easily intimidated. A small, but important thread in the pattern.

P2 - The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine

To me this is tale is a warning flag; an indicator of pilot training and thinking error. “descending through heavy rain” – Why was the ‘spark’ not selected to manual (ON) before entering ‘heavy rain’. It should be an automatic action to turn the crackers on – long before entering; same as the icing gear – get it hot and working before – basic common sense. Training, corporate or pilot error? It costs maintenance money to replace the ‘crackers’ – but be buggered if I’d sit and wait five seconds for a relight even once – let alone twice. It took two flame outs before the crew selected ‘ON’. Tea and biscuits on my watch for that crew.  

P2 - A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

We have all done it – thumped one on – hard. Quartering crosswind sneaking in behind; strong gusty conditions etc. But you really need to mess it up to damage an inherently tough airframe. You can – even OEI go around from a very low height – you can also ‘feel’ when the aircraft has become a well trimmed manhole cover and take preventative action; maybe you ‘bang’ it on – but you don’t break it.

P2 - A search of the VARA occurrence database for over speed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO over speed event on descent.

Speed excursions happen – not very often – certainly not with this monotonous regularity. Particularly during a descent phase. There is a great deal of difference between a professional assessment of the conditions and the descent profile being ‘worked’ to suit the ambient conditions, than simply programming the Auto to get you to 1500 feet at five mile from Kickinatinalong. Lots of time spent ‘discussing’ and ‘briefing’ the approach plate – but little on the conditions expected throughout the ‘descent’ phase. Over speed is a training and airmanship matter.

Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching in heavy rain. These three known items may not be potential killers – but by Golly, they are man made holes in that famous Swiss cheese. How this becomes a matter for ATR to solve is beyond my ken; this, before we even get to the meat and spuds of how the control channels became separated in fairly routine conditions between Canberra and Sydney; and, how ATR are expected to re-jig their aircraft to prevent terminal stupidity. More to follow – you can bet on it.

Aye well - back to my knitting. Before I do :-

Cute as a button. Or; funny coincidence department? – You pick. Either way it is a classic of ATSB aberrations; all part of being the PR extension for the big guns. I’m rattling on about the exquisite timing of the ATSB release of the long awaited report into the badly damaged ATR. Go figure the odds; five years and change we waited for the release and when does it happen?
 
Apart from Cready and Oz Aviation – the media completely missed this one; and, there is a story there, a scary one to boot. But what with the world watching the Moscow tragedy and the 737 Max brouhaha and some kind of conference; and, a federal election on the boil - ATSB choose this particular time to quietly slip this report into he public arena. Thing’s that make you go Hmm indeed.
 
Coincidence – not a ducking chance 
 
Toot – toot.

Plus:

(10-31-2019, 08:24 PM)P7_TOM Wrote:  Cracks in the ‘deeper’ foundations?

Over the last 12 month; I have, looking through the boarding passes done 20 domestic sectors – four international and four domestic ‘overseas’ - as a passenger. I get about a bit – back and forward to work.

The four overseas sectors were in the USA – lovely smooth landings – as usual from well managed approaches, despite the traffic and schedule – no complaints, operationally whatsoever. The ‘usual’ 'whinges' are purely personal preferences.

Of my domestic sectors – only four were on Virgin; two into Brisbane, two into Sydney. They were the last I ever flew with that airline – totally and utterly the very last. The first ’scare’  was into Brisbane – being sensitive to the handling of the aircraft, my own little alarm started ring about 20 miles out. By 18 miles, the aircraft felt and sounded like there was a ‘speed/ glide-path control problem; by about 14 miles, I was convinced that there was little control over either – hard landing approaching I reckoned. Proved correct – IMO the resulting landing, from that approach was indeed ‘heavy’. I was much surprised to see the aircraft taxi out again about 30 minutes later. When an almost picture perfect repeat of this event happened this occurred, a couple of weeks later; I simply decided not to ever again fly on a line where aircraft were not under complete control during the approach, made earth shattering landings and taxied out ‘on schedule’ after what was, by any reckoning a very hard landing and significant bounce..

I did two sectors with Tiger – no complaint whatsoever, the approach was nicely managed, the landing most acceptable.

The rest I did with Qantas. Same sectors over a three month period – out and back. Not once, was I subjected to a landing I would deem ‘acceptable’. Bang, crash, wallop – big reverse and some fairly sloppy taxi-ing, along with harsh braking.

Now, they ‘discover’ cracks in air- frames – Wow!   I wonder how they happened?

HR have a lot to answer for; profiling to find ‘the right type’ of corporate citizen to fit their mould of ‘what’ makes for a decent pilot. Used to be an ability to actually manage the aircraft – alas; no longer it seems. Not to worry – its all about the ability to type 60 WPM with your left hand and reliance on the ability to manage the software.

Aye, us Dinosaurs must learn to look the other way – toward the blessed day when ‘travel’ is no longer a requirement. Soon, very soon – I won’t have to give a monkeys; or fly anything that is repeatedly ‘slammed onto a runway’ - driven, no matter what – onto the markers at the scheduled speed, rather than ‘flown on’. “Oh, I do ‘em like that all the time” – the old answer to a ‘greaser’ in a fluky crosswind – off a hand flown ILS, middle of the night. Of course it was a fluke  - but I have ‘fluked’ it quite a lot of times. Enough to know the difference anyway. Not my problem - as are the repair and rectification bills.

Just saying my two bob’s worth – cracks in airframes ain’t a good thing; are they? However, now is the time for all good men of legal age to imbibe. BRB full session to ‘manage’ – the boy wants his new keyboard back – time for a quiet, calm, reflective Ale, before the BRB/IOS storm.

Yesterday the ATSB finally released their report into the ATR heavy landing at Canberra airport -  Shy

  Via the Oz:


Quote:Virgin plane damaged after pilots’ stuff-up

[Image: e89d79d66cf783d2dbed4279abe0eab5?width=650]

The pilots of a Virgin Australia aircraft that landed so hard it was substantially damaged, were undergoing flight checks at the time, an Australian Transport Safety Bureau investigation has revealed.

The ATSB’s final report on the incident at Canberra Airport on November 19, 2017, found the pilots failed to adhere to standard operating procedures as the ATR 72 descended.

To make matters worse, a check captain was on the flight deck conducting an annual line check of the captain and a six-month check of the first officer.

According to the report, just four seconds from landing, the aircraft was descending at a rate of 784 feet per minute – or more than 200 feet per minute above the normal descent rate.

“At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component,” the report said.

“This resulted in a further loss of lift and the captain later stated he felt the aircraft drop out from under him.”

READ MORE: Qantas tests London to Sydney | Rex gets go ahead for foreign pilots

As a result, the turboprop reached a recorded 928-feet per minute descent rate at touchdown, resulting in a 2.97G hard landing on the main landing gear, tail skid and underside of the rear fuselage. All were substantially damaged.

The ATSB investigation found the power was incorrectly set for descent, but despite calling twice for an increase, the captain who was the pilot monitoring, did not physically intervene until it was too late.

The call for a go-around was made just as the aircraft touched down. Fortunately none of the 67 passengers or five crew on board were hurt.

ATSB transport safety executive director Nat Nagy said the crew should have conducted a go-around when the approach became unstable.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures,” Mr Nagy said.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

He noted that unstable approaches continued to be a leading contributor to approach and landing accidents, and runway excursions or overruns.

The report revealed the captain had more than 8000-hours of flying experience and the first officer, 1320-hours.

In response to the incident, Virgin Australia had amended ATR 72 operational documentation, and reinforced existing training regarding speed management during approach and landing.
 
And the accompanying Hooded Canary MR: 


Quote:Unstable approach, failure to go-around leads to a hard landing

[Image: ao2017111_atr.jpg?width=670&height=375.2]
[b]The ATSB is highlighting the importance of adhering to standard operating procedures following the release of a final investigation report into the hard landing of an ATR 72 airliner resulting from an unstable approach.[/b]


On 10 November 2017, ATR 72-212A VH-FVZ operating as Virgin Australia flight VA646 was arriving at Canberra Airport in conditions of light turbulence. On the flight deck were the captain (who was also a training captain), the first officer (who the captain had previously trained), and a check captain. The check captain was conducting a routine annual operational line check of the captain and a six-month operational line check of the first officer over four flights on the day. The occurrence flight was the last of these flights. In the main cabin were two cabin crew members and 67 passengers.


During the landing approach the first officer, who was the pilot flying, assessed that the aircraft was overshooting the desired approach profile. In response, at a height of 118 feet above the runway, he reduced engine power to idle, but this resulted in an abnormally high descent rate (in turboprop aircraft large propellers spinning rapidly in low pitch create a significant increase in drag).


The aircraft captain, who was the pilot monitoring, identified that power was incorrectly set, and twice called for an increase in power before subsequently intervening and increasing power himself. This intervention, however, occurred too late to arrest the high rate of descent.


Four seconds prior to touching down, the aircraft was descending at a rate of 784 feet/minute, already greater than the design limit of the undercarriage and above the normal descent rate for the approach of about 575 feet per minute. At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.


Consequently the aircraft reached a recorded 928 feet per minute descent rate at touchdown, resulting in a 2.97 G hard landing on the main landing gear, tail skid and underside of the rear fuselage, resulting in substantial damage.


Unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.
The aircraft subsequently required inspection of landing gear components, reskinning of sections of the fuselage underside, and replacement of the tail skid and a drain deflector mast before it could return to service.

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures and conducting a go-around when an approach becomes unstable.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions. No shit Sherlock -  Dodgy

[b]Read the report AO-2017-111: Hard landing involving ATR 72, VH-FVZ, Canberra Airport, Australian Capital Territory on 19 November 2017[/b]

Which brings me to this O&O'd / yet to be completed, investigation within a completed investigation... Dodgy 

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

Quote:...As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.


The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:
  • interviews with current and former staff members of the operator, regulator and other associated bodies

  • examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used

  • reviewing other investigations and references where similar themes have been explored.
 
Note that the last update states the expected completion of this investigation as the '1st Quarter 2020' but the investigation status is only listed as 'evidence collection', so early 2020 is optimistic at best ... Confused   Shirley, given the above evidence the Hooded Canary could put a little bit more priority towards completing that investigation... Dodgy 

This brings me to the other former high profile completed investigation that has an associated investigation within an investigation: https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/   

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

Quote:..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.
  
To which I add this post link which highlights the snail pace progress of yet another investigation that you would think would have a much higher priority : Strange dissonance in the Hooded Canary's coop? - Part II


Quote:
Kharon Wrote: 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: Wrote: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...

Hmm...why do I get the impression that not only are the powers to be actively avoiding addressing the significant holes in the Swiss cheese that these high profile accident investigations have identified but are also actively engaging in contributing to making the holes bigger to help facilitate the next high profile accident?  Dodgy 

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MTF...P2  Tongue
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Its the Bullshit which baffles, bothers and bewilders..

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

That is about the only honest line in the latest load of Pony-pooh from the ATSB PR division. Even so, it fails (miserably) to mention one important fact. This type of event is a ‘flight school’ common occurrence; instructor pilots earn their corn teaching proper approach and landing technique. Ask any experienced instructor how many times they have patiently nursed a neophyte through the ‘proper’ management of an approach and how ‘alert they are to this type of basic error occurring. By the time a pilot gets to fly an ATR, preventing this type of event should be a reflex action; long before imitating a well trimmed manhole cover. Ye Gods; managing the aircraft through turbulence, wind shear, crosswinds, wind gusts etc. are a routine part of daily life; yet here we see three (3) pilots with front row seats, who on fine day, without any problems, sat through a crash. WTD………

At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

I’m having a hard time even believing the statement above, let alone that the conditions cited had any bearing, whatsoever, on an aircraft supposedly crewed by ‘professional’ pilots. FDS there are these things called wind socks; there is a thing which tells you speed (in the air and over the ground)_, there is a thing which tells you how fast you are descending, there is even a thing to tell you, at about three miles this is getting out of shape – do something – that is good training and experience. Perhaps one of these elements was missing?

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

I say BOLLOCKS. Had the original causes been identified, the approach should have been under control long before ‘crash – down’. This was a good day to be flying, good enough for a hand flown visual approach, with every conceivable external factor benign, a serviceable aircraft and a tiny wind shift for the last 30 feet. My Grand Mama could land it with all that going for her. Go around – bullshit; thumb in bum, mind in neutral applicable. This was a typical pre solo student pilot error, overseen and watched by two supposed ‘training pilots’ all the way to the wreckers yard. Bloody disgraceful.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

The time to remedy an unstable approach is not when ‘time is short’. The time to remedy an unstable approach is at flight school, not on a passenger service with 60 odd in the back, on a good day.

No excuses the Australian Tenuous Substandard Bullshit (ATSB) can pen will remove the major problems. Double flame outs (One crew) – Tail plane damage (One crew) – Crash landing (one crew) that’s seven (7) pilots complicit in three (3) nearly serious events. Yet ATSB only spouts ‘go around’ early. Sage advice? – BOLLOCKS.

Aye, steam off; but there is something seriously wrong. You can kill yourself and your passengers as often as you like –provided it’s all done nice and ‘legal’ like. Don’t worry if you can only fly the Sim – and a wizard on the software – that’s what modern pilots do best, dontchyaknow. “Bong - Autopilot disengaged” “OMG we all be killed”. “Did you sign off the paper work” – Famous last words – thank the gods we’re legal. -  Cue CRASH sounds and screams.…
Toot – toot. Big Grin
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