Proof of ATSB delays

(08-12-2020, 08:23 AM)Kharon Wrote:  A game of shadows.

It was a simple enough question – one posed to the BRB as a follow up to the twiddle I stuck on the board – HERE -. The response not only unanimous but completely unambiguous – stunned disbelief.

The Hawkesbury (spell checked for ST) river crash of a Beaver was one of those 'mystery' ones; competent pilot, safe aircraft, good weather etc. Not clear cut, similar to the Essendon King Air event – i.e. why and what the Hell happened.

Dec 31, 2017 was the date of the event – today is August 12, 2020. Only recently have folks like the ABC picked up the story line of CO gas in the exhaust fumes as being the villain in the piece.

Would you expect that as soon as possible there would be an autopsy conducted?

Could you reasonably expect ATSB to factor in the results of that examination to the reporting process, in the first instance – as soon as possible?

With an event like the Jerusalem Bay fatal; the early discovery of any toxic, mind bending or prescribed chemicals would be an essential consideration – ruled in or out as the case may be.

After two years and eight months ATSB start whispering that CO in the exhaust gas killed the aircraft and its passengers? Seriously -

It may well be that CO did for the pilot and passengers; but, if so, then why was this not made public at the time of autopsy – or at least as soon as legally possible; with a final report stating this as 'proven fact', with supporting evidence? Gold plated, cash and no bull-shit evidence would have put the matter to bed with hardly a ripple. “Pilot incapacitated; CO level of 25%; end of story. But no, we get fed a line of 'elevated' CO levels; a small lately discovered 'crack' in one exhaust pipe and some tiny (PK screw size) holes in the firewall. How many thousands of hours have been flown in the Beaver by pilots on long days of top dressing and all the other utility jobs the Beaver has been use for in its long history – you think none of those aircraft had leaky exhaust gaskets, cracks in the manifold or even the odd hole or two in the firewall?

Is feeding half baked stories to the media the right way to wrap up a two year eight month investigation?

Toot – toot.

P2 addendum:

(07-04-2020, 09:40 PM)Peetwo Wrote:  AO-2017-118 : Cover-up or cock-up? - Part II

Interesting OBS "K", after some scrounging around some of the usual cyber-dustbins, I am now leaning towards a cover-up of the cock-up... Rolleyes

Note the following extract from the prelim report -  Shy 

Quote:The ATSB will continue to consult the engine and airframe type certificate holders, and utilise the expertise of the Seaplane Pilots Association of Australia. Accredited representatives from the Transportation Safety Board (TSB) of Canada and the United States National Transportation Safety Board (NTSB) have been appointed to participate in the investigation. A representative from the United Kingdom (UK) Air Accident Investigation Branch (AAIB) has been appointed as an expert to the investigation team under the same provisions. The AAIB will provide liaison with the passenger’s next-of-kin, citizen’s in the UK.


Given the accident pilot's dual citizenship with Canada, the TSBC reference in particular got me thinking -  Huh

1st reference TSBC AAI report A00C0059 

The following part very much supports the "K" opinion:


Quote:Toxicological tests did not reveal the presence of alcohol or any other intoxicating drugs in the blood of the captain or the first officer. However, the levels of carbon monoxide in the blood of both crew members were elevated. The captain's carboxyhaemoglobin level was 17.9 per cent, and the first officer's level was 8.7 per cent. It was learned that the captain smoked more than one package of cigarettes per day and that the first officer was a non-smoker. Cigarette smokers may routinely have saturation levels of 6 to 8 per cent, and the effects of carbon monoxide are cumulative. Tolerance to carbon monoxide is not increased by smoking.

Many different classifications of severity of carbon monoxide poisoning are documented, indicating that the severity of symptoms does not correlate well with carboxyhaemoglobin levels. Generally, saturation levels of less than 5 per cent are not considered to cause any obvious symptoms. At saturation levels less than 25 per cent, physiological functions and the performance of skilled physical tasks are rarely affected. However, complex psychological functions involving judgement, situational decisions, and responses would be affected by levels between 5 and 20 per cent.Footnote3 Some classifications indicate decreased visual acuity at saturation levels of 10 to 20 per cent.Footnote4 Once the victim of carbon monoxide poisoning is removed from the carbon monoxide source, the levels decline. Information indicates that the half-life of carboxyhaemoglobin is about five hours. Altitude affects the saturation level because the partial pressure of oxygen decreases with altitude. Information concerning the altitude of the flights was not available.

The next reference provides a 'passing strange' coincidence in timing with the ATSB's belated, nearly 2 year request for toxicology review of the accident victims blood samples held by the NSW Coroner's office - https://www.tc.gc.ca/en/services/aviatio...019-07.pdf - note the release date was 12 December 2019... Undecided

Quote:CO has no color or odor. The onset of CO poisoning
can be insidious: victims are often unaware that their
environment is contaminated by this poisonous gas
and that their mental and physical functions are
being degraded. For these reasons, a CO warning
device is a very sensible investment for owners and
operators of GA aircraft. A suitable CO detector will
provide reliable, early warning of elevated levels of
this poisonous gas, allowing the pilot to take
appropriate actions. A CO detector can also
enhance the effectiveness of aircraft maintenance
actions. An inspection of the aircraft cabin with a
detector can confirm that maintenance or repair of
the exhaust or heating systems has corrected and/or
not introduced damage that could be associated with
the CO leaks. The type of functional check enabled
by a CO detector is not otherwise possible.

TC has concluded that preventive actions in addition
to those required by AD CF-90-03R2 may be
beneficial for owners and operators of GA aircraft in
Canada. These additional preventive actions are
described in the following section of this CASA.

So my question is that given the timing of the above Transport Canada CASA and the association of the TSBC with the active investigation, did the powers that be have an 'OH DUCK' moment when they discovered that toxicology reports weren't mandatory done in order to discount possible means of pilot and/or front RHS pax incapacitation?
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By Carrier Pigeon?

Well, no not quite; twas our ever cheerful 'Postie' who dropped the ubiquitous 'brown envelope' into the box. Two sheets of A4 – printed text; related to the ever changing final report into the C441 event, in 2017 which claimed three lives. That was it – of course I read them, then read 'em again. Put them aside – then read through them again. It depends on which corner of the blame game you stand in how you'd translate the missives; but, as  an impartial spectator from the back of the room, it is a fascinating match. To the looser, blame will be sheeted home, the winner will toddle off free of blame. The only folks not ferociously represented are the aircrew; the opposition being ATSB, CASA and the Operator, scrambling to avoid the blame and shame. The opening moves of the end game are being made.

I've only clipped some of the lines from the letters: that should be enough for the serious student to see the defences being erected.

“I provide you here with a copy of CASA’s Regulatory and Safety Review in relation to the accident involving VH-XMJ on 30 May 2017.”

“I remind you of the limited objectives of the review, which, by its nature, focuses on particular matters germane to the accident, but which does not, and was not intended to, address causal or contributory considerations.”

Now there is a great surprise – history clearly supports the notion that its easier to stuff a wet noodle in a tigers arse – than get a FOI request met by CASA – yet that above was sent prior to request – voluntary like. That, stand alone raises multiple red flags – why? For whatever reason it was provided you can rule out 'from the goodness in their hearts'. 

The ATSB 'addendum' opens a basket of snakes; and also defines a certain odour emanating from the MoU. Like most bad smells, it is the very devil to cover up and its not the first time the whiff of it has been detected during Estimates or 'Inquiry'. However, this time around, it seems that some attempt has been made to eliminate it.

With respect to the change in the POH procedures applicable to serial number 0173 and onward, the aircraft manufacturer advised that: there was no material difference between the aircraft from serial numbers 0173 and onward and the earlier serial numbers (0172 and prior) that necessitated a different method of simulating an engine failure in the take-off configuration the statements in the earlier POH procedure that referenced the demonstration of VMCA have the same intent as the warning note in the POH for aircraft with serial numbers 0173 and onward, which states this procedure must not be practised at an altitude below 5,000 feet above ground level.”

Then this:-

"The additional information that we have included in the report was the result of feedback we received from one of the involved parties during their review of the draft report.
Specifically, they questioned the validity of the ATSB’s conclusion that Textron intended the same method of simulating an engine failure in the take‑off configuration to be used across all serial numbers of Cessna 441, despite there being variation in the pilot’s operating handbooks (POHs) between 0173 and onward and the earlier serial numbers."

"During the course of the investigation, and as presented in the draft and final report released on 30 April 2020 , the ATSB concluded that the manufacture’s intent had been that simulation of an engine failure in the take-off configuration was not to be practised below 5,000 ft above ground level for all serial numbers of the aircraft (despite the variation in POH wording)."

"Following receipt of the feedback to the draft report, the ATSB sought additional advice from the aircraft manufacturer however, due to the impact of the Coronavirus in the US (widespread shutdown of industry), it was not possible to obtain that advice in a timely manner. Consequently, the decision was made to continue publication of the final report while also continuing to seek input from the manufacturer, with a view to including additional information once the manufacturer’s intent was received."

"Advice was subsequently obtained from the manufacturer, confirming that the ATSB’s interpretation of the POHs was correct and, in the interest of clarity, additional text was added to the investigation report in July 2020 and the amended report provided to the involved parties."

Standing out like the proverbial dog's whatsits are two major items. There are many other sidebars which need to be addressed; several of serious legal weight; but I digress. In essence; like it or not, the manufacturers Pilot Operating Handbook (POH) clearly states the restrictions placed on demonstrating and practising flight at minimum control speed and single engine emergency procedures. “Not below 5000 feet AGL”. Full stop. BUT, the manufacturer quotes 'engine shutdown'; and (I believe) offer a zero thrust setting – which negates the 'shut down' and opens the door to current practice, with which I have no quarrel.

I'd bet my best boots that every single operator of the type simulates EFATO, using 'zero thrust' well below the mandated 5000' bench mark; after becoming airborne, during an instrument approach; during a go around and during routine 'on type' training. The spirit, intent and POH warnings blithely (or legitimately) ignored; for operational expediency, time/money; and, importantly, to satisfy the CASA requirements for training and checking. Statistically, Zero thrust operations have a very good record:- Aye, 'tis a puzzle. 

Consider – had both operator and CASA actually read the POH the clear restriction would have been identified. To define and demonstrate an 'equivalent level of safety' with a 'shutdown engine', would require a 'no objection' from the manufacturer, quite a procedure and unlikely to succeed. So all that remain are two words – 'engine shutdown'. It all pivots on whether the engine was 'stopped' or merely restricted, using a simulated 'zero thrust' setting. Which of course raises another 'curly' issue – what if an engine did quit, for real, below 5000' on a dark and stormy night; what then? Is that 'safe?

While the blame is being shuffled about – who is addressing the 'safety case'. I remind you that as yet, there is no clear picture of what actually occurred in that cockpit – none. So, where lay the bare bones of the Ross Air event; lost in the verbiage of “Not me M'lud” perhaps.

“The great enemy of truth is very often not the lie--deliberate, contrived and dishonest--but the myth--persistent, persuasive and unrealistic. Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought. JFK.....
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The tale of the opening batsman -

Dancing about the Daises may be good fun on a balmy evening – but: when folks are killed in an aircraft crash; the pan pipes and the dancing have to stop. For the Ross Air loss of control of a Conquest; claiming three lives – the serious questions demand answers.

Been poking about a bit and there are some questions which – IMO – are germane to the investigation. For instance:-

The manufacturer of the aircraft has never; as far as I can detect, issued in the AFM  a written 'Zero Thrust' setting. This has been passed down through the generations and become an accepted 'norm'. All well and good except I cannot find test flight data or any other 'official' data which provides this setting for use in simulating an engine emergency procedure. Perhaps there is one – love to see it – but damned if I can find it. A serious normalised deviance – why?

Then, a clear written instruction in the AFM prohibiting 'engine shut down' below 5000 feet. That is a fairly serious piece of 'advice. But, is it enforceable? Here we enter the bizarre world of 'acceptance' of flight manuals – and boy, is the legislation confused. The FAA have their way of interpreting the AFM – Limitations mandatory – the rest under advisement – but; they come down hard on any light and loose liberties taken with the spirit and intent of the AFM. Not so with CASA; their views (multiple) of the way an AFM is 'binding appears to be subjective – in the extreme – even to different FOI whim. But 'we' need to know what is 'black letter' in an AFM and what is not. Blessed if I can find clear, concise policy. If there is then I wish they'd publish the bloody thing. Nearly done:

Last – an item which has sparked some serious debate – unresolved to date. It would be an understatement, bordering oblivion, to say what and what is not a CASA 'directive'. For instance several flight tests require (read demand) an engine failure scenario for various phases of flight – after take off for example. CASA demand this box be ticked. CASA approves almost every page of an in house Check and Training system – every one of 'em – down to spelling errors. Yet in this case we have a clear 'directive' from a manufacturer that 'engine shutdown' etc must not be contemplated below 5000 feet. Ross Air whittled that down to 3000 feet – approved by CASA – then wrote that 'simulated' engine failure was not be conducted below 400' AGL – approved by CASA there was even a time when 300' was considered and approved as acceptable.

Now, using a manufacturer promulgated; tested during certification – zero thrust setting; below 5000' in lieu of that determination is righteous and proper. But in the absence of such data and approval – a 'made up' ZTS, used to satisfy a CASA directive to comply with their 'testing' paperwork requirements; leaves many questions to be answered. Men died that day – unnecessarily IMO. So how, and at who's direction and approval of the CT system did that situation develop?

I know – zero thrust is an acceptable, normal procedure – until the legal fellahin get a hold of it, in a court – when there's blood and money on the table – not to mention liability.

Don't shoot the messenger – I only turned up for a quiet Ale and walked into the discussion – Cheers..............
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Chalk & cheese, plus the Ghost Who Walks is back??  Dodgy

I note that through the week that the ATSB prelim report into the tragic Broome R44 inflight breakup accident was released -  Angel : 

[Image: ao2020033_fig3_prelim.png?width=670&heig...4534257121]

Ref: https://www.atsb.gov.au/publications/inv...-2020-033/

I also note that the 'Ghost who walks and talks beyond Reason' is back and has been promoted, at least for this week, to the seemingly ever changing executive position of 'ATSB Director of Transport Safety'... Huh : https://www.atsb.gov.au/media/news-items...t-breakup/

Via the Oz:


Quote:No check flight after maintenance for fatal crash chopper

[Image: 14ad808a8e83cd00ededda0945d59140?width=650]

The owner of a helicopter that crashed in Broome when its tail rotor fell off shortly after takeoff, had not conducted a check flight in the chopper after an engineering inspection.

The Australian Transport Safety Bureau has delivered its preliminary report on the July 4 crash that killed owner and pilot Troy Thomas, 40, and passenger Amber Jess, 12, and left two other passengers seriously injured.

The report found in the week before the crash, two pilots who flew the Robinson R44 on two separation occasions experienced vibrations in the tail rotor pedals, likened to “tapping their feet with spoons”.

An engineering inspection was arranged for July 3, involving an examination of the helicopter including the tail rotor assembly.

Electronic equipment was used to measure the dynamic balance of the tail rotor with the readings suggesting no adjustment was needed.

The licensed aircraft engineer and a maintenance pilot also started the helicopter but could not feel any vibration with their hands on the pedals.

However the pilot elected not to fly the chopper within the confined storage area which meant the tail rotor system could not be not assessed for vibration under load.

Late in the day, Mr Thomas was told no vibrations had been detected and the balance of the tail rotor was good.

“The maintenance pilot also relayed an instruction from the engineer to conduct a check flight,” said the report.

The accident flight took place the following afternoon with the owner as the pilot.

ATSB director of transport safety Dr Mike Walker said it was not clear if the pilot experienced any vibrations through the pedals before the crash.

“Nevertheless, the ATSB urges any R44 pilot who experiences unusual vibrations through the tail rotor pedals to land as soon as possible and follow the advice in the pilot’s operating handbook,” Dr Walker said.

The handbook advises that a “change in the sound or vibration of the helicopter may indicate an impending failure of a critical component. If unusual sound or vibration begins in flight, make a safe landing and have the aircraft thoroughly inspected before flight is resumed”.

The investigation into the fatal crash was continuing with particular focus on policies and procedures for maintenance check flights, and the helicopter’s construction, assembly, flight and maintenance history.

A final report was expected to be delivered in the next 12-months.

  
  Hmm...the Hooded Canary must be really scraping the bottom of Lake Burley Griffin if the best he can put up for Transport Director?? Remember this was the dude that brought us this load of codswallop: 

[Image: page58image1432.jpg]

And who could forget this insult to our collective intelligence and PelAir survivors Kaz Casey and Dom James: The hidden agenda of PelAir MKII IIC Dr Walker


Quote:Full Steam GD.  Pour it On.

Damn the guns and hammer the engines – we have an urgent pick up and delivery mission.

Made a routine ‘how gozit’ call Karen Casey, see what was new and how things were progressing. On the positive side Sen. Cameron has taken an interest in the matter and there are positive signs from that. Here endeth the good news.

To business: stunned is the only way I can describe my reaction to the following; incredulous followed, then fury. Plain old fashioned outrage, in spades, redoubled.  It goes like this, paraphrased for brevity.

KC rings ATSB – Walker, to see when the second ATSB report may emerge from deep sleep chamber.

Walkers response was unbelievable; but notes and a statutory declaration take the matter to truth. In short, he was rude and aggressive. Statements like “Karen, just what do hope to gain from this report” “What do you want to get out of it”.  “It is your fault there is a delay”.  The whole debacle seems to be Karen’s fault all of a sudden and the ATSB is offended; etc. grossly miffed.

It was not Karen’s fault the aircraft ditched; it was not Karen’s fault she got badly hurt and it most certainly was not Karen’s fault that the ATSB and CASA got caught sweeping the whole thing under the table; nor was it Karen’s fault that Albo dived out of the back door as soon as the smoke alarum went off.  Karen had little to do with the Senate findings and the pasting dished out to both ATSB and CASA was well deserved. They got away very lightly, considering.

None of this is any excuse for being rude to anyone. Who the duck does Walker think he is? ATSB should be calling for his resignation.  No matter who rings with a genuine concern no one should be treated in the manner Karen was.

What chance a honest report when the man in charge turns out to be a coward and a bully?  Those types, when under pressure and attempting to justify that which cannot be justified habitually turn out to be not only disingenuous but happy to offset the blame to anyone else they can.

If the Walker attitude reflects the ‘new’ ATSB approach to victims of air accident then it is time for the minister to step in. I know that had I spoken to anyone in the workplace in that manner, my head would be following my arse out of the door before I could say ‘Sorry’.

If Walker won’t resign, then the minister needs to act, swiftly.  Fair warning, this is not going away.

A metaphorical head in basket is demanded: I don’t care how it gets there.

I cannot properly express the full measure of contempt and disgust this story has generated. The Pel-Air charade was a national disgrace; mentally kicking an accident victim when they are down and struggling to get through life with pain and grief is beneath contempt, particularly when the thread which keeps Karen attached to this world is tenuous, even on a good day.

Lets go and pick up this prick GD; seems he is late for his appointment with the Boss.

More to follow - bet your life on it.

Toot – bloody – toot.



[Image: SBG-280620-1024x723.jpg]

The Chalk: Regardless of the return of the 'Ghost Who Walks', the efforts of the IIC and his investigative team in compiling a factual and concise prelim report without any apparent political and bureaucratic influence, spin and bulldust is refreshing -  Wink   
The Cheese: Which is in stark contrast to the topcover snowjob that appears to be occurring with the, fast approaching, 3 year  ATSB investigation into the Essendon DFO approval process, which (without any public notification) was recently updated (14 August 2020) with yet another delay to the anticipated completion date: 
  
Quote:  Anticipated completion: 3rd Quarter 2020  

Hmm..no comment required - Dodgy

MTF...P2 Cool
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Quite simple really P2.
An aircraft hit a building that shouldn't have been there.
End of story.

I sometimes wonder how long it will take them to investigate when an aircraft plows into the edifice being built on the southern side of Bankstown airport, or flips trying to land, caused through turbulence generated by the massive structures.
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DTS Godlike back to DTS 'The Ghost Who Walks' in the space of two days - WTF?  Dodgy 

Via the Hooded Canary's aviary... Rolleyes 


 Sudden control input to prevent overspeed results in injuries to cabin crew

[Image: virgin_b737.png?width=670&height=376.5222623345367]

Key points:
  • A sudden wind change during high-speed descent resulted in the airspeed suddenly increasing towards the aircraft maximum operating speed

  • The captain responded by abruptly pulling back on the control column, causing autopilot to disconnect

  • Subsequent sudden pitch attitude and vertical acceleration changes resulted in injuries to cabin crew members.

 
The actions of the captain of a Boeing 737 in response to a sudden speed increase during a high speed descent resulted in sudden pitch changes and injuries to two cabin crew members, a new ATSB report details.



The Virgin Australia-operated Boeing 737-800 was at the top of the descent 136 nautical miles south-east of Adelaide Airport conducting a scheduled passenger flight from Melbourne on 13 September 2017, with the first officer acting as pilot flying.


Air traffic control instructed the crew to perform a high speed descent, which they commenced with the autopilot engaged with a target descent speed of 320 knots, which was higher than the normal descent speed of 280 knots.


During the descent, the first officer attempted to manage airspeed by using changes in the autopilot modes and reductions in the target airspeed. As the aircraft descended through around 17,000 feet, the tailwind affecting the aircraft decreased suddenly and significantly, which caused the indicated airspeed to increase and approach the maximum operating speed limit of 340 knots.


Highly concerned about overspeeding the aircraft, the captain responded by abruptly pulling back on the control column, causing the autopilot to disconnect. The resulting control forces caused sudden changes to the aircraft’s pitch attitude and vertical acceleration.
Two cabin crew members who were standing in the aircraft’s rear galley eating a meal received injuries during the upset, with one sustaining a broken leg.


ATSB Director Transport Safety Dr Stuart Godley said that during the occurrence, the aircraft only exceeded its maximum operating speed by one knot, which did not require any structural inspections to ensure the ongoing airworthiness of the aircraft. Instead, the safety implications associated with this event related to the actions of the captain in response to the sudden change in airspeed.


“Even though the autopilot was operating correctly, when the aircraft was approaching and exceeding the maximum operating speed, the captain’s perception was that the autopilot was not controlling the aircraft and that urgent intervention was necessary,” Dr Godley said.


“However, the captain did not follow the normal procedure for taking over control of pilot flying duties, and the large pitch control inputs made by the captain were probably influenced by a perception of urgency.”


Dr Godley said the investigation serves to remind pilots that they are entitled to decline air traffic control instructions where they do not perceive they can safely comply.


“Due to increased kinetic energy and reduced margins to placard speed limits, high-speed descents involve a higher level of risk, including increased risk of harm due to abrupt control input.”


The investigation also highlights the challenges pilots face when responding to sudden or unexpected situations, Dr Godley said.


“There will often be a reduction in safety when pilots perceive a situation is urgent and when they make decisions rapidly and reflexively. In these situations, pilots may not be able to effectively process information or make good decisions.”


The investigation also notes that it took over 90 minutes for the injured cabin crew member, who had sustained a badly-broken leg, to be removed from the aircraft after its arrival at Adelaide, while the operator’s ground operations supervisor, Aviation Rescue Fire Fighting Service (ARFFS) officers and SA Ambulence officers co-ordinated the extraction.


The injured cabin crew member was not able to walk or to sit in a wheelchair, and an ambulance stretcher would not fit down the aircraft aisle, however, the ground operations supervisor declined an ARFFS request to use a catering truck, the report notes.


Instead, emergency services personnel used a slide sheet to drag the injured cabin crew member along the aisle to the front of the aircraft, then placed the injured cabin crew member on a stretcher.


Virgin Australia has subsequently updated the training and information provided to pilots about overspeed and overspeed recovery. The airline has also changed procedures for ground handling staff when responding to requests from emergency services.


Read the investigation report AO-2017-092: Overspeed and pitch up resulting in cabin crew injury involving Boeing 737, VH‑VUE, 42 NM ESE Adelaide Airport, South Australia, on 13 September 2017
  



And then from Wanker Walker today:


Taxiway design, flight crew distraction and incorrect mental model, lead to Perth Airport runway incursion

[Image: ao2018032_runwayincursion.jpg?width=670&...0000000005]

Key points:
  • 737 taxied toward active runway; second 737 rejected take-off

  • Taxiway location and design significantly increased the risk of a runway incursion

  • Runway incursions are a significant risk to safe aviation operations and a key global safety priority

 
The crew of a Boeing 737 had to reject their take-off roll when a second 737 did not stop at a holding point and passed through an illuminated stop bar after landing at Perth Airport, an ATSB investigation report details. 


On 28 April 2018, a Qantas Boeing 737, registered VH-XZM, landed on runway 03 at Perth, exiting the runway onto taxiway J2, which led to a holding point for crossing runway 06. The aircraft did not stop at the holding point and crossed an illuminated stop bar (a set of lights embedded across the taxiway surface) without an air traffic control clearance.


At that time, a second Qantas 737, VH-VZL, had commenced its take-off roll from runway 06. An automated warning within the Perth air traffic control tower alerted the aerodrome controller (ADC) of the stop bar violation and the controller issued an instruction for the departing 737 to ‘stop immediately’.


Soon after, the flight crew of VH‑XZM became aware of their position and stopped their aircraft just before crossing the edge of runway 06. VH-VZL’s wingtip passed about 15 metres from VH-XZM’s nose at low speed just before coming to a stop.


Among other findings, the ATSB found that the captain of VH-XZM was not expecting to cross runway 06, having developed an incorrect mental model of their location and thinking the aircraft was on taxiway J1 which led directly to the terminal area.


“Due to this incorrect mental model, and a combination of workload and distractions at key times, the flight crew did not detect the runway crossing issue until their aircraft had almost reached the edge of runway 06,” said ATSB Director Transport Safety Dr Mike Walker.


Taxiway J2 was the preferred runway exit for jet aircraft landing on runway 03, the ATSB’s investigation report notes.


“The location and design of the taxiway significantly increased the risk of a runway incursion onto runway 06/24,” Dr Walker said.


“The relatively shallow intersection angle with the runway and wide turn radius meant pilots were more likely to take the exit at a higher speed, and this combined with the short distance to the holding point gave pilots less time to see the illuminated stop bar lights at the runway holding point and stop.”


Although the junction around taxiway J2 was identified as a ‘hot spot’ on aerodrome charts, there was no detailed information about the reasons for it.


Also, Qantas did not specifically require pilots to brief hot spots during departure and approach briefings.


In response to the runway incursion, Airservices Australia made taxiway J2 unavailable for use, and Perth Airport subsequently removed taxiway J2 from aerodrome charts.


In addition, Airservices changed the settings of an alerting system to ensure tower controllers at Perth Airport performing multiple roles received appropriate aural and visual alerts at their workstation.


“Runway incursions are one of the most significant risks to safe aviation operations and a key global safety priority,” Dr Walker said.


“Airport operators and local runway safety teams are strongly encouraged to identify and mitigate the risk of hot spots, especially those that involve short distances between runways, complicated junctions, and the potential for higher taxi speeds.”


Since the incident, Qantas published a safety information notice to all pilots containing information about the background of runway incursions. The airline also updated its Flight Administration Manual to include a requirement for pilots to brief relevant airport hot spots and their contingency planning to mitigate against the possibility of collision or runway incursion.


“Pilots can help prevent incursions by identifying runway hot spots during departure and approach briefings, and discussing the actions they will take to reduce the risk of a runway incursion,” Dr Walker said. 


“The ATSB also strongly encourages air traffic controllers to provide safety alerts and/or clear instructions – such as ‘stop immediately’ – to the flight crews of all aircraft involved in runway incursions and related occurrences.”


Dr Walker noted that the aerodrome controller and flight crew of VH-VZL exhibited a high level of situational awareness to respond to the incursion.


Read the investigation report AO-2018-032: Runway incursion involving Boeing 737, VH-XZM, and subsequent rejected take-off involving Boeing 737, VH-VZL, at Perth Airport, Western Australia, on 28 April 2018




MTF...P2  Tongue
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Stewie Macleod is back as this week's DTS?? -  Rolleyes

Via the Oz:


Pilots ‘unaware’ of position caused near crash

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

2:24PM NOVEMBER 12, 2020
[Image: 35b1d5002547395dc8ff3ce71d5a2847?width=650]
A Virgin Australia Regional Airlines’ ATR 72 like the one involve in the near collision at Albury.

The final report on a “near collision” between a training flight and a commercial passenger service has revealed the two aircraft came within 22m of a crash because both pilots were oblivious to the other’s position.


The Australian Transport Safety Bureau report said the Piper PA-28 turned in front of the Virgin Australia ATR 72 as both came into land at Albury Airport on October 19, 2019.
As a result, vertical separation between the aircraft was reduced to 22m, and horizontal separation to 110m.

The Piper, operated by the Australian Airline Pilot Academy in Wagga Wagga, had a student pilot and instructor on board while the ATR 72 was carrying 66 passengers and four crew.

The ATSB report found neither pilot was aware of the position of the other aircraft despite the Piper being told to follow the ATR 72.

“The pilot of (the Piper) advised the ATSB that when (the Virgin aircraft) was first sighted, it was so close that the pilot lowered the nose of the aircraft to increase separation,” said the report.


The incident triggered the traffic collision avoidance system on the Virgin ATR72, and the pilots executed a missed approach.

Air traffic control was unaware of the developing near collision, the report said, as the controller was “not effectively monitoring the aircraft” due to their attention being focused elsewhere.

The pilot of the Piper was an international student who only obtained their private pilots licence the day before, and was doing a navigation exercise as part of the commercial pilot licence syllabus, the report said.
In the case of the Virgin crew, they were aware of another aircraft but did not receive information about it and did not assess where it was in relation to their approach.

ATSB transport safety director Stuart Macleod said the circumstances of the near collision illustrated the “danger of assumption and incomplete situational awareness”.

“As the Piper was operating under visual flight rules, separation between the two aircraft was the pilots’ responsibility, and the pilots on both aircraft made incorrect assumptions about both each other’s movements, rather than taking positive action to confirm that adequate separation would be maintained,” said Mr Macleod.

He said a number of safety actions had stemmed from the occurrence and the ATSB investigation.

This included discussions among industry stakeholders and operators on the ongoing risk to air operations at airports with non-controlled airspace, such as Albury, Mr Macleod said.

Virgin Australia no longer operates ATR 72s, after making the decision to go with an all Boeing 737 fleet as a result of the airline’s administration.


And the report etc..via the Hooded Canary's aviary Rolleyes


Assumptions, incomplete situational awareness contribute to Albury near collision between training aircraft and regional airliner

[Image: ao2019066_flightpath.png?width=670&heigh...0453514739]

Also from HVH central -  Wink

Turbulence during shallow approach results in collision with terrain

[Image: ao2020020_flightpath.png?width=670&heigh...6606822263]

Key points:
  • Approach profile was lower than intended.

  • Aircraft pitched up on encountering turbulence.

  • Accident highlights the importance of aircraft adopting an approach profile that mitigates the effects of gusty or turbulent conditions.

Hmm...got to wonder about that last one ie why would they bother? 

MTF...P2  Tongue
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A mini rant – or; a ride on my pet hobby horse; ignore it if you like:-

Five, for tea and biscuits; One for serious bollocking.

Positive separation is what Air Traffic Control (ATC) provide; Tower hours of operation: 0615 - 2030 Mon-Fri.

“Air traffic control was unaware of the developing near collision, the report said, as the controller was “not effectively monitoring the aircraft” due to their attention being focused elsewhere.”

Bit 'fluffy' in the language use there director; was the tower fully manned, or not? To enter the Albury (AY) airspace a clearance is required, this is a specific directive, based, in part, on the Estimated Time of Arrival (ETA). The tower controller would be fully aware of the position and ETA of both aircraft. The ATR's ETA would have been known for quite a while. The PA28's time of request for entry to the zone is not mentioned in the report, however there are clearly defined VFR approach points and several 'check points' at which the local aircraft could request a clearance to enter the 'zone'. So, in any event ATC would have been aware of the position and ETA of both aircraft. It begs a question – why were the aircraft not 'sorted' out long before both entered the circuit? Two aircraft, this close in controlled airspace – and all ATSB can come up with is “focused elsewhere” and not even sure if it was collective loss of focus or a single loss of focus. There is a systematic problem, it needs to be properly addressed.

The PA28 operation has not been critically examined. Where did the flight request clearance? Was an ETA provided? Were there two radio's in the aircraft. There were two qualified pilots on board; one an instructor – were they monitoring both Area and AY frequencies? If not, why not? Melbourne Centre and the Tower – would have provided enough information for the crew to realise they were going to arrive in close formation with the ATR. This is a loss of situational awareness – even if the tower was closed – the potential conflict should have been resolved long before the close call. The chances of 'spotting' the ATR were slim – only on the Right downwind leg could they have 'seen' the aircraft; once base leg was turned – the focus would be on the runway; had the ATR been ahead of them; they might have spotted it. But it was behind.

The ATR has no excuse whatsoever. TCAS and being IFR, traffic information; they too have the ability to monitor all frequencies; the check list would be complete nothing to do but fly an easy straight in. The conflicting aircraft would have been on the TCAS; you could reasonably expect at least one professional pilot to be looking outside for the symbol showing (flashing) so clearly on the screen in direct view– but no


“The incident triggered the traffic collision avoidance system on the Virgin ATR72, and the pilots executed a missed approach.” At 22 m and 110 horizontal – Hell, the PA28 was bloody near in the ashtray by then.

That's my tea and biscuits crew sorted; but the bollocking is reserved for this Muppet:-

Bollocks 1 - ATSB transport safety director Stuart Macleod said “the circumstances of the near collision illustrated the “danger of assumption and incomplete situational awareness”. A bit more to it methinks; deserving more than a glib, slippery, politically correct throw away line. Nearly another major mid air in our skies and stating the bleeding obvious will not prevent another incident. This was a complete failure of system, demonstrated, almost in blood, bodies and fire. But ATSB are happy to feed happy horse shit to an unsuspecting public. The chances of a mid-air collision happening are slim; but not infinite. Every close call shortens the odds -

Bollocks 2 - "the two aircraft came within 22m of a crash because both pilots were oblivious to the other’s position." Oh, FCOL they were fully aware – the PA28 told to sight and follow; the ATR fully aware and the TCAS serviceable. Who writes dribble like this; and, why is he still employed by ATSB.

Bollocks 3 - “As the Piper was operating under visual flight rules, separation between the two aircraft was the pilots’ responsibility,” in CTA – really?

Bollocks 4 - "The ATSB report found neither pilot was aware of the position of the other aircraft despite the Piper being told to follow the ATR 72". Given the visual dynamics it was a long shot to expect the PA 28 to spot the ATR – however, there was an instructor on board who should never have allowed the turn to be made without sighting or positive information of where the ATR actually was. The ATR had both TCAS and ATC to define where the PA 28 was – and should not have pressed on without positive confirmation of adequate separation.

Rant over – just get cranky when ATSB gloss over and obfuscate a serious event. Aye, Murphy had a bit to do with this episode – but, in this day and age around heavy passenger traffic there should never be any doubt about who's on first and what's on second – even in gin clear blue skies. 

Toot – toot.
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UP 'passing strange' coincidence on Essendon DFO B200 accident??

To begin I note that there has been no update since 10 Sept 2020 to the now 2.5 year+ ATCB AI-2018-010 investigationDodgy

However there has been recent SME comment/reference to the Essendon DFO accident cover-up... Rolleyes

Via the EHAMC:

Quote:The DFO crash at Essendon is a good example of inappropriate planning around airfields. On what
empirical evidence were the buildings allowed to be built so close to the runways leaving precious
little allowance for a safety margin should things go wrong as they did when that crash occurred?

And there is the related question, where is the Public Safety Zone at the end of the runway? If you
use the parameters used by the Queensland government for PSZs then around 100 residential
properties and a primary school are in the way for the runway used by the pilot in the DFO crash.
What if the pilot had continued on and crashed into a residential area?

Of course, we will hear the conventional argument about making best use of expensive land but this
is usually made by those who have a commercial interest and not necessarily the public interest in
mind. And it is not as if Australia is running out of land!
 

Next via AIPA submission:

Quote:A Way Forward

To be clear, AusALPA recognises that the economic decisions surrounding airports, i.e. determining the balance between the economic benefits of developments and the detriments to the accessibility, efficiency and capacity of an airport, rest entirely with the relevant jurisdiction within which the airport is situated or which retains legal control. The issues of enforceability and dispute resolution of development approvals would remain consistent with those jurisdictional norms.


However, contrary to current practice, we are proposing that the assessment, mitigation and enforcement of the safety consequences of all relevant developments be ceded by those jurisdictions to CASA as an independent decision-maker.

Consequently, CASA needs to change its model of how airport standards are applied and enforced so as to obviate the gaming of the system so exemplified by the Essendon experience or by the uncontrolled expansion of the thousands of airspace penetrations at Sydney. As a further consequence, DITCRD should seek major amendments to the Airports Act 1996 that change the current subservient and excessively constrained role attributed to CASA and that also clarify the safety considerations that ABCs must undertake in regard to minor developments.

And then via the Airports thread:

(12-12-2020, 01:35 PM)Peetwo Wrote:  
(12-12-2020, 05:06 AM)Kharon Wrote:  Wow, wudja look at all 'em tall buildings Martha!

Or; more colloquially; “have seen what they're doing at Kickinatinalong”? It is a common enough question in aviation circles; and usually ends up with those discussing 'developments' shaking their heads and left wondering 'how' this rape of an innocent aerodrome could occur.

Wonder no more; well, less anyway. - HERE - is a link to Sub.48 made to the latest Senate Inquiry. It is a solid read, but worth the time, easiest to read it in 'small doses' for there are some genuine pearls of wisdom contained within. 

Sub. 48: - P8 :- ”The Making Ends Meet Report makes it very clear that there are limits to the operation of the market place, a lesson which we have been ignoring at our own peril and the lives of those involved in aviation. Of course, this is an issue which may be impossible to resolve because of the entrenched position that some self-interested players will hold but there is a need to transcend that and ask are the decisions which are being made in the ‘public interest’,and where is the evidence to support a particular claim beyond the standard, generic rhetoric which is invariably not tuned to the specific issue(s) at hand?

Sub. 48: - P9 :- ”An anorexic dowry accompanied the handover of airfields to councils under the ALOP arrangement but future maintenance funding was cut off by the federal government and local government was left to make do as best it could once the once-off dowry ran out. The flawed, unsubstantiated view that local government ‘knew best’ what to do with aviation infrastructure prevailed,aided and abetted by the zeitgeist of the time that the free market along with local government would be best placed to determine the future of our aviation infrastructure notwithstanding, in many cases, a complete lack of understanding of aviation and its’ needs by local government.

Will the submission make any difference? Who knows, at the rate this current inquiry is moving, the buildings will up and running long before any 'positive' action is taken to ensure essential 'safety' margins are met and that vital infrastructure does not become another shopping centre. The fatal accident at the Essendon DFO should have been ringing bloody big alarum bells along the corridors of power – Is it just me gone deaf?

Toot – toot.

AIPA addendum: Extract from - https://www.aipa.org.au/media/1847/20-11...020-dp.pdf

AIRPORT SAFEGUARDING


Nearly three years later, AIPA, through AusALPA, made a submission to DITRDC as part of the 2019 NASF Implementation Review. Unsurprisingly, the main themes were in regard to jurisdictional fragmentation, transparency and Commonwealth leadership. While we are committed to the NASF, we are also keenly aware of the impediments to fully implementing a consistent national scheme for at least RPT airports. We concluded as follows:

A Way Forward

To be clear, AusALPA recognises that the economic decisions surrounding airports, i.e. determining the balance between the economic benefits of developments and the detriments to the accessibility, efficiency and capacity of an airport, rest entirely with the relevant jurisdiction within which the airport is situated or which retains legal control. The issues of enforceability and dispute resolution of development approvals would remain consistent with those jurisdictional norms.


However, contrary to current practice, we are proposing that the assessment, mitigation and enforcement of the safety consequences of all relevant developments be ceded by those jurisdictions to CASA as an independent decision-maker.

Consequently, CASA needs to change its model of how airport standards are applied and enforced so as to obviate the gaming of the system so exemplified by the Essendon experience or by the uncontrolled expansion of the thousands of airspace penetrations at Sydney. As a further consequence, DITCRD should seek major amendments to the Airports Act 1996 that change the current subservient and excessively constrained role attributed to CASA and that also clarify the safety considerations that ABCs must undertake in regard to minor developments.

Furthermore, we are proposing that the visibility of developments affecting the safety outcomes at airports is vastly improved in all jurisdictions.

The public interest is best served by accepting that the potential hazard created by a development on or near an airport is not a function of cost but rather the amalgam of the issues set out in the Guidelines. Each jurisdiction should commit to a public register of development proposals that may present a potential hazard to safe airport operations, enhanced by a published list of stakeholders who are alerted to each new relevant development submitted to the jurisdiction for approval.

AIPA, through AusALPA, will continue our commitment to airport safeguarding and look forward to participating in NASAG discussion post-pandemic.

How can airspace protection balance the needs of the aviation industry with those of land owners and surrounding communities?

AIPA suggests that this question should have been comprehensively answered in 1996. The lay reader of the relevant text (quoted below) from the Explanatory Memorandum for Part 12 for the Airports Bill 1996 could be forgiven for believing that the proponent of a controlled activity bore the onus to prove that any effect on the “safety, efficiency and regularity of air transport operations into or out of an airport” was acceptable, contemplating a range of future aviation activities:

This Part enables the Commonwealth to make regulations to prevent certain incursions into airspace where it is in the interests of the safety, efficiency and regularity of air transport operations into or out of an airport to do so.

The provisions can be applied to airports where the site is a Commonwealth place, as well as to airports specified in the regulations, where the site is not a Commonwealth place. As an example, the Part will enable the Commonwealth to control the construction of buildings or other structures, the height of which would adversely affect the ability of an airport to which the Part applies to cater for existing or future air transport operations. The restrictions can be applied to on-airport or off-airport areas, such as along or adjacent to current or future flight paths, where the height of the proposed building or structure would interfere with prescribed airspace.


Similarly, the relevant text from the Explanatory Statement for the Airports (Protection of Airspace) Regulations 1996 (APARs) might give similar comfort:

The approval authority for proposed controlled activities is the Secretary of the Department of Transport and Regional Development. If a proposed activity would result in an incursion into the PANS-OPS surface or if the Civil Aviation Safety Authority (CASA) advises the Secretary that in the interests of the safety of air transport the application should not be approved. then the application to conduct that activity cannot be approved. In other cases, the Secretary must assess the application having regard to the views of the proponent, the airport-lessee company, CASA, Airservices Australia, relevant building authorities and, in the case of a joint-user airport, the Department of Defence.

Unfortunately, the practical application of the APARs by DITRDC and its predecessor Departments, observed by AIPA over the last 10 years at least, appears to have become legislation that protects developers above all else. CASA advice to the Secretary only gains significance if the magic threshold of “an unacceptable effect on the safety of existing or future air transport operations”, whatever that actually means in practice. Our experience with assessing the several applications for controlled activities that have come to our attention is that the proponent/developer never addresses the safety or other consequences of the activity. It seems highly likely that the status quo established by DITRDC and CASA is that there is no such requirement and that the onus to prove detriment is reversed and placed upon those conducting the air transport operations.

On 15 June 2018, AIPA wrote to Sydney Airport Corporation Ltd in regard to the proposed Hayes Dock development at Port Botany that involved an OLS penetration of nearly 30 metres. In that letter, we canvassed many of the above issues. On 09 August 2019, we significantly expanded upon those same issues in a letter from AusALPA to Adelaide Airport Ltd in regard to a proposed development at 207 Pulteney Street Adelaide, which included a copy of an AusALPA Position Paper8 related to OLS penetrations. We presume both of those letters were forwarded to DITRDC in accordance with the APARs procedures related to controlled activities.

AIPA considers that the Position Paper specifically addresses the question.

AIRPORTS ACT 1996 DEFINITION OF CONTROLLED ACTIVITIES

The recent DITRDC approval for cranes to permanently penetrate the Obstacle Limitation Surface (OLS) by 21 metres, the effects of which by definition must be acceptable, has also revealed a definitional issue in relation to regulation 182(1)©. That paragraph refers to a “thing attached to, or in physical contact with, the ground” which precludes the consideration of ships underway. We presume that a ship at anchor or moored to a wharf falls within ambit because they are attached directly or indirectly to the ground.

DITRDC have indicated that they do not intend to take urgent action to resolve the issue, despite the ships underway or anchored at Hayes Dock that can be serviced by the new cranes will both penetrate the OLS and create a potential windshear and turbulence hazard to operations at KSA. Hand-balling the problem back to CASA is also unhelpful – while they are apparently indifferent to the OLS penetration, their risk management response to the latter hazard is to restrict operations at the airport for the duration of any hazard that eventuates.

AIPA considers these outcomes to be inconsistent with the stated objectives of the Act and APARs and unacceptable on safety grounds. WE urge DITRDC to commence amendment action to correct this and related deficiencies in the definitions.

Which brings me back to the UP where as a passing strange coincidence the long dormant thread (19 July 2019) on the DFO accident has suddenly returned to life with what appears to be another blaming the pilot campaign -  Huh

However in amongst the 'pilot done it' dross and bollocks there lies an actual post of worth from someone who I would regard as a SME on the operations of the BE20 -  Wink

Quote:Al Fentanyl

Originally Posted by machtuk
Quote:I'm of the opinion an off centre rudder trim tab was not thecste cause. Christ if it was that dangerous tyen the A/C would not have got certified without additional warnings!
a properly adjusted seat, a healthy strong pilot should be able to overcome an out of trim rudder or at least a good proportion of its effect.
we'll never truly know what happened!

Having once started a takeoff roll with full left rudder trim wound in, after a series of OEI approaches, I can make the following observations:

The trim was visually checked by both pilots, the square white indicator at the end of travel looks - at a glance - very much like the square white indicator at the centre of travel.

Through about 50kt, the aircraft was drifting left and could not be managed with the full strength of the pilots leg input which is considerable. This is well before takeoff speed and I believe it highly unlikely that the incident pilot was in the same situation and still allowed the aircraft to accelerate to takeoff speed. In fact I doubt whether he could have physically held it on the runway strip long enough to even get to takeoff speed.

The situation was only examined in a SIM. It was not trialed in a real aircraft. I have also tried it in the same SIM and found it relatively easy to hold direction, very much different to the aircraft.

My opinion only.

Hmm...now that posts brings back some memories... Rolleyes

Via P9:A ramble; definitely not for the professionals.

Plus: Just cribbed this from the U 

MTF...P2  Tongue
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[Image: GettyImages-520866626-3f05936-1.jpg]

ATSB the Remora (topcover/sucker) fish of Oz aviation safety??  Dodgy

Over on the UP the King Air down thread would appear to have been hijacked by CASA-fied individuals bent on diversion? This is despite all the broken links and glossed over possible contributory factors within the investigation final report, their opinion is that in some bizarre isolated bubble (that totally ignores the factual obs of Al Fentanyl's post above) it was the pilot that did it - END OF!!

Before I go on I note, with a more than passing interest, that over on the UP Centaurus has opened up a new thread that perhaps highlights why the continued attempted ATSB cover-up/obfuscation of proper examination of the Essendon DFO accident is so significant and perhaps pivotal to exposing all that is wrong with the current version of our supposedly ICAO Annex 13 & 19 compliant Aviation Accident Investigator: ATSB protracted investigation process. Flight safety lessons lost in time.


Quote:Centaurus

ATSB protracted investigation process. Flight safety lessons lost in time.




The Weekend Australian newspaper January 2-3, 2021, under the Business Section, published a story called “Dream to fly leaves student with $77k debt and no licence.” It concerns the demise of Soar Aviation at Moorabbin. The journalist David Ross has put together an excellent article.

The student pilot interviewed for the story related his concern about safety and teaching standard at Soar after witnessing a dangerous crash that almost claimed the life of a fellow student in 2019.

According to the article, a Soar student pilot was left trapped after being involved in a serious crash at Moorabbin Airport on December 12, 2019 that saw his plane flip and crash. A Finding into the crash is yet to be handed down by the ATSB.

I have often wondered why an accident of this sort involving one person and a light sports aircraft, has taken over one year to investigate with still no result. If anyone in ATSB reads PPRuNe, and I am sure they do, perhaps they could explain why a seemingly simple straight forward accident such as the Soar accident in December 2019, can take such an inordinate length of time to produce a Finding.

Despite the availability of ever increasing sophistication of technical resources to make the investigation process more efficient and faster, delays of this nature are nothing new for ATSB; Why is this so? Any lessons from this accident become lost in time.
       



compressor stall

Timely release won’t help Centy. Many ATSB reports these days are fundamentally vacuous and miss any concrete safety lessons - as the recent stall at low level in the circuit report showed.


Aircraft down at Braidwood, NSW



Checklist Charlie

Unfortunately the ATSB has over the last 25 -30 years developed a real skill in writing reports that avoid any criticism of CAsA, CAsA employees or any of the regulatory suite that CAsA is supposed to administer.



The production of useful, timely reports has also gone by the wayside.

CC


PoppaJo

They lost me with Air Asia X. I mean I’ve lost count but over a dozen, eye raising incidents, and they continued to fly in our airspace without sanctions. I have never seen such disregard (well complete non compliance) for basic Airbus operating procedures in my career. I had to re read some of those reports multiple times to make sure I wasn’t in some delusional state of mind, yes what I was reading was correct.



My whinging to both bodies around why I wanted them out of our airspace, got one answer which was it was up to the responsible minister to take action. Albanese didn’t want to upset our foreign neighbours, putting trade deals ahead of safety. It’s just some bottom feeding low cost , who gives a ****. No loss!

So in the lead up to the next BRB, I am here to tell you that on the AP we will not be allowing ourselves to be diverted from the task of exposing the Hooded Canary's aviary for merely being a Remora fish feeding from and providing top-cover for the miniscule, the Iron Ring and the bloated aviation safety bureaucracy... Dodgy 

Finally, to return back to ToRs on the Essendon DFO accident start with this AP blog piece: “Let sleeping dogs lie — who wants to rouse them?”

And in particular this (AP edited) ATSB overhead picture of the accident sequence... Rolleyes

[Image: Dwv6NAYUwAE-wR8.jpg]
Ref: https://www.atsb.gov.au/media/5775076/ao...nal_v2.pdf

Now remember that from lift off to crash took no more than 10 seconds (ie the red line)??  Rolleyes

Definitely much MTF!! P2..  Tongue
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Lead Balloon back to ToRs - err maybe??Rolleyes

Over on the UP Lead Balloon attempts to drag the thread back to ToRs... Wink


Quote:For Groggy, I note the ATSB report says this about flight carried out in a Level D simulator for a similar model aircraft:

Quote:
Quote:The pilot who performed the flight commented that:

The yaw on take-off was manageable but at the limit of any normal control input. Should have rejected the take-off. After take-off the aircraft was manageable but challenging up to about 140 knots at which time because of aerodynamic flow around the rudder it became uncontrollable. Your leg will give out and then you will lose control. It would take an exceptional human to fly the aircraft for any length of time in this condition. The exercise was repeated 3 times with the same result each time. Bear in mind I had knowledge of the event before performing the take-offs.

The unambiguous implication of that outcome (assuming it substantially replicated the performance of ZCR) is that it is not physically possible for the aircraft to fly away ‘like a homesick angel’, if the rudder trim is set to full deflection (or at least full nose left deflection), unless the pilot is an “exceptional human”.

Have you any first-hand experience, either in the simulator or the aircraft, of flight with the rudder trim set to full nose left deflection and both engines delivering maximum thrust?


Much MTF! P2  Tongue
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Lead Balloon back to ToRs - Part II

Slight drift here (from the DFO cover-up) but it is all IMO totally related (ie ATSB merely a top cover agency for the aviation safety autocracy and therefore for the Minister McDonaught -  Dodgy )

Via Oz Flying (Warning: PROB > 30% that a bucket will be required for Hooded Canary comments on the linked ATCB media release and at the bottom of the page) :
Quote: 

 [Image: atsb_mooney_coffs-harbour1.jpg]

ATC Action scrutinised after Mooney Crash
19 January 2021
Comments 0 Comments

The actions of air traffic controllers have been put under scrutiny after the fatal crash of a Mooney west of Coffs Harbour in 2019.


Mooney VH-DJU was on a flight from Murwillimbah to Taree in September 2019 when it was refused a clearance to transit controlled airspace at 6500 feet, leading to the aircraft descending into non-VMC and colliding with high terrain. Two people on board the aircraft were killed.


The ATSB investigation report released today concluded that the information provided by ATC impacted the pilot's decision to descend, and that the pilot was not properly prepared for the conditions encountered.


“Information provided by air traffic control likely resulted in the pilot deciding to descend the aircraft from 6500 feet instead of other available safe options, such as proceeding around the Class C airspace at or above 6500 feet, diverting, or descending to the north of Grafton to proceed coastal beneath the cloud layers south to Taree,” said ATSB Chief Commissioner Greg Hood.


“The ATSB also found that the pilot was not carrying suitable navigation equipment–the pilot was likely using a handheld GPS unit while air navigation charts for the area were found stowed in a flight bag–and had most likely not obtained the required weather forecasts.


"These factors reduced the pilot's ability to manage the flight path changes and identify the high terrain. This led to the aircraft being descended toward the high terrain in visibility conditions below that required for visual flight, resulting in controlled flight into terrain.”


After being refused a clearance to transit at 6500 by a trainee controller, the pilot was given the option of contacting the Class D controller at Coffs Harbour, who subsequently advised the pilot that VFR flight would be possible only below 1000 feet due to cloud.


After announcing his intention to descend to "not above 1000 feet", the pilot diverted slightly west and descended to 4500 feet, infringing the C class airspace anyway. He then reported clear at 4100 feet and continued to Taree, before descending in the vicinity of the high terrain near Dorrigo.


The investigation also found that the pilot was not provided clearance to transit Class C airspace due to the trainee controller’s conservative assessment of their workload, although there was no conflicting traffic, meteorological factors or limiting air traffic control instructions or procedures that would have precluded providing the clearance.


The trainee’s supervisor accepted the assessment as an alternate option – transiting through Coffs Harbour Class D airspace – was provided to the pilot.


“The pilot was not provided with a clearance to transit Class C airspace despite there being no limiting meteorological factors,” Hood said. “Instead, the Class C controller provided the option to seek a clearance at a lower altitude with an increased risk of encountering poor weather.


“Further, the limited information provided by the Class D controller to enter that airspace probably led to the pilot’s decision to descend into a hazardous area instead of opting for other available safe options.”


During the investigation, the ATSB found that the pilot had also not completed the required flight reviews or proficiency checks.


"This resulted in the pilot not possessing the required licence to undertake the flight and likely led to a deterioration in the knowledge and skills required for effective flight management and decision‑making," the report states.


“This accident illustrates the significant influence that air traffic control can have on the conduct of a flight,” Hood added.


“And it also serves as another reminder of the risks for visual flight rules pilots flying into non-visual conditions.


“As a former air traffic controller and private pilot myself, I urge all current controllers and private VFR pilots to read this thorough and illuminating report. It contains pertinent lessons that others can learn from.”


The full report is on the ATSB website.
 


Confused Dodgy - Now back to ToRs, (beyond the Dick bashing -  Rolleyes ) via the UP: https://www.pprune.org/pacific-general-a...st10970864


Quote:Dick Smith

The ATSB final report has been released on the Mooney crash with two fatalities west of Coffs Harbour on 20 September 2019. Here is a link: https://www.atsb.gov.au/media/577925...-052-final.pdf

I believe the ATSB is deficient in this report because they don’t mention that the only way to operate Class C airspace satisfactorily in the terminal environment is to use an approach radar facility. The Minister’s directive of 2004 made this quite clear.

It is all very well to blame the air traffic controller and pilot, but to ignore a Minister’s directive with no explanation, and then not even cover it in the ATSB report, shows that something is going on here.




Old Akro

Before we play the normal "pile on Dick" game. I think the point he is making is that there is a pre-existing directive from the Minister about use of approach radar in the airspace of the accident. If there is a Ministerial directive as Dick asserts and if AsA has not complied with this directive then subsequently there has been an accident that could have been avoided if AsA complied with the Minister's directive, then Dick is absolutely correct in suggesting that the ATSB has been deficient in its investigation.


&..

Sunfish

So basically according to the Coroner, Airservices murdered the pilot and passenger. Judging by what happened to Glen Buckley, CASA murders the industry and judging by the quality of its reports, ATSB murders the truth.

How can anyone consider anything these institutions do as promoting safe aviation? All of these alleged behaviours encourage industry participants into unsafe behaviours.



Finally Leady brings the thread full circle back to ToRs... Wink

Lead Balloon

My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.


As another recent example, the ATSB report on the Renmark tragedy says:

Quote:

Quote:The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
...
Despite the operator’s procedure being approved by the Civil Aviation Safety Authority (CASA), reducing the power to flight idle on a turboprop aircraft is not representative of the drag associated with a real engine failure as it does not take account of the beneficial effect of auto-feather/negative torque sensing systems. Consequently, had flight idle been selected it would have created significantly more drag on the ‘failed’ engine, making it more difficult to control the aircraft and achieve the expected OEI performance. While the operator’s procedure only required use of this power setting during the initial ‘phase one’ checks (which would be expected to be completed in less than 30 seconds), it has been a contributing factor to previous asymmetric loss of control accidents (for example AO-2010-019 in the section titled Related occurrences).

The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

Well that’s OK then. Nothing more can usefully be done to find the truth. Move on, nothing to see here. Only three dead.

(Perhaps the deceased, including the CASA FOI, were among the critics of CASA identified in Mr Carmody’s ‘research’ as being the kinds of people likely to have accidents. Maybe those involved in the Mangalore tragedy, too...)

ATSB has powers to compel the disclosure of information, and the failure to disclose when compelled to do so is a criminal offence. The only people excused are coroners in their capacity as coroners. Those powers are there precisely to enable ATSB to obtain information when it is not volunteered, and that includes when not volunteered by CASA.

Although the procedure was - according to ATSB - “not necessarily contributory to the accident”, the procedure was - according to ATSB - “inappropriate and, if followed, increased the risk of asymmetric control loss.”

Wouldn’tcha think it might be important to find out whether CASA had insisted on the risk-increasing, folklore-based procedure to be in the operator’s C&T Manual, or whether CASA had overlooked the existence of the risk-increasing, folklore-based procedure in that Manual? If either of those were true, would it not follow that CASA may be part of the problem? And wouldn’tcha think it might be important to make a recommendation - or whatever the weasel word is these days - for CASA to find out whether the risk-increasing, folklore-based procedure is in other T&C Manuals and get the procedure removed?

The “safety issues and management” part of the report focussed on procedures for the safety of CASA personnel! “The [CASA temporary safety instruction’s] intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).” Make CASA FOIs ‘safer’ and the job’s done!




And Checklist Charlie puts down a (nailed it) dots-n-dashes OBS in reply to that... Rolleyes

 I do wonder if Lead Balloon's observation


Quote:

Quote:My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.

could perhaps be further explained by the career path involving all 3 organisations of the current ATSB Commissioner.

May be, maybe not!

CC


Must be high time for the Hooded Canary to sing me thinks??  Rolleyes  



MTF...P2  Tongue
Reply

Going a bit bi-polar here – (just for a moment).

It has become abundantly clear, since our Hooded Canary was promoted to his level of incompetency, exactly what the ATSB has become. There is little anyone outside the sheltered workshop could say or do which would make the levels of disgust and humour they have reached any worse than it appears in the eyes of their peers and betters. The solution is dead simple; release them from the MoU and make the organisation independent, crewed by qualified 'professionals' reporting only to their paymaster i.e. a Senate Committee. Firing Hood from the biggest cannon available would greatly assist; but then I digress into public, rather than my own opinion.

Two incidents mentioned by P2 (above) – chalk and cheese events; except for the poor quality of report, that which we have all come expect from ATSB. However, I ask that you seriously consider a rare post from 'Look-Left ' in relation to the 'Mooney' accident. 

LL - “Could you please comment on what you think should be done about pilots who do not do any flight planning or even obtain a weather forecast before they operate? Do you agree that pilots should always plan contingencies for any flight they conduct or that a single plan of action will do?”

The man raises some very, very valid points. Navigation 101 – bad weather ahead; leave a back door open – monitor flight conditions and always understand where you are, where you can go and when you discover that you cannot go further; execute plan B or even plan C.

LL - “Transits through coastal CTZ should not be a rarity but denial of a clearance is always a possibility and should be planned for. The lesson out of this report to pilots is stay current. plan your trip and accept your responsibility as PIC. With the information provided in the report this bloke did none of that and the unfortunate confluence of circumstance lead to his death and that of his passenger. If he had got a clearance through Coff's then maybe the accident would not have happened but with such an attitude to his responsibilities it was possibly only a matter of time before it did.”


Concur. There is a lot of this going around – expectations, GPS slaves, not a WAC on board and no 'second or even third 'best' option. This is an area the 'old' ATSB would have focused on and produced some of their world class 'notes' (or tales) in the digest. Alas; no one reads that any longer - ( comment deleted).

The Ross Air event is whole new ball game; but the threads interwoven connect with a few 'similar' events; the Braz being another early 'system' trouble warning classic. The problem; to my mind is both simple and sinister. CASA approval of any and all words in a Check and Training (C&T) manual is mandatory; no option, no argument. The manual MUST be 'approved'. Not just accepted; but approved, in writing, signed off by a delegate. No matter who followed the 'scripted' procedures; if CASA have 'approved' that practice then the liability must; repeat must, lay with those who have complete control over every word drafted into a C&T manual. How many HOTAC and Chief pilots have burned millions of candles trying to gainsay a directive from their FOI team. You see one cannot, not with impunity, tell the CASA guy to go boil his fool head. Ross Air a classic; AFM states – ABC. CASA want and approve DEF – result tragedy; why? CP overruled by a CASA paid ego. Should you dare challenge a bloke who has a little experience as an instructor, on type, the real world - or whatever; and, stand your ground as CP; there is only one of a possible two outcomes. Permanent unemployment; or, you kow-tow and take all the risk, all the blame without the option of blaming the Moke who 'approved' your system.

Want to know what's broken here? – The system is. Well and truly buggered; piss poor airmanship and terrified chief pilots. What a way to run aviation.

A DAS who is not afraid of the iron Ring through political backbone on tap; a Board with experience and balls; a few FOI who actually 'know' how to operate aircraft on a daily basis; some engineers who know which end of spanner will fit a nut; and last, but by no means known to man – last – someone sane (for pity's sake)  running the 'legal' department. In short – a new top shelf Senators, or we have just wasted another million or two going through the never ending cycle of the usual 'motions' and empty promises? Fair question.

You do realise that this is all going to become very 'political'. It is only one serious accident away from the ICAO and the FAA taking the gloves off and beating seven different colour crap out of a national 'safety' system which is only concerned with two things. Keeping the ministers sorry arse out of a sling and self protection of the bounteous trough and bounties 'aviation' safety provides. It is BOLLOCKS. We all know that – so what are the 'government' going to do to fix it? - Same as always; hours of 'gab' then SFA?

Arrggh! To Hell with it all. How many more 'system' related deaths must we have before someone with 'clout' a conscience and the well being of an industry and the nation at heart steps up and simply say's ENOUGH, it stops here. Aye; Dream on old fool.

Thirsty now; so there is a ray of sunshine – “Pint – Here; yes, now would be good'.

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Incompetence it is then? - Rolleyes

Via the Hooded Canary Aviary:

Quote:Hawkesbury floatplane accident highlights the insidious danger of CO exposure




Quote:Key points
  • Pilot’s ability to control the aircraft likely significantly degraded due to carbon monoxide exposure;

  • Cracks in aircraft exhaust and holes in firewall very likely allowed carbon monoxide to enter the aircraft cabin;

  • ATSB recommends mandated fitment of recording devices in smaller passenger aircraft, active CO detectors in piston aircraft.

Carbon monoxide exposure likely significantly degraded the ability of the pilot of a Beaver floatplane to safely operate the aircraft before it collided with water in Jerusalem Bay on the Hawkesbury north of Sydney in December 2017, fatally injuring all six people on board, the final report from Australian Transport Safety Bureau investigation into the accident has found.

As advised with the ATSB’s publication of two safety advisory notices arising from the investigation in July 2020, several pre-existing cracks in the aircraft engine’s exhaust collector ring very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main firewall where three bolts were missing. The pilot also undertook a 27-minute taxi - to free the dock for another arriving and departing aircraft - before the passengers were boarded which likely exacerbated the pilot’s elevated carboxyhaemoglobin level.

“Shortly after take-off for the return flight from Cottage Bay to Sydney Harbour’s Rose Bay, the aircraft conducted a 270 degree right turn in Cowan Water and then entered Jerusalem Bay, below the height of the surrounding terrain,” said ATSB Chief Commissioner Greg Hood.

“It stopped climbing, continued along the bay and then made a very steep right turn. The aircraft’s nose then dropped and the aircraft collided with the water.”

From detailed analysis of photos recovered from the camera of one of the passengers on board the aircraft, as well as witness accounts, the ATSB was able to establish the accident sequence of events, and found that some of the circumstances of the flight were unexpected, given the nature of the flight and the pilot’s significant level of experience.

“The aircraft entered a known confined area, Jerusalem Bay, below the height of the surrounding terrain, when there was no operational need to enter the bay,” Mr Hood noted.

“Further, the aircraft did not continue to climb despite being in the climb configuration, and a steep turn was performed at low‑level and at a bank angle in excess of what was required.

“The aircraft likely aerodynamically stalled, with insufficient height to recover before colliding with the water.”

Toxicology results identified that the pilot and passengers had higher than normal levels of carboxyhaemoglobin in their blood. This was almost certainly due to elevated levels of carbon monoxide in the aircraft cabin.

“The pilot would have almost certainly experienced effects such as confusion, visual disturbance and disorientation,” said Mr Hood.

“Consequently, the investigation found that it was likely that this significantly degraded the pilot's ability to safely operate the aircraft.”

Mr Hood noted that at the time of releasing an interim report into the accident in December 2018, investigators were considering the possibility of pilot incapacitation due to the series of unexpected, and up to that point, unexplained events during the flight.

The ATSB engaged an aviation medical specialist, who, working with other medical specialists closely examined all aspects of the pilot’s medical history including electrocardiogram traces and medical reports, with no pre-existing medical conditions evident.

The ATSB was of the understanding that testing for carbon monoxide exposure on the aircraft’s occupants was conducted as part of initial toxicology examinations. However, in late 2019, the ATSB’s aviation medical specialist recommended that this be confirmed, Mr Hood noted.

“Subsequent toxicological testing indicated that the pilot and all passengers had elevated levels of carboxyhaemoglobin.”

Mr Hood thanked the families and colleagues of those lost in the accident for their understanding and support while the ATSB progressed this comprehensive investigation, culminating in the public release today of the 144-page final report.

“This investigation report release will bring the families of those lost in this tragic accident a greater sense of understanding of the circumstances of the loss of their loved ones.”

Mr Hood said the investigation would have been considerably aided if the aircraft had been fitted with an on-board recording device. The accident Beaver aircraft’s maximum take-off weight was less than 5,700 kilograms and so was below the regulatory threshold requiring the fitment of a flight recording device (such as a cockpit voice recorder and/or a flight data recorder).

“Recording devices have long been recognised as an invaluable tool for investigators in identifying the factors behind an accident, and their contribution to aviation safety is irrefutable,” said Mr Hood.

Historically, due to cost considerations and technological limitations, the fitment of recording devices has only been mandated for larger aircraft.

“However, advancements in technology have made self-contained image, audio and flight data recording systems far more cost-effective and accessible to all aircraft.

“That is why we are today formally recommending that the International Civil Aviation Organization and the Civil Aviation Safety Authority consider mandating the fitment of lightweight recording devices to smaller passenger-carrying aircraft.

“There are a large number of commercial passenger-carrying operations conducted in aircraft that do not require the fitment of flight recorders. So there remains the potential for unresolved investigations into accidents involving smaller passenger carrying aircraft, which poses a significant limitation to bringing about safety improvements in this sector of aviation.”

Mr Hood said the circumstances of the Jerusalem Bay accident highlight the insidious danger CO exposure poses to aircraft occupants.

“This investigation reinforces the importance of conducting a thorough inspection of piston-engine exhaust systems and the timely repair or replacement of deteriorated components,” he said.

“In combination with maintaining the integrity of the firewall, this decreases the possibility of CO entering the cabin.”

Further, the investigation also highlights that the use of an attention attracting CO detector provides pilots with the best opportunity to detect CO exposure before it adversely affects their ability to control the aircraft or become incapacitated.

“The ATSB strongly encourages operators and owners of piston-engine aircraft to install a CO detector with an active warning to alert pilots to the presence of elevated levels of CO in the cabin. Where one is not fitted, pilots are encouraged to carry a personal CO detector.”

The

Quote: ATSB has recommended that the Civil Aviation Safety Authority consider mandating the carriage of active warning CO detectors in piston-engine aircraft, particularly passenger carrying aircraft.

Read the final report: AO-2017-118 Collision with water involving de Havilland Canada DHC-2, VH-NOO Jerusalem Bay, NSW, 31 December 2017
Spot the disconnection: "...Mr Hood noted that at the time of releasing an interim report into the accident in December 2018, investigators were considering the possibility of pilot incapacitation due to the series of unexpected, and up to that point, unexplained events during the flight.[/color]

The ATSB was of the understanding that testing for carbon monoxide exposure on the aircraft’s occupants was conducted as part of initial toxicology examinations. However, in late 2019, the ATSB’s aviation medical specialist recommended that this be confirmed, Mr Hood noted.

“Subsequent toxicological testing indicated that the pilot and all passengers had elevated levels of carboxyhaemoglobin.”..."

ASSUME - Can make an ass out of u and me... Big Grin

Still don't understand how it can possibly take a year to a) engage an aviation medical specialist; then b) taking a further year to discover that the original Coroner toxicological testing was (presumably?) deficient in screening for carbon monoxide poisoning?  Dodgy


MTF...P2  Tongue
Reply

(01-29-2021, 12:12 PM)Peetwo Wrote:  Incompetence it is then? - Rolleyes

Via the Hooded Canary Aviary:

Quote:Hawkesbury floatplane accident highlights the insidious danger of CO exposure




Quote:Key points
  • Pilot’s ability to control the aircraft likely significantly degraded due to carbon monoxide exposure;

  • Cracks in aircraft exhaust and holes in firewall very likely allowed carbon monoxide to enter the aircraft cabin;

  • ATSB recommends mandated fitment of recording devices in smaller passenger aircraft, active CO detectors in piston aircraft.

Carbon monoxide exposure likely significantly degraded the ability of the pilot of a Beaver floatplane to safely operate the aircraft before it collided with water in Jerusalem Bay on the Hawkesbury north of Sydney in December 2017, fatally injuring all six people on board, the final report from Australian Transport Safety Bureau investigation into the accident has found.

As advised with the ATSB’s publication of two safety advisory notices arising from the investigation in July 2020, several pre-existing cracks in the aircraft engine’s exhaust collector ring very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main firewall where three bolts were missing. The pilot also undertook a 27-minute taxi - to free the dock for another arriving and departing aircraft - before the passengers were boarded which likely exacerbated the pilot’s elevated carboxyhaemoglobin level.

“Shortly after take-off for the return flight from Cottage Bay to Sydney Harbour’s Rose Bay, the aircraft conducted a 270 degree right turn in Cowan Water and then entered Jerusalem Bay, below the height of the surrounding terrain,” said ATSB Chief Commissioner Greg Hood.

“It stopped climbing, continued along the bay and then made a very steep right turn. The aircraft’s nose then dropped and the aircraft collided with the water.”

From detailed analysis of photos recovered from the camera of one of the passengers on board the aircraft, as well as witness accounts, the ATSB was able to establish the accident sequence of events, and found that some of the circumstances of the flight were unexpected, given the nature of the flight and the pilot’s significant level of experience.

“The aircraft entered a known confined area, Jerusalem Bay, below the height of the surrounding terrain, when there was no operational need to enter the bay,” Mr Hood noted.

“Further, the aircraft did not continue to climb despite being in the climb configuration, and a steep turn was performed at low‑level and at a bank angle in excess of what was required.

“The aircraft likely aerodynamically stalled, with insufficient height to recover before colliding with the water.”

Toxicology results identified that the pilot and passengers had higher than normal levels of carboxyhaemoglobin in their blood. This was almost certainly due to elevated levels of carbon monoxide in the aircraft cabin.

“The pilot would have almost certainly experienced effects such as confusion, visual disturbance and disorientation,” said Mr Hood.

“Consequently, the investigation found that it was likely that this significantly degraded the pilot's ability to safely operate the aircraft.”

Mr Hood noted that at the time of releasing an interim report into the accident in December 2018, investigators were considering the possibility of pilot incapacitation due to the series of unexpected, and up to that point, unexplained events during the flight.

The ATSB engaged an aviation medical specialist, who, working with other medical specialists closely examined all aspects of the pilot’s medical history including electrocardiogram traces and medical reports, with no pre-existing medical conditions evident.

The ATSB was of the understanding that testing for carbon monoxide exposure on the aircraft’s occupants was conducted as part of initial toxicology examinations. However, in late 2019, the ATSB’s aviation medical specialist recommended that this be confirmed, Mr Hood noted.

“Subsequent toxicological testing indicated that the pilot and all passengers had elevated levels of carboxyhaemoglobin.”

Mr Hood thanked the families and colleagues of those lost in the accident for their understanding and support while the ATSB progressed this comprehensive investigation, culminating in the public release today of the 144-page final report.

“This investigation report release will bring the families of those lost in this tragic accident a greater sense of understanding of the circumstances of the loss of their loved ones.”

Mr Hood said the investigation would have been considerably aided if the aircraft had been fitted with an on-board recording device. The accident Beaver aircraft’s maximum take-off weight was less than 5,700 kilograms and so was below the regulatory threshold requiring the fitment of a flight recording device (such as a cockpit voice recorder and/or a flight data recorder).

“Recording devices have long been recognised as an invaluable tool for investigators in identifying the factors behind an accident, and their contribution to aviation safety is irrefutable,” said Mr Hood.

Historically, due to cost considerations and technological limitations, the fitment of recording devices has only been mandated for larger aircraft.

“However, advancements in technology have made self-contained image, audio and flight data recording systems far more cost-effective and accessible to all aircraft.

“That is why we are today formally recommending that the International Civil Aviation Organization and the Civil Aviation Safety Authority consider mandating the fitment of lightweight recording devices to smaller passenger-carrying aircraft.

“There are a large number of commercial passenger-carrying operations conducted in aircraft that do not require the fitment of flight recorders. So there remains the potential for unresolved investigations into accidents involving smaller passenger carrying aircraft, which poses a significant limitation to bringing about safety improvements in this sector of aviation.”

Mr Hood said the circumstances of the Jerusalem Bay accident highlight the insidious danger CO exposure poses to aircraft occupants.

“This investigation reinforces the importance of conducting a thorough inspection of piston-engine exhaust systems and the timely repair or replacement of deteriorated components,” he said.

“In combination with maintaining the integrity of the firewall, this decreases the possibility of CO entering the cabin.”

Further, the investigation also highlights that the use of an attention attracting CO detector provides pilots with the best opportunity to detect CO exposure before it adversely affects their ability to control the aircraft or become incapacitated.

“The ATSB strongly encourages operators and owners of piston-engine aircraft to install a CO detector with an active warning to alert pilots to the presence of elevated levels of CO in the cabin. Where one is not fitted, pilots are encouraged to carry a personal CO detector.”

The

Quote: ATSB has recommended that the Civil Aviation Safety Authority consider mandating the carriage of active warning CO detectors in piston-engine aircraft, particularly passenger carrying aircraft.

Read the final report: AO-2017-118 Collision with water involving de Havilland Canada DHC-2, VH-NOO Jerusalem Bay, NSW, 31 December 2017
Spot the disconnection: "...Mr Hood noted that at the time of releasing an interim report into the accident in December 2018, investigators were considering the possibility of pilot incapacitation due to the series of unexpected, and up to that point, unexplained events during the flight.[/color]

The ATSB was of the understanding that testing for carbon monoxide exposure on the aircraft’s occupants was conducted as part of initial toxicology examinations. However, in late 2019, the ATSB’s aviation medical specialist recommended that this be confirmed, Mr Hood noted.

“Subsequent toxicological testing indicated that the pilot and all passengers had elevated levels of carboxyhaemoglobin.”..."

ASSUME - Can make an ass out of u and me... Big Grin

Still don't understand how it can possibly take a year to a) engage an aviation medical specialist; then b) taking a further year to discover that the original Coroner toxicological testing was (presumably?) deficient in screening for carbon monoxide poisoning?  Dodgy


MTF...P2  Tongue

Addendum: Read Pg 45-50 - https://www.atsb.gov.au/media/5779428/ao...-final.pdf

Reply

FWIW, and beyond.

Aunt Pru does have an extensive 'loop' system for emails; in and out. Many of our associates prefer 'privacy' to even anonymity (as if anyone on the 'net' remains private). But, nevertheless, through our 'system' we do receive some real, valuable pearls of wisdom; often in the guise of an unasked question. 

I'm not as nimble as the boys when it comes to 'getting' the message, that delivered from an abstruse 'sentence' in a short, often terse reply to an Aunt Pru QwoN. But, the drums have been busy, sending and receiving, in regard to the (another) spectacular mess ATSB have made of the Hawksbury River fatal event. Particularly from our long absent friends from both Canada and the USA; where they know (perhaps) just a little bit about air-frames on floats and the venerable DHC2 – a.k.a 'The Beaver.' Millions of safe flying hours, etc.

I won't expand any further, I reckon if you don't know how this PAIN system works then I'm wasting my wind. For those who can see beyond 'the veil' then the following is 'self-explanatory'.

1) “but the ATSB has no concrete evidence of exhaust leakage, non whatsoever”.

2) ATSB  should not make unqualified statements of this (any) kind.  

3) The aircraft was not fitted with ventilation louvres in the roof at the front of the cabin, which, according to Airag Aviation Services were standard fitment on DHC-2 aircraft. (Refer CASA airworthiness and FOI required knowledge base).

4) “A periodic inspection (100-hourly) of the aircraft was completed on 6 November 2017 and certified by a licensed aircraft maintenance engineer. At that time, other inspections and rectifications were carried out. To allow access for this work, the rudder, elevators and horizontal stabiliser were removed and subsequently refitted. A scheduled engine change was also carried out at this time and the corresponding inspection/s were certified by a licensed aircraft maintenance engineer. The replacement engine had been previously fitted to VH-AAM.”

5) “You might expect problems with the exhaust system to be picked up during this engine change: wouldn’t you”?

That last quote is from a very highly qualified, skilled man who asks but one simple question. “If not, why not”? 

There is no way that ATSB can be allowed to get away from this (an other) complete shambles. In aviation terms, they've had a lifetime to sort out this 'event' on the Hawksbury. There are some 'hard eyes' reading reports and examining some of the openings provided for an aggressive Barrister to exploit  The report smacks of astounding incompetency, intransience, ignorance, arrogance and plain, old fashioned, made on the farm - bull-pooh. 

Never have been known as a 'begging' sort of fellah; but, please, before we are made into a complete international laughing stock, can someone put their boot on the ATSB brake. Before we are all tarred with the same brush – it is embarrassing. Cringe worthy even – in the international. 'professional' world, it has become a joke which is wearing pretty thin.

And, I'm no frame of mind to answer silly questions – get 'em in boy; Pints will do - unless they have bigger (kidding).

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Of Teddy bears and picnics:- sing along......

"IF – you go down to the crypt today

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Your sure of a big surprise!

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For every prang that ever there was is there today
Covered in dust forever because
ATSB are playing at silly biuggers.

I'm certain you've all be reading and considering the multitude of finalised accident reports being churned out over the past twelve month by ATSB. Ayup; Covid has given them the time to catch up and complete the five, three and even the two year old accidents – hasn't it. So where the duck are they?

Toot – bloody – toot!!
Reply

BOLLOCKS!

I may, on occasion – get a little testy; grumpy even; but, rarely 'angry'. This latest ATSB report has sparked that anger. It is yet another risible, pathetic, anaemic response, which completely betrays the 'purpose' principal and tenets of accident investigation. Shame on them who wrote it and on those as let it be published.

“Solo training flight stall-spin accident highlights the potential consequences of deviating from safety-critical procedures and regulations.”

NO!  – it bloody well ain't. In fact 'truth' is so far removed from that line of bull-shit, it beggars any notion that ATSB have the first blind clue about the 'accident' or the radical cause.

Item 1 – the student could not manage the 'cross-wind' – all 12 kts of it?. Question – then who sent him solo without the 'skill' demanded (by law) to manage the simple task of keeping an aircraft 'on the runway'? Bog standard crosswind landing – mismanaged – then why was he solo? What was the wind and what was the cross-wind component?

"The crosswind component at the time of the loss of control was calculated to be about 13 kt, accounting for the observed 15 kt gust. The Moorabbin automatic terminal information service was advising of a 12 kt crosswind at that time and the student pilot reported noting this during the flight."


ATSB -“aware that they hadn’t received any crosswind or stall training”.

I expect most professional pilots, those who hold the 'single engine land' endorsement, treat it with the caution due. Insurance and those from whom an aircraft is hired do not. No stranger can waltz into a FBO and simply 'hire' an aircraft. Not going to happen; not in the real world at least. Now, we need to take one more step forward to understand why not.

Consider this: 'Single engine – Land'. Sounds great don't it; SDA to do with the lethal, 'legal' and 'insurance' realities' of attempting to exercise that blanket endorsement. For all involved.

Way – way, back in history, (when the earth was soft and the sky was misty) as a junior hanger rat; I had (mostly through luck) picked up some tail wheel expedience. Did this qualify me to for the 'big guns' – i.e. the P51 Mustang.

Of course not: not in a million. Even for practical (safe/economical) use the useful Cessna workhorse range – 172, 177, 180, 182, 206, 207, 210 – you needed to 'how' to operate 'that' aircraft.

So, what's my point – well it is a simple one. The Bristell is essentially as 'specialised' an aircraft (in it's own way) as is the Mustang is.

The questions that ATSB failed (miserably) to answer are:-

1 – When the Bristell is on short final – where is the elevator trim set?

2 – When 'Go-around' power is applied at low 'energy' which way will the aircraft 'yaw'?

3 - When 'Go-around' power is applied at low 'energy' which way will the aircraft ' Pitch' ?

4 – Had the pilot been trained to anticipate the aircraft response in this configuration and situation?

5 – Had the pilot been specifically briefed on the effect of slip stream torgue; pitch trim changes, ground effect, crosswind effect and the rapidity at which all four 'effects' can occur, with a rapid increase in power??

6 – What are the 'company' limitations' relating to authorising solo flight in forecast cross wind conditions; and, what are the minimum requirements set down for 'approval' to conduct solo flight in crosswind conditions?  (a) Did the pilot meet these requirements?

7 – What are the company 'minimum' (in -house) requirements of type experience before authorisation for 'solo' flight on a 'unique' aircraft.

These may not be 'legal' requirements – but; common or garden sense should have been expected from the instructor who 'authorised' this event. The Mustang was a demanding aircraft; the instructor who showed me 'the ropes' was a 'demanding' man. I asked him why one day – his reply – succinct and accurate – “I can't afford the flowers for your funereal - learn to 'operate' this individual aircraft – 'properly' – (not all the same)  or; don't bother to become a 'professional pilot'.

Could I/ would I jump into a Bristell tomorrow and deal with a miserable 12 Kt crosswind without some 'training'? NO: I bloody well would not - and neither should you.

Totally 'over' ATSB pissing about the Daisy patch. The minister may be held in thrall by 'RA Oz' – but we who grieve the loss or injury of young, inexperienced pilots and the degradation of safety standards - ain't.

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