[Peetwo]

Timeline of bureaucratic O&O, embuggerance & sheer bloody bastardry - 

This AM "K" has written this post on the Closed loop thread: Safety Loop or Hangman’s noose?

Cheers P2; this has been coming for a while now and is well over due. Sen. Fawcett tried to get the ball rolling in the right direction way back in 2012, yet seven years later the core subject matter has not been properly addressed in a positive or even a satisfactory fashion.

We did do an abridged version of the analysis we ran – HERE – but – as I recall we left it on the shelf after while when the promised legislation and amendments failed to materialise (as per usual). There is a long list of them; and all that seems to have surfaced is more ways to allocate blame, but little in the way of ‘preventing’ a reoccurrence. The same ‘accident’ has been claiming lives for quite a while, clearly demonstrating that ‘rules’, no matter how complex, simply are not preventing repeat accidents. 

16/10/2012 - Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Fawcett, with a flick of his wrist has unveiled the Elephant in the room. It is a simple concept which, IMO the departments involved have been at some pains to avoid acknowledging. The construct is a simple one:- (a) there has been a fatal; (b) ATSB have, best they may defined the nature of it; © there is a Coroners court; (d) the Coroner makes recommendations and hands down his findings; (e) nothing further happens – in real terms.

For some reason that thread post title sounded very familiar?? So with a quick AP forum search, to my amazement I was to discover there was a "K" thread post with the same title from almost exactly three years ago, which ironically and disturbingly highlights the issues that "K" is banging on about -   

Safety loop or hangman’s noose?

Ventus 45.

The final paragraph of:-
Investigation number: AO-2014-032 Updated: 10 June 2014
( https://www.atsb.gov.au/publications/inv...FI.twitter )

“The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser.”

For a “supposedly” benign and “routine” encounter with so called “moderate” turbulence, that should not have caused “any” damage or flight upset at all, the nature of this structural damage is alarming.

What we do know, is the aircraft was partially repaired and flown back to the manufacturer by the manufacturer’s test pilots, where it was “repaired” – presumably with the entire vertical tail and tail-plane removed and replaced – and was then subsequently flown back to Australia, to Virgin, and placed back in service.

Presumably, the “removed vertical tail and tail-plane” have been “examined” and or further “tested” by the manufacturer, and possibly (presumably) the “Design Certifying Authority”.
Presumably, the results of those investigations have identified the “reasons(s) for failure”, and have been dealt with in an “appropriate” manner, and the ATSB have been fully advised – of course. Frankly, I doubt it.

It is also interesting to note, that presumably, both the ATSB “AND” CASA were “quite happy” to grant a “permission to fly” for a “damaged” (partially repaired) aircraft over Australian Territory (and by inference – all other countries involved) for the “ferry flight” back to the manufacturer. Interesting point that, interesting indeed M’lud.

Why did they do so ? Why was the “physical evidence” (the tail and tail-plane) “allowed to leave the jurisdiction of the investigation”?

Why indeed ?

Two years on, and no definitive “structural report” ?

As the copper says at the crime scene: “Nothing to see here folks, move right along “thank you”, (and be bloody-quick-smart about it too).

I lifted the entire Ventus 45 post from Ben’s blog as it steps us through to what should have provided definitive answers to at least the ‘engineering’ parts of this puzzle.  It is remarkable that a manufacturer investigation of an event of this magnitude has not been fully documented.  It is not from idle curiosity or vicarious thrill seeking that answers are sought.  There are, clearly demonstrable areas of real concern which need to addressed: for example:-

Flight crew training and response to an uncertainty situation; there are many areas which have not been even cursorily examined.  The PIC ‘interference’ with the FO actions begs questions; why not call ‘taking over’; or, why not monitor and advise; or, why was there such confusion that the elevator channels were split. Etc.  There’s many more related to crew actions and reporting to engineering.

Then we examine what were the engineers told against what was committed to the tech log. This may give some insight into the initial maintenance actions.

The subsequent flights and tech logs preceding to eventual ‘discovery’ at Albury need to be examined in detail and crew questioned in relation to the in-flight performance of the aircraft.

No one is on a witch hunt here; not looking for a scapegoat in the form of an engineer or pilot.  However, this incident, like several others raises several red flags over ‘system’.  Hiding facts and delaying reports, then producing a ‘thing’ like the latest ATSB rubbish simply assists to hide potential problem areas, which, if not addressed could, when luck runs out end in an avoidable, preventable accident.

ATSB can do better than this – we know they can; so why are they not performing design function.  Perhaps when the minister gets done with taking selfies and studying phallic symbols, he could ask that question; maybe even do something about the shameful, deceitful way an expensive investigative body does it’s job.  He could even consider doing something to resurrect the inutile and transform it back to at least being honest, if not effective.  

Yes GD, I know there’s an election in the wind; so much more important than bodies and aircraft parts blowing in the same breeze.  Aye well; tempus fugit and tempers fray; I hope the inevitable never happens on some another day.

Toot toot.

Now keep in mind that today's "K" post was written 1 week short of 6 years from when the very damning findings and recommendations of the Senate Inquiry into Aviation Accident Investigations - see HERE & HERE - was made public; plus approaching a decade after the VH-NGA ditching and just over a decade since the ignored wake up call immersed inside of the significant findings and recommendations of the 2008 ICAO Audit report of Australia - see from page 30 HERE.

         

Hmm...see what I mean? - MTF...P2