[Peetwo]

Supplementary Estimates - WQON.

(N.B AQON for Sup Estimates are due 06/12/19)


ATSB:

Question on notice no. 387

Senator Glenn Sterle: asked the Australian Transport Safety Bureau on 8 November
2019—

What is the status of the following investigations?
o AO-2016-084
o AO-2017-066
If these investigations are still classified as "pending", when do you expect them to be
finalised?
Is there a time period within which ATSB would normally expect investigations to be
complete?
In the case of AO-2017-066 why was the aircraft diverted to Perth rather than landing
at its nearest alternative, Learmonth? Is this considered best practice?
In relation to investigation AO-2015-084:
o What recommendations were included in this report?
o Have all recommendations been adopted by the airline?
o Does ATSB hold any concerns about the safety of this airline to operate in
Australia?

P2 - These are the ATSB investigations in the order that Sen Sterle mentions them:
 

AO-2016-084

AO-2017-066

AO-2015-084

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Given the context of the above questions, in relation to AirAsia X, I thought the following articles in regards to a just released ATSB report into an occurrence of a subsidiary airline, AirAsia Indonesia, should be of interest/concern to Senator Sterle?

Via Airlineratings.com : 

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INVESTIGATORS CALL FOR CLEARER INSTRUCTIONS AFTER AIRASIA CHAOS


A passenger on the AirAsia Indonesia flight. Photo: Seven News

Cabin crew shouting inappropriate instructions such as “brace” and “crash position” contributed to passenger confusion and panic during a cabin pressurization problem on an AirAsia Indonesia flight from Perth to Bali, according to Australian investigators.

Australian Transport Safety Bureau investigators also found the Indonesian carrier’s pre-flight safety briefing did not include clear instructions about the operation of oxygen masks deployed during the incident.

As a result,  the bureau issued a safety recommendation calling on the airline to review its passenger safety briefing material and ensure instructions on how to activate the masks are clear and effective.

The AirAsia Indonesia Airbus A320 was about 30 minutes out of Perth on October 15, 2017, when it dropped quickly from 34,000ft to 10,000ft and the pilots manually deployed the passenger oxygen masks.

The pilots were responding to a master caution warning of a malfunction of the aircraft’s pressurization system.

“During the emergency descent, some oxygen masks did not deploy or passengers felt they were not receiving oxygen,’’  the ATSB said.

“Consequently, some passengers then moved around the cabin to find a functioning oxygen mask unit.

“Passengers later surveyed by the ATSB recalled that the cabin crew shouted commands such as ‘BRACE’, ‘GET DOWN’ and ‘CRASH POSITION’, increasing their level of confusion and panic.”

Investigators found that AirAsia Indonesia’s pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen in emergency masks or that a bag on the masks may not inflate when oxygen is flowing.

It said this may have resulted in some passengers failing to understand whether or not oxygen was flowing to the mask.

“Further, cabin crew provided additional commands to passengers that were inappropriate for a depressurization, which had the potential to increase confusion in the cabin and likely increased the level of panic experienced by some passengers,’’ it said.

ATSB transport safety director Dr Stuart Godley said the incident highlighted the importance of a crew’s ability to recall and use appropriate standard commands in managing passengers.

“Passengers generally responded well when appropriate commands were used, but incorrect commands resulted in some confusion and panic among (those) in the cabin,” he said.

“Cabin crew emergency procedures training that includes role-playing of the full range of expected passenger behavior, including panic and confusion, can better prepare cabin crew when exposed to more complex real-world scenarios.”

Dr Godley said the inclusion of information highlighting that oxygen was flowing through the mask even though the bag may not inflate would improve passengers’ knowledge and reduce anxiety and their susceptibility to a hypoxia-related event.

The ATSB report also indicated the entire incident could have been avoided if AirAsia Indonesia had followed manufacturer advice to improve the pressurization system.

The pressurization problem was traced to an intermittent rare fault with one of two independent cabin pressure controllers.  The fault resulted in warnings of excess cabin altitude and prompted the emergency descent.

“The ATSB found that the operator had reviewed and elected not to incorporate the manufacturers recommended, but not mandatory, improvements to the pressurization system,’’ investigators said.

“The improvements were communicated to the airline by service bulletins. Incorporating the bulletins would have likely prevented the emergency descent incident.”

AirAsia said in a statement that it had cooperated fully with the ATSB.

“Since this incident in 2017, AirAsia has reviewed our processes to ensure we always remain fully compliant and that our safety procedures continue to be robust,” it said.

“Given the findings in this latest ATSB report, we will review the recommendations, including our pre-flight safety briefing and cabin crew emergency training procedures, as a matter of priority.

“Australia’s aviation safety standards are amongst the highest in the world and AirAsia operates within the same strict guidelines as any airline operating in Australia.

“All AirAsia operated flights to and from Australia have achieved IOSA certification which is the global benchmark for upholding the highest safety standards.”

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Via the Oz:

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AirAsia review ordered after flight chaos


ROBYN IRONSIDE
AVIATION WRITER
@ironsider

5:42PM NOVEMBER 27, 2019

Low cost carrier AirAsia Indonesia has been urged to review its pre-flight passenger safety briefing after an incident on a Perth-Bali service which descended into mayhem when the pressurisation system malfunctioned.
The Australian Transport Safety Bureau’s final report on the incident on October 15, 2017, found incorrect commands from cabin crew resulted in “confusion and panic”.
As the aircraft descended from 34,000 feet to 10,000 feet at a rate of 2300 to 4300 feet a minute in response to cabin pressurisation warnings, crew announced over the public announcement system “emergency descent, emergency descent, emergency descent”.
Oxygen masks were deployed but some passengers felt they were not dispensing oxygen and started moving around the cabin to find a spare despite the seatbelt sign being illuminated.
In response, cabin crew began shouting “brace”, “sit down” and “crash position” which increased confusion and panic among some passengers.
The A320 returned to Perth and on arrival it was noted that several passengers had donned life jackets.

“During disembarkation, the cabin crew manager received several passenger reports of cabin crew members at the rear panicking, shouting and alarming children,” the report said.

“When she followed up with those members, they reported that they were shouting as this was the procedure.
“One reported that she shouted at a passenger who stood up during the descent due to the risk of a fall.”

The pressurisation issue was found to stem from a rare fault with the cabin pressure controller one circuit board, resulting in incorrect control of the outflow valve.

“This led to the over-pressurisation of the aircraft cabin and activation of the cabin safety valve,” the report said.

ATSB Transport Safety Director Dr Stuart Godley said in an emergency, cabin crew were required to perform a safety leadership role for passengers.

“This incident highlights that an important aspect of managing abnormal passenger responses is the cabin crew’s ability to recall and use appropriate standard commands,” Dr Godley said.

“Passengers generally responded well when appropriate commands were used, but incorrect commands resulted in some confusion and panic in the cabin.”

A formal safety recommendation had been made to AirAsia Indonesia to review its safety card and pre-flight briefing to better inform passengers about the use of oxygen masks.

“Inclusion of information highlighting that oxygen is flowing through the mask even though the bag may not inflate will improve passengers’ knowledge and reduce anxiety and their susceptibility to a hypoxia-related event,” said Dr Godley.

He said cabin crew emergency procedures training that included “role playing of the full range of expected passenger behaviour” would also better prepare cabin crew when exposed to more complex real-world scenarios.

The incident followed another involving AirAsia in June 2017, in which the pilot told passengers to pray when their aircraft began shaking and vibrating during a flight from Perth to Kuala Lumpur.

The A330 returned to Perth without further incident.

Of the depressurisation incident, an AirAsia spokeswoman said the airline had cooperated fully with the ATSB throughout the investigation.

“Since this incident in 2017, AirAsia has reviewed our processes to ensure we always remain fully compliant and that our safety procedures continue to be robust,” she said.

“Given the findings in this latest ATSB report we will review the recommendations, including our pre-flight safety briefing and cabin crew emergency training procedures, as a matter of priority.”

She said all AirAsia operated flights to and from Australia met the high safety standards of the regulator.

“AirAsia operates within the same strict guidelines as any airline operating in Australia,” the spokeswoman said.

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And for reference here is a link for the report: https://www.atsb.gov.au/publications/inv...-2017-098/

MTF...P2