Before we begin this journey, there is some essential background information which we hope will assist the reader to follow the trail of breadcrumbs to what we believe is an inescapable conclusion.
Quote:Duck-shove is first recorded in The Australian National Dictionary from 1870 to describe the pushy behaviour of Melbourne cab drivers. It seems to have grown out of observations of ducklings, waddling in an orderly queue behind mother duck. The idea is that there’s always one little duck that is pushy, and elbows the others aside to get what it wants. If that is correct, then it means that the original duck-shoving was actually done by ducks – from where it extended to human behaviour that involves “elbowing others”. (Thanks to ABC News Radio for this excerpt)
Quote:Dictionary – avoid or evade (a responsibility or issue).
“this sniping and duck-shoving between county councils and the Electricity Commission should cease”.
Quote:“..AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety..”
The AIPA are, without doubt, one of the most respected associations in the aviation world with a fine track record for presenting balanced, realistic comment and solutions to ‘problem’ areas across a wide range of topics associated with ‘matters aeronautical’. In short, no lightweight raggedy ass bunch of cowboys, but a very serious professional body, not given to making facetious claims or crying wolf. When the AIPA make a comment, such as the quote above, you can bet it is a rock solid assessment, based on fact, not made lightly and only published after careful, due consideration. P2 has, in the post above provided more on the topic. The AIPA submission to the Senate inquiry is essential reading.
But, we need to work backward from the P2 post, if we are to reach journeys end. The incident under discussion is the Virgin 777 incident on a SHEED arrival to Melbourne’s Tullamarine, not the preceding one, which has quietly disappeared from public radar. P2 goes on to highlight several divergences noted in the final report from the ATSB, particularly the differences between the IIC investigation (interim), DIP review and the final, glossy product provided after the Commissioner’s ‘review’. Marty Khoury published a first class analysis based, in advance of the Interim report which brought several important elements into causal chain considerations; many of these were considered by the investigators in the Interim report as being pertinent.
This brings us to our starting point. Long before the ATSB final report was being ‘reviewed’ by the Commissioner, there would be at least three definitive, expert reports not only presented, but acted on, promptly and correctly by VA, with minimal, if any ATSB assistance. In theory, the VA safety management system should have captured the event and provided the basis for an internal assessment at management level. From this a plan for risk mitigation would have been developed and provided to those who would institute and manage the proposed changes. The ‘flight operations’, fleet management and Check/Training would have played their part. In a very short time, internally at least the risks should have been mitigated, expertly, efficiently and properly. Any Safety Recommendations to flight crew published, promulgated and delivered, in a timely manner.
There is very little wrong, theoretically, within the airline system of safety management and risk mitigation; it is, after all what it’s supposed to do. Whether the VA system had worked ‘properly’; or not, should be a definitive part of the ATSB investigation which examined, in detail that area to decide whether any undue management pressure was brought to bear, even subtly on flight crew or the procedures. One must hope that the ATSB examined this important element honestly. For it is clearly apparent that any flaw found in the first (and only) real time line of defence ignored by the ATSB could and probably would have disastrous repercussions in a repeat event. Natural diffidence and a reluctance to hang their dirty linen outside aside; management do have a legally binding responsibility and duty of care, to ensure that things are ‘done properly’ and honestly reported. The ATSB are equally obliged to ensure that ‘all is well ’ and provide proof positive of this; even if just a passing acknowledgement.
In a perfect world, ATSB involvement from day one was, technically and operationally, of little use in, the first instance. What ATSB could do was to assess the patch made by VA and accept the proposed fix or, propose (insist) on a different approach to the identified problems; assuming those matters had been correctly isolated. With the initial patch in place, what needed to follow was a holistic appraisal of why the event occurred. The airline knew how and moved quickly to prevent a reoccurrence but the time required for a full, in depth analysis of all factors was not within the airline’s purview. That is a job for the ATSB, to confirm the initial findings, assess the remedy, evaluate the results and inform which ever power that be of those findings. In this case ASA, CASA and VA. Not do this in a proper manner defeats the purpose of ATSB risk mitigation evaluation, lets down the travelling public and betrays the faith flight crew must have in the probity of the ATSB.
This is where P2 has been digging; the results are concerning. For starters, there is the vexed question of ‘unstable approach’. I happen to disagree with the notion – technically, IMO the approach flown was ‘stable’ but stable on the wrong glide path. Academic I know, but essentially this was a potential CFIT; steady as a rock right into the ground, well short of the runway, had not the error been picked up. The question of initiating an overshoot or not could and probably will be debated; but for my two bob’s worth; visual, stable, runway in sight, I could well have been tempted to level off, maybe pitch up a little and land. But I digress.
This discussion is not about what has been done by the airline or flight crew, but of the ATSB abysmal management of the final incident report. To understand this, we must examine the history of several recent, very close calls at Melbourne; which holds the all time, world record high for such events; certainly over the past two years. There is a rapidly emerging pattern. During the two years the ATSB fiddled about with one report, there have been a number of similar events, including the event preceding ‘SHEED. How many – good question. P2 (research guru extraordinaire) groaned when I asked the question. The ATSB web site is a nightmare; if you want to do some serious digging.
Now here it get’s a little tricky, so bear with me; I’ll try to explain why. Say you were to be taxed on the number of Hens, but not Ducks on your farm. A smart operator would hide some the chickens in the duck pen, send some to his mate over the way and generally disperse the flock, to minimise the taxable total. It gives the investigator a tough time, tracking them all down, identifying ‘yours’ and arriving at a realistic figure. So it is for P2. The working notes provided give you a fair idea.
Events with similar characteristics spread out over a number of different categories, which, effectively hides the Chooks with the Ducks, in different pigeon holes.
Similar elements, similar incidents at Melbourne, similar circumstances: a short (not complete) list of potential suspects:-
Complex STAR, badly presented, easily confused tracking details (nightmare plates).
Multiple, closely spaced waypoints. Short notice, close in changes to tracking over the same multiple, closely spaced waypoints.
Automatics dependency (sub topics SOP and Manufacturer recommendations, which lead to company training and checking practices, back to basic flight training, experience levels and selection process, and much more).
CRM and PM practices (trend noted) related back to who flying and who’s watching; who’s programming the computer; who checks; etc. VA was a classic, both crew trying to sort out ‘the box’ during an 8 mile visual approach, so the AP could fly it.
Loss of situational awareness (multiple recent events), fatigue used again as an excuse. Etc.
The list goes on, and on; but, a definitive count, topic specific and related cannot be easily found. One must look at many categories; ‘short reports’, un finished reports, fatigue, failed to follow SOP. Etc. Multiple, non connected pigeon holes. A virtual extravaganza of ‘category’, all hiding their part of the true picture. The ATSB monster jig-saw puzzle.
I’ve run out of time: but we will; soon, begin to unravel the ATSB obfuscation jig-saw puzzle, find all the chickens and bring ‘em home. It looks as though there is a serious pattern, a trend if you like. I can see a dozen incidents, at Melbourne alone all of which have similarities, all of which could have been serious. None of this has been addressed by the ATSB and had it not been for prompt action by airlines concerned a repeat was always on the cards. Maybe we are chasing our tails; or, maybe there should be some heavy duty SR out there, heading to CASA and ASA. Can’t say for certain just yet; but, stay tuned.