[Peetwo]

PASO, dots, dashes & an unfortunate ditching - Part III

In the process of following up on the missing ICAO occurrence notification for VH-NGA, I remembered that this wasn't an isolated aberration...

This notification glitch apparently also occurred for the tragic fatal accident at Canley Vale involving Mojave VH-PGW: Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010

What happened

At about 0806 Eastern Standard Time on 15 June 2010 a Piper PA-31P-350 Mojave aircraft, registered VH-PGW, with a pilot and a flight nurse on board, collided with terrain in a suburban area about 6 km north-west of Bankstown Airport, New South Wales. At the time of the accident, the pilot was attempting to return to Bankstown following a reported in-flight engine shutdown. Both occupants were fatally injured and the aircraft was destroyed by the impact forces and an intense post-impact fire.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) found that following the shut down of the right engine, the aircraft’s airspeed and rate of descent were not optimised for one engine inoperative flight. In addition, spectral analysis indicated it was unlikely that the left engine was being operated at maximum continuous power as the aircraft descended.

As a result, the aircraft descended to a low altitude over a suburban area and the pilot was then unable to maintain level flight, which led to the collision with terrain.

Examination of the engines, propellers and governors and other aircraft components found no evidence of any pre-impact faults. However, the engine surging identified by the spectral analysis of radio transmissions during the flight was consistent with uneven fuel distribution to the cylinders.

What has been done as a result

The Civil Aviation Safety Authority has started a project to amend advisory material relating to multi-engine aircraft training and operations to include guidance information about engine problems encountered during the climb and cruise phases of flight. This amended guidance material will include information about aircraft handling, engine management, and decision making during these phases of flight.

Safety message

This accident reinforces the importance when flying twin-engine aircraft with one engine shutdown that the optimal speed be selected, along with maximum continuous power on the operative engine, and that the aircraft’s performance should be verified prior to conducting a descent. Pilots should also use the appropriate PAN or MAYDAY phraseology when advising air traffic control of non-normal or emergency situations.

  
Here is the ICAO iStar database page that should have the entry for VH-PGW:

Although one flight was an international operation and the other was domestic, it is passing strange how VH-NGA and VH-PGW were both air ambulance operations, operated under the same regulatory 'Aerial Work' classification, with both AOCs oversighted by the former CASA Bankstown regional office...   

And both ICAO notifications were lost in the mail or in translation? - Yeah right...

It should also be noted that when Nancy Graham could not find the details of VH-NGA on the iSTAR database back in 2015, this would also indicate that at that time there was no Preliminary or Final Report filed under the ICAO ADREP/ECCAIRS system.

On ADREP and the ECCAIRS PC application tool, it is worth noting the following finding and recommendation from the 2004 ATSB ICAO audit report:

5.6.2.2 ADREP reporting

5.6.2.2.1 The procedures in place for the ATSB to report to the ICAO ADREP system, contained in the ATSB Notifications Procedures Manual (Section 8 – ADREP Reporting), meet the international reporting requirements of Annex 13, Chapter 7.

5.6.2.2.2 In practice, the ATSB has been reporting accidents and investigated incidents to the ICAO ADREP system as a result of a discussion between ATSB personnel and the ICAO ADREP system administrator some 18 months before this audit. The ICAO audit team was informed that no feedback had been received from ICAO as to the status and format of the reported data.

5.6.2.2.3 According to the ICAO ADREP system administrator, the data received from Australia constituted ADREP Preliminary Reports and no ADREP Data Reports had been received in the last few years. It is worthy to note that there was some confusion prior to the audit between the ATSB and the ICAO Secretariat, which meant that the ATSB was unaware of the ADREP reporting problems.

5.6.2.2.4 Since the ATSB is in the process of acquiring a new accident and incident data reporting system, it is recommended that the new database system be ADREP-ECCAIRS compatible in order to facilitate ADREP reporting and an international exchange of accident and incident data. It is envisaged that the ATSB may transfer accident data from its old system to the new system in due course, thus also facilitating the reporting to ADREP of older accident records in an ADREP-ECCAIRS taxonomy format.

5.6.2.2.5 It is also recommended that further discussions take place between the ATSB database system personnel and the ICAO ADREP system administrator in order to facilitate the reporting to the ADREP using the ATSB existing system before the new ATSB system becomes operational (Appendix 5-1 refers).

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CORRECTIVE ACTION PROPOSED BY THE ATSB:

There was some confusion prior to the audit between the ATSB and the ICAO secretariat which meant that the ATSB was not aware of the ADREP reporting problems. The ATSB is currently investigating the feasibility of incorporating an ECCAIRS compatible ADREP into the new accident/incident database. However, a determination is still several months away. As a result of the audit, the ATSB has obtained a copy of the latest ADREP (Form D) and is seeking to create a template that will capture the necessary data applicable.

The ATSB is committed to fully meet the ICAO obligation in both the short and longer terms.

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ACTION TAKEN BY THE ATSB:

The use of ECCAIRS was considered as an option for the occurrence database module of the ATSB's newly developed Safety Investigation Information Management System. Given that most of the aviation data collected by the ATSB is high-volume, low-detail data, the complexity of the ECCAIRS taxonomy was not considered appropriate. A bespoke taxonomy for safety events and safety factors was developed by the ATSB which better suits its needs, particularly for the purposes of safety research and for the application of its investigation safety analysis methodology. However, a mapping exercise was carried out to ensure that there was comparability between the ATSB and ECCAIRS taxonomies. For the purposes of notification, preliminary and final ADREP data reports, the ATSB continues to provide this information in the ECCAIRS format, including the use of the ECCAIRS taxonomies.

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STATUS: Completed

 
According to the status this recommendation was fully actioned, couple that with a review of the ICAO 2008 audit report, would appear to indicate that the ATSB disconnection with the ICAO ADREP system had been resolved.

However it is of interest that with the introduction of the ECCAIRS PC application tool, the issue of compatibility with the ADREP/ECCAIRS taxonomy was a common problem with some individual signatory States.

But the issue was identified and proactively addressed by the ICAO (IAG) Secretariat at the ACCIDENT INVESTIGATION AND PREVENTION (AIG) DIVISIONAL MEETING 2008 (Reference PDF PG 65-67):

4.1 INTRODUCTION

4.1.1 The meeting considered ways for improving the collection, exchange and representation of safety data.

4.2 SAFETY DATA COLLECTION AND EXCHANGE

4.2.1 The meeting agreed with the following proposals, which foster the better management and representation of safety data.

a) to urge States to adopt an ADREP compatible taxonomy as an aviation occurrence taxonomy;

b) to encourage the dissemination of ECCAIRS in the ICAO Contracting States which

do not have their own ADREP compatible occurrence database;

c) to encourage the facilitation of data-exchange between the existing ADREP compatible databases;

d) to recommend establishing a means to facilitate a periodical revision of the ADREP taxonomy; and

e) to recommend that States use ADREP/ECCAIRS or a compatible system to collect, analyse and share safety data.

4.2.2 The meeting was informed that an ADREP compatible software that had been developed by the European Union, namely the European Co-ordination Centre for Aviation Incident Reporting System (ECCAIRS), was available to all States.

4.2.3 The meeting raised several issues with respect to the implementation of the proposals.

These included: legacy systems, availability of ADREP compatible systems in all official languages of the Organization, and resource and training requirements.

4.2.4 The Secretariat informed the meeting that it will consider these and other issues when implementing the recommendations of the Meeting under this item.

4.3 REPRESENTATION OF SAFETY DATA

4.3.1 The meeting agreed with a proposal to recommend that States have publications on safety data accompanied by a clear description of, or reference to, the data sampled and parameters used...

 
Therefore 'lost in translation' or 'lost in the mail' as an excuse for no notification, no preliminary or final reports, of either the VH-NGA or VH-PGW occurrences, would IMO seem highly implausible...


MTF...P2

Ps From that AIG08 report:

4. SECRETARIAT

4.1 The Secretary of the meeting was Mr. M. Costa, Chief, Accident Investigation and Prevention (AIG) Section. The Deputy Secretaries were Mr. T. Thormodsson, Technical Officer (AIG), Mr. A. de Kock, Technical Officer (AIG).

&..from Mount NCN thread:

Thor ToR & ICAO & IATA reoccurring theme -  



Reference:

Safety boost from Thor’s ICAO audit

Thor Thormodsson has spent the past eight years travelling the world undertaking safety oversight audits for the International Civil Aviation Organization (ICAO).

Now there's a bloke that should be able to access the necessary paperwork -