[Peetwo]

Dots-n-dashes missing on Popinjay's search 4 IP (QON for Senator Canavan) - 

Follow along the following timeline of discontinuity in the never ending ATSB search for (ICAO endorsed)  investigative probity - 

Via the ATSB 2016-17 Annual Report (page 134): 

In April 2017 the International Civil Aviation Organization (ICAO) conducted an on-site
audit of the ATSB’s compliance with ICAO’s standards, recomme nded practices
and guidance material for aircraft accident investigation. Australia sought the audit
from ICAO with ATSB Chief Commissioner Greg Hood stating, ‘This is an important
opportunity for the ATSB to demonstrate its accident investigation capabilities against
the benchmark set by ICAO. We know that we are doing well in a number of areas but
the results of an audit can give us new insights into how we conduct investigations,
with a view to enhancing our capacity to deliver outcomes for aviation safety’.

The audit covered core areas including:

> promulgation of aircraft accident investigation legislation
> establishment of an independent accident investigation authority
> allocation of sufficient financial resources
> qualifications and training of personnel
> availability of facilities and equipment
> establishment and implementation of investigation procedures
> the conduct of timely investigations and publication of findings.



Ref: https://www.atsb.gov.au/media/news-items...-from-thor

The ICAO auditor sent to Australia was Mr Thor Thormodsson. He has a background
as a commercial and instrument-rated pilot and as an accident investigator. He has
conducted ICAO audits for the past eight years.

Mr Thormodsson said the following in relation to his work as an ICAO auditor, ‘On
the whole, my job is highly rewarding. It keeps me in touch with the outside world.
ICAO perform an audit, then go back to the country and see significant differences due
to the audit fndings and safety recommendations’.

Australia is fortunate that it has a relatively mature safety oversight system and expects
that the audit will reect well on Australia’s conformance with ICAO’s requirements for
accident investigation. Where there are identified opportunities to improve, the ATSB
will be working to ensure positive change.

The results of the audit will be made available through ICAO’s online portal.

Then ffwd to this - ICAO ICVM Final Report summary:

1st this bit:

The ICVM team was composed of:

a) Mr. Nicolas Rallo, team leader, primary aviation legislation and specific operating regulations (LEG)/civil aviation organization (ORG)/ aircraft accident and incident investigation (AIG);

Then this:

4.2 In the case of Australia, the ICVM team visited the following organizations:
Airservices Australia (Air Navigation Services Provider National Operations Centre – Air
Traffic Flow Management, Aeronautical Information Services), Bureau of Meteorology
(Aeronautical Meteorological Services) and Australian Maritime Safety Authority
(Aeronautical and Maritime Search and Rescue Services) (ANS).

Hmm...funny there is no mention of Thor's (HVH endorsed) visit to the ATSB??

But then there is this (possible -  ) mention here of Thor's audit of Hoody:

3.1.3 A second USOAP audit (AIG area only) conducted in 2017 resulted in an overall EI of 85.05 per cent for the eight CEs of the State’s safety oversight system.

However the only outstanding finding (apparently) of Thor's audit was stated here in the ICAO ICVM audit report summary:

AIG:

Fully implement the ATSB’s action plan to ensure that all accident and incident investigation reports are completed within the established timelines.

Hmm...so was the 'action plan' developed from the findings of Thor's report? Who would know because we've never actually seen Thor's report, nor has there ever been made any further mention of Thor's audit ever since the publication of Hoody's 2016-17 AR??

Let's now ffwd to 14 March 2019 where the ANAO released their report into the ATSB to which these recommendations were issued:

Recommendation no.1

Paragraph 2.8

The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.2

Paragraph 2.18

The ATSB report on the efficiency with which it uses resources in undertaking investigations.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.3

Paragraph 3.5

The ATSB establish more realistic targets for investigation timeframes addressing both calendar and investigator (effort) days.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.4

Paragraph 3.21

The ATSB continue to progress actions that it has recently commenced to benchmark its investigation performance against relevant international comparators and use the results to identify strategies to improve its performance.

Australian Transport Safety Bureau response: Agreed.

Now ffwd to the following interim report, which was issued over 7 months after the incident occurred...

Interrupted engine start and evacuation involving SAAB 340B, VH-ZRK Melbourne Airport, Victoria, on 5 April 2022

This interim report details factual information established in the investigation’s early evidence collection phase, and has been prepared to provide timely information to the industry and public. The report contains no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this interim report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

 
Hmm...the following is an extract from ICAO Annex 13:

Dispatch

7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available.

Next, despite stating this...

Safety action

Following the occurrence, Regional Express took the following safety action:

• A new hand signal was developed to indicate an interrupted engine start and was included in face-to-face and computer-based training content.
  
• A training package and guidance was provided to ground staff about dispatch procedures and hand signals.
  
• Guidance highlighting the correct marshalling signals was issued to all flight crew.
  
• Posters detailing ground signals were placed in ground crew high traffic areas.
  
• Operational manuals for both the flight crew and ground crew in relation to hand signals were reviewed and updated.
  

It would seem to me that the safety issues highlighted in the interim report have effectively been addressed internally by REX, however the ATSB goes onto say...

Further investigation

The investigation is continuing and will include review and examination of:

• flight crew failure management procedures
  
• crew communication and coordination
  
• flight crew, flight attendant and ground staff recurrent training
  
• on-board recordings. 
  

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

WTF - 

MTF...P2