[Peetwo]

Dots-n-dashes missing on Popinjay's search 4 IP - Part II

Via Accidents Domestic:

Popinjay's bollocks excuse for not investigating Gympie midair?? - 

Via the Yaffa: 

We won't investigate Gympie Crash: ATSB

18 November 2022



ATSB Chief Commissioner Angus Mitchell told Australian Flying the decisions were in line with the ATSB's normal procedures.

“We understand the perceived inconsistency regarding the ATSB’s response to these occurrences, and I welcome this opportunity to clarify these decisions, which are in line with our Ministerial Statement of Expectations," he said.

“The propeller loss occurrence related to the manufacture, design and/or maintenance of the aircraft itself. As Australia is the state of design and state of manufacture for the Jabiru aircraft, and there are aircraft of the same type on the VH register, and operating overseas, the ATSB investigated the occurrence to determine if there were broader lessons for the aircraft type.

“In contrast, the Kybong mid-air collision was an operational event, involving an RA-Aus registered kit plane manufactured in the Czech Republic, and a VH-registered–but unpowered–glider, which was also not designed or manufactured in Australia.

"Neither of these aircraft therefore fall under the ATSB’s standard remit for investigation.

"The ATSB would only investigate accidents such the Kybong mid-air collision on an exception basis, as its resources permit, where conducting such an investigation has the potential to highlight wider safety issues."

UFB! - 

Hmm...so where in the SoE does it state anything like "Thou shalt not...investigate recreational aircraft fatal midair accidents...especially if the aircraft involved are a kit plane made in the Czech republic and a unpowered, foreign manafactured glider -   
  
All the SoE says is this:

"..(b) give priority to transport safety investigations that have the highest risk or potential to deliver the greatest public benefit through systemic improvements to transport safety;.."

The current SoE also says:

..I expect the ATSB to perform its functions consistent with Australia's international obligations where appropriate, including the requirements of the International Civil Aviation Organization.

I also expect the ATSB to implement any recommendations of the Australian National Audit Office and continue to work towards the timely finalisation of investigations to support continuous improvement in transport safety...

     

Okay...'cleared to backtrack'  - 1st in line with above, a quote from the 2013 Senate ATSB AAI Inquiry: 

3.17 The committee is aware that Annex 13 of the International Civil Aviation Organization's (ICAO) Chicago Convention, to which Australia is a signatory, places certain requirements on the ATSB and CASA.9 This means that ATSB reports should, in theory, comply with these requirements. 3.18 The annex sets out rules for the notification, investigation and reporting of an accident, who should conduct the accident investigation and how, which parties can be involved and their rights, as well as how results of the investigation should be reported. Accident investigations conducted by member states are required to:

• gather, record and analyse all available information on a particular accident or incident;
• issue safety recommendations where appropriate;
• determine the causes of the accident if possible; and
• produce a final report.

3.19 The investigation authority, in this instance the ATSB: …shall have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of this Annex.

3.20 The annex stipulates that final reports should be released as soon as possible in the interest of accident prevention, preferably within 12 months. If reports cannot be produced within 12 months, an interim report is to be released on each anniversary of the accident.

 

And ICAO obligations in regard to the issuing of preliminary and/or ADREP reports:

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.

Hmm...I wonder if the details of the Gympie midair fatal has been forwarded to ICAO? 

Next we ffwd again to 2017-18 after HVH took over and just prior to the release of the ANAO audit report and Thor's lost in the mail audit report - 1st via the Oz:

Air investigator ATSB vows to speed up complex probes


ATSB Chief Commissioner Greg Hood. Picture: Dylan Coker

By ANNABEL HEPWORTH
12:00AM JUNE 15, 2018

The nation’s air investigator says it expects to finish its complex investigations in a “timelier manner” after a program aimed at clearing a backlog of reports.

The latest figures show the Australian Transport Safety ­Bureau expects to publish 30 per cent of complex investigations within 12 months in 2017-18, against a target of 90 per cent.

ATSB chief commissioner Greg Hood said the ATSB was finishing complex investigations in an average of 16 months but was “actively working” to improve the timeliness.

The “Back on Track” program, aimed at clearing a backlog of reports, had been “productive”. Some 30 investigations that were behind time were now finished, while a further five to eight were expected to be done by the end of the financial year.

“Back on Track has required a diversion of significant resources away from our business as usual operations and therefore the percentage of complex investigation reports that have been completed remains around 30 per cent for this 2017-18,” Mr Hood said.

“I remain confident that when the Back on Track program is completed and these diverted resources return to business as usual operations, the ATSB will be positioned to complete its investigation reports in a timelier manner.” Mr Hood also pointed to other measures aimed at getting investigations completed more promptly, including moves to hire more transport safety investigators and be more selective in what it investigates.

While the headcount had gone down by about 25 per cent since the ATSB became an independent statutory body in July 2009, a recent budget boost had enabled an extra 17 transport safety investigators to be recruited.

“These investigators are currently being trained and a number have already had the opportunity to deploy to accident sites,” Mr Hood said.

“The process of establishing investigator competencies generally takes 18 months to complete, so we anticipate that we will begin to see the benefits of these additional resources in the next financial year results.”

As well, the ATSB would use its database to pinpoint cases with “the greatest potential for improving transport safety”.

The ATSB had started 120 investigations this financial year, compared with 162 investigations in 2016-17. “There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity. We are also placing emphasis on addressing accidents and incidents that recur through safety education.”

Then this weasel worded presentation by HVH to the 2017 ITSA (junket) conference in Tokyo:

Extracts :- 

...Like our colleagues from the Accident Investigation Board Norway (in reference to the organisational challenges presented through their abstract), the ATSB was enduring significant resourcing challenges which was seriously impeding its ability to meet prescribed deliverables and Key Performance Indicators, particularly in regards to the time taken to complete its safety investigation reports - on average the ATSB was completing about 30% of its complex investigation reports within the prescribed 12 months with some reports taking up to three years to finalise.

Since becoming an independent statutory authority in July 2009, the ATSB’s base appropriations had continued to reduce over successive financial years as the agency competed for funds with other important initiatives within the federal budgets. To manage these fiscal constraints, the ATSB had progressively reduced its staffing profile by an overall 25 per cent. In managing these reductions we facilitated a proportioned downsize across every business area within our organisational structure including corporate services...

...The Act states that the ATSB’s primary function is to improve transport safety, and our government’s “Statement of Expectations” requires us to continue to give priority to transport safety investigations that have the potential to deliver the best safety outcomes for the travelling public. When taking into account the known and projected financial and environmental challenges facing the agency, it was incumbent upon me to seek ways to maximise the efficiency and effectiveness of our operations. We could no longer afford (literally) to be complacent and continue with the mantra of “that’s the way we do things around here”...

...Our resources and deliverables were primarily geared towards completing occurrence investigations and I was concerned these resources were not being selectively allocated towards investigating those accidents and incidents that would have the greatest potential for safety learnings and enhancement...

...Effectively we needed to embark on a “step change”, where we would take our current resources (people and business operating systems) and realign them to achieve greater operational efficiencies and effectiveness. Along the way I needed to create an environment which empowers our people and maximises their opportunities for personal and professional growth.

Therefore I knew that a critical success factor for this evolution would be a paradigm shift in the way we think, moving from an accepted point of view to embracing a new one - noting the ATSB had not undergone any significant change in a number of years. Bringing to bear my knowledge of other multi-modal/multi-sectorial agencies and acting on my own experiential learnings, I decided to implement a significant transformation initiative known as the “Evolution” program. This program, in essence, was designed to enable better resource allocation and utilisation across the agency...

...Concurrently, we have progressed a sub-program known as “Back on Track” which by design has allowed us to accelerate the completion of approx. 50 investigations that had overrun duration and effort targets. This has also provided us the opportunity to review and carefully refine our investigation practices, procedures and workflows leading to a number of improvements including:

The introduction of an initial strategic planning session for each investigation which considers known information from site and initial inquires and decides on:

 Should the investigation be discontinued?
 Potential safety factors and issues?
 Key lines of further inquiry to substantiate or discount factors
 Predicted investment of effort required & agreed investigation Category
 Communications strategies (including Preliminary report, Web updates, discontinuation statement) 
 The introduction of periodic safety factor reviews (every 2-3 months) to consider information from investigative inquiry and analysis to decide on:

 Validated and discounted safety factors
 Validated, discounted and potential safety issues
 Safety action proposed and undertaken  Investigation profile ranking and risks
 Further lines of inquiry & assignment
 Re-categorisation (up or down)
 Communications strategy review.
 The inclusion of a final safety factor review which the Chief Commissioner attends - to consider the proposed findings and safety issues, and confirm:

 Validated safety factors
 Validated safety issues
 Safety action undertaken and any further proposed
 No further investigation required  Stakeholder risks & mitigation
 Communications strategy review (report, media engagement, industry, NoK)
 Executive approval workflow stages required.

Combined, these initiatives will enable us to improve the timeliness of our reports while maintain high standards of quality assuredness.

 
Then to the ANAO audit: Ref- https://www.aph.gov.au/Parliamentary_Bus...59%2F27991

Extract: 

Governance
3.10The ANAO acknowledged that the ATSB has been active in improving investigation efficiencies through improved governance structures and processes.15

3.11 In 2017, the ATSB initiated two programs aimed at increasing the efficiency of investigations: The Evolution Program and the Back on Track Program. The Evolution Program enables better resource allocation and utilisation to maximise the efficiency and effectiveness of operations by addressing the organisational structure, culture, efficiency, learning and development, talent management, succession planning and leadership of the ATSB.16

3.12 The Evolution Program also included the transformation of the agency to a multimodal, teams-based agency which aims to improve the effectiveness of the ATSB’s investigators. This was achieved by enabling investigators to investigate any type of accident,17 where previously they investigated one mode of transport only.

3.13 The Back on Track program, implemented in mid-2017, targeted the ongoing backlog of open investigations for completion. Significant resources have been allocated to this initiative to clear this backlog and meet newly framed KPIs. After the 40 investigations identified as a priority are finalised, diverted resources will be brought back in line to perform business as usual tasks.

Performance Measurement and Management

3.14 The ATSB has amended KPIs for investigation timelines. A KPI focusing on demand capacity has been introduced which considers the ATSB’s workload at a point in time and how much work can be taken on, realistically, against the resources on hand. The demand capacity KPI projects a decline from the current caseload of around 100 over the next three to four years. The ATSB explained:

That KPI recognised where we were at, which was a caseload of around 100 investigations, and what it's doing is projecting out to understand the resources we have available to get us down to a realistic case load. That is projecting out over the next three to four years, to dropping down to 50 or 60 complex cases on our books at any one time, and that’s being reviewed on a rolling monthly basis.18

3.15 The ATSB advised that work is underway to improve data collection and analysis that will help inform assessments of investigation efficiency.19 This will assist the ATSB with the development of more realistic and effective investigation timeframes.

3.16 Since the audit the ATSB has taken on 17 new transport safety investigators who will be trained, skilled and mentored to maturity within approximately three years. Further, investigator training will now be handled by RMIT University. This change releases resources within the ATSB previously utilised for training new staff. This sits well against the Chief Executive Officer’s description of the ATSB as a ‘doing organisation not a training organisation’20. Operations will slow down during this training and ‘getting up to speed phase’ but the efficiency metrics will improve once training has been completed.21

So that's the background, now to assess whether all that Hooded Canary self-serving gobbledy gook actually achieved any real positive reform; or was it just another bureaucratic 'make work' series of initiatives to justify the ATSB's existence?

MTF...P2