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The search for investigative probity.
Finally.

At long last; someone on the UP actually see's why the ATSB, under Hood, is drowning in it's own excrement. The following post, from 'Compressor Stall' should be made poster size and nailed up on the wall of the ATSB dream factory walls - as a reality fix; it may remind 'em of what they are supposed to do.  


Quote:Coincidentally I am currently on a course with a (foreign) pilot turned investigator who has worked on several high profile accidents that are well known to just about any pilot on the planet.

In discussion it would seem that the good and the bad human factors are to be integral to any report. Rereading this report tonight, it isn't the inclusion of the acknowledgement of the following of SOPs that now is of concern to me. It's the fact that the report has been released without any factual investigative information of the root cause of the event.

Quote:
however the examination was not completed in time for the release of this report.

Quote:
At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.

The crew's following of SOPs would normally have been drowned out in the investigation of the engine and other factors that actually caused the event. i.e. These detailed technical factors caused a situation which (incidentally) was well handled. The primary safety message would be in the reasons for the engine failure.

CS say's it all; summing up what every 'professional' worth the name thinks - neatly, succinctly and accurately.  Tim Tam cupboard key delivered.

Selah.
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PC Hoody obfuscates reoccurrence trend vector  - Confused

[Image: risk-impact-trending-charts-og-img.jpg]

Timely post "K"... Wink - I also thought the following Centaurus comment worth regurgitating:

"..This writer has no problem with ATSB commending a pilot for superb flying skill in a serious situation. But not where everyone gets lots of kudos and hand claps like kindergarten kids simply for using SOP's..."

Although I notice the general message in that quote was predictively lost on the resident Pprune sycophant and CASA-sexual Lookie Loo... Rolleyes   

However coming back to Hoody and the ATSB "drowning in it's own excrement"; I note that there is a couple of recent initiated ATSB AAIs of interest and intrigue that both have a déjà vu familiarity about them... Huh

Quote:Aircraft loading event involving Saab 340 VH-ZRB, Sydney Airport, NSW, on 14 September 2017

Investigation number: AO-2017-093

Investigation status: Active
 
[Image: progress_1.png] Summary

The ATSB is investigating an aircraft loading event involving Saab 340, VH-ZRB, Sydney Airport, NSW on 14 September 2017.

During unloading at Wagga Wagga, ground crew detected 239 kg of freight was loaded and carried in error from Sydney. Retrospective calculations revealed that the aircraft was about 77 kg over the maximum take-off weight.

As part of the investigation, the ATSB will obtain relevant loading documentation, interview personnel involved in loading the aircraft and gather additional information.

Operational event involving B737, VH-VUE, 78 km ESE Adelaide Airport, SA on 13 September 2017
 
Investigation number: AO-2017-092
Investigation status: Active
 
[Image: progress_0.png] Summary

The ATSB is investigating an operational event involving a Boeing 737, VH-VUE, on approach to Adelaide Airport South Australia, on 13 September 2017.

During descent, the airspeed trend vector started to increase. Control inputs made by the flight crew disconnected the autopilot and a minor airframe overspeed occurred. One cabin crew member sustained serious injuries and a second cabin crew member sustained minor injuries.

As part of the investigation, the ATSB will:
  • interview members of the aircraft crew and gather operational information
  • download and analyse data from the flight data and cockpit voice recorders
  • review air traffic control radar and audio recordings
  • review meteorological information.
    
Now it could be that both occurrences turn out to be non-events but their are some definite reoccurrence trends that in the normal course of an Annex 13 AAI investigation should at some point be examined. However given the list of reoccurrence events continues to grow seemingly unabated and without acknowledgement/recognition from the Hoody team, I won't be holding my breath... Dodgy

 Way too early to say - & I guess it depends on how much the investigation is affected by political correctness - but this bit from the above summary...

 "..During descent, the airspeed trend vector started to increase. Control inputs made by the flight crew disconnected the autopilot and a minor airframe overspeed occurred..."

...could possibly have the investigation identify some sort of 'automation complacency'. This provides me with an opportunity to regurgitate an excellent Harvard Business Review article that rehashes the AF447 disaster in the context of automation dependency/complacency... Wink :

Quote:The Tragic Crash of Flight AF447 Shows the Unlikely but Catastrophic Consequences of Automation
  • Nick Oliver
  • Thomas Calvard
  • Kristina Potočnik
September 15, 2017


Executive Summary

The tragic crash of Air France 447 (AF447) in 2009 precipitated the aviation industry’s growing concern about “loss of control” incidents, and whether they’re linked to greater automation in the cockpit. As technology has become more sophisticated, it has taken over more and more functions previously performed by pilots, bringing huge improvements in aviation safety. But while overall air safety is improving, loss of control incidents are not. In fact, they are the most prevalent cause of fatalities in commercial aviation today, accounting for 43% of fatalities in 37 separate incidents.

Research examines how automation can limit pilots’ abilities to respond to such incidents, as becoming more dependent on technology can erode basic cognitive skills. The case reveals how automation may have unanticipated, catastrophic consequences that, while unlikely, can emerge in extreme conditions.

[Image: sept17-15-97593616.jpg]
The tragic crash of Air France 447 (AF447) in 2009 sent shock waves around the world.

The loss was difficult to understand given the remarkable safety record of commercial aviation. How could a well-trained crew flying a modern airliner so abruptly lose control of their aircraft during a routine flight?

AF447 precipitated the aviation industry’s growing concern about such “loss of control” incidents, and whether they’re linked to greater automation in the cockpit. As technology has become more sophisticated, it has taken over more and more functions previously performed by pilots, bringing huge improvements in aviation safety. In 2016 the accident rate for major jets was just one major accident for every 2.56 million flights. But while overall air safety is improving, loss of control incidents are not. In fact, they are the most prevalent cause of fatalities in commercial aviation today, accounting for 43% of fatalities in 37 separate incidents between 2010 and 2014.

Loss of control typically occurs when pilots fail to recognize and correct a potentially dangerous situation, causing an aircraft to enter an unstable condition. Such incidents are typically triggered by unexpected, unusual events – often comprising multiple conditions that rarely occur together – that fall outside of the normal repertoire of pilot experience.

For example, this might be a combination of unusual meteorological conditions, ambiguous readings or behavior from the technology, and pilot inexperience – any one or two of which might be okay, but altogether they can overwhelm a crew. Safety scientists describe this as the “Swiss cheese” model of failure, when the holes in organizational defenses line up in ways that had not been foreseen. These incidents require rapid interpretation and responses, and it is here that things can go wrong.

Our research, recently published in Organization Science, examines how automation can limit pilots’ abilities to respond to such incidents, as becoming more dependent on technology can erode basic cognitive skills. By reviewing expert analyses of the disaster and analyzing data from AF447’s cockpit and flight data recorders, we found that AF447, and commercial aviation more generally, reveal how automation may have unanticipated, catastrophic consequences that, while unlikely, can emerge in extreme conditions.

Automation on the Flight Deck
Commercial aircraft fly on autopilot for much of the time. For most pilots, automation usually ensures that operations stay well within safe, predictable limits. Pilots spend much of their time managing and monitoring, rather than actively flying, their aircraft.
Cockpit automation, sometimes called the “glass cockpit”, comprises an ensemble of technologies that perform multiple functions. They gather information, process it, integrate it, and present it to pilots, often in simplified, stylized, and intuitive ways.

Through “fly-by-wire,” in which pilot actions serve as inputs to a flight control system that in turn determines the movements of the aircraft’s control surfaces, technology mediates the relationship between pilot action and aircraft response. This reduces the risk of human errors due to overload, fatigue, and fallibility, and prevents manoeuvers that might stress the airframe and endanger the aircraft.

Automation provides massive data-processing capacity and consistency of response. However, it can also interfere with pilots’ basic cycle of planning, doing, checking, and acting, which is fundamental to control and learning. If it results in less active monitoring and hands-on engagement, pilots’ situational awareness and capacity to improvise when faced with unexpected, unfamiliar events may decrease. This erosion may lie hidden until human intervention is required, for example when technology malfunctions or encounters conditions it doesn’t recognize and can’t process.

Imagine having to do some moderately complex arithmetic. Most of us could do this in our heads if we had to, but because we typically rely on technology like calculators and spreadsheets to do this, it might take us a while to call up the relevant mental processes and do it on our own. What if you were asked, without warning, to do this under stressful and time-critical conditions? The risk of error would be considerable.

This was the challenge that the crew of AF447 faced. But they also had to deal with certain “automation surprises,” such as technology behaving in ways that they did not understand or expect.

Loss of AF447
AF447 was three and a half hours into a night flight over the Atlantic. Transient icing of the speed sensors on the Airbus A330 caused inconsistent airspeed readings, which in turn led the flight computer to disconnect the autopilot and withdraw flight envelope protection, as it was programmed to do when faced with unreliable data. The startled pilots now had to fly the plane manually.

A string of messages appeared on a screen in front of the pilots, giving crucial information on the status of the aircraft. All that was required was for one pilot (Pierre-Cédric Bonin) to maintain the flight path manually while the other (David Robert) diagnosed the problem.

But Bonin’s attempts to stabilize the aircraft had precisely the opposite effect. This was probably due to a combination of being startled and inexperienced at manually flying at altitude, and having reduced automatic protection. At higher altitudes, the safe flight envelope is much more restricted than at lower altitudes, which is why pilots rarely hand-fly there. He attempted to correct a slight roll that occurred as the autopilot disconnected but over-corrected, causing the plane to roll sharply left and right several times as he moved his side stick from side to side. He also pulled back on the stick, causing the plane to climb steeply until it stalled and began to descend rapidly, almost in free-fall.

Neither Bonin nor Robert, nor the third crew member (Marc Dubois, the captain) who entered the cockpit 90 seconds into the episode, recognized that the aircraft had stalled despite multiple cues. In the confusion, Bonin misinterpreted the situation as meaning that the plane was flying too fast and actually reduced the thrust and moved to apply the speedbrakes – the opposite of what was required to recover from the stall. Robert overruled him and attempted to take control, but Bonin continued to try and fly the plane. He and Robert made simultaneous and contradictory inputs, without realizing that they were doing so. By the time the crew worked out what was going on, there was insufficient altitude left to recover, and AF447 crashed into the ocean, with the loss of all 228 passengers and crew.

The AF447 tragedy starkly reveals the interplay between sophisticated technology and its human counterparts. This began with the abrupt and unexpected handover of control to the pilots, one of whom, unused to hand flying at altitude, made a challenging situation much worse. A simulation exercise after the accident demonstrated that with no pilot inputs, AF447 would have remained at its cruise altitude following the autopilot disconnection.

With the onset of the stall, there were many cues about what was happening available to the pilots. But they were unable to assemble these cues into a valid interpretation, perhaps because they believed that a stall was impossible (since fly-by-wire technology would normally prevent pilots from causing a stall), or perhaps because the technology usually did most of the “assembling” of cues on their behalf.

The possibility that an aircraft could be in a stall without the crew realizing it was also apparently beyond what the aircraft system designers imagined. Features designed to help the pilots under normal circumstances now added to their problems. For example, to avoid the distractions of false alarms, the stall warning was designed to shut off when the forward airspeed fell below a certain speed, which it did as AF447 made its rapid descent. However, when the pilots twice made the correct recovery actions (putting the nose-down), the forward airspeed increased, causing the stall alarm to reactivate. All of this contributed to the pilots’ difficulty in grasping the nature of their plight. Seconds before impact, Bonin can be heard saying, “This can’t be true.”

Implications for Organizations
This idea – that the same technology that allows systems to be efficient and largely error-free also creates systemic vulnerabilities that result in occasional catastrophes – is termed “the paradox of almost totally safe systems.” This paradox has implications for technology deployment in many organizations, not only safety-critical ones.

One is the importance of managing handovers from machines to humans, something which went so wrong in AF447. As automation has increased in complexity and sophistication, so have the conditions under which such handovers are likely to occur. Is it reasonable to expect startled and possibly out-of-practice humans to be able to instantaneously diagnose and respond to problems that are complex enough to fool the technology? This issue will only become more pertinent as automation further pervades our lives, for example as autonomous vehicles are introduced to our roads.

Second, how can we capitalize on the benefits offered by technology while maintaining the cognitive capabilities necessary to handle exceptional situations? Pilots undergo intense training, with regular assessments, drills, and simulations, yet loss of control remains a source of concern. Following the AF447 disaster, the FAA urged airlines to encourage more hand-flying to prevent the erosion of basic piloting skills and this points to one avenue that others might follow. Regular, hands-on engagement and control builds and maintains system knowledge, enabling operators, managers, and others who oversee complex systems, to identify anomalies, diagnose unfamiliar situations, and respond quickly and appropriately. Structured problem-solving and improvement routines that prompt one to constantly interrogate our environment can also help with this.

Commercial aviation offers a fascinating window into automation, because the benefits, as well as the occasional risks, are so visible and dramatic. But everyone has their equivalent of autopilot, and the main idea extends to other environments: when automation keeps people completely safe almost all of the time, they are more likely to struggle to reengage when it abruptly withdraws its services.

Organizations must now consider the interplay of different types of risk. More automation reduces the risk of human errors, most of the time, as shown by aviation’s excellent and improving safety record. But automation also leads to the subtle erosion of cognitive abilities that may only manifest themselves in extreme and unusual situations. However, it would be short-sighted to simply roll back automation, say by insisting on more hand-flying, as that would increase the risk of human error again. Rather, organizations need to be aware of the vulnerabilities that automation can create and think more creatively about ways to patch them.


MTF...P2  Cool
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ATSB update on Mallard investigation - Confused

Via Oz Flying:

Quote:[Image: g-73_mallard_vh-cqa.jpg]VH-CQA as it appeared at Ausfly in 2013. (Steve Hitchen)

Air Show Approvals under Scrutiny after Mallard Crash
29 September 2017

The Australian Transport Safety Bureau is looking closely at air show approvals following the fatal crash of a Grumman Mallard into the Swan River in Perth earlier this year.

Mallard VH-CQA was part of an air display on 26 January when it stalled mid turn and crashed into the water, killing both occupants.

In an update to the investigation issued last week, the ATSB said they could find no sign of pilot incapacity or defect in the aircraft that would account for the crash.

"The investigation has not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water," the ATSB stated in the update.

"Further analysis around the aircraft performance and operational factors, as well as the review of the planning, approval and oversight of the air display is ongoing."

During the investigation ATSB has examined the sequence of events leading up to the occurrence, aspects of the air display coordination, as well as the regulations, procedures and guidance relating to CASA-approved air displays, including:
  • approval process for the Perth Australia Day Sky Show going back several years and for other air display events across Australia
  • air displays applications from this and other events
  • CASA's Air Display Safety and Administrative Arrangements manual in use at the time and the revised version published earlier this month
  • surveillance and oversight of air displays as a whole
The ATSB has also examined the UK Air Accidents Investigation Branch report into the crash of Hawker Hunter G-BXFI at Shoreham in August 2015, which killed 11 bystanders.

The ATSB investigation is currently ongoing.


Read more at http://www.australianflying.com.au/lates...1mCWfmj.99
Makes you wonder why they would discontinue this airshow/display related accident:
Quote:Collision with terrain involving Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, VH-GPT, Lismore Airport, NSW on 29 July 2017
 
Investigation number: AO-2017-077
Investigation status: Discontinued
  Discontinued
Section 21 (2) of the Transport Safety Investigation Act 2003 (the Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 29 July 2017, the ATSB commenced an investigation into a collision with terrain involving a Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, registered VH-GPT, at Lismore Airport, New South Wales.

The ATSB found that while conducting an aerobatic display, the glider impacted the ground heavily during the final manoeuvre. The pilot was seriously injured. Examination of the aircraft identified no mechanical issues or faults that may have contributed to the accident.

The Gliding Federation of Australia has conducted an investigation of this accident and the public report (S-1010) is availiable on their website.

The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements. The ATSB investigation AO-2017-013, Mallard aircraft, Perth, January 2017 is examining a range of issues associated with air shows, including the suitability of the regulations, approval and oversight of air shows, and compliance with regulatory approvals during air shows.

In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB will discontinue this investigation.
Penny drops... Confused
Think I have just spotted the disconnection Big Grin :
"..The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements..."  P2 - Think that should read "self-regulatory requirements.."

&..

"..In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations..."
Hint Wink
[Image: Pollies_TW_2016_CB82A5C0-1576-11E6-99C802D27ADCA5FF.jpg]
MTF...P2 Cool
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ATSB fading into oblivion - Rolleyes

Over on the 'Accidents - Domestic' thread Cap'n Wannabe also picked up on the (above) Oz Flying article and an incident that occurred at Essendon Airport yesterday:

(10-01-2017, 06:22 PM)Cap\n Wannabe Wrote: Story with video here

Quote:Passengers scramble to safety after plane makes rough landing at airport
A plane has made a dramatic emergency landing after running into trouble above Essendon Fields in Melbourne this afternoon.

Emergency services responded to the runway about 6pm after reports the landing gear of the plane was not working.

The pilot was forced to burn off fuel for more than 15 minutes, according to the Metropolitan Fire Brigade (MFB)

The 9NEWS chopper camera captured the aircraft hitting the runway with force, with smoke seen coming from the wheels as it came to a stop.

All five people onboard were shown running from the door of the plane, with two girls hugging on the tarmac.

No one was injured in the incident.

More to come.
Quote:From Oz Aviation..

With both of these occurrences there is some interesting scuttlebutt and trivia that IMO highlights how the ATSB under Hoody continues to slide towards inevitable oblivion as an effective State (ICAO Annex 13) AAI.

Beginning with the Mallard investigation, I was under the misconception that the important update was disseminated by Hitch in the context of an ATSB media release. However after a brief search on the ATSB Newsroom and Social media it would appear that Hitch on his own initiative had diligently sourced the update from the investigation webpage:

Quote:Updated: 22 September 2017

On 26 January 2017, a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA, aerodynamically stalled and impacted water while participating in an air display, as part of the City of Perth Australia Day Skyworks event. The pilot and passenger were fatally injured.

This web update complements information already provided in the preliminary investigation report that was published on the ATSB website on 8 March 2017.

The investigation has not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water. Further analysis around the aircraft performance and operational factors, as well as the review of the planning, approval and oversight of the air display is ongoing.

During the investigation of the occurrence, the ATSB has examined the sequence of events leading up to the occurrence, aspects of the air display coordination, as well as the regulations, procedures and guidance relating to Civil Aviation Safety Authority (CASA)‑authorised air displays. This has included:
  • approval processes for several years of the Perth Australia Day Sky Show air display and for other air display events across Australia
  • the applications to conduct air displays, from this event and others across Australia
  • Air Display Safety and Administrative Arrangements manual (in use at the time of the occurrence) and the revised Air Display Administration and Procedure Manual (published September 2017). This manual provides guidance to CASA and the air display organiser
  • surveillance and oversight of air displays.
The ATSB has also examined the Aircraft Accident Report AAR 1/2017 – G-BXFI, 22 August 2015 that was published by the Air Accidents Investigation Branch United
Kingdom.[1] In summary:

At 1222 UTC (1322 BST) on 22 August 2015, Hawker Hunter G-BXFI crashed on to the A27, Shoreham Bypass, while performing at the Shoreham Airshow, fatally injuring eleven road users and bystanders. A further 13 people, including the pilot, sustained other injuries.

Preliminary analysis of this information has identified differences in the approval process within CASA, between civil and military (including combined) displays and between Australia and other countries. The ATSB is continuing to analyse this information, to determine whether there are any systemic safety issues in relation to authorised air displays.

The investigation is continuing.

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update.
-----
[1]     AAIB reports can be viewed via www.gov.uk/aaib-reports

Note that the update occurred on the 22 September, the same date that the ATSB discontinued the 7 week AO-2017-077 investigation... Huh   

With the Essendon incident yesterday the ATSB are yet to indicate whether they will be conducting an investigation into Australian registered B200 aircraft, VH-OWN.

Quote:ASN Wikibase Occurrence # 200056

Last updated: 1 October 2017
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information. If you feel this information is incomplete or incorrect, you can submit corrected information.

Date:
01-OCT-2017
Time:
07:18Z
Type:
[Image: BE20.gif]
Beechcraft B200 King Air
Owner/operator:
Private
Registration:
VH-OWN
C/n / msn:
BB-936
Fatalities:
Fatalities: 0 / Occupants: 5
Other fatalities:
0
Airplane damage:
Substantial
Location:
Essendon Airport, Melbourne, VIC - [Image: VH.gif]   Australia
Phase:
Landing
Nature:
Private
Departure airport:
Sunshine Coast Airport (MCY)
Destination airport:
Essendon Airport (MEB)
Narrative:
The aircraft sustained a partial landing gear collapse upon landing after the gear failed to lock-down. There were no injuries.

Sources:

http://www.9news.com.au/videos/cj88fnf26...cy-landing
http://www.9news.com.au/national/2017/10...alfunction
________________________
https://www.flightradar24.com/data/aircr...wn#f0f24db


Images: [Image: 200056_59d0c820952c4fr242.jpg]

If they do investigate I wonder if this is the first time that an incident aircraft will be involved in two active ATSB investigations at the same time? 

Ironically this brings me to the next non-notified ATSB AAI update because apparently the other 'serious incident' investigation involving this aircraft was updated just last week - AO-2015-108 :
Quote:Updated: 27 September 2017

The draft report has been finalised and is currently undergoing an internal review process prior to approval by the ATSB Commission. Once complete, the draft report will be forwarded to relevant parties for comment prior to the completion and release of the final report.
 
It should also be remembered that AO-2015-108 occurrence involved the pilot that was tragically killed in the Essendon B200 DFO accident (Preliminary report AO-2017-024.). It is also rumoured that the DFO accident aircraft (VH-SCR) was the replacement aircraft for VH-OWN, which went U/S that tragic day... Angel

With the bizarre disconnect with the lack of dissemination of ATSB identified safety issues and information in active investigations, one wonders how hard it would be for the ATSB investigation updates to auto-notify on the accident investigation webpage index... Huh


MTF...P2 Cool
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Another one bites the dust.

P2 – “With the bizarre disconnect with the lack of dissemination of ATSB identified safety issues and information in active investigations, one wonders how hard it would be for the ATSB investigation updates to auto-notify on the accident investigation webpage index"...

The ‘bizarre’ thing is that ATSB have not done a ‘performance’ analysis, drawn a profile and determined if there was enough airspace allocated to the Mallard flight. It is a simple analysis; speed v distance; turning radius required, minimum height and distance for final approach etc. If they have not the expertise to do this, then the pilot’s ‘mud-map’ calculations would assist. Shirley, CASA would have a copy. A simple sketch, showing that the aircraft needed a base turn @ 1000’ to arrive on a two mile final @ 700’ to allow for a minimum landing distance. That sort of thing would assist greatly. An analysis of the actual wind profile, weight, speed and distance parameters on the day (temperature corrected) would help.

If ATSB spent more time ‘investigating’ instead of dancing around the ministerial daisy patch and not upsetting CASA we may return to the good ol’ days, when we had a benefit from a world class accident investigator. That has to be better than using 500 pages to justify a CASA cock-up.

FWIW – I’ve run the numbers on the Mallard flight – ‘tight’ is an understatement; razors edge goes closer. But who’s going to own up to being part of a fatal accident; or, being reluctant to investigate it - properly?





Toot toot.
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Update: ATSB PC accident investigation AO-2014-032

Remember when High Viz Hoody was singing like a Canary at the Drone Wars inquiry in regards to the 3.5 year VARA ATR busted tail investigation? Here is a reminder - Wink  





Well there is still no sign of the 3rd interim report - see HERE. However there was some progress recorded on the ATR safety recommendation (AO-2014-032-SI-02) that occurred prior to the singing Canary Hoody's proclamation at the 29 Aug DW1 public hearing.. Rolleyes

Quote:Recommendation


Action organisation: ATR

Action number: AO-2014-032-SR-014

Date: 05 May 2017

Action status: Released


The ATSB recommends that ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.


Correspondence


Date received: 11 August 2017

Response from: ATR  

Action status: Monitor

Response text:

In an update provided on 11 August 2017, ATR briefed the ATSB on the results of:
•flight testing to determine the pilot input profile following an intentional pitch disconnect
•a comparison of the dynamic model computation against flight test data
•the analysis of the pitch system jamming cases.

The flight testing identified a consistent post-disconnect pilot input profile for use in the dynamic model and indicated that there was no discernible difference in the profile across the tested speed range. Also, the results from the dynamic (engineering) model compared well with the flight test results, indicating that the dynamic model satisfactorily represents the aircraft behaviour during an in-flight pitch disconnect.

ATR applied the dynamic model to assess the effect of an in-flight pitch disconnect at the maximum operating speed (VMO) in two representative pitch system jamming cases. The results indicate that there is a margin between the peak elevator deflection during the pitch disconnect and the deflections required to generate the ultimate loads, at VMO.



ATSB response date: 05 September 2017

ATSB response:

The ATSB accepts that ATR has completed part of the engineering assessment of the transient elevator deflections following an in-flight pitch disconnect.

The ATSB notes that to date, we have only been provided with basic analysis results and that those results have been presented to EASA in a similar timeframe. The ATSB has not yet been provided with documentation showing an independently reviewed engineering assessment, but acknowledges that this would not be practical until the engineering assessment has been completed.

The ATSB also notes that the following engineering analyses will be required to meet the intent of this Safety Recommendation:
•Cases of inadvertent pitch disconnect events from dual control inputs
•Evaluation of the effects of variation of the pitch channel stiffness in the fleet

The ATSB will continue to monitor the work carried out by ATR in response to the identified safety issue.

Then about a week ago the following new investigation was initiated (note new investigation No.) that was bizarrely co-joined to the ongoing ATR broken tail investigation - Confused

Quote:Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 
[Image: progress_0.png] Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:
  • interviews with current and former staff members of the operator, regulator and other associated bodies
  • examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  • reviewing other investigations and references where similar themes have been explored.
.
 
General details

Date: 19 October 2017
 
Investigation status: Active
 
Investigation type: Safety Issue Investigation
 
Location   (show map): 47km WSW, Sydney 
 
State: New South Wales
 
Occurrence class: Technical
 
Occurrence category: Other
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: October 2018 
 
 
[Image: share.png][Image: feedback.png]
Last update 19 October 2017

Hmmm....why does the summary and ToR for this case study investigation sound so familiar - Huh


MTF...P2 Cool

P2 OBS: This is an investigation within an investigation that has some very real parallels to the PelAir cover-up re-investigation (examining 'organisational influences').  Yet the PelAir ongoing investigation still carries the original investigation No. - Why?
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The ledger – debit and credit.

Book keeping is one of the ‘black arts’; an arcane art and a mystery to the uninitiated. I’ve no idea how the figures on a bank statement are produced – but even I can read ‘em and remember  Mr Micawber's famous, and oft-quoted, recipe for happiness:

"Annual income twenty pounds, annual expenditure nineteen [pounds] nineteen [shillings] and six [pence], result happiness. Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery."

Seems to that the ATSB annual income is less than their outgoings and credit is going to be hard to get. Make no mistake, it is credit they’re asking for. To me they are high risk bet and I’d want lots of security, a high interest rate and my own bookkeeper ‘on the job’. Even the ‘new’ business plan is riddled with holes, makes many promises and yet fails to convince. For example:-

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

One could forgive a new credit manager for believing the above statement; for many would. To the jaundiced, experienced eye of a veteran, the big red flags would be waving and the little bells would be ringing. Why – because it’s Bollocks, that’s why.

With the ATR case we have a very serious event, it could, so very easily, have ended in tragedy. Consider this – all over the world, some in tough conditions the ATR variants deliver passengers to destinations without the elevator channels disconnecting; hour after hour, day in day out, 24/7 rain, hail or shine. The ‘engineering’ aspect which ATSB have been ‘investigating’ for a number of years now, whilst important is not, statistically at least, the main suspect. A thorough inspection of the elevator system for the usual suspects, should have put an end to that element of the investigation; and, if it weren’t broke then another cause must be sought. The investigation into ‘how’ the initial disconnect was a disgrace. But only now, under a new investigation number is ATSB going to have a look behind the scenes.  


Statements like – “[investigation] was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, etc.” are purest pony-pooh. There is no such ducking thing when CASA is involved. When a company elects to use an aircraft, like the ATR, there is a long, complex process to be gone through. Even if the company go with the ‘off-the-shelf’ training and operating procedures it takes time to process. Lots of time and lots of money. Which only leaves the SMS system for ATSB to fool about with. Now what the hell the SMS has to do with two pilots buggering up a descent and disconnecting the elevator channels is beyond my comprehension. Perhaps it’s time to look elsewhere for the answers. Watch closely as ATSB take another three years to exonerate CASA and blame the SMS. CASA approve the training systems, the operating systems and the SMS. However:-

[and] also explored the role of the regulator in oversighting the operator's systems.

Did they now? Sorry ATSB, no credit at this bank. Maybe your Granny can assist….

Toot – toot.
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High viz Hood and his merry men take over the Comedy Hour - Rolleyes

[Image: movieposter.jpg]

Today in the Oz Dick and 'that man' yet again 'rock' Hoody's Chookhouse shed... Wink

Quote:Why was crash pilot at controls?

[Image: 0aece0571ae444275e729e1e653d2d5f]12:00amEAN HIGGINS

Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened.


Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened with the revelation that it will have been 2½ years ­before the agency reports on a ­potentially catastrophic near-collision of two aircraft at Mount Hotham in Victoria.

The near-miss in September 2015 is particularly significant ­because the pilot allegedly at fault, Max Quartermain, was killed, along with four American passengers, when his plane crashed near Melbourne’s Essendon airport in February this year.

Former Civil Aviation Safety Authority chairman Dick Smith told The Australian that if the ATSB had completed its Mount Hotham investigation within a reasonable timeframe, and concluded that Quartermain had ­engaged in poor airmanship, ­endangering lives, he might have been grounded or given retraining. In that case, Mr Smith said, the second incident, in which Quartermain crashed a Beechcraft King Air into a retail outlet nine seconds after take-off from Essendon, might not have happened.

The ATSB, in its initial determination of the Essendon disaster, could find no evidence of catastrophic engine failure.

Despite publicity about the same pilot being in charge in the Mount Hotham and Essendon incidents, the ATSB has again ­delayed the release of its report into the 2015 near-miss.

In April, with 18 months having passed since the Mount Hotham near-miss, the ATSB said it would make its report public in June.

But an ATSB spokesman has now said the investigation will not be completed until February, and even the draft report was “currently undergoing an internal ­review process prior to approval by the ATSB commission”.

“Once this is complete, the draft report will be forwarded to the relevant directly involved parties for comment prior to the completion and public release of the final report,” the spokesman said. “The involvement of directly ­involved parties is an important measure for the ATSB to ensure factual accuracy, and the validity and transparency of its investigation processes. There have been some delays experienced; most ­recently due to new information becoming available.”

The ATSB launched its Mount Hotham investigation after a pilot claimed Quartermain, flying a King Air from Melbourne, had confused other pilots in his radio communications and nearly crashed into his aircraft, also a King Air, as they both were preparing to land.

Quartermain was flying staff from Audi to an event at the alpine resort when, investigators determined, he came within 1.8km horizontally and 90m vertically of the other aircraft. At one point, it was alleged, Quartermain radioed to say he was 10 nautical miles west of Mount Hotham, before correcting himself to say he was 10 nautical miles east.

Mr Smith said he was suspicious about the delay, and whether it reflected concerns about whether action should have been taken against Quartermain after the Mount Hotham incident.

He said the ATSB’s system of sending draft reports to interested parties gave them the chance to frustrate the process, including requesting that adverse findings or implications be censored.

“It’s sent secretly to those who have a vested interest before the general public see it, and it’s wrong,” Mr Smith said.

The ATSB spokesman said the bureau was “independent of regulators, service providers and policymakers and this is reflected in the integrity of our investigation ­reports”.

Hmm...I can feel another Hoody 'correcting the bollocks' moment coming on -   Rolleyes  

[Image: talking-bollocks.jpeg?w=316]

...said the bureau was “independent of regulators, service providers and policymakers and this is reflected in the integrity of our investigation ­reports”. Big Grin

 In the meantime the Carmody hour comes to the HVH (ATSB) studios -






MTF...P2 Shy
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Part II of Comedy HR comes to HVH (ATSB) studios - Rolleyes

(11-08-2017, 08:25 AM)Peetwo Wrote: High viz Hood and his merry men take over the Comedy Hour - Rolleyes

[Image: movieposter.jpg]

Today in the Oz Dick and 'that man' yet again 'rock' Hoody's Chookhouse shed... Wink

Quote:Why was crash pilot at controls?

[Image: 0aece0571ae444275e729e1e653d2d5f]12:00amEAN HIGGINS

Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened.

Via the Oz today:
  
Quote:ATSB vow to be more selective in investigations

[Image: 1ff99331659b498e8d72301986b9ffd6?width=650]
ATSB chief commissioner Greg Hood, right, and Transport Minister Darren Chester.

The Australian
12:00AM November 10, 2017


ANNABEL HEPWORTH
[Image: annabel_hepworth.png]
Aviation Editor
Sydney

@HepworthAnnabel




The nation’s transport safety ­investigator has vowed to become more selective in the accidents and incidents it investigates as it tries to rein in a backlog of reports.

Australian Transport Safety ­Bureau chief commissioner Greg Hood said the ATSB was trying to “improve its efficiency by becoming more data-driven”.

While the ATSB has a target of publishing 90 per cent of complex investigations within 12 months, in 2016-17 it got just 32 per cent away within that time frame.

“By being more selective with our investigations, and with the introduction of more resources through a recent recruitment drive, we will be in a better position to meet this target over the coming year,” Mr Hood said.

Fresh questions about the ATSB’s ability to conduct air safety investigations in a timely manner were raised this week when it emerged that an investigation into a 2015 Mount Hotham occurrence involving pilot Max Quartermain — the pilot involved in February’s Essendon plane crash — will now not be released until February.

Infrastructure and Transport Minister Darren Chester said he understood the report had been delayed for many reasons, including the need to consider recently-obtained material.

“Timeframes for investigations can vary based on their complexity, available resourcing and a range of other factors,” Mr Chester said.

“I am confident that, should a critical safety issue be identified during the course of an investigation, the ATSB will immediately bring this to the attention of relevant authorities and organisations to be addressed.”

Mr Chester also backed ATSB moves to improve the timeliness of its reports.

The ATSB’s latest annual report shows that for complex aviation investigations, 39 were completed in 2016-17, with 31 per cent done within 12 months, compared to 18 per cent the previous year. At June 30, there were 69 ongoing complex aviation investigations.

Mr Hood said the ATSB aimed to complete most of its complex investigations within 12 months.

As there were 17,000 incidents, serious incidents and accident notifications made to the ATSB last year — an average of 46 per day — “it is not possible for the ATSB to investigate everything”.


[Image: 12f7d7471d80dff96dec2e2ca218e3da?width=650]

He said the ATSB was looking to use its data of safety-related occurrences to bolster its efficiency.

“By actively interrogating this data, we are able to more selectively allocate our resources to investigating those accidents and incidents that have the greatest potential for improving transport safety, with a particular focus on the travelling public,” Mr Hood said.

“If there is no obvious public safety benefit to investigating an accident, the ATSB is less likely to conduct a complex, resource-intensive investigation.”

The 2014 Aviation Safety Regulatory Review report, chaired by industry veteran David Forsyth, compared the time the ATSB had taken to produce reports compared to the US’s National Transportation Safety Board, New Zealand’s Transport Accident Investigation Commission and Britain’s Air ­Accident Investigation.

This followed criticism in submissions over the time the ATSB took to produce safety reports.

“The panel considers that the ATSB’s reporting timelines are longer than desirable and significant delays for some individual reports are a concern,” the report found. “However, the panel notes that the timelines are broadly consistent with international performance.” That analysis looked at 2004 to 2013.

Mr Hood said that daily senior managers and safety data analysts would review notifications they got in the last 24 hours. Decisions would be made on whether to investigate and what type of investigation to do.

“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,” Mr Hood said.

“Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity.”



Comment from Sandy... Wink :

...I think we get it, ATSB with around 100 staff and the CEO (former Civil Aviation Safety Authority Manager) in his hi vis jacket can take as much time as they like to finalise reports. Rubbery figures? In this report we have 17,000 incidents to consider, funny, it was a nice round 15,000 a couple of days ago. Then we have to work out what is a ‘complex’ incident, do they mean like the one where they and CASA whacked the pilot who ditched at Norfolk Island? Luckily the Senate took an interest and after nearly nine years it seems that the authorities were at fault, not the unfortunate and officially maligned pilot. The first investigations, with G. Hood working in CASA at the time, were sloppy at best or malicious at worst, take your pick.

Alex in the Rises. 

MTF...P2 Cool
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Aviation safety issues and actions

If you click on the web link above you will see it takes you to the ATSB webpage with links for 849 recorded safety issues and/or recommendations dating back to 1996 when the ICAO Annex 13 State AAI was called the 'Bureau of Air Safety Investigation'.

Example:  

Quote:Output No: R19980161

Date issued:18 August 1998

Safety action status:

Background: See report B98/90 -'Systemic investigation into factors underlying air safety occurrences in Sydney Terminal Area airspace'.

Output text

The Bureau of Air Safety Investigation recommends that Airservices Australia review the relationship between the Sydney Safety and Quality Management section and the Sydney Terminal Control Unit with a view to developing procedures to improve the effectiveness of the safety management system, thus contributing to the overall "safety health" of Sydney Terminal Control Unit operations.

Remembering that in 1998 the concept of SMS was still some 14 years away from being enshrined and written into ICAO SARPs in the form of Annex 19.  

Quote from post - Yes: But…. - from the Ferryman gives a bare bones explanation to the average layman on how a properly functioning SMS is supposed to work and how an ATSB identified 'safety issue' leading to a safety recommendation could interact with that company/AOC SMS:

 "..One of the little problems ATSB have is that their ‘recommendations’ have no legal bind on company management. A small shift in ‘thinking’ could remedy that. An ATSB recommendation to the company SMS system would need to be acknowledged and considered through the SMS. Say ATSB recommended that pilots wear Pink socks on Tuesday and Blue on Friday. This is fed into the grass roots level of the SMS; the system is then triggered. This is a legitimate call by the government safety agency and cannot be denied entry. So the ATSB recommendation is duly considered; dealt with and the system decides it’s a crock. This is fine, but should the next incident involve pink socks, not blue, then there is a paper trail leading right to the top mans door. If a middle level decision to deny the recommendation was made it matters not – at the end of the shift the responsibility lays with the top dog. That is how a SMS is structured..."

However the ATSB under Beaker and now Hoody would seem to have lost sight of what the purpose is (other than a CASA auditable tick-a-box routine) for a properly functioning SMS i.e. to identify and risk mitigate 'safety issues' through a company hazard and incident reporting system operating under a 'Just Culture'.

In fact from recent correspondence between DJ and ATSB legal it would appear that the bureau are internally fractured or confused on what exactly their remit is when it comes to proactively addressing identified safety issues.

From the bottom of the ATSB 'Terminology, investigation procedures and deciding whether to investigate' webpage there is a 'safety issue' definition: 

Quote:Safety issue: a safety factor that:
a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and

b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.
    
However the legal weasel from the ATSB would seem to be arguing the toss on the term and definition of a safety issue within the TSI Act - WTD?? Undecided
Quote:Dear Sirs,

See attached internal CASA email correspondence, which is a clear breach of the TSI Act. I expect there are other similar emails and I will forward them to you as soon as I have them. Further, it would appear that CASA have not controlled the distribution of the draft internally, and that persons not providing or contributing to the CASA’s draft feedback document have copies of the draft report or are privy to the draft report’s contents.

As the ATSB prides itself as a ‘no blame’ organisation, I would hope the ATSB would act on this matter promptly and appropriately.

Regards,

Dear DJ

Thank you for your email regarding correspondence within CASA concerning the draft report from the reopened investigation into the ‘Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009’.  The ATSB will confirm with CASA its practices for disclosure of the draft report in this matter in the context of section 26 of the Transport Safety Investigation Act 2003.  Please note that section 26 of the Act does permit disclosure and copying of the draft report necessary for:

                  (a)  preparing submissions on the draft report; or
                  (b)  taking steps to remedy safety issues that are identified in the draft report.

Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.  The email you have provided does not establish, prima facie, a breach of the Act with respect to copying or disclosure of the draft report.  The ATSB will make enquiries with CASA.

I note that you have included the ATSB’s Chief Commissioner, Mr Greg Hood, in the recipients list for your email.  As you may be aware, Mr Hood has recused himself from this investigation acknowledging his employment at CASA at the time of the accident.  Mr Hood is not involved in the ATSB’s decision making with respect to this investigation.  You may send any future correspondence on this particular matter to either myself or Colin McNamara, Chief Operating Officer.  Mr McNamara’s email address is colin.mcnamara@atsb.gov.au.

Regards

Hi ATSB Legal Weasel,

Given that this accident occurred 8 years ago and that the information in the draft is not materially new, how can this be viewed as CASA remedying a safety issue? I’m already back flying and this matter deals with an opportunity for me to be promoted to a captain, so what contemporary safety case or pressing hazard needs to be addressed? To me it appears that a CASA officer is using an ATSB draft to inform their administrative processes, so doesn’t TSI Act 12AA (3)(d) refer?

If this is of no interest to the ATSB, then why would anyone participate candidly in an investigation if the ATSB doesn’t protect those involved from CASA inappropriately using draft reports?

Regards,

P.S. the link below to a Youtube clip of the recent CASA Estimates relates, especially at the 4:00 mark.

https://www.youtube.com/watch?v=tt7DDChxI-Y

Dear DJ

Thanks you for your follow up email.  I watched CASA's appearance at Senate Estimates on 27 October 2017.  As I advised in my email of 1 November 2017, the ATSB is making enquiries with CASA with respect to this matter

Regards

LW

Hi LW,

I'm not trying to labour the point, but I sincerely don't understand how no breach is evident in the CASA email extract; maybe I've referenced the wrong part of the Act.

Does 26(1) limit what a draft report can be used for, and in this case, CASA are acting outside of this?

Regards,

DJ

Dear DJ

Section 26 of the Transport Safety Investigation Act 2003 places limits on copying and disclosing the draft report.  However, there are exceptions to the prohibition on copying and disclosure.  As mentioned, it can be copied and disclosed where it is necessary for the purposes of:

(a) preparing submissions on the draft report; or
(b) taking steps to remedy safety issues that are identified in the draft report.

The content of the draft report can be taken into account to remedy safety issues.  This could include CASA performing its safety related functions  The issue is whether or not the report was disclosed for the purpose of remedying safety issues.  I am following up with CASA.

There is a restriction on use in subsection 26(6) which states that a person who receives a draft report is not entitled to take any disciplinary action against an employee of the person on the basis of information in the report  Further, s.27 prevents the draft report (as well as the final report) from being admissible in evidence in civil or criminal proceedings.

I hope this clarifies the operations of section 26.

Regards

LW

Hi LW,
 
Thank you - that answers my question.
 
Re CASA’s DIP protocols, I would expect that CASA has:
  • carefully identified those persons with history or expertise in this accident whose input is essential to their DIP feedback
  • formally retained those persons in writing and explained to them how the TSI Act applies to them and the draft’s contents
  • ensured that those people in the DIP process are aware of who else is a DIP participant and therefore aware of who they cannot discuss the draft report’s contents with  
 
Do you know if the above resembles CASA’s present protocol?
 
Regards, DJ

Dear Mr James
 
The Transport Safety Investigation Act 2003 details that the report should not be copied or disclosed except as provided for by section 26.  We are checking that they follow that practice.
 
Regards
 
LW

Hi LW,
 
Thank you for that - much appreciated.
 
Re an earlier email where you said that CASA were entitled to use the draft report to respond to 'safety issues', can I draw your attention to the following ATSB document and a section from it:
 
ATSB TRANSPORT SAFETY RESEARCH REPORT
Aviation Research and Analysis Report – AR-2007-053 
2.3 Safety issue
  1. 2.3.1  ATSB definition
A safety issue is a safety factor that:
    • can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
    • is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. 
 
Is this definition consistent with the definition used in the TSI Act? If not, could you please direct me to the definition of ‘safety issue’ that is used in the TSI Act?
 
Regards, DJ

P2 comment: Note that the safety issue definition from AR-2007-053 is the same as the current listed (above) definition off the ATSB webpage. Ironically the person who came up with that definition is none other than the PelAir re-investigation IIC Dr I'm a Psychopath-Ghost-who-walks  


Dear Mr James

 
The Transport Safety Investigation Act 2003 does not define the term ‘safety issue’.  The Explanatory Memorandum to the Act does not indicate that the term in the Act is limited to identification of organisational safety issues.
 
Regards
 
LW

I can only presume this ATSB legal stance is to support the provision of top-cover for CASA while faciliting the CASA Sydney Regional office continued 8yr embuggerance (anniversary today) of DJ... Dodgy



MTF?- Definitely...P2 Cool
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