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The search for investigative probity.

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.

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

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.

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
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.

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
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
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

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.

[Image: BE20.gif]
Beechcraft B200 King Air
C/n / msn:
Fatalities: 0 / Occupants: 5
Other fatalities:
Airplane damage:
Essendon Airport, Melbourne, VIC - [Image: VH.gif]   Australia
Departure airport:
Sunshine Coast Airport (MCY)
Destination airport:
Essendon Airport (MEB)
The aircraft sustained a partial landing gear collapse upon landing after the gear failed to lock-down. There were no injuries.


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
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.
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


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.


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?
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:-

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.
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
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

[Image: annabel_hepworth.png]
Aviation Editor


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
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'.


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.


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


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?


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

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



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?



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.



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.

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:
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.

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
ATSB search for IP remains elusive - Dodgy  

Extract from the ATSB press release yesterday: reference - PelAir coverup MKII - Final report released.
Quote:“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.

The significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

Due to the above statements yesterday from the slightly less 'invisible Manning' it is now obvious that the ridiculous addition of 454 pages to the original Final Report, in what should have been a relatively straightforward systemic investigation and AAI factual report, is a very expensive ($?) attempt to regain credibility in the eyes of industry and the average ATP (Australian Taxpayer) 

Therefore I am proposing to use the search 4 IP thread to systematically analyse the new 531 page incarnation to highlight how this report falls far short of the ATSB achieving any respectable probity and credibility.

To start with here is the 'safety message' summary from the FR:

Quote:Safety message

The investigation report contains 36 safety factors that provide lessons to flight crews, operators, regulators and/or other organisations. Overall, the most fundamental lesson for all flight crew, operators and regulators is to recognise that unforecast weather can occur at any aerodrome. Consequently, there is a need for robust and conservative fuel planning and in-flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.

Additional safety messages include:
  • Flight crew should discuss and consider options to manage threats when there is time available to do so.
  • Operators should ensure their flight crew proficiency checks assess the performance of all key tasks required of their flight crew.
  • Operators should not rely on informal risk controls for managing the performance of safety-critical tasks, particularly when there is significant turnover of pilots in a fleet.
  • Operators of air ambulance flights should ensure medical personnel have clearly defined procedures and appropriate practical training for using the emergency equipment on board to ensure they can effectively assist a patient in the event of an emergency.
  • All organisations in safety-critical industries should use proactive and predictive processes to identify hazards in their operations.
  • Organisations that use a bio-mathematical model of fatigue as part of their fatigue risk management system should ensure they have a detailed understanding of the assumptions and limitations associated with such models.
  • Regulators should develop effective methods for obtaining, storing and integrating information about operators and the nature of their operations so that they can develop effective surveillance plans.

The 'safety issues & actions' starts at page 356 and goes to 387.

To kick it off I will (reference - PelAir coverup MKII - Final report released.) quote what is IMO the major hole in the Swiss Cheese the non-provision by Nadi of both a weather report (SPECI 0739) and an amended weather forecast (the 0803 AMD TAF that contained a operational - Alternate - requirement).  

Quote: Wrote:ATC weather updates?

Given the huge missed opportunity by ATC to inform the co-pilot and myself of the new TAF which changed the fuel requirements for Norfolk, and that exemptions from ICAO policy have been granted in this regard re informing crew in international operations of such changes, why is a lengthy discussion on this topic missing?

ATSB IIC Dr Walker's nasty and arrogant reply to the above Captain DIP comment:
Quote: Wrote:No change required

In addition to the content in The occurrence section, the draft report discusses the provision of flight service in the Nadi and Auckland Oceanic FIRs in detail (about 5 pages). The topic is also discussed in the Safety analysis (2 pages), and findings are included in relation to the Nadi IFISO and Auckland air/ground operator’s actions.

It is not clear what ‘exemptions from ICAO policy’ the captain is referring to. In relation to amended TAFs, ICAO guidance (in document 7030 for most regions) stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination. However, this did not apply to the Nadi FIR (although it did apply to the Auckland Oceanic FIR and the Australian FIRs). Overall, the Fijian and New Zealand flight information service providers’ procedures were consistent with ICAO standards and recommended practices.

Limited information about the reasons for the actions of the Nadi IFISO and Auckland air/ground controller regarding VH-NGA on 18 November 2009 were available to the ATSB reopened investigation. The ATSB discussed the topic in as much relevant detail as it could, given the available information. The importance of the meteorological information that was not passed by ATS to the flight crew has also been highlighted in the draft report.

Overall, further discussion of the topic was not considered warranted.

The dismissal by Walker of what essentially is IMO an ATSB identified significant safety issue...

ICAO guidance..(sic)..stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination extremely problematic and disturbing in an international perspective.

How hard would it have been for the ATSB to issue a safety recommendation or notice to ICAO suggesting that maybe the document 7030 guidance should be revisited and possibly amended.  

Now from the MKII report some relevant quotes from the Dr Walker referred pages.

From Pg 97:
Quote: Wrote:CAAF also reported:

- The Nadi Air Traffic Management Centre normally received METARs/SPECIs and TAFs within a few minutes of them being sent by the disseminating station.
 - METARs/SPECIs and TAFs were delivered automatically to two printers, including one at the IFISO’s workstation.
 - The IFISO’s workstation was enclosed in a soundproof booth.
 - When SPECIs were received, they were displayed to both the IFISO and the controller.

On 20 November 2009, the ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI.

P2 - Note the non-inclusion of the 0739 SPECI & 0803 AMD TAF. However this was explained in the next paragraph where the timeline of investigation bizarrely seems to jump from the original investigation back to the present reiteration:

CAAF advised it was not aware of the 0739 SPECI and the 0803 amended TAF until it received the ATSB’s investigation report in 2012. CAAF contacted the ATS provider, who advised it had provided CAAF with all the weather reports it had received at the time (in 2009). The ATS provider advised CAAF it no longer held the hard copy print outs and therefore CAAF could not verify whether the 0739 SPECI or the 0803 amended TAF had been received.

Q/ We now know that the ATSB and CASA in their parallel investigation activities were both aware of the existence of at least the 0803 AMD TAF by 23 November 2009. Therefore why did the ATSB in the course of their investigations - especially after receiving the Auckland & Nadi ATC transcripts -  not query the CAAF on why it was they didn't have copies of the 0739 wx report & the 0803 amended forecast?  

Quote from "K" post above - A thumbnail, dipped in tar. - once again the significance of the non-relayed wx report and AMD TAF in the context of this 531 page re-hashed 'the pilot did it' bollocks report... [Image: dodgy.gif]

Quote: Wrote:...The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

MTF...P2 Cool
Pirate code: "..more guidelines than actual rules"  Big Grin

I note that off the UP Lead Balloon (aka Creampuff) gets it but then again from my memory I think he always did... Wink   

Quote:I seriously believe someone’s hacked Lookleft’s username. The ‘real’ Lookleft would not have been silly enough to suggest that Table 10 is a ‘transcript’. It’s a paraphrasing and summary by a third party. In any event...

A trap was set for the PIC by the system in which he was variously allowed, encouraged and forced to operate. The ‘tripwire’ on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC.

The PIC’s primary sin was that he did not have ESP.

The controversy around the classification and standards applicable to this kind of operation are merely a manifestation of the broader classification of operation dog’s breakfast that will never be cleaned up by CASA.

While on the typical ill-informed, arrogant and narcissistic Lookleft post, I was intrigued by this almost emotive, strangely biased and complimentary statement in regards to the FO's performance on that fateful night Huh :
Quote:..The report finally sheds some light on the F/O's contribution to the event. She was doing a lot of managing upwards. The PIC just seemed to be shutting down to any course of action other than ditching. I'm not sure if the first report stated that she had sustained a serious injury but I am not surprised that she did not want any part of any discussion outside of the ATSB investigation. In my view she did a good job but short of taking over she was restricted by the PIC's performance...
P2 comment - Perhaps LL has just given a clue to why he has never been able to holistically look at the PelAir ditching investigation in a systemic top down approach and without what would appear to be a personal grudge against DJ... Huh     

This creates a perfect opportunity to bring up another aspect of the report that IMO seems to have been glossed over through either reckless and arrogant ineptitude by the IIC Dr Walker; or once again through 'malice and aforethought' Walker has attempted to muddy the waters... Dodgy   

From page 14 of the report (note part in bold):

Quote:..The first officer did not recall hearing any weather information provided by the Nadi IFISO. Both of the crew stated that at some stage after reaching FL 390, the first officer had a controlled rest (or ‘cockpit nap’), which was an approved component of the operator’s fatigue risk management system (see Cockpit strategic napping). The first officer believed she had this controlled rest at the time the Nadi IFISO provided the weather reports. The extent to which the first officer was subsequently briefed regarding the 0800 weather report could not be determined...

From the pg 14 part in bold, one gets the impression that the IIC and/or investigators have checked that the FO's 'cockpit nap' was being conducted in accordance with the safety risk mitigation FRMS (i.e. SMS) SOPs - from page 225:

Quote:Cockpit strategic napping

The FRMS manual stated that, even though the FRMS was intended to ensure flight crew were well rested:

… the nature of Pel-Air operations can present unique challenges to crew alertness, despite meeting crew rest requirements. Pel-Air scheduled and ad-hoc charter operations tend to involve lengthy sectors at critically fatiguing periods of the night as well as fatiguing tasks in demanding flight scenarios, as such deliberate crew napping is seen as a suitable means of improving crew alertness during more critical portions of the flight.

Accordingly, the manual stated ‘cockpit strategic napping’ was permitted subject to specified conditions. These conditions included:

- only one pilot was able to nap at a time
- napping could only be done during low workload parts of a flight
- naps were limited to 30 minutes maximum (to prevent problems associated with sleep inertia254)
- pilots should be woken 30 minutes before any anticipated high workload event
 the autopilot was engaged
- pilots were not permitted to disconnect their headset or turn down the volume of their radio.

Many Westwind pilots reported cockpit napping was regularly used as a risk mitigator on long flights at night.

254 Sleep inertia: a short period of time immediately after awakening associated with poorer task performance and a feeling of mental sluggishness.
However after a couple of quick phone calls (ala Barry O) I was able to establish a couple of (unfortunately) hearsay facts:

Q1/ Was the flight crew or medical crew aware of the FRMS conditions for an approved 'cockpit nap'?

A1/ Unfortunately I cannot establish whether the FO or Doctor was aware of these conditions but I can confirm that the Capt & Flight nurse were not aware.

Q2/ Was the FO's approved 'cockpit nap' conducted in compliance with the FRMS (SMS) safety risk mitigation conditions?

A2/ Both replies were no:

1/ The 'nap' went for longer than 30 minutes.

2/ The nap was conducted without headsets on or with volume up and neither was the cockpit speaker selected on and with the volume up.

Note: a) It was also stated to me that this 'normalised deviance' was a regular routine for the FO with other aeromed flights and with different Captains.
b) Surprisingly the EP training for medical crew (although not completed under an approved CAR217 CAO 20.11 course) did not include awareness of the FRMS (SMS) fatigue risk mitigation components - WTD? Dodgy   
c) Disturbingly the safety risk mitigation conditions as published in the FRMS manual were not published in the FCOM (Flightcrew operating manual) and that would be because apparently PelAir didn't have FCOMs for at least the Westwind operations... Confused  

Quote from page 23:

 ..As the first officer had not flown the leg from Apia to Norfolk Island before, the captain asked her if she would like to be the pilot flying. The first officer agreed...

After contemplating all of the above I have to keep pinching myself that the FO was the PF for this flight. Personally I always saw a FO pilot flying leg as an opportunity to display your aptitude and ability for a future command upgrade. Therefore I find it quite reprehensible that the FO saw fit to make an ICUS decision to take a non-compliant 'cockpit nap'.

The command aptitude aside, just consider that if the FO had of been compliant with the FRMS 'crew nap' conditions that she may just have heard the 0801 exchange and therefore may have questioned and discussed the mixed weather messages received from Nadi. This may have led to Nadi discovering the MIA 0739 SPECI & 0803 AMD TAF and (as they say) all this would be history... Rolleyes

IMO the worst command decision DJ made that fateful day was to allow the FO to be the pilot flying on that leg... Blush

MTF? - Definitely...P2 Cool
PelAir MKII & the quest for IP: cont/-

Quote from this week's SBG: Quantity v Quality. 

Quote:...It is small wonder that the aviation world is looking more and more to the Senate and the Senators to lend a hand and get a rope on the lunatics. The ATSB were emasculated during the Lockhart River affair and CASA dodged a large calibre bullet; many years later we have the Pel-Air and Norfolk Island farrago. The total cost of this debacle is staggering, the quality of the result disgraceful; but by far the worst is total zero improvement in system or safety lesson of value; to anyone. When the dust has settled a long, hard look, in terms of value for investment will be taken of this almost unbelievable saga. Perhaps by then there will be a minister who actually gives a damn and finally matters aeronautical will take a turn for the better. Do not hold your breathe…….

Not sure how accurate the estimates are but there are some older wiser BRB heads who reckon that the total cost (so far) for the PelAir cover-up is North of 50 million Aussie dollars. That equates to a conservative figure of $10 million per 100 pages of the PelAir MKII final report. The question is will this 531 page report prove to be the catalyst for the ATSB getting back to AAI (ICAO Annex 13) ToRs and rediscovering it's investigative probity - so far I think not... Dodgy

However to give Hoody's posse the benefit of the doubt, let us continue with reviewing the ATSB identified safety issues and the recommendations, suggestions for DIP proactive risk mitigation.

Starting with this from the MH370 forum: MH370, PelAir & the ELT connection

Quote:Via RT: Many have speculated that MH 370’s ELT failed to send out a signal when the plane disappeared from radar screens on March 8 last year, somewhere near Indonesia, because it had crashed into water. If the ELT had worked, authorities could have avoided the 18-month search that has cost over $100 million dollars so far, and which may only now be coming to an end.


From page 31 of PelAir cover-up MKII final report:

Quote: Wrote:..During the ditching impact, the aircraft’s 406-MHz beacon emergency locator transmitter (ELT) transmitted one alert signal. Although the alert was detected by a geostationary satellite, the single alert was insufficient for the search and rescue services to determine the location of the ELT...
Okay apparently the boys'n'gals on the coalface did identify this safety issue as being significant. The executive/commissioners agreed and didn't deem the issue one that needed to be PC'd... Rolleyes

Extract from page 386-387:

Quote:Additional safety action regarding emergency locator transmitters

Satellite detection of emergency locator transmitters
Although unrelated to the circumstances of this accident, during 2003 the International Cospas-Sarsat Programme had commenced developing the Medium-altitude Earth Orbiting Satellite System for Search and Rescue (MEOSAR). The system consisted of search and rescue signal repeaters installed on the Global Navigation Satellite Systems (GNSS) of Europe, Russia and the USA; complementing the existing Low-altitude Earth Orbit (LEO) and Geostationary Earth Orbit (GEO) satellites from the LEOSAR and GEOSAR systems.

Once fully operational, the MEOSAR system will be capable of near-real-time transmission of distress messages and if the distress beacon is within coverage of three or more GNSS SAR repeater-equipped satellites, an independently calculated position of the distress beacon location.

With a full satellite constellation, it will be possible to calculate the location of the distress beacon within 10 minutes, 95 per cent of the time. The MEOSAR system will facilitate additional enhancements, such as a return-link-service to suitably equipped distress beacons acknowledging receipt of the distress message.

The Cospas-Sarsat MEOSAR system was not operational in 2009. A demonstration and
evaluation phase commenced in 2013 and in late 2016, the system achieved an early operational capability for search and rescue agencies. Full operational capability of the MEOSAR system is anticipated during 2018.

Use of emergency locator transmitters
In May 2013, the ATSB published a research report titled A review of the effectiveness of emergency locator transmitters in aviation accidents (available from The research report provided an overview of the use of emergency locator transmitters (ELTs) and provided basic quantitative evidence of their effectiveness. Analysis of ATSB’s aviation occurrence database from 1993 to 2012 indicated ELTs functioned as intended in about 40–60 per cent of accidents in which their activation was expected. In addition, ELT activations accounted for the first notification to the Australian Maritime Safety Authority (AMSA) in about 15 per cent of incidents and ELT activations had been directly responsible for saving an average of four lives per year.

In accidents where ELTs did not work effectively (or not at all), it was found a number of factors could affect their performance. Those factors included incorrect installation, lack of water proofing, lack of fire proofing, disconnection of the co-axial antenna cable during impact, damage and/or removal of the antenna during impact and an aircraft coming to rest inverted following impact.

The safety messages highlighted in the research report included:

- pilots and operators of general aviation and low-capacity aircraft needed to be aware that a fixed fuselage mounted ELT cannot be relied upon to function in the types of accidents in which they were intended to be useful.
- the effectiveness of ELTs in increasing occupant safety and assisting SAR efforts could be enhanced by using a GPS-enabled ELT, using an ELT with a newer 3-axis g-switch, ensuring it was correctly installed, ensuring the beacon was registered with AMSA and activating the beacon pre-emptively if a forced landing or ditching was imminent.
    - carrying a personal locator beacon (PLB) in place of (or as well as) a fixed ELT would most likely only be beneficial to safety if it was carried on the person, rather than being fixed or stowed elsewhere in the aircraft.

Additional information regarding distress beacons
AMSA’s booklet Distress Beacons and MMSI Information contains important information and recommendations about the use of distress beacons and their use by persons in life threatening situations (available from It provides information on the types of distress beacon and the advantages of beacons that are GNSS equipped. AMSA recommends the use of GNSS-equipped beacons because they provide the quickest and most accurate alerts.

Advice for using distress beacon includes that when in grave or imminent danger, two-way communication (such as phone or two-way radio) is the most effective means of communicating. If two-way communication is not available, then a distress beacon should be activated.

AMSA also recommended that personal locator beacons are physically carried on the person or within easy reach.

Credit where credit is due, that is a good proactive and monitored response to an identified safety issue.

However this identified safety issue obviously predates the PelAir re-investigation. Since May 2013 we have had several high profile aviation accident investigations, including the ongoing MH370 investigation, where the ELT has either failed or not operated as advertised.

Yet the ATSB PelAir reinvestigation report does not expand to include references to these AAI's; nor does the report recognise ICAO and other signatory States; or aviation stakeholders (like NASA above) on proactively addressing the obvious fallibilities of the current technology ELTs.

Reference PelAir MKII post: The hidden agenda of PelAir MKII IIC Dr Walker 

Quote:Whatever the reasons for these ATSB administrative glitches it would also appear that there is some serious issues with the ICAO iSTAR receiving office, remembering that the examples mentioned above were only 3 of many that I was able to identify as not existing/filed on the iSTAR/ECCAIRs databases.

Could it be that there are still 'taxonomy' and/or compatibility issues with the current ATSB SIIMS database and the forwarding of safety and accident reports being sent to the ICAO iSTAR database office? Why wouldn't a State endorsed Annex 13 AAI at least check that there are no issues at the receiving end of some important forwarded Annex 13 compliant reports? After all we are talking about the integrity and security of valuable safety information that deserves to be properly disseminated to the worldwide aviation industry as per the good intent and philosophy of ICAO Annex 19.

From the previous post #209, the above reference post and the closed off ELT issue; we are beginning to see a trend that bizarrely the ATSB was a closed shop that did not encourage any outside input, any new information/evidence; nor did they want to address any additional externally identified safety issues.... Dodgy

[Image: 652_320_3d6db293-ulkemizde-yanlis-batililasma.jpg]

TBC...P2 Cool
I believe the ‘Walker  (aka Fig-jam )- attitude, arrogance and plain old fashioned rudeness, combined with any form of empathy has been discussed several occasions; not only here. His attitude toward Karen and Dom has offended many – not that he’d give a fundamental fig for those opinions.

We can let this all pass, for the while, as insignificant in comparison to some of the ‘glossed over’ major items which have been given a PC ‘tick-a-box’ treatment from the invisible Manning. Small items, of a ‘psychological nature’ which have been ignored. Like feeling that the SMS is a lip service exercise; or, fatigue is only a figment of imagination; or, that company culture has no effect on the ‘upright’ pilot. There is more, lots more which, in the BRB opinion, shows clearly the deeply flawed approach ATSB is taking – without going into the Mildura bun fight or even the ATR events (now plural) and, heaven forbid we ever mention Essendon.

Walker has some ‘deep and meaningful’ questions to answer; not just on Pel-Air, considering the attitude, although the stance he has adopted toward just to Karen and Dom alone demands answers. Maybe, when the RRAT committee hauls ATSB back in for a ‘chat’ we can have those questions answered.

Dry argument and nearly my throw – best get one in to keep me focussed on the important things – “Yes please – right here”. Why do they always ask “same again”?
PelAir MKII & the quest for IP: SMS a lip service exercise - Huh  

From P7's pointed post... Wink

Quote:...We can let this all pass, for the while, as insignificant in comparison to some of the ‘glossed over’ major items which have been given a PC ‘tick-a-box’ treatment from the invisible Manning. Small items, of a ‘psychological nature’ which have been ignored. Like feeling that the SMS is a lip service exercise; or, fatigue is only a figment of imagination; or, that company culture has no effect on the ‘upright’ pilot. There is more, lots more which, in the BRB opinion, shows clearly the deeply flawed approach ATSB is taking – without going into the Mildura bun fight or even the ATR events (now plural) and, heaven forbid we ever mention Essendon...

Now to join the dots - from page 353 under 'Contributing Factors':

Quote:Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. [Safety issue]
Extracts from under Safety Management and management oversight (page 337-341):

Quote:Hazard identification processes

The operator had a safety management system (SMS) in some form for several years prior to it being formally mandated in regulatory requirements for Australian RPT operators in 2009. Although ideally an SMS will allow an operator to identify and address hazards in its operations, the effectiveness of these processes can be affected by many factors.

The operator’s processes to identify hazards in its flight operations relied heavily on flight crew submitting incident, hazard and fatigue occurrence reports. If a report was submitted, it could then be assessed and considered by personnel other than those involved in the relevant fleet’s operations. However, the reporting culture within the operator was such that flight crew were generally only submitting reports when requested or for incidents that external parties had already reported. There were minimal voluntary or discretionary reports submitted. Although the available evidence indicates this situation was improving in the operator’s other fleets during 2009, this did not appear to be the case in the Westwind fleet...

...The primary task of the Westwind fleet was traditionally night freight operations. It commenced air ambulance operations with the air ambulance provider in 2002, and the extent of these operations significantly increased from 2007 to 2009, and by 2009 it was the main activity undertaken by the Westwind fleet. During 2007–2009, the number of bases routinely conducting air ambulance operations increased from one to four, and there was a significant turnover of flight crew, particularly with the captains based in Sydney.

Despite these changes, the operator’s formally-defined risk controls, particularly for training and checking, still appeared to be better suited to routine freight operations. There also appeared to be a significant reliance on the informal transfer of essential knowledge to flight crew regarding international operations and operations to remote islands, and an assumption flight crew would acquire the knowledge and skills appropriate for their tasks.

Given the expansion of the operator’s air ambulance operations, and the inherent nature of international ad hoc air ambulance operations, there was a need for the operator to closely monitor and review the conduct of operations to assure itself they were being conducted to an appropriate standard, and that the implemented risk controls were suited to the nature of the tasks being conducted. As indicated above, the processes used to identify hazards and monitor operations were not adequate to achieve this purpose.

Safety management is an evolving discipline, and it is undoubtedly difficult for a relatively small air transport operator to conduct hazard identification activities to the standard expected of major airline operators. There were indications the operator was taking positive steps to improve its hazard identification processes during 2009. However, these efforts had limited effect on the Westwind fleet’s operations up until the time of the accident.

In summary, the operator’s processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. Overall, had the operator adopted more thorough proactive and predictive hazard identification processes, it is likely at least some of the inadequate risk controls associated with its air ambulance operations would have been identified, particularly in terms of flight/fuel planning and in-flight fuel management.
On reviewing the various ATSB identified PelAir SMS preamble and deficiencies (above), it is very hard to go past the very disturbing parallels to the tragic Lockhart River investigation, with familiar issues like lack of proper CRM training and obvious deficiencies in the CAR 217 organisation.

The following is some quoted extracts from an excellent 2008 ASASI presentation by former ATSB Executive Director Kym Bills... Wink

Quote:...All these factors strongly indicate to an industry where experience levels are reducing dramatically. Add to this the financial pressures of rising fuel costs and rapid growth, and we are starting to paint a picture of an industry that will need to withstand increasing stress in the future. In Australia in particular, there will be significant challenges for the industry to meet societal and political expectations that rural and regional Australian air services will be maintained to a high standard. We face an environment where resistance to pressures to cut corners in training will be paramount; where real and meaningful safety management systems need to be integral to an organisation’s operation. It would come as no surprise to you I am sure that the ATSB has seen many examples during investigations of safety management systems that are little more than a book on a shelf, or loose words that are readily bandied about. Hand in hand with this is the need for commitment to the establishment of strong safety cultures. Again, while we see excellent examples of such strong cultures, we see many examples where translation of the words into action and reality is far removed, and it is clear that manager lack of awareness of human performance remains an issue in this regard...

It is a matter of some frustration that we continue to see the same types of fatal accidents, particularly controlled flight into terrain, VFR into IFR conditions, fuel exhaustion/starvation, wire strikes and needless and indeed reckless high risk GA behaviour. While, some are what I would describe as the unfortunate result of innocent human fallibility, we continue to see too many of these accidents that are clearly avoidable and the result of poor preparation and decision making, and what it seems can only be described as a disregard for the lessons of the past. Learning from others and mindfulness of past lessons are crucial to curbing the continuing trend of avoidable accidents. Understanding of the limits to human performance and organisational behaviour, risk analysis, and threat & error management will need to feature more so than ever in the future.... 

...While the need for timeliness in investigation has always been important (if not always achieved), media, political and societal expectations have certainly changed, and there is a need more than ever to strive for better timeliness. (P2 -How's that working out Kym, Beaker err Hoody - Huh ) Careful consideration is needed as to what trade-offs might be made between investigation timeliness and thoroughness, but the greatest challenge is probably how we achieve both.

A prime example is the ATSB’s Lockhart River investigation report. I believe the quality of this 500-page report into the worst civil aviation accident in Australia since 1968 is first rate, but more problematic was that the final report took almost two years to be released. (P2 - Duck me 2yrs that's good) While there were several interim reports and the investigation was complicated by an inoperative CVR, no witnesses and the extent of destruction of the Metroliner 23, two years is a long time. The ATSB is examining ways that this could be improved, which may require directing fewer resources to other lesser priority investigations.

I suspect that the ATSB is not alone in battling with this problem, and while there will always be exceptions, getting the balance right between professionalism and timeliness and explaining any need to take longer than societal expectations, will be an increasing challenge if safety investigations are to remain relevant.

The other matters that featured strongly in the responses from my colleagues when questioned on challenges for the future, were the need to strike the right balance between no-blame and culpability in a ‘just culture’, and the need to strike the right balance between the need to protect safety data and the demands of legal systems. (P2 - "..let's do the timewarp again.." Undecided 

The confusion or industrial agenda that ‘just culture’ means no blame or liability, even in instances of serious and deliberate wrongdoing by aviation industry practitioners is an issue that needs to be addressed. As James Reason has argued, engineering a ‘just culture’ in which the 10 per cent or so of wilful and culpable actions do not escape sanction, while encouraging reporting and learning from the other 90 per cent of actions that lead to accidents and incidents is ‘the all-important early step’. But there are those who would suggest that a just culture involves only ‘no-blame’ investigation and who seek protection for 100 per cent of behaviours. Meanwhile, we have seen judicial systems imprison crew members who have done little more than be involved in an accident because of actions and omissions that were the types of error expected among all humans. Closer to home we are seeing safety investigations becoming increasingly subject to external scrutiny. On one level, such external scrutiny should be welcome and investigations should withstand reasonable objective scrutiny. Significant scrutiny of ATSB investigation reports is applied through coronial inquests. However, while technically inquisitorial in nature, such forums are in reality often adversarial as our increasingly litigious society has led to parties attempting to divert attention from, and dilute important safety issues in pursuit of their own agendas. This unfortunately often leads to protracted proceedings and results in a significant drain on ATSB investigative resources. 

The desired implementation of the Global Aviation Safety Roadmap in terms of protecting safety data to enable its wider and timelier sharing is predicated on robust legislation in member states. This is a great challenge for many poorer ICAO states, but also for some of the otherwise best practice members. For example, the US NTSB is required to make available much sensitive data it holds, including CVR transcripts, in a public docket even where it is sourced from another state of occurrence, and France’s BEA has similar challenges because of the power of its judicial system. The new Attachment E to Annex 13 seeks to provide guidance with respect to some of these legal difficulties but serious tensions remain in the Annex itself.

In Australia, the ATSB has not been immune from legal and regulatory pressures. The Transport Safety Investigation Act 2003 mentioned earlier, protects safety information obtained and analysed by the ATSB as a ‘no-blame’ safety investigator. As an example, the TSI Act recently stood up to legal challenge, in what became known as the Elbe shipping case, where a party in a civil case relating to the leakage of oil from a ship in Gladstone harbour sought to obtain the ATSB’s investigation evidence. The Executive Director refused to issue a certificate for the release of the evidence and the party challenged the TSI Act as being unconstitutional, as it claimed such decisions should reside with the courts. The Federal Court upheld the legitimacy of the TSI Act and the party was ordered to pay costs.

That is not to suggest that the ATSB doesn’t recognise the need for a just culture. A just culture is preserved through the ATSB taking a cooperative approach to any required parallel investigations by regulators, police or other bodies, which must be entirely separate and gather their own data and evidence. This is particularly important because the ATSB can compel evidence that may otherwise incriminate and ATSB reports are unable to be used in criminal or civil courts. However, as I mentioned earlier, they can be used in a coronial inquest. In addition, Australian legislation provides for a CVR to be used in cases of severe criminality unrelated to normal crew duties, such as in the case of drug running or terrorism.

Accident investigation by safety investigators remains essential, if only to remind us of the continuing need for vigilance to avoid the human and other factors that have led to so many unnecessary accidents and fatalities in the past. In many cases, professional investigations do much more than just remind us of past lessons. There are new and novel twists based on differing organisational cultures and pressures, regulatory environments and human interfaces with other humans and with changing systems and technologies.

In closing, it is clear that using all available means to avoid a major accident is a primary challenge. This includes good safety management systems among all key players, understanding of the limits to human performance and organisational behaviour, risk analysis, data collection and analysis, threat & error management, and excellence in regulation. Human factors will without doubt continue to dominate as a key element of safety investigation. It is crucial that we learn the lessons from the past and the experiences of others. Close cooperation within the aviation community is essential to ensure that those lessons that will benefit safety are shared openly.

Please someone bring back Kym Bills - ASAP Wink
Next from another 2008 Kym Bills presentation:

Quote:Safety Management Systems

• Before looking at methodology and aviation

examples, I want to reinforce that robust

safety management systems (SMS) can

make a major difference to safety

• The ATSB often finds poor SMS and weak

safety culture contributes to accidents

• SMS compulsory among aviation operators

from 2009 (aerodromes already)

• An International Civil Aviation Organization

(ICAO) Manual published in 2006 is a key

document and is to be updated with cases.


Lockhart River and SMS

• Among the many contributing safety factors

the ATSB Lockhart River investigation

found Transair’s SMS to be poor

• Poor company organisation structure, weak

Chief Pilot commitment to safety, and

inadequate risk management processes

• Other factors included Ops Manual,

variable training including HF/CRM, poor

supervision of flight ops, TAWS not fitted.

Transair’s SMS

• Chief Pilot was also MD & head of Check &

Training and regularly in PNG – overloaded

& poor organisational structure back-ups

• He did not demonstrate a high level of

commitment to safety, eg Cairns base

largely unsupervised and checked itself,

reported pilot hazards not addressed, etc

• SMS largely in manuals not reality - virtual.

Transair’s SMS

• Transair did not have a structured process

for proactively managing safety-related

risks associated with its flight operations

• This included the move from charter into

RPT with passengers in QLD, & expansion

of operations in QLD and NSW to 25 pilots

with new ports such as Lockhart River

• Training was variable and sometimes

entailed little more than an open book exam

Transair’s SMS

• Transair’s Operations Manual involved a

mass of Word documents slapped onto a

CD with no indexing or version control

• Manual requirements for human factors

training, like crew resource management for

multi-crew operations, did not happen

• Transair appeared to have a SMS and a

commitment to best practice but actual

practice reflected a poor safety culture

driven from the top (cf ICAO 2006 Manual).
Hmm...see what I mean? Rolleyes

MTF...P2 Cool

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