[Peetwo]

Continued from Planetalking comments:

37
PAIN_P2
Posted October 3, 2015 at 12:29 pm | Permalink

 ..& again good stuff...

[*]38
Fred
Posted October 4, 2015 at 11:23 am | Permalink
P2 – Most of Australia’s notified differences to ICAO SARPS are minor and relate to variations in the definitions of certain terms under Australian law, or differences that are required by Australian legislation such as privacy law. The US and other countries file variations for the same reasons.

Other differences, such as those in Chapt 5, reflect the reality that the ATSB simply doesn’t have the resources to investigate every accident or serious incident. Annex 13 stipulates that the state of occurrence “shall” institute an investigation into the circumstances of an accident, and “should” do the same for a serious incident. The Australian differences state that the decision to proceed with an investigation depends on “resources and the likely benefit to future safety”. The ATSB would no doubt love to have a bottomless pit of money to investigate each and every report that comes their way, but what’s the alternative when that’s not the case?

The ATSB is not perfect, by any means, but the notion that Australia is “marching to the beat of a very different drum” and that we are on the “wrong side of the ledger” when it comes to the intent of Annex 13 is stretching things a bit far, in my opinion.

Regarding the Hotham incident, is it the investigation that’s a problem, or the fact that the incident occurred at all? If it’s the former, my understanding is that the investigation is ongoing and a report has not yet been released. If it’s the latter, I would suggest that the ATSB’s role is to investigate and make recommendations, but they have no power to force change. That power lies with the regulator and the responsible Minister.

[*]39
Ben Sandilands
Posted October 4, 2015 at 12:03 pm | Permalink
The term ‘responsible Minister’ has been problematical in the administration of air safety issues in this country for a very long time.

Ministers in Australia take advice from the administrations that are failing to serve the public good.

It’s a dangerous closed loop, and it will given enough lack of political will, cause huge grief and anger at some time in the future.

[*]40
Fred
Posted October 4, 2015 at 12:20 pm | Permalink
I agree. My comments relate to the ATSB, which has no power to do anything other than investigate and write a report.

[*]41
Fred
Posted October 4, 2015 at 12:24 pm | Permalink
I should also add that CASA’s adversarial approach to safety regulation doesn’t help either!

[*]42
Sam Jackson
Posted October 5, 2015 at 8:07 am | Permalink
Mild disagreement here Fred with your #40. Look at the exemplar NTSB, they can and do issue Safety Recommendations, serious ones and they make them stick. They are a force to reckoned with and FAA don’t mess with ‘em. Then compare the ATSB performance and, if you can stomach it; study some of the ‘reports’ handed down; start with Pel-Air.

Then have a look at what has been recommended, what has happened to those very few recommendations. Then, if you can manage it, look back at the BASI approach.

ATSB do have the legal ‘clout’ to affect changes; but, they simply defer to CASA, bend over for the AILU both of whom run things as best pleases them, in the name of strictly no liability. Not just my opinion; the evidence is all there, just need to do your homework. It’s a sad indictment of a once great agency.

[*]43
Fred
Posted October 5, 2015 at 2:12 pm | Permalink

Sam,
Sorry, but I respectfully disagree with some of your comments in #42 above. Under Australian law, the ATSB can compel parties to respond to its safety recommendations, but it cannot force those parties to accept and act upon them. The relevant party only needs to state the reasons why it does not accept the ATSB’s recommendations. The USA’s NTSB is similar, in that it has no power to regulate the aviation industry in that country. That said, the NTSB does have enormous resources and a wealth of experience, and its recommendations are normally acted upon, as you stated.

I make no apologies for the performance of the ATSB. The Pel-Air investigation was woeful and Transport Canada’s subsequent review highlighted a number of problems with the ATSB’s investigation. Nevertheless, Transport Canada’s review also stated that the methodologies and processes used by Australia ‘are generally considered to meet or exceed the intent and spirit of the Standards and Recommended Practices in Annex 13’.

I previously stated that ‘the aim of an incident or accident investigation is to find out what happened and why, and to make recommendations to prevent it happening again’. I still firmly believe that to be the case. Whether the ATSB does it effectively or not is another matter entirely.

[*]44
Sam Jackson
Posted October 5, 2015 at 4:26 pm | Permalink

Fred
Rushing out, I phrased my point very badly. I agree with your analysis of what ATSB can do; “legal clout” was inaccurate, my apologies. Just get so disappointed when glaringly obvious recommendations from investigation are ‘rolled’; cranky when an investigation report is ‘massaged’ after an unseemly delay, even more so when SR are not issued when needed and ‘argued out’ – as the NTSB do, regularly. Seen some very good results from the ‘natural tension’ between FAA and NTSB where a good result is ‘hammered’ out – and better risk mitigation is produced. I do firmly believe that a strong, independent ATSB is, as a risk mitigation tool, much better than enforced, prescriptive, complex regulation used to over ride expert, impartial, independent ‘analysis’. But, something is terribly wrong with the system, perhaps the ‘balance’ needs some attention. Anyway – it’s a deep, complex subject, best discussed with suitable lubrication.

[*]45
Fred
Posted October 5, 2015 at 4:58 pm | Permalink
I’ll drink to that!

[*]46
PAIN_P2
Posted October 7, 2015 at 8:40 pm | Permalink

@Fred enjoying this discussion & debate, it seems a pity to let it stop there, so again with Ben’s indulgence I thought I would continue this with a slight change of tack.

To begin here is a P9 post which I don’t think he has included here?

“…Only my own opinion; a notion or ramble may be a more fitting description – but the deep, systematic flaws in the ‘training’ programs seem to be appearing on a regular basis. We have quite a long list from the last couple of years; Mildura, Mooranbah, Melbourne, Sydney, etc. Newcastle being the exemplar where the crew were rescued from landing on the coal loading dock by an alert ATCO.

My mind keeps picking at what I can only call – ‘disconnection’. The modern aircraft, particularly the Airbus are so ‘automated’ that it is quite possible for the crew to feel ‘remote’ from the operational reality. When you have a control column’ in one hand and the power levers in the other, the aircraft is ‘with you’, firmly between your feet on the rudder pedals. The flight path, profile and speed – controlled by you. Reality. It is quite a surreal experience to be playing with automatic systems, remotely asking a computer to sort out the task at hand. Is it possible that crew are becoming more focussed on the ‘keyboard’ and connected to the computer; rather than cognisant of the external factors? It’s academic; but clearly something is going wrong, regularly, and if the ATSB can’t or won’t provide a solution, we need to examine the basic tenets.

Then there is the simulator syndrome; in the ‘sim’ the event being discussed here could have been stopped; a discussion held while the ‘aircraft’ patiently waited at 1000 feet until the point of the exercise was understood; then, reversed back to where the initial problem occurred and- it’s off to the races, problem solved. Is this ‘attitude’ endemic? the reality of a 50 ton aircraft at 135 KIAS on final approach is that it will not patiently park at 1000’ while the mysteries are unravelled, it’s real. It’s dynamic and it is no place for a crew to be disconnected from the task at hand.

Please note; not knocking or denigrating anyone or anything; just trying (struggling) to understand the radical causes. Thinking out loud if you like…”

Okay to which I have replied on Aunty Pru today:

“..To begin excellent thought provoking post by the Ferryman..

..’Disconnection’ is indeed the key word here and it is not solely in the cockpit where this ‘disconnection’ is occurring. The investigator – & to a certain extent the regulator – seems to be failing to join the dots, although maybe there is a light at the end of the tunnel..

…Moving on from the Sydney Jetstar approach dust-up incident and back to more familiar ground with Melbourne approach incidents…

..Noticed that the ATSB today have just released their latest Bulletin of aviation short investigations – Issue 43.

Hidden in the SIB – within the Jet aircraft section – there was this incident – Flight below minimum altitude involving a Boeing 777, A6-ECO, near Melbourne Airport, Vic on 18 July 2014 – http://www.atsb.gov.au/publications/inve...4-128.aspx

To see more of this post go to:- http://auntypru.com/forum/-The-search-fo...23#pid2323

Cheers

P2

[*]47
Seth Knoepler
Posted October 8, 2015 at 2:29 am | Permalink

Pain:
In suggesting what the simulator version of this “teachable moment” might look like you’ve led me to speculate about why the Jetstar captain might have acted as he did. Going back to Ben’s original post, I see that he intriguingly referred to what the captain did as a “partially unauthorized” exercise, and included this sentence:

“A referee pilot suggests that ‘discussion’ in the ATSB report was a euphemism for what was really going on in the cockpit between the tough school training captain who disagreed with the Jetstar company rules for this sort of exercise.”

As you suggest, the trainee could have been (and presumably had, in fact, been) confronted with the same challenge in a simulator. However, Ben’s reference to the Jetstar pilot as a “tough school” training captain makes me wonder whether he was convinced that any trainee who had never been forced to confront such a challenge thousands of feet above terra ferma would not be adequately prepared to deal with such a situation if he were ever forced to do so without an experienced trainer looking over his shoulder.

Now that our flying machines can “think” to an unprecedented degree we are certainly in uncharted territory with respect to how this may affect the behavior of the humans who remain (at least for now) the machines’ commanding officers. However, in this case I wonder whether the Jetstar training captain may have been pushed towards being overly skeptical about whether a relatively “disconnected” simulator experience would adequately prepare a pilot to deal with the same situation during a revenue flight.

[*]48
Fred
Posted October 8, 2015 at 11:33 am | Permalink

P2,
Interesting points you raise – that sense of ‘disconnection’ has been with us for some time and is getting worse as our world becomes increasingly automated. In the past, pilots would rely on their previous experience and fall back to basics to get them through when things went wrong. Nowadays, we have become so dependent on automation that many of the traditional piloting skills are fading through lack of practice. Our training systems have not kept pace with the changing world, leaving pilots poorly equipped to deal with the challenges they face.

I believe the two biggest challenges for safety management amongst pilots (and others!) are decreasing experience levels and fatigue. A new generation of pilots is being trained to move directly into the right hand seat of advanced airliners. Those pilots have not had the opportunity to develop their skills in GA or the military and have no past experience to fall back upon if something goes horribly wrong. Fatigue is also becoming a problem, as airlines push their crews for more productivity. The buffers are being eroded as pilots are pushed to operate continuously at the legal limits, often at the ‘back of the clock’ and across multiple time zones. The combination of low experience and fatigue is, in my opinion, a disaster in the making.

It was good to read about the investigation into B777 incident at Melbourne. Some great input by all concerned, valuable lessons learnt and useful recommendations to prevent a recurrence.

Seth,
I tend to think that the Jetstar training captain was motivated by a desire to get more training value out of the autoland exercise, but not necessarily due to the sense of ‘disconnection’ experienced in the simulator. An autoland in the aircraft, once it is setup and configured, is essentially a ‘non-event’. The pilots only have to sit back and monitor the automation and watch while the aircraft does its thing. It’s essentially a ‘box ticking’ exercise required by the regulator and doesn’t have a lot of training value. I think the training captain tried to increase the value of the exercise by simulating failures to reinforce the training already done in the simulator.

[*]49
Dan Dair
Posted October 8, 2015 at 7:33 pm | Permalink
If there is a disconnect between the flight-systems & pilots getting a ‘feel’ for what the aircraft is really doing
and
an element of ‘unreality’ about the training methods in a simulator,
surely these are matters which the regulators AND the unions should be discussing amongst themselves and raising with airlines & Government, to ensure that this situation changes for the better.?

IMO, whatever the best intentions of that particular training captain,
final approach and with a whole bunch of passengers sat behind them is not the correct place to ‘spring’ a non-standard training ‘scenario’ on an unsuspecting novice first officer.?

[*]50
Sam Jackson
Posted October 8, 2015 at 11:47 pm | Permalink

Seth, Dan, Fred et al.
I don’t believe any of us here can, not in half brief page solve the puzzle. Given the time, money and resources of the ATSB, a substantive, credible, report of value could be provided by industry. It is very much in ‘our interests to do so. There is indeed a world wide pattern emerging, which, even to the most jaundiced, commercially focused eye can be clearly seen as detrimental to vested interests. However, we do pay, handsomely, for an independent safety investigator and we may, quite rightfully expect that they, as an independent arbiter and ‘expert’ could provide a study into these complex matters. At very least, each incident could be holistically examined and reported with the ‘trend’ identified and even some suggestions for a fix. For an airline to undertake such a study would be pointless, for practical purposes, except for their own SOP.

The ‘thing’ that most annoys is the simple plain fact that there are identified problems with the MEL arrivals system; the facts are all there, yet has any constructive move been made to identify a pattern, a system, or even a waypoint which could be identified as a potential threat? No, except for the overseas carriers (who did their own heavy lifting). But there a string of incidents associated. Take SHEED, that waypoint could easily be relocated to provide a ‘stable’ approach gradient; but that would involve relocating the strobes, that would cost money, hard cash; and someone would be blamed. Whereas soft, PC reports delayed analysis and ‘company fixes’ are all used to dilute the impact, defray the pattern and diffuse the clear picture.

This before we even begin to contemplate the strange and wonderful mystery of pilot automatics dependency; slavish behaviour to the computer Captain; loss of ‘stick and rudder skills, let alone what that does to situational awareness, confidence and fatigue. The incident discussed here is deep and complex just on those matters stand alone, before we even begin delve into the more esoteric issues.

This is an enjoyable discussion and in the spirit of ‘discussion’ I will pose one question. Both engines ‘suddenly’ go back to flight idle and the auto throttle disconnects; what is your first instinct? – bump the taps back to where they should be and do the necessary; or, grab a book for ‘instructions’ then use a key board to ask the computer what is wrong, then, ask the computer to fix it for you? N.B. Not situationally specific, but in ‘general’ terms. Now, I’ll just go quietly back to my knitting and beer, wishing I said nothing.



[/url] [url=http://blogs.crikey.com.au/planetalking/2015/09/29/what-happened-when-a-jetstar-captain-and-trainee-locked-horns-approaching-sydney/?comment_page=1/#comments]1 2

• 51
  Sam Jackson
  Posted October 9, 2015 at 12:02 am | Permalink
  Addendum
  I might add, that I can well understand the Captains ‘fury’ and the FO’s confusion and defensive anger; what I fail to grasp is ‘why’ the loss of ‘situational awareness, until the computer chimed in? As stated; it’s complicated. Now where did I leave that beer?
  

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MTF?- Hopefully