Thread Rating:
  • 0 Vote(s) - 0 Average
  • 1
  • 2
  • 3
  • 4
  • 5
Accidents - Domestic
Yet another ATSB PC'd report - Dodgy

The ATSB report - Incorrect configuration involving ATR - Gie Avions De Transport Régional ATR72, VH-FVL - & via Oz Aviation:

Quote:ATSB highlights crew workload in Virgin Australia ATR go-around report
September 6, 2017 by australianaviation.com.au
 
[Image: ATR-72-VIRGIN-AUSTRALIA-BNE-SEP11-RF-IMG_0399.jpg]A file image of a Virgin Australia ATR 72 turboprop at Brisbane Airport. (Rob Finlayson)

A Virgin Australia ATR 72 operating a flight from Moranbah to Brisbane had to conduct a go-around after an incorrect flap settings was selected on approach, the Australian Transport Safety Board (ATSB) says.

The incident occurred on April 2 2017 when ATR 72-500 VH-FVL, with 38 passengers and four crew onboard, was turning onto final approach for Brisbane Airport’s Runway 19.

At that time, the captain, who was the pilot flying, directed the first officer, who was the pilot monitoring, to select flap 30, set the airspeed indicator bug to the approach speed (VAPP) and start the before landing checklist.

However, the ATSB report said the flightcrew noticed during final approach the aircraft was “not performing as expected”, with its airspeed higher than during a normal approach.

“The captain had to keep adjusting the aircraft attitude and engine torque setting to control the speed,” the ATSB said.

Later, as the aircraft descended to 173ft, the enhanced ground proximity warning system activated with the alert, “TOO LOW FLAP”.

The captain then immediately conducted a missed approach and during the subsequent climb, called “flap 15, check power” and the first officer responded accordingly.

The aircraft then conducted the same approach to Runway 19 and after landing the captain decided to stand the crew down and not conduct the next two sectors.

Flight data showed the flaps were incorrectly set for conducting a normal landing.

“During the approach, the first officer moved the flap lever up from flap 15 to flap 0, instead of from flap 15 to flap 30 as intended. This resulted in an unstable approach,” the ATSB report said.

“The crew did not identify the incorrect flap setting until the ground proximity warning system alerted them to an incorrect configuration, likely due to workload.”

The ATSB report said the first time the captain became aware of that the flap was set to 0 degrees was during a review of the flight data animation conducted by the airline.

“Since the incorrect flap setting was not detected by the crew on approach, had they managed to slow the aircraft to the VAPP of 104 knots for flap 30, they would have been 2 knots below the stall speed for the actual flap setting (106 knots),” the ATSB said.

Meanwhile, the ATSB report noted the workload of the crew increased during the approach, when there was a combination of turning onto he final approach path, conducting a visual approach, managing radio calls with air traffic control and responding to the unexpected aircraft performance.

“Flap settings are generally confirmed through the completion of the before landing checklist, whereby the flap lever and indicator must be visually checked,” the ATSB report said.

“However, in this case, this part of the checklist happened during a high workload period, and it was subsequently rushed. This checklist item may have been missed.

“This investigation highlights the potential impact crew workload has on flight operations as it can lead to adding, shedding, or rescheduling actions. Handling approaches to land continues to be a safety priority for the ATSB.”

However back to the Jetstar tailstrike incident and the Oz Aviation coverage of this would seem to confirm that it was a cadet who was the PF of this flight:

Quote:ATSB releases Jetstar tail strike report
September 5, 2017 By australianaviation.com.au 3 Comments

The Australian Transport Safety Bureau (ATSB) has released its report into a tail strike incident involving a Jetstar Airbus A320 taking off from …

 Although a little ambiguous, it could be interpreted that the cadet pilot was in fact conducting the flight as a CTL First Officer:

Quote:..It was the cadet pilot’s first flight as the pilot flying. Alongside him in the flightdeck was a training captain in the left seat and a safety pilot in the jump seat...
  
P9: ..Why could the PIC not put a steadying hand on the side-stick to prevent the over pitch – we’ve all done it – the nose rears up and the steadying hand acting as a buffer to prevent enthusiasm turning to disaster. You would not consider doing this with a qualified, clear to line operations FO, but with a ‘cadet’ – you’d be watching like a hawk on a mouse. (Oh, it was an Airbus, then things are different; no matter)...

Absolutely spot on "K" - Shirley the CASA approved Jetstar T&C system for 'cadets' has a more robust simulator CTL to facilitate the line training fallibilities and limitations of the A320 vs the Boeing equivalent... Huh  

MTF...P2  Cool
Reply
(09-06-2017, 07:41 PM)Peetwo Wrote: However back to the Jetstar tailstrike incident and the Oz Aviation coverage of this would seem to confirm that it was a cadet who was the PF of this flight:

Quote:ATSB releases Jetstar tail strike report
September 5, 2017 By australianaviation.com.au 3 Comments

The Australian Transport Safety Bureau (ATSB) has released its report into a tail strike incident involving a Jetstar Airbus A320 taking off from …

 Although a little ambiguous, it could be interpreted that the cadet pilot was in fact conducting the flight as a CTL First Officer:

Quote:..It was the cadet pilot’s first flight as the pilot flying. Alongside him in the flightdeck was a training captain in the left seat and a safety pilot in the jump seat...
  
P9: ..Why could the PIC not put a steadying hand on the side-stick to prevent the over pitch – we’ve all done it – the nose rears up and the steadying hand acting as a buffer to prevent enthusiasm turning to disaster. You would not consider doing this with a qualified, clear to line operations FO, but with a ‘cadet’ – you’d be watching like a hawk on a mouse. (Oh, it was an Airbus, then things are different; no matter)...

Absolutely spot on "K" - Shirley the CASA approved Jetstar T&C system for 'cadets' has a more robust simulator CTL to facilitate the line training fallibilities and limitations of the A320 vs the Boeing equivalent... Huh  

Follow up - Rolleyes

Extracts from the ATSB report:

Quote:..The flight was scheduled as a training flight with the cadet pilot conducting his fifth sector of line training and the first sector of the current shift. There was also an FO in the jump seat acting as a safety pilot. The four previous sectors had been flown with the cadet pilot as pilot monitoring (PM). This was the first flight for the cadet pilot as PF...


&..

Due to the higher than normal rotation rate and the noise heard by the cabin crew, the captain elected to stop the climb and return to Melbourne. The first officer swapped seats with the cadet pilot and the aircraft landed uneventfully on runway 27.


Findings

From the evidence available, the following findings are made with respect to the tail strike during takeoff involving Airbus A320 VH-VGF at Melbourne Airport, Victoria on 11 May 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factor

The cadet pilot applied a larger than normal sidestick pitch input to initiate rotation. This resulted in a high rotation rate during the take-off and the aircraft’s tail contacted the runway.

Other factor

The potential tail strike was not adequately communicated to Melbourne air traffic control. This delayed checking the runway for aircraft debris.

Besides the seemingly glossed over T&C issues mentioned previously, I also question why the ATSB did not probe the safety issue with the Training Captain, apparently in the middle of conducting a Abnormal operation, made a command decision to stand down the cadet pilot and fly the aircraft single pilot until the Safety Officer FO had swapped seats with the cadet??

 Maybe I am missing something?? - But Shirley it would've been more advisable for the cadet to remain in the RH seat and conduct the rest of the flight as PM, a role that he had successfully carried out on five previous sectors... Huh       


MTF...P2 Cool
Reply
Terminology and ‘clutter’.

The use of the term ‘cadet’ muddies the waters a bit and without hard fact we are left making assumptions. But if we look on the ‘bright’ side, lets assume the ‘cadet’ had completed a simulator type rating and all the trimmings; before doing either in the aircraft, we can assume that both take off and landing had been correctly executed to a satisfactory standard. The modern simulators very closely represent the actual aircraft and, in theory at least there is little to no difference that matters. Soon or late the ‘cadet’ must fly the real aircraft – on line. The system using a TC as PIC and a seasoned FO in the jump has proved to be a good one, I assume many ‘cadets’ have been eased into operational flying through the system, quite safely and properly. So let’s not quarrel over the word ‘cadet’, it may be a misleading title, but we have to call ‘em something until they become FO’s proper. I don’t think we can lay any blame at the door of the ‘training’ given or the system used. Which takes us back to the shabby report.

Item 1: let's say the cadet has had a good grounding in the sim and four sectors as PM; so this is not the first rodeo; yet there was a tail strike – why? An independent analysis of what caused the strike would be of benefit to all and sundry.

“The cadet pilot applied a larger than normal side-stick pitch input to initiate rotation. This resulted in a high rotation rate during the take-off and the aircraft’s tail contacted the runway.”

This is cited as a ‘contributing factor’. Bollocks, after the fact result.  “a larger than normal side-stick pitch input to initiate rotation”. What brought that on? IMO it is essential that we understand why the child, despite training, practice, mentoring and monitoring managed such a thing. Under rotation due to caution – OK, I could accept that. Over rotation due to unfamiliarity - in the Sim; I could accept that; but by the time young spotty is conducting a take off, for real, then the reasons for the action need to be examined – if only to fully understand it as a matter for future training. It is no ones fault and I don’t seek to lay blame, however I would like to know exactly what was going on in the ‘cadets’ head at the time, simply to prevent this happening again. An independent assessment by the ATSB could have shed some light on this event and perhaps prompted a minor modification to the training system – one which may have  been overlooked - who knows. Statistically, this event would be a tiny dot; betcha there are 100 good, clean, first real take offs made by ‘cadets’ to this one. Even so – if it can happen once, it can happen again and early prevention is better than a late cure. No doubt the airline T&C system has already taken pro-active steps; but without the ATSB being involved in any meaningful way – again.

The changing of seats puzzles me; the PIC effectively operating single pilot for the short period. Now if the ‘cadet’ was full bottle why bother? It was only a tail strike, and return – ops normal - not a full on ‘emergency’. What if there had been fire, smoke or any of the other gremlins which make a time critical ‘emergency’. What then? Low level, emergency, turbulence, two out of three pilots unstrapped, falling over each other trying to reposition while the whistles and bells are demanding multi crew attention - now - now. Nah, not funny. If the rules say that the FO must be qualified to be ‘crew’ during abnormal or emergency operations; then the crew operating must be capable of dealing. You can’t have people leaping about the cockpit when the do-doo hits the windmill. ATSB fail, yet again, to offer advice or analysis on a potential cluster of ducks. Once again we must rely solely on the good sense of the operating company T&C system to take a long hard look at the case, draw their own conclusions and fix it. This does not excuse the ATSB from having a meaningful, independent input to the incident.

Aye well; something nothing – that ‘cadet’ is unlikely to repeat the error; the T&C will sort it out and the ATSB will continue providing reports with less meaning than the Sunday papers mention of it. It’s Hi-viz, hot air and no responsibility for all in the political world of the ATSB.

Toot toot.
Reply
Story here..
Quote:ROSSAIR TO FLY AGAIN AFTER SA CRASH

A South Australian based charter airline, grounded since a fatal crash earlier this year, will fly again.
Rossair on Friday announced a joint venture with Victorian based AusJet.
The company's CEO Warren Puvanendren said the partnership would allow the airline to resume services for SA's mining, energy and tourism industries.
"After a challenging few months, the combination of both groups' fleet and experienced staff will allow us to commence servicing our clients immediately," Mr Puvanendren said.
"We are proud of what this opportunity with Ausjet can deliver to the SA charter market."
A Rossair plane on a training exercise crashed in the Riverland in May killing three people, including the company's chief pilot.
An initial report by Australian Transport Safety Bureau found the Cessna Conquest hit the ground nose first soon after take off from the Renmark Airport.
Killed in the crash was chief pilot Martin Scott, 48, fellow pilot Paul Daw, 65, and Civil Aviation Safety Authority inspector Stephen Guerin, 56.
The ATSB is expected to hand down its full report within 12 months.
Reply
Gee Whiz – there’s a ‘fuss’ going on over at UP. Some cadet failed to set the flap for landing; the skipper stood the crew down after a flapless landing. All kinds of bitch slapping and hair pulling going on – except no one has asked the important question.

Why didn’t the PIC ‘look’ and ‘check’ that the flaps were indeed where they should be?  Had a 1000 feet to do it in; just a quick glance; make certain all is as it should be.

Where is the SOP which says ‘cross check’  - ALWAYS. Routine - in my poor old wooden head - check speed – call for flap – note running and check set – “Flap 30?” – Confirmed. Poor old cadet gets a UP flogging though; for strange PIC behaviour and piss poor SOP.
Reply
Reported on back up here Ol'Tom:

Quote:Yet another ATSB PC'd report - [Image: dodgy.gif]

The ATSB report - Incorrect configuration involving ATR - Gie Avions De Transport Régional ATR72, VH-FVL - & via Oz Aviation:

Quote: Wrote:ATSB highlights crew workload in Virgin Australia ATR go-around report
September 6, 2017 by australianaviation.com.au
 
[Image: ATR-72-VIRGIN-AUSTRALIA-BNE-SEP11-RF-IMG_0399.jpg]

A file image of a Virgin Australia ATR 72 turboprop at Brisbane Airport. (Rob Finlayson)
 
Also covered by PT where some of the comments are a little bit more balanced than off the UP:
Quote:[Image: VA-ATR-wikipedia-e1504658769218.jpg]
Botched Virgin turboprop landing attempt sees captain stand himself down

Ben Sandilands Sep 6, 2017 6 Comments
Safety investigator silent on how Virgin Australia responded to pilot confusing flaps zero with flaps 30 in botched landing approach


On April 2 this year a Virgin Australia ATR turboprop was flown at the wrong speed and flap setting toward an intended landing at Brisbane Airport with 38  passengers as well as two cabin crew and two pilots on board before the captain broke off the approach after an audible warning from its enhanced ground proximity warning system.

The high wing regional airliner was less than 172 feet off the ground when the synthetic voice called TOO LOW FLAP and the captain, who was flying the approach, initiated a go-around, climbing away from the airport and bringing the flights which had started at Moranbah back for a properly configured landing.

According to the [b]ATSB investigation[/b] into this serious incident, published today, the captain was so concerned at the events of that initial landing attempt that he then decided to stand himself and the rest of the crew down and not operate the next two intended regional flight sectors.

As the ATSB reports, it turned out that when the captain had called for the first officer to set the aircraft’s flaps to 30 degrees the junior pilot set them to the other end of the scale, at zero degrees.

The ATSB points out that had this setting been retained, the aircraft would have been moving at just under stalling speed, that is, no longer technically flying, when it made contact with the ground.

The ATSB doesn’t elaborate on the perils of such a situation, but they should be self evident. A stalled airliner discharging its kinetic energy without control on a runway at night. What could possibly go wrong?

There is no detailed explanation as to why the captain cancelled his and his crews participation in the intended next two flight sectors for this duty period.  Yet the ATSB reveals that the captain didn’t learn that the first officer had set the flaps to zero at the wrong moment, until the airline showed him a post flight animation, some time after the serious incident occurred.

This report is very thorough on the technical side as required by such an investigation. But it is silent on what actions Virgin Australia may have taken subsequently to prevent such incidents exposing their employees and their customers to the dangers or risks they pose.

In compiling this report on the ATSB investigation no media response has been sought from the airline. All that counts in these investigations is what the ATSB says it found, not statements from carriers that unfailingly state that safety is their Number One priority.

It might be this or any carrier’s number one priority, and it can be argued that it is in fact an absolute requirement of their holding an air operator certificate for the aircraft concerned and the procedures the company undertakes to enact.  These responsibilities are mandatory for Australian airlines and the personal responsibility of each and every one of their board members.  They aren’t optional, and they don’t involve the exercise of choice to make them ‘the priority’. They are compulsory.

In this case, if its accepted that safety is the number one priority of the carrier, then that priority wasn’t successfully applied.


MTF...P2 Tongue
Reply
(08-18-2017, 08:36 AM)Peetwo Wrote: Angel Flight oversight to be reviewed - Angel

By Meredith Booth via the Oz:

Quote:
Quote:[Image: images?q=tbn:ANd9GcS5WL0nDdi1OX8Jf2HOsh5...6lTARtktlQ]


CASA to re-examine charity flight standard

The Australian 8h ago

Two fatal Angel Flights in six years have prompted Australia’s civil aviation safety regulator to re-examine standards for community service flight providers.

The review was prompted by the June 28 crash of an Angel Flight near Mount Gambier airport that killed private pilot Grant Gilbert, 78 and his passengers Emily Redding, 16, and her mother Tracy Redding, 43 who were on their way to a medical appointment in Adelaide.

It was the second doomed Angel Flight, after experienced volunteer pilot Don Kernot and passengers Julie and Jacinda Twigg, died in August 2011 when their plane crashed in country Victoria on a return flight from Melbourne to Nhill.

Jacinda, 15, was being treated for juvenile arthritis in Melbourne and was returning to her home near Nhill, when the plane came down in poor weather.

Angel Flight Australia is a charity that co-ordinates non-emergency flights to help rural Australians to access city medical services, providing almost 22,000 flights since 2003.

Prompted by the 2011 crash, the Civil Aviation Safety Authority toughened regulations for the sector in 2014, saying the status quo, where any aircraft could be used by any privately licensed pilot, was not “sound safety regulation”. Although it pushed for the charity to self-regulate — including overseeing pilot training, regular pilot checks and aircraft approvals — strong resistance from Angel Flight and its regional supporters prompted any proposed changes to be shelved.

CASA spokesman Peter Gibson said the discussion was now being revisited. “CASA is looking at the safety issues relating to community service flights in the wake of the tragic accident at Mount Gambier,” he said. “However, given the (Air Transport Safety Bureau’s) full analysis will not be available for some months, it is too early to comment on the accident itself or any factors that may have caused the accident.

“As a prudent regulator, CASA always reviews safety issues following serious accidents.”

Angel Flight chief executive Marjorie Pagani said the charity already sought stronger-than-­required CASA standards for its volunteer pilots, including at least 250 hours in command experience. Any changes to regulations on community service flights was the responsibility of CASA.

“We’re happy to co-operate with CASA and the Australian Transport Safety Bureau,” Ms ­Pagani said. “We have 3200 registered pilots; five to six times more than CASA requires for private pilots in a private flight, all documents are checked including current insurance and $10m public liability. We cant do anything but rely on CASA’s standards.’’

The Nhill pilot, Mr Kernot, had 6000 hours in command and Mr Gilbert had “well in excess” of 250 hours.

Ms Pagani said the Mr Gambier crash had not damaged Angel Flight’s reputation. “The support that we had from people in the community, from the passengers from pilots has been nothing short of amazing. The general tenor is this is a tragedy, but please don’t stop,’’ she said.

ATSB’s full report on the Mount Gambier crash is expected by the middle of next year.

In a follow up to the CASA review of Angel Flight, I note the following addition to the HoR Adjournment debate, courtesy of the member for Farrer the Hon Sussan Ley MP... Rolleyes :

Quote:Air Safety
[Image: 00AMN.jpg] Ms LEY (Farrer) (16:56): I rise to discuss matters concerning aviation safety and to submit to the parliament a view that Australia needs new safety standards for community service flights conducted on a voluntary basis. Many who live in rural and remote Australia, as I do, are familiar with Australia's best known charity medical air service, Angel Flight, operating since 2003, an organisation that coordinates non-emergency flights flown by volunteer pilots to transport country passengers to medical appointments, usually in capital cities.

In the last six years, there have been two fatal flights, the most recent being on 28 June near Mount Gambier, in which the pilot and two passengers were killed. In August 2011 another flight crashed near Nhill in western Victoria, again with no survivors. I will resist commenting on the causes of the accident earlier this year, as its circumstances are subject to an ongoing Aviation Transport Safety Bureau investigation. At the end of 2013, the ATSB released its report into the 2011 accident and found as follows:

… the pilot probably encountered reduced visibility … due to low cloud, rain and diminishing daylight, leading to disorientation, loss of control and impact with terrain.
This was a clear safety message about the risk of such flights made by pilots without high instrument flying proficiency and recent night experience.

In 2014, CASA released a discussion paper in which it sought to toughen regulations for community service flights. The paper argued:

As community service flights become more widely used, the variable pilot qualifications and aircraft certification and maintenance standards become significant potential risk factors.

It canvassed 10 administrative and/or operational options, noting that too heavy a regulatory hand would mean the cost of compliance would effectively rule such flights impossible. At the time there was strong resistance to change from Angel Flight and from regional communities, and the proposed changes were shelved. However, following the latest tragedy, CASA announced that it will re-examine standards for flights like Angel Flight. That is a good thing. As a general aviation pilot, with a commercial licence I earned in 1980 and having had a career as a bush pilot and still flying myself across the big distances of western New South Wales, I am the very last person to wish for additional regulation on pilots, and it gives me no pleasure to call for change within a charitable organisation that has at its heart and soul the volunteering, giving spirit of so many country people. But a passion for flying and a love of helping people are not sufficient without adequate safety standards.

Most people are familiar with charter flights that leave their local regional airports from time to time—small planes that come and go from out-of-the-way places—and they would consider that the Angel Flight used by their family member is covered by the same rules and regulations. I believe they'd be surprised to know that this is not the case. Operators of charter flights must have an air operators certificate and conform to a far higher standard than regular private flights. Much of this standard is frustratingly bureaucratic, but at its heart is the critical imperative of aviation safety. In the case of a charity flight, the relationship that would exist in a private flight doesn't exist. The members of the public are unsuspecting. There is an element of vulnerability about their circumstances, particularly when children are involved. This may introduce a degree of operational pressure. The level of competency of pilots flying the trips may be as high as or higher than that of those who fly regular public transport routes, or it may be lower than the level of an average pilot.

I have criticised CASA many times over the years, but their 2014 discussion paper should be revisited. Their preferred option—an approved self-administering aviation organisation—would allow this sector to regulate itself. Changes must be made, and I do believe a way forward can be found so that our volunteer pilots can continue to help support country people's access to medical services.

House adjourned at 17:00
 


MTF...P2 Cool
Reply
More tea Vicar?

‘Tis but a ramble M’lud; with your indulgence (or without) I will proceed:-

“Two fatal Angel Flights in six years have prompted Australia’s civil aviation safety regulator to re-examine standards for community service flight providers.”

“As community service flights become more widely used, the variable pilot qualifications and aircraft certification and maintenance standards become significant potential risk factors.”

You can almost hear the barricades being raised, the knives being sharpened and the same old saws being tuned up. This has dragged on for years now and we are no closer to an acceptable – compromise – solution.

There are some good ideas around although if AF don’t sink ‘em, then CASA will. AF will take a position that if the CASA ‘standards’ for PPL are not good enough then – blah, blah. CASA will say they are and then blah, blah. The ‘legal eagles’ do what they do and the party continues.

One of the better solutions, IMO, comes from the AOPA and is worth some thought. I’ll not go into the nitty-gritty for sake of brevity; but it runs something like this. Put together a couple of ‘week-end’ training courses, for AF pilots to attend. Draw CASA into the construction of those courses, to add value and to make it ‘official’. There are a variety of subjects which are of value – Meteorology – understanding and ‘reading’ of actual and forecast conditions. Flight and contingency planning for the expected conditions and time frame. Aircraft performance and fuel planning. Fatigue and delay anticipation; CFIT analysis; Icing. All valuable ‘add on’ to a basic licence. You could add in current  night proficiency and ‘bad weather’ circuits; even forced landings on the practical side. In short, provide the ‘tools’ needed for survival when the going gets tough.  I’d love to include basic ‘instrument proficiency’ to the list; but the deeply entrenched ‘sides’ will not consider compromise of any description. Shame really; only my personal take, but if a pilot has the ‘basics’ then those may be ‘practiced every flight; speed and height control, turns to a heading – etc. to maintain a level of competence in a situation where control could be lost – if the pilot was dopey enough to get into a situation which required the ability. Leaving it there – I can hear the old chain saw engines firing up.

A tailor made course, for AF crews, a record of current experience and a small amount of operational rostering control.  AF offers Bloggs a long day – every chance of a return after dark – night current (Yes) – (No); simple go or no-go decision.

There is a notion to align ‘qualification’ to ‘region’ which is worth (IMHO) a moments thought. Extreme would be a pilot who has flown mostly out of say St George to Roma taking on a flight from Bendigo the Melbourne in the middle of winter on a bad day. There is nothing legally preventing that from happening – however, from a practical point of view…..

I don’t believe CASA want to come down ‘heavy handed’ on a valuable community service; AF certainly don’t want their operations constrained; but, there have been two, high profile, fatal accidents and because it involves ‘sick people’ the topic is ‘emotive’ which makes it fodder for political animals and the media.

Proactive cooperation, collaboration and serious, considered, balanced input from ALL those concerned is needed – well, that and a brave umpire; wonder if Solomon is available? Hate to see the AF wings clipped; but, we can’t have the percentage chances of a fatal accident any higher than they are now. Pity AOPA is on the ministerial nose – there is enough sense being talked there at the moment to be of value to the discussion.

Ramble over- just the stray thoughts and musings of an idle mind.

Toot - toot
Reply
An observation or two and a couple of questions regarding these incidents K.
Why in the US do more than 80% of the private pilot brigade hold instrument ratings but in Australia less than 20% hold that qualification? Wouldn't be that gaining and maintaining that qualification is just too expensive and onerous here compared with there? Would holding that qualification have reduced the likelihood of these events occurring?

I wonder how many "Items" are in the ATR before landing checklist? I know with some of the older transport aircraft checklists designed way back when and probably designed by the manufacturers lawyers with "liability" in mind, tended to contain a myriad of "As required" responses to non critical items which created a forest of trees masking the wood. As an example the Boeing 767 before landing checklist contains only three items as opposed to fourteen in a fairly sophisticated Corporate type.
Our aviation "Experts" simply will not listen to reason as to why, in the modern era,  these checklists should be modified to better emphasise the kill items make the checklists much shorter and less likely to be interrupted by workload.

'K" edit - Choc Frog and Amen.
Reply
The latest ATSB REX final report -  Huh


Via Oz Aviation.. Wink :
Quote:ATSB releases Rex engine failure report
September 18, 2017 by australianaviation.com.au 2 Comments

[Image: Saab-340-Rex-VH-RXS-SYD-AM-2.jpg]A file image of VH-RXS (Andrew McLaughlin)

The Australian Transport Safety Bureau (ATSB) says a lack of lubrication was the most likely cause of an engine failure involving a Regional Express (Rex) Saab 340B on March 23 this year.

The incident occurred shortly after the turboprop VH-RXS took off from Dubbo bound for Sydney carrying 26 passengers and three crew.

When the aircraft was climbing through 4,300ft, the flightcrew “heard several bangs from the right engine accompanied by jolts through the aircraft”, the ATSB final report published on Monday said.

This was accompanied by a burning smell in the flightdeck alongside cockpit master warnings.

The pilots conducted a shutdown of the right hand engine, declared a PAN to air traffic control and requested emergency services at Dubbo Airport.

They then completed standard failure management procedures before the captain conducted a visual approach back to Dubbo Airport, landing on Runway 05.

There were no injuries, while the aircraft suffered minor damage.

The ATSB report said an initial engineering examination found the number four bearing on the right hand engine failed.

“The bearing failure allowed the high pressure compressor to move off-centreline within the engine. This caused further damage and led to complete failure of the engine,” the ATSB said.

“The damage to the failed bearing was consistent with overheating due to a lack of lubrication. 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 ATSB said the engine manufacturer’s engineering examination of the failed engine was not completed at the time its final report into the incident was released.

The Saab 340B is powered by two General Electric CT7-9B turboprop engines.

Meanwhile, the report said comments from the captain indicated emergency procedures and simulator training prepared the flightcrew well for the incident and allowed it to effectively manage the engine failure.

“Faced with an abnormal situation, the training provided to the flightcrew ensured they were able to effectively implement the standard failure procedures, secure the failed engine and return for a safe landing,” the ATSB report said.

“During an emergency, flight crew prioritise the management of the emergency to ensure that the safety of the flight is not compromised. Completing the emergency procedures, along with the coordination of emergency services and communications with supporting agencies may absorb a significant amount of time before the flightcrew are able to provide an update to passengers.”

The two comments are IMO also worth regurgitating:

Quote:Comments

  1. AlanH says

    September 18, 2017 at 8:47 pm

    This, along with the loss of a propeller above Camden. The Saab 340Bs are a terrific aircraft that have served Rex exceptionally well and certainly are a good “fit for purpose” for Rex operations, but they are getting long in the tooth. Perhaps Rex needs to look at updating its fleet sooner rather than later before a catastrophe occurs. ATR 42 perhaps?

  2. Adrian P says

    September 19, 2017 at 10:20 am

    Not sure how it is possible to have a final report when the engine manufacturer’s engineering examination of the failed engine is not completed. If the primary issue is a lubrication failure, need to know why, before another lubrication failure occurs.


Adrian makes an excellent point and I would add that it is normally accepted that a 'serious incident' investigation will inevitably take at least a year to complete and therefore given this incident occurred on 23 March 2017 I have to ask - what the hell is the rush??

For those interested here is the link for the final report: https://www.atsb.gov.au/publications/inv...-2017-034/

P2 comment - This bit under the 'WTD happened' kind of bemused me... Huh

Quote:Figure 1: Regional Express SAAB 340B, registered VH-RXS
[Image: ao2017034_figure-1.png?width=463]
Source: VJ Bhana

After completing the memory items, the flight crew commenced the standard failure management procedures. The flight crew secured the right engine and established that the aircraft was performing satisfactorily. The flight crew declared a PAN[2] to air traffic control and requested emergency services. The flight crew then descended the aircraft to 4,000 ft and identified an area to the south-east of Dubbo which was clear of cloud and other traffic. The first officer manoeuvred the aircraft to this area in order to reduce workload while the flight crew continued the standard failure procedures. The captain identified Dubbo as the most suitable airport for landing. The flight crew reviewed the weather conditions for Dubbo and elected to conduct a visual approach and landing. The flight crew then briefed the cabin crew member on the situation, advised that they were returning to Dubbo and to expect a normal disembarkation.

Maybe it is the disjointed way it is written but the above text gets even more confused when you consider the Captain's comments:
Quote:Captain comments

The captain of the flight provided the following comments:
  • The first officer remained as the pilot flying until they were prepared to make the approach, as this allowed the captain to focus on the engine failure checklist.
  • Emergency procedures and simulator training undertaken by the flight crew was effective. The training prepared the flight crew well for the incident and along with the procedures in place, allowed the flight crew to effectively manage the engine failure.
  • During emergencies, it is important to follow procedures and not rush. This ensures all necessary actions are completed correctly. At each step, take a moment to review the overall situation and aircraft performance to ensure that it is safe to continue.
  • The engine failure checklist instructs the flight crew to consider a restart of the failed engine. At the time of the failure the right engine low oil pressure, over-temperature and chip detector[3] warnings all illuminated. As the warnings indicated that the engine was damaged and not recoverable, the captain elected not to attempt to restart it.
  • There was cloud in the area of the runway 05 area navigation (RNAV)[4] approach, the captain elected to remain clear of cloud and conduct a visual approach. As the runway 05 RNAV approach had quite a high minimum descent altitude, entering cloud may have resulted in a single engine missed approach.
  • After the flight, the captain received reports that passengers were concerned at the length of time taken after the engine failure for the flight crew to update them on the situation.

Maybe it is lost in translation in the butchered ATSB desk top report but the Captain's comments would seem to be attempting to justify why it was that the flight crew elected to conduct a single-engine cloud break procedure in lieu of a much safer runway 05 IAP... Huh


MTF...P2 Cool
Reply
Breaking news: Fatal accident near Jimboomba QLD.

Via QLD Times:

Quote:BREAKING: Two dead as light plane crashes in Scenic Rim
26th Sep 2017 10:32 AM | Updated: 11:07 AM

[Image: planecrash-mjdbxfs8nk7god7jzo2_ct620x465.jpg]
Two people have been killed in a light plane crash at Allenview, near Jimboomba. Credit: Nine News Queensland


by Helen Spelitis


POLICE are working to contact the families of two men killed in a light plane crash. 
The plane came down in a grassed area at Allenview, near Jimboomba about 9.45am. 
Emergency services were alerted to the incident by a member of the public who sounded the alarm just before 10am.

The aircraft is a Diamond Da 40 and was significantly damaged in the crash landing. 
Emergency services are still on the scene. 

A Queensland Ambulance spokesperson said the plane came down on a grassed area and multiple units responded.

"No one required transport," the QAS spokesperson said. 

RIP - Angel
Reply
(09-26-2017, 11:24 AM)Peetwo Wrote: Breaking news: Fatal accident near Jimboomba QLD.

Via QLD Times:

Quote:BREAKING: Two dead as light plane crashes in Scenic Rim
26th Sep 2017 10:32 AM | Updated: 11:07 AM

[Image: planecrash-mjdbxfs8nk7god7jzo2_ct620x465.jpg]
Two people have been killed in a light plane crash at Allenview, near Jimboomba. Credit: Nine News Queensland


by Helen Spelitis


POLICE are working to contact the families of two men killed in a light plane crash. 
The plane came down in a grassed area at Allenview, near Jimboomba about 9.45am. 
Emergency services were alerted to the incident by a member of the public who sounded the alarm just before 10am.

The aircraft is a Diamond Da 40 and was significantly damaged in the crash landing. 
Emergency services are still on the scene. 

A Queensland Ambulance spokesperson said the plane came down on a grassed area and multiple units responded.

"No one required transport," the QAS spokesperson said. 

Update: Via SBS & Youtube.

Quote:Mayday call attempted before fatal crash





[Image: Plane_4-3_12728828_1777683_2017092613092...1506396880]
Two men are dead after a light plane crashed on a turf farm south of Brisbane. (AAP)

An instructor and his student are dead after a light plane crash in southeast Queensland.

A mayday call was made but not completed by the pilot of a training flight which crashed into a paddock south of Brisbane, killing two men aboard.

The instructor and his student died when their single-engine, four-seat Diamond DA-40 crashed into a turf farm at Allenview, near Beaudesert, on Tuesday morning.

A distress call was sent from the aircraft but not finished, a Civil Aviation Safety Authority spokesman said.

It's believed the training flight took off from Archerfield airport.

Efforts are under way to formally identify the men, and police are still trying to contact the victims' families.

Teams of Australian Transport Safety Bureau investigators are on their way from Brisbane and Canberra.

They will spend days examining the site of the crash and interviewing witnesses and are hoping to retrieve flight data from recording devices attached to avionics.

Photos from the scene show the broken plane lying on a large expanse of grass but it is too early to speculate about what caused the fatal crash, the ATSB and CASA say.

It is the second fatal aircraft crash in southern Queensland in a week.

Experienced instructor Jeremy Thompson and his 60-year-old student Norbert Gross died when their glider nosedived 15 metres and crashed into a field near the runway at the Darling Downs Soaring Club last Tuesday.

Conditions were fine that day and Gliding Federation of Australia operations executive manager Christopher Thorpe believes the pilot must have suffered a medical event.

Following investigations into the Allenview crash the ATSB will prepare a report, which is expected to take months to complete.


RIP -  Angel
Reply
Please explainNah, don’t bother.

Quote:There were no injuries, while the aircraft suffered minor damage.

The ATSB report said an initial engineering examination found the number four bearing on the right hand engine failed.

“The bearing failure allowed the high pressure compressor to move off-centreline within the engine. This caused further damage and led to complete failure of the engine,” the ATSB said.

“The damage to the failed bearing was consistent with overheating due to a lack of lubrication. 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 ATSB said the engine manufacturer’s engineering examination of the failed engine was not completed at the time its final report into the incident was released.

The Saab 340B is powered by two General Electric CT7-9B turboprop engines.


There, in half a dozen short, accurate sentences the ATSB report is complete – so why all the fluff and nonsense about flight crew actions – they followed SOP – end of. So how can this be a ‘final’ report? This ‘report’ is fatuous and contributes SFA to the overall safety of the SAAB fleet. We really need to know why there was a lack of lubrication to the  #4 bearing. There are lots of #4 bearings in service.

All this bollocks about what the bloody flight crew did is, IMO, deliberately drawing attention away from the radical cause of the incident; I wonder why ATSB has taken to salting their puerile, trite little offerings with this type of non essential rubbish.  Captains comments – WTD – why publish that? What purpose can it possibly serve? A straight forward engine shut down and return to land; surrounded by umpteen miles of fluff and little substance.

Please explain how this report can be considered adequate; let alone ‘final’.  Bucket please.

Toot – bollocks – toot – bollocks – toot, toot, toot…..
Reply
Awww K. The poor old bastard child of CAsA is simply following the screaming Skull protocols.

These are invoked in the case of RPT operators, especially those that have made significant "donations" to politicians.

They consist of:

"The pilot Dun nit" protocol, which is the primary tenet.
If its difficult to establish the pilot dun nit the "Skew the report" protocol is invoked.
This requires requires any perceived deficiencies by the pilot brought to the forefront in the report, everything else hidden in a maze of gobbledygook. If this doesn't look to convincing we then move on to the "Clutching at straws" protocol. This involves employing a myriad of "experts", for credibility, to forensically examine ever facet of the pilots perceived actions or inactions, then drafting, opinions, fiddled figures, or simply made up stuff into the report to strongly imply the pilot dun nit. Of course this protocol can be incredibly expensive, experts like G. Thomas  don't come cheap.
Love to know whats been spent so far on the Pelair report.

Over on UP a post to send a shiver up your spine.

Quote:

Well I can tell a few stories about non-standard SOPs at JQ...

I joined JQ about a decade ago. New to AB but many many years on Boeings. Early line training taught the JQ go-around "double-tap" technique, where you briefly advance the thrust levers to TOGA and immediately pull them back. No documentation. No SOPs. No FCOM amendment. All word-of-mouth. I queried and remember saying that it was a set-up, bound to trap someone and at the very least, it should be documented and run by AB. Told to wind my neck in, quite abusive actually and treated like an idiot.

If I'd put in paperwork I'd have been a hero for predicting exactly what occurred in YMML six months later when a JQ aircraft went within 50'AGL during a mis-handled GA, where the very technique I was criticising failed for the exact reasons I gave. However it transpired that the paperwork for THAT incident was suppressed by JQ and not passed to CASA, so I have long comforted myself with the theory that if I had said anything at the time my efforts would have been similarly suppressed, as well as facing the possibility of becoming known as a trouble maker, and that being held against me when it came to command upgrade.


During command training while on a turn-around we had a minor maintenance issue, that I duly wrote up in the Tech Log, annotated with the correct MEL actions. This was allowed at outports with no maintenance support if the MEL only had "O" actions, and no "M" actions. A reasonable and sensible policy. However the Checker queried my actions because it would make us late. I had a copy of the turn-around sequence, where everything is mapped out and timed to the minute, to make turn-arounds 35 minutes. I pointed out that no where on this sequence allowed any time for maintenance actions, therefore if there is any Tech Log/maintenance duties we would automatically be late. His response: I should leave all Tech Log/maintenance/MEL actions to be done at the end of the day, after the last leg, and disregard the MEL on turn-arounds. He was smart enough not to put that in writing, but he wrote me up badly, especially highlighting how I could not "manage time during a turn-around".

Pressure to not follow CASA rules. On the MEL. From a checker. On command upgrade.


Again I should have put paperwork in, directly to CASA. At the very least this checker should have lost his quals as a checker, but as it appeared to be unofficial JQ policy the whole attitude of JQ needed adjusting. I needed the job and the upgrade, so I kept quiet.

A friend had a loss of hydraulics on take-off from Melbourne. Followed the ECAM. Second hydraulic system failed. Flew circuit, returned on the blue system (this is the tiny little third system -practically nothing on it - for those not familiar with AB). Called into office and bollocked. Why didn't you turn off the PTU* they asked? I followed the ECAM he said. Oh, but everyone KNOWS that's what you do with loss of fluid to prevent a double hydraulic failure, they said. He stood his ground, said he followed the ECAM**.

*(PTU might be a Boeing term, after so long I can't remember the AB name). It powers either of the two main hydraulic systems from the other main one. With loss of fluid in one system it seizes, causing a loss of hydraulics in both mains. There is an AB mod for it to automatically shut down, but JQ didn't purchase the mod. JQ ALSO did not amend their documentation so that pilots knew to do this manually. The end result: piss poor SOPs, pilot disciplined. JQ said it was all his fault. This was after he flew an exemplary double-hydraulic failure approach and landing (not trivial in an AB).

**(again, memory fails me. It MIGHT have been in the ECAM at the time, but buried way down the list. In AB, the first ECAM following a loss of hydraulics is that the gear won't retract, so they were dealing with that ECAM first (as per AB procedures), and the loss of hydraulics is later in the ECAM list, and possibly somewhere in there is the instruction to turn off the PTU***) ***or whatever the damn thing is called.

I learnt to not trust JQ SOPs. Nor management.

A while later, Adelaide base closed. Friend of mine there was told on Anzac Day (? or maybe just after) and he had ten days to start work in Darwin. Ten days to cancel his rental contract, lose his bond, find new accommodation, get his wife a new job and find schools for his kids. His description of the "help" given by JQ was astonishing, and too long for here. In the end he got tired of his questions being unanswered (I think he had to get a boat and a dog to Darwin, and wanted to know if that would be reimbursed) so he just billed JQ anyway. He said towards the end the liaison office didn't even bother to answer phone calls or emails.

A while after that, more Ansett pilots came back from the ME and I was told I had to go to Darwin. I said no, seniority meant blah blah. I was told how that wasn't fair to the Ansett pilots because they needed to back in Melbourne and told a sob story of how hard their life was. Basically I was told to shove it, I would not get the aircraft type I wanted (in seniority), the base
I wanted (in seniority) nor the C+T upgrade I was trying for (based mainly on previous Boeing experience).

Put on a four sector flight. First sector a C+T in the right seat (not my check, they were short of FOs). We got a manual loadsheet. He had no idea how to check it, I had to teach him. We got airborne. He had no idea about ETOPs. Got to ToD and told to cross waypoint X at time blah. He couldn't figure that out either. In conversation he told me he joined in 1989, was originally a low hour bush pilot and if it wasn't for what went on then he'd never have gotten his career. I don't hold his choice against him, but he was clearly still a marginal pilot now, twenty years later. Obviously coasting. This was a C+T and I was being told I couldn't get that because Ansett pilots deserved it better.

[color=#3333ff]Second sector: new FO. Had flown with this FO in the sim four weeks prior. He failed the sim - not by a little bit, but by a lot. He was well below standard. Sim instructor after much hemming and hawing said he would give a "conditional pass" (whatever that means) and would schedule the FO for some extra sim sessions to "catch up". So I asked the FO about the extra sim sessions. He never got them, nothing. I flew the entire way thinking that if anything happened I would be single pilot ops.[/color
]

Landed. Spoke to a friend in the ME. Resigned from JQ. Had no job to go to at the time. Never regretted it, never looked back.

Got a nice letter from the Chief Pilot asking me why. I never replied to him but I should have, and I should've told him the above story. I had no rancour or bitterness, it was just that I didn't want to be part of a company that treated people this way, and had such a poor standard of C+T. I wish I'd been braver about standing up to regs being breached, but I know I would have risked my career and nothing would have changed. The CP wasn't bad, but he clearly couldn't change things. IIRC he left a little after me.

I fly in China now. Aircraft are better maintained, never a single thing wrong with them. All ops according to the manual. Any time I've seen a (very slight) deviation, all I have to do is pull out the FM or the MEL, and there is no problem. Everything is standard. Compared to JQ, it's a dream job, very easy to fly. No special procedures, nothing non-standard.
Reply
Just heard there was another King Air accident at YMEN in the last 10-15 minutes.....stand by..

EDIT: It was an undercarriage collapse. All got out OK.
Reply


Forum Jump:


Users browsing this thread: 4 Guest(s)