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Overdue and Obfuscated.
ATSB O&O Investigation number: AO-2014-043

So after 1352 days we end up with a ATSB investigation that is summarised like this:

Quote:What happened
On 3 March 2014, the flight crew of a Tiger Airways Australia Pty Ltd (Tigerair) Airbus A320 were preparing for a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia. The flight crew had earlier completed uneventful sectors from Sydney to the Gold Coast, Queensland, and return. As part of that preparation, the flight crew reviewed the operational flight plan (OFP) for the sector. The OFP was produced by the operator’s Operations Control Centre. That OFP contained significant errors in the aircraft weights, and as a consequence the required fuel upload for the sector was also significantly in error. The aircraft captain chose to re-calculate the required fuel load using resources available on the flight deck. The resultant required fuel load calculated and uplifted by the captain did not include the operator's requirement to carry a '60 minute top-up' additional fuel, resulting in the fuel upload being below that required under the operator's operations manual. The aircraft’s flight computers, however, identified that the aircraft would arrive at its destination with more than the minimum inflight fuel requirements. During the subsequent flight, the flight crew regularly checked the fuel usage and expected arrival fuel at Perth. All company and regulatory inflight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves.

What the ATSB found
There were deficiencies within the processes and procedures used by the operator's Operations Control Centre that permitted incorrect plans to be produced and subsequently provided to flight crew. This increased the risk that, in the time pressured environment of pre-flight planning, flight crews could either overlook incorrect data and accept an incorrect flight plan, or err in the calculation of the required fuel upload. Further, the operator provided limited guidance and assistance for flight crews on the processes and procedures for correcting identified fuel planning errors. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, resulted in the decision to determine a correct required fuel load calculation using only those resources available on the flight deck. Due to the short layover between sectors, which was further aggravated by curfew restrictions, this increased the risk of critical fuel planning considerations being overlooked.

Safety message
A correctly calculated flight plan not only provides assurance to both the captain and the operator that all operational factors likely to influence the flight have been considered and accounted for, it also forms an important inflight validation tool to allow crews to monitor and continually assess those decisions made at the pre-flight stage. Where variances are noted, timely alternative plans can be implemented to ensure that aircraft arrive at either the destination or an alternate aerodrome with required fuel reserves preserved.

However if you continue to read down the page you will eventually get to the 'nuts & bolts' section of the final report i.e. the safety analysis/conclusions/safety issues.

 'Safety analysis' (note part in bold):

Quote:Tiger Airways Australia Pty Ltd used an Operations Control Centre (OCC) to provided flight planning support for the flight crew of their regular public transport flights. Operations controllers (OC) were responsible for the production of flight planning and supporting documentation, which included generating the operational flight plan (OFP) and associated air traffic services flight plan.

There are various reasons for using an OCC for flight planning, including cost and duty time considerations. The use of an OCC system to produce flight planning products enables operators to reduce the flight crew’s flight planning task from gathering information and developing the flight plan, to one of reviewing prepared documentation and a finalised OFP. This has enabled operators to significantly reduce the time spent by flight crew in the flight preparation phase. Under regulation and the operator’s own policy and procedures, however, the aircraft captain was responsible for the proper planning and conduct of a flight.

The production of a correct OFP is essential for the safe completion of a flight. It ensures, amongst other things, that:
  • the calculated fuel upload contains all required components
  • the fuel upload is sufficient for the required flight given the conditions expected for that flight
  • there is an accurate method of tracking inflight fuel usage
  • the aircraft will arrive at the destination with sufficient fuel to ensure a safe landing.
   
Does this indicate that despite 'just culture' and the fact that the aircraft under 'Other Findings' met...

"...All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves..."

...that the Captain may have been scapegoated in order to allow time for the ATSB to again O&O an investigation (to the benefit of the operator) but at the detriment of the real glossed over safety issues i.e. safety risks associated with quick turn-around & LCC operations. 
 

MTF...P2 Cool
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"...that the Captain may have been scapegoated in order to allow time for the ATSB to again O&O an investigation (to the benefit of the operator) but at the detriment of the real glossed over safety issues i.e. safety risks associated with quick turn-around & LCC operations. "

So what is the "Issue"?

The crew picked up the "error", mitigated it, and successfully completed the mission.

"...All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves..."

Still don't get it, but one could draw parallels to the Pelair debacle. Crew undertook the flight and broke no rules, yet still get mentioned in dispatches implying they had done something dodgy. In the Pelair case the pilot is still paying the price for having the temerity to point out that it wasn't just him. There were other severe deficiencies within the processes used by the operator, as well as the provision of timely weather information and regulatory oversight. That was completely ignored by the ATSB, pushed aside to focus blame entirely on the pilot.
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Of delay and denial.

"Mistakes are not always the result of someone's ineptitude."

The report above intrigues me: 1352 days invested in a report which changes nothing. Why bother. Quick turn around and ‘on time performance’ are management and PR tools, nothing whatsoever to do with ‘aircrew’ duties and responsibilities. Now if the air crew are too worried about ‘pressure’ there is a union to complain to: but, and most importantly, there is a Safety Management System (SMS), which is legally binding and fully auditable.

A report in the SMS system demands attention; an incident, like the one mentioned above should have an open ‘action’ trail, in which the response from ‘management’ may be clearly seen and the ‘remedy’ examined.

An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place. The company SMS in a perfect world would have identified, much more quickly than the ATSB where the problem lay and been able to quickly effect a solution – which the ATSB have failed (again) to provide. The company can, in a heartbeat, issue ‘orders’ to change an anomaly in their system; ATSB cannot. So why even involve the ATSB in any way except as an ‘auditor’ of the SMS?

Tiger SMS team are obliged, by law, to investigate – there would be a paper trail. All ATSB need to do is send in a couple of auditors to check that all has been attended to – correctly and that should be the end of the story. We either trust and use the SMS; or, save the company the cost.  This double up, where there are no effective cross checks or balances is ridiculous. Why not let Tiger sort out the problem, audit their response and ‘order’ any changes ATSB deemed necessary. Would save some time and money; we’d probably even get an accurate, valuable ‘report’ back in 13 days, not 1300.

The way the ATSB present this latest load of Tommy-Rot suggest that the aircrew need to back to planning their own fuel burns – for indeed they are ultimately responsible. But the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure.

[we] are not ill provided but use what we have wastefully.”

Toot toot.
Reply
(11-15-2017, 06:43 AM)kharon Wrote: Of delay and denial.

"Mistakes are not always the result of someone's ineptitude."

The report above intrigues me: 1352 days invested in a report which changes nothing. Why bother. Quick turn around and ‘on time performance’ are management and PR tools, nothing whatsoever to do with ‘aircrew’ duties and responsibilities. Now if the air crew are too worried about ‘pressure’ there is a union to complain to: but, and most importantly, there is a Safety Management System (SMS), which is legally binding and fully auditable.

A report in the SMS system demands attention; an incident, like the one mentioned above should have an open ‘action’ trail, in which the response from ‘management’ may be clearly seen and the ‘remedy’ examined.

An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place. The company SMS in a perfect world would have identified, much more quickly than the ATSB where the problem lay and been able to quickly effect a solution – which the ATSB have failed (again) to provide. The company can, in a heartbeat, issue ‘orders’ to change an anomaly in their system; ATSB cannot. So why even involve the ATSB in any way except as an ‘auditor’ of the SMS?

Tiger SMS team are obliged, by law, to investigate – there would be a paper trail. All ATSB need to do is send in a couple of auditors to check that all has been attended to – correctly and that should be the end of the story. We either trust and use the SMS; or, save the company the cost.  This double up, where there are no effective cross checks or balances is ridiculous. Why not let Tiger sort out the problem, audit their response and ‘order’ any changes ATSB deemed necessary. Would save some time and money; we’d probably even get an accurate, valuable ‘report’ back in 13 days, not 1300.

The way the ATSB present this latest load of Tommy-Rot suggest that the aircrew need to back to planning their own fuel burns – for indeed they are ultimately responsible. But the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure.

[we] are not ill provided but use what we have wastefully.”

Toot toot.

Excellent post "K"... Wink

I to am bemused by this report and still trying to fathom why this particular incident was investigated at all. Especially when you consider that the ATSB has chosen to discontinue many other on par investigations, stating lack of available resources and/or higher priority (i.e. serious incident) investigations as reasons for discontinuing... Dodgy

Q/ So why did this particular non-event, & supposedly proactively addressed by airline occurrence, require the ATSB to instigate a topcover O&O investigation?

 P9 - "..An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place..."

Maybe "K" that it is where the problem lies? Could it be that at that particular time the Tiger SMS was simply a tick-a-box routine that on paper met the CASA regulatory and oversight requirements but in actual fact was ineffectual in identifying and mitigating serious safety issues?

After all it wouldn't be the first time that an AOC holder, operating under a CASA approved SMS, was found to be operating with significant safety deficiencies that the SMS failed to identify and/or effectively risk mitigate.

"..the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure..."

Yes the classic example of a failed 'in operation' SMS is of course PelAir.

The following is an extract from former CASA Manager of Human Factors Ben Cook's Special Audit report of PelAir's FRMS (reference: CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012; (PDF 5428KB) ):

Quote:[Image: Untitled_Clipping_111517_090335_PM.jpg]
 
Note that Ben Cook highlights that the 'special audit' was a 'systemic investigation' and that he took steps to de-identify company personnel in order to not jeopardise the Rex position on positively fostering a 'just' internal safety culture.

When you consider the ongoing embuggerance of DJ it is kind of ironic that a former CASA officer was taking such steps to protect the fundamental concepts of a 'just culture' that is integral to the effective operation of a company SMS (i.e. you don't have 'just culture', you don't have an SMS).

Reference search 4 IP post: Update: ATSB PC accident investigation AO-2014-032

Quote: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 - [Image: confused.gif]

Quote: Wrote: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.

So maybe the ATSB investigators and HF experts on the coalface have come to realise there are some serious deficiencies in the CASA regulated and oversighted SMS of some of our major operators and SSP defined service providers (e.g Airservices, BOM) - Huh

Naturally it would then follow that Hoody and his fellow commissioners, in the interest of political correctness and not embarrassing the minister, have developed an O&O campaign to allow the commercially and/or politically sensitive DIPs time to get their shit together and shred the negative evidence of SMS/SSP complacency - Just surmising... Rolleyes   


MTF? Definitely...P2 Cool
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Yes: But….

Well caught P2; the ’rub’ clearly defined; however we are only scratching at the high gloss paint covering. Making effective use of the SMS requires all parties – ATSB included to contribute. The ‘law’ supporting SMS is ‘robust’ and drags top level management into the spotlight and ensures that ultimate ‘responsibility’ cannot be delegated. At the end of the session, the ‘buck’ has a place to stop.

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.

If the aircrew don’t file a report into the system, then little can be done – unless someone else spots the deviance or the deficiency; but once that report is in ‘the system’ it must go through process, before being binned (by who and why) That ‘binning’ is now part of the system and may be called up as part of an investigation into why an event has occurred; part of a causal chain, if you will. All fully auditable, clear lines of responsibility and nowhere to hide.

A healthy company would embrace the SMS, make it real, make it live, make it useful; it is a very sound notion. Tiger have used theirs, responsibly; and, made the requisite changes. Of course the incident will happen again; there are always ‘little’ problems like the one mentioned, particularly with ‘paper-work’. The trick is to reduce the reoccurrence ratio in a demonstrable, systematic, quantifiable way.

“In 2015 we had 24 reported instances of paper-work bungles; in 2016 we had 8, in 2017 we had 3”.

Bravo, big cheer all around – the SMS at work and doing it’s job. What could be wrong with that?

Toot toot.
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