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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
Reply
"...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.
Reply
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
Reply
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.
Reply
ATSB O&O investigation No. - AO-2015-131

Via 'that man' in the Oz today:

Quote:
Quote:Anger at chopper crash probe delay

[Image: 0b5bfc18ac36d2a5214f5485a6a9120a]12:00amEAN HIGGINS

It has now been two years since Richard and Carolyn Green and John Davis died when the helicopter they were in crashed.


Delays to chopper crash inquiry ‘ridiculous’: Felicity Davis


Felicity Davis says while many other people have complicated marital histories, hers was simple: she married documentary maker John Davis and had two children with him. “We stuck together for 43 years,” she said.

That marriage ended two years ago when, in early November 2015, her husband died when a helicopter piloted by his friend, landscape photographer Richard Green, crashed in rugged country in the NSW Hunter Valley region during a storm. Green’s wife, Carolyn, also died in the crash, and the tragedy of the prominent Sydney environmentalist trio made huge headlines.

Ms Davis has done her best to put her life back together after losing her husband but is still tortured by not knowing how the accident happened.

That’s because the Australian Transport Safety Bureau, which initially told her it would finalise its investigation in less than a year, still hasn’t done so two years on.

“I just feel we are getting fob­bed off,” Ms Davis told The Australian. “The other day, I came back and I just thought, this is getting ridiculous.” Ms Davis has found her treatment by the ATSB disrespectful and undignified.

“I have just been waiting and waiting,” she said. “They keep saying they are going to file a report.”

There is still mystery about how the accident happened.

A farmer reported seeing the Airbus Eurocopter EC 135 land in a field at one stage, Ms Davis said, but it returned to the air. “What I want to know is, why did they set off again?” Ms Davis said.

But apart from her obvious personal interest, Ms Davis says she wants the investigation to achieve what the taxpayer-funded ATSB is supposed to do in the first place: work out what happened for the good of aviation safety.

“Was it something that the pilot did wrong, or the helicopter? We need to know because it would stop other people doing the same thing,” she said. “It’s a safety issue.”

It is exactly what an ATSB ­investigator said in a corporate video the bureau made to explain the investigation process.

“The whole idea is that perhaps we can prevent another accident happening,” the investigator said in the video.

The log on the ATSB website about the helicopter crash investigation shows repeated failure to meet its own deadlines. In October last year it said a draft report would be issued in November that year, and a final report a month later.

The ATSB then kept pushing back the date, citing “workload and competing priorities”, and now says it expects completion in “the first quarter of 2018”, which would be 2½ years since the ­accident.

An ATSB spokesman refused to answer questions about the helicopter crash investigation “until the final report into the accident is released”.

Transport Minister Darren Chester declined to comment.
 

MTF...P2  Cool
Reply
Update to O&O investigations & the secretive ATCB - Confused

(11-24-2017, 10:14 AM)Peetwo Wrote: ATSB O&O investigation No. - AO-2015-131

Via 'that man' in the Oz today:

Quote:
Quote:Anger at chopper crash probe delay

[Image: 0b5bfc18ac36d2a5214f5485a6a9120a]12:00amEAN HIGGINS

It has now been two years since Richard and Carolyn Green and John Davis died when the helicopter they were in crashed.


Delays to chopper crash inquiry ‘ridiculous’: Felicity Davis


Felicity Davis says while many other people have complicated marital histories, hers was simple: she married documentary maker John Davis and had two children with him. “We stuck together for 43 years,” she said.

That marriage ended two years ago when, in early November 2015, her husband died when a helicopter piloted by his friend, landscape photographer Richard Green, crashed in rugged country in the NSW Hunter Valley region during a storm. Green’s wife, Carolyn, also died in the crash, and the tragedy of the prominent Sydney environmentalist trio made huge headlines.

Ms Davis has done her best to put her life back together after losing her husband but is still tortured by not knowing how the accident happened.

That’s because the Australian Transport Safety Bureau, which initially told her it would finalise its investigation in less than a year, still hasn’t done so two years on.

“I just feel we are getting fob­bed off,” Ms Davis told The Australian. “The other day, I came back and I just thought, this is getting ridiculous.” Ms Davis has found her treatment by the ATSB disrespectful and undignified.

“I have just been waiting and waiting,” she said. “They keep saying they are going to file a report.”

There is still mystery about how the accident happened.

A farmer reported seeing the Airbus Eurocopter EC 135 land in a field at one stage, Ms Davis said, but it returned to the air. “What I want to know is, why did they set off again?” Ms Davis said.

But apart from her obvious personal interest, Ms Davis says she wants the investigation to achieve what the taxpayer-funded ATSB is supposed to do in the first place: work out what happened for the good of aviation safety.

“Was it something that the pilot did wrong, or the helicopter? We need to know because it would stop other people doing the same thing,” she said. “It’s a safety issue.”

It is exactly what an ATSB ­investigator said in a corporate video the bureau made to explain the investigation process.

“The whole idea is that perhaps we can prevent another accident happening,” the investigator said in the video.

The log on the ATSB website about the helicopter crash investigation shows repeated failure to meet its own deadlines. In October last year it said a draft report would be issued in November that year, and a final report a month later.

The ATSB then kept pushing back the date, citing “workload and competing priorities”, and now says it expects completion in “the first quarter of 2018”, which would be 2½ years since the ­accident.

An ATSB spokesman refused to answer questions about the helicopter crash investigation “until the final report into the accident is released”.

Transport Minister Darren Chester declined to comment.
 

Via the Courier Mail:
Quote:Shameful heel-dragging on air incident probes
[Image: 04a154f4b4ca491a4cb0eac5a1651984?width=150]
Mike O’Connor

December 1, 2017 12:00am



AS tens of thousands of Australians prepare to head to the airport for the great Christmas holiday migration, they might care to ponder the following.

In the skies over the Gold Coast on July 21 last year, an arriving Jetstar A320 and a departing AirAsia X A330, with a combined seating capacity of 520 passengers, came frighteningly close to flying into each other.

The Australian Transport Safety Bureau says the jets came as close as 183m vertically and 630m laterally when regulations stipulate the separation should be 305m and 6km respectively.

The ATSB said the results of its investigation into this would be made public in July this year. This has not happened.

According to the ATSB website, completion of the draft investigation report into the incident “has been delayed by the involvement of the investigator in charge on other aviation safety investigations and tasks”. It says a final report is anticipated to be released to the public in May 2018, almost two years after the event.

In February this year, four American tourists and their pilot were killed when their aircraft crashed soon after takeoff from Melbourne’s Essendon Airport.

It was later revealed that the pilot was being investigated over a near collision at Mount Hotham on September 3, 2015.

[Image: 28f11abb0e9ae0555f437d8384792aa9?width=650]Essendon DFO shopping centre in Melbourne following the crash of a light plane. (Pic: Jason Edwards)

The completion of this investigation has been delayed three times due to competing priorities and workload of the investigator in charge.

In July it was promised by October. It still has not been released.

According to the ATSB, “the draft report has been finalised and is currently undergoing an internal review process prior to approval by the ATSB Commission”.

It begs the question that if the investigation had been carried more quickly, would that pilot have been at the controls at Essendon and would the Americans still be alive?

Just over two years ago, three people died in a helicopter crash in the Hunter Valley region of New South Wales.

Among the victims was pilot Richard Green, who had a history of close calls.

He had lost his licence for six months in 2013 after being involved in four dangerous flying incidents in 11 days in May 2012.
Six months later he was in trouble again when his helicopter struck power lines.


Following the Hunter Valley tragedy, the ATSB said it would complete its investigation in a year. Two years on, Felicity Davis, whose husband John died in the crash, is still waiting for the report.


Only a third of ATSB investigations are completed within 12 months.


[Image: 9281b7c0f17358e9b38c9071e412cf90?width=650]Dick Smith has called the ATSB “secretive” and “insecure”. (Pic: Dylan Coker)



Dick Smith, a former chairman of the Civil Aviation Safety Authority, has described the ATSB as “secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals”.


“They are basically a secret, secret organisation,” he said this week.
It is screamingly obvious that there needs to be a public inquiry into the workings of the ATSB.


Business as usual, with inquiries into incidents that involve the safety of passengers dragging on for two years, is no longer acceptable.

The aim, surely, is to discover the reason for accidents or “near misses” as quickly as possible and prevent them happening again.

The system appears to be broken. The public deserves a better deal.

TICK TOCK Hoody Confused


MTF...P2 Tongue
Reply
ATCB O&O investigation No: AO-2015-007

Boy oh boy the ATCB are good at keeping these types of serious incidents under wraps - FDS...1071 days or 2yrs 11 months & 6 days for this... Huh

Quote:What happened
On the morning of 9 January 2015, a Regional Express operated SAAB 340B aircraft, registered VH-OLM struck a flock of birds during its landing roll at Moruya, New South Wales. Inspection of the aircraft by the flight crew found bird impact marks but no visually identifiable damage. The crew continued their schedule to Merimbula, New South Wales. At Merimbula, the first officer noticed the tip of one propeller blade was missing, and the aircraft was subsequently grounded.

What the ATSB found
The blade tip failure was almost certainly a result of the birdstrike during the landing roll of the previous flight, weakening the internal structure of the blade.

The flight crew conducted a visual inspection in accordance with the operator’s procedures, and this inspection did not find any damage. However, the propeller manufacturer’s birdstrike inspection procedure was deemed a maintenance task. As such, it was not suitable for flight crew.

What's been done as a result
The operator changed its birdstrike procedures to ensure aircraft remained on the ground until a maintenance inspection was carried out in accordance with appropriate documented inspection procedures. In addition, pilot and engineering notices were issued clarifying these requirements.

Safety message
Adherence to regulations and company procedures is essential for the ongoing airworthiness of aircraft. Therefore, it is vital that procedures are clear and do not lead to ambiguity or misinterpretation. Where uncertainty exists, seeking clarification from the relevant authority can reduce the risk of an unserviceability affecting flight safety.

From FlightGlobal:

Quote:Birdstrike caused Rex Saab 340 propeller tip failure
  • 14 December, 2017
  • SOURCE: Flight Dashboard
  • BY: Ellis Taylor
  • Perth
Regional Express has changed its maintenance procedures following a propeller failure incident on one of its Saab 340s that was caused by an earlier birdstrike.

The aircraft, registered VH-OLM, struck a flock of galahs during its landing roll at Moruya, the Australian Transport Safety Bureau (ATSB) states in its final report on the incident.
In accordance with Rex’s procedures, the crew carried out a test of the ice protection system before the engines were shut down, and no anomalies were detected. During the turnaround, the pilots conducted a visual inspection of the aircraft which showed signs of a bridstrike. However, there was no evidence that birds had been ingested into the engines, nor was any apparent physical damage.

“The examination included rotating the propellers so that the forward and aft blade surfaces could be inspected for cracking, buckling, chips, dents or deformation along each affected blade’s leading edge,” says the ATSB. “When no damage was identified, the captain contacted the operator for further technical advice and the crew were subsequently cleared to continue with the flight schedule.”

After completing the subsequent flight to Merimbula, the first officer noticed that the tip of one of the left-hand propeller blades had detached, and the aircraft was subsequently grounded.

[Image: getasset.aspx?itemid=72486]

Image Source: Regional Express via ATSB

There were no injuries reported to passengers and crew, and no other damage to the aircraft was found.

The ATSB says that that impact from “multiple galahs almost certainly reduced the structural integrity of a propeller blade, resulting in the separation of its tip during the subsequent flight”.
It also looked closely at the inspection procedures for suspected birdstrikes. In their inspection, the flight crew focused on seeking visible damage to the propeller blade, and liaised with Rex’s engineering crew. However, no on-site engineering inspection of the propeller was made.

“Regardless of the nature of the flight crew’s inspection, both [the Civil Aviation Safety Authority] and the propeller manufacturer considered the inspection to be a maintenance task, and required it to be carried out by qualified maintenance personnel,” says the Bureau.

Subsequently, Rex changed its procedures to require an engineering inspection before an aircraft departs if there are signs that wildlife may have struck the propellers.

"..Adherence to regulations and company procedures is essential for the ongoing airworthiness of aircraft..." -  Is this why, for what would appear to be a relatively straightforward investigation, the ATCB saw the need to O&O this final report? Dodgy

Oh well at least Hoody can say he kept it under 3 years - Big Grin

Speaking of 'serious incidents' that have been O&O'd with the standard excuse of lack of resources, apparently the following 'serious incident' had the additional incentive of covering the embarrassing inclusion of a certain Turnbull Government VIP - or so the story goes... Blush

Quote:10/11/2017

201705227


Serious Incident

West Sale Aerodrome


38° 5.502' S


146° 57.918' E


VIC

Cessna Aircraft Company

337

Charter


Passenger


CTAF

G

During approach, the crew did not extend the landing gear resulting in a wheels-up landing. The aircraft sustained minor damage.


.xlsx   Copy of ATSBSearchResults.xlsx (Size: 125.43 KB / Downloads: 5)
      

MTF...P2 Tongue


Ps.

Quote:



Plane carrying federal transport minister in serious safety scare


A plane carrying the federal transport minister has been involved in a serious safety scare.
Reply
Naughty P2 – well, naughty if you are hinting that the Chester derriere suffered gravel rash or ‘bitumen burn’. That would be quite a way to ‘man-scape’ the furry parts into a new style. Probably why it wasn’t widely reported. Lucky there was a thick layer of spilled Cheezels on the floor – foam is foam; no matter how it gets there.

I wonder why a simple ‘forgot to put ‘em down’ has been kept so bloody quiet? Apart from the furry modifications – probably all to do with ‘furmolising’ his acquaintance with what, exactly, a runway is. Butt. No es problemo – the hair stylist is on the fifth floor of the large building, 30 meters to the left of ‘incident’ runway centreline, not even a long walk for a mug, two minutes by ministerial transport. Is he going to put the before and after pix on Twitter? Hope so – Oh, I can’t hardly wait to see the before and afters.
Reply
  
Update - O&O investigation No: AO-2015-007

Reviewing the ATSB webpage for this O&O investigation and final report there are some bizarre omissions to what should normally be on the public record... Huh 

From investigation webpage: 

Quote:Birdstrike involving SAAB 340B, VH-OLM, Moruya Airport, NSW, on 9 January 2015
 
Investigation number: AO-2015-007
Investigation status: Completed
 
[Image: progress_completed.png] Final Report
Download final report
[ Download PDF: 2.08MB


General details

Date: 09 January 2015
 
Investigation status: Completed  

Time: 10:50 ESuT  

Investigation type: Occurrence Investigation  

Location   (show map): Moruya Airport
 
Occurrence type: Birdstrike  

State: New South Wales  

Occurrence class: Operational  

Release date: 14 December 2017

Occurrence category: Serious Incident  

Report status: Final

Highest injury level: None  


Original ATSB occurrence report record:
.xlsx   SAAB Birdstrike Moruya.xlsx (Size: 117.89 KB / Downloads: 0)

Quote:During the landing at Moruya, the aircraft struck multiple galahs. The crew conducted an inspection and the aircraft subsequently departed for Merimbula. On descent into Merimbula, the crew detected abnormal vibrations through the flight controls. After landing it was determined that a section of propeller was missing. The investigation is continuing.

From the above we can establish that the occurrence was reported properly by REX and/or the flightcrew. However there is no record of a preliminary report being published; there is no record of interim reports/summaries being published on the anniversary of the occurrence; in fact besides the FR there is no update record for the entire 1071 days that this investigation was supposedly active - Huh

Now compare that to a ATSB investigation that took a similar amount of time to complete - AO-2013-100 (i.e. The Mildura Fog duck-up); or the ongoing Essendon DFO accident investigation: AO-2017-024.

Kind of makes you wonder if perhaps the ATSB are only properly adhering to the ICAO Annex 13 protocols when and if an investigation is high profile and/or not politically sensitive... Dodgy

Next on my 'to do' list is to check whether ICAO was notified of this 'serious incident' and sent a copy of the final report... Huh


MTF...P2  Cool
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HVH record on prelims, interims & Final Reports - Huh 

Credit where credit is due and it would appear that since HVH has been in charge that prelim reports have been delivered mostly on time and within the prescribed Annex 13 SARPs.

E.g. AO-2017-118 (see AD thread post #264

Quote:Ongoing investigation

The ATSB investigation is continuing and will include consideration of the following:
  • engine, propeller and aircraft component examinations
  • flight and engine control positions
  • aircraft maintenance history
  • obtaining and evaluating witness information
  • pilot qualifications, experience and medical information
  • impact sequence
  • survivability
  • aircraft performance and handling characteristics
  • aircraft weight and balance
  • operator policies and procedures
  • stall warning systems
  • nature of seaplane operations
  • environmental influences
  • sources of recorded information
  • similar occurrences in Australia and internationally.

While the extensive media coverage etc. died down I noted that the anniversary for another high profile ATSB AAI - AO-2017-013 - came and went without so much as a squeak; a whistle; or even an interim statement coming out of the HVH PR machine. However towards the end of 2017 there was a typical 'no fanfare' update that would seem to indicate that a final report may still be a long way off Sleepy

Quote:Updated: 22 December 2017

The investigation into the collision with water involving a Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 is continuing. The investigation has completed the information-gathering phase and the team is engaged in detailed analysis of material. This involves a substantial amount of review, as well as consultation with external parties.

On completion of the draft report and internal review, the report will be sent to directly involved parties for comment before the report is finalised and published.

Should any safety issues be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

So HVH is not big on keeping with the Annex 13 'interim statement' protocol. Undecided

Therefore there is no guarantee that we will receive any public statements as we approach a couple more high profile accident investigation anniversaries:

Quote:In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014 - https://www.atsb.gov.au/publications/inv...-2014-032/


Collision with terrain involving B200 King Air VH-ZCR at Essendon Airport, Victoria on 21 February 2017 - https://www.atsb.gov.au/publications/inv...-2017-024/

As the VARA (now Virgin) ATR accident investigation is approaching the 4th anniversary, I was trolling the internet records for previous years and came across the following article headline from the 'late & great' aviation blogger Ben Sandilands (may he RIP Angel ) - Nothing can excuse the Albury Virgin ATR safety fiasco, not even this recycled piece of ATSB fluff.

This at first made me smile but then I reflected on the post and the first comment from P9 and I began to despair on how serious matters of aviation safety appear to be stuck in a deeply troubling timewarp:

Quote:PT - ..The then minister, Warren Truss, was presumably told nothing by his department because he said nothing, and being an upright champion of aviation safety  transparency, undoubtedly would have been concerned by its contents.

Now we have a new minister, Darren Chester, and it is too early to determine whether he does what his department tells him to do, or even asks whether it tells him what he really should be told...
P2 - Well at least that Q/ has been comprehensively answered... Blush  

And from Sam (aka P9)... Wink :
Quote:Sam Jackson
April 13, 2016 at 7:03 pm

Mountains to Molehills – ATSB style.

When this ‘incident’ first came to light there were serious questions raised, to which ATSB has not deigned to investigate or answer. The aftermath – 13 passenger flights – are not the aberration, but a resultant of the first in a series of events which remain firmly ignored, unmentioned and; not, as yet addressed.

In short; the root cause of the initial ‘problem’ remains unresolved. The ATR has a facility which allows the two normally interconnected flight control systems (yokes) to be disconnected and operate independently. This in case a manual flight control channel is lost. With a significant amount of opposite direction pressure from the other yoke, (e.g. one pulls up, ‘tuther pushes down) the two flight control systems may be separated. This event occurred during a ‘routine’ descent to approach at Sydney, with no noted flight control problem. The potential for stress and damage caused by opposing control inputs, from two viable systems should have engineering alarm bells ringing, demanding serious, in depth inspection. It did not. The controls were simply reconnected, a cursory inspection conducted and the aircraft returned to service; for the remaining 13 flights.

In other accident events ATSB have played the accompaniment to the CASA preconceived notion, Canley Vale and Pel-Air for example. Where ATSB report supported a stern, rapid prosecution of pilots and operators, through to Coroners court, where required. There are some very serious incidents still on the books at the moment related to turbo-prop powered aircraft – Moranbah and the Newcastle coal loader incident for example; there are some serious, outstanding heavy jet transport incidents, such as Perth and Mildura which are still patiently awaiting their ATSB final report.

If we are serious about ‘safety’ the minister, the government and travelling public need to get over the bi-partisan system of relying on ATSB and CASA to ‘sort it’ and start demanding changes to the way our ‘aviation watchdogs’ set about doing their expensive business. But, enough said it. All been said before, and precious little changes. But gods help the government in power when the unthinkable happens and a Royal Commission is demanded. The time is now, to get our aviation safety house in order, before we run out of dumb luck. (E&OE, can’t do it properly on the small screen).

Hmm...see what I mean - Undecided

Which brings me to the 1st anniversary of the tragic YMEN B200 DFO prang... Huh

According to the webpage there was a recorded update/revisit on the 12th December 2017 but there is no accompanying update statement. This would suggest that the FR is still a long way (years) from completion. The question now is whether the good Senators will accept a now normalised ATSB delay on this particular AAI. Especially considering the fact that we are fast approaching the Senate Inquiry due date for reporting on the proposed 'Airports Amendment Bill 2016' : Interim Report


Recent aviation incidents

1.12      On 21 February, soon after the initiation of this inquiry, a Beechcraft B200 Super King Air VH-ZCR crashed at Essendon Airport. The aircraft impacted the DFO shopping centre alongside the airport resulting in a major fire. An Australian pilot and four American tourists on board died in the crash. 

1.13      These tragic events brought into stark relief the importance of appropriate airport planning regulation and processes. 

1.14      Evidence received by the committee at Additional Estimates on 27 February detailed the accident investigations currently underway by the Australian Transport Safety Bureau. In addition, the Department of Infrastructure and Regional Development (the Department) noted that it was examining 'development approval processes involved in the land‑use planning at the airport'.[11] Departmental Secretary, Mr Mike Mrdak informed the committee that the Department had provided advice to the Minister on the accident investigation process as well as the development approval process for buildings allocated at the DFO site.[12]

1.15      The committee was also advised that the National Airports Safeguarding Advisory Group (NASAG) was considering the adoption of draft national guidelines, regarding runway public safety zones around airports, and runway end safety zones. Queensland is currently the only Australian jurisdiction to have public safety zone legislation.[13]

1.16      On 2 March, correspondence was received from Minister Chester requesting that the committee consider extending its inquiry in light of the tragic accident and subsequent investigations underway (at Appendix 1).

1.17      The committee recognises that the findings and recommendations of the investigations into this tragedy, and the work of NASAG, may have implications for the bill. It takes the view that sufficient time should be provided to allow the investigations to proceed and for the committee to then properly consider their findings.

1.18      Therefore, the committee recommends that its inquiry on the bill be extended to allow consideration of the investigations and any other relevant aviation regulation developments.

1.19      Submissions already received and published by the committee (at Appendix 2) will be considered as part of the inquiry following the outcome of the investigations.

Recommendation 1

1.20      The committee recommends that the Senate grant an extension of time for the committee to report to the first sitting day of March 2018.


Senator Barry O'Sullivan

Chair


 TICK..TOCK HVH & BJ - you now own this... Rolleyes


MTF...P2 Cool


Ps Looks like it is not just the good Senators that have an interest in the outcome of ATSB investigation AO-2017-024: BJ's airport conundrums: All woes lead to CASA
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A national sport – no less.

Throwing sportshave been around since the cave; but, ASA and it’s highly remunerated sportsmen have reclaimed the game

On 21 June 1982, Julian Critchley of The Times (London) wrote "President Galtieri had pushed her under the bus which the gossips had said was the only means of her removal.”

Which is scandalous, as the origins of the ‘sport’ were not mentioned. Yes, the game began here. Along with ‘dwarf tossing’.  Australian trough dwellers have devolved the sport to a ‘political’ standard response. The ‘dwarf’ may well be of normal physical stature; which is quite politically correct. The latest craze in Canberra is to ‘throw’ a mental midget – to win the beers. Or; so it was until the ‘bus’ wrinkle was introduced. Now, not only are mental bantamweights lobbed - for laughs; there are extra points to be garnered for getting one ‘under a bus’.  

Physically Halfwit is no light weight – but; with a head so full of hot air (i.e. brain fart gas) there will be a scramble to ensure which of the ‘tossers’ will get to pitch him under the # 9 bus from capitol hill to the local cat house.

I do hope they televise it.

Wall street – eat your heart out; all the greatest scams and the ‘best’ games of all are (dontcha know)  Australian mate (or, perhaps made?) Who knows.

Toot - toot.............
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HVH's magic O&O minions - Huh

In the course of backing up another one of Mr Peabody's enlightening posts - see Airports thread post: Safety Case????? - I just so happened to bear witness to the magical skills of Hoody's O&O fairies... Undecided

Let me explain: - Shy

To begin I was pleasantly surprised that Hitch managed to trump me on the discovery of the 'investigation within an investigation' - choccy frog to Hitch... Wink

As is now SOP for the ATSB there was no media release/announcement, nor was the investigation reference AI-2018-010 immediately transparent when referencing the Aviation investigation webpage: Reference pg 4 - HERE.

When I first clicked on the AI-2018-010 link I noted that this investigation (within an investigation) had been initiated/updated 11 days before on the 08 February 2018. It was also stated that the expected completion date was August 2018:
 
Quote:General details
Date: 21 February 2017
Investigation status: Active
Location   (
show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
Investigation type: Safety Issue Investigation
State: Victoria
Report status: Pending

Expected completion: August 2018
 
 
[Image: share.png][Image: feedback.png]

Last update 08 February 2018

Some scant 5 minutes after completing my airport thread post I revisited the investigation webpage link and that was when I discovered that the O&O fairies had done their magic... Rolleyes

Here is what the webpage now reads:

Summary

On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.

The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.
 
General details

Date: 21 February 2017
 
Investigation status: Active
 
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
 
Investigation type: Safety Issue Investigation
 
State: Victoria
 
Report status: Pending
 
Expected completion: February 2019 
 
[Image: share.png][Image: feedback.png]

Last update 19 February 2018



So in the space of 11 days this 'investigation within an investigation' has had it's expected completion date put back by a further 6 months - UDB!  Dodgy

Considering this is the 3rd active high profile investigation (which I am aware of ) that the HVH crew have initiated within the last 12 months - see search 4 IP post #203 & 4 above: ATSB update on Mallard investigation (which again was captured by Hitch Wink ) - one has to wonder is this the new top-cover obfuscation tactic being deployed by Hoody and his O&O minions?? 


MTF...P2 Cool
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