Overdue and Obfuscated.
A Totally Substandard Beat-up.  

P2 - Err WTD?  - I would have thought the greater 'safety issue' was the fact the crew missed resetting the altimeters to actual local QNH - Just saying.

Aye, ‘tis a big no-no – however I think this is a ‘classic’ Reason model case and probably a good report to have in the library to demonstrate just how very easy it is, even for experienced crew to fall into a ‘trap’.

My ‘Jepp’ chart series for Kosrae is well out of date, but it will serve for now. One of the first things you note is no ATIS, the next is the rather oblique statement – “ Trans level by ATC” followed by (Trans Alt : by ATC). This may have changed since my chart was published; but ATSB make no mention of the stated ‘transition altitude’ in effect at the time. This is an important ‘trigger’ prompting an almost instant reflex action - write the setting on the TOLD card – set the local barometric reading on the Altimeter and cross check. It’s a curiosity only, but say the crew habitually used F 130 as ‘transition’ from flight levels to barometric altitude, but were obliged to remain on the 1013 datum to almost the beginning of the approach – (traffic separation?) you still must wonder why the approach checks were not complete by then – even if there was a low transition. Has human factors and fatigue played a big role in this little drama?  ATSB make no mention of the duty period or the flight schedule so it’s hard to quantify how much that element of the causal chain is attached to the incident. The ultimate message is clear enough but the bare facts, as presented, fail to provide insight as to why a routine, deeply ingrained almost habitual action was not completed by an experienced crew.

The next item is the approach itself. ATSB cite it as being a ‘dive and drive’ event; this is grossly misleading. The profile chart is drawn using ‘step’ down; but its not flown in the manner depicted – ATSB should know this. D&D was outlawed by serious operators years ago, with bloody good reason. The D&D method is not only potentially lethal, but inefficient and ‘unstable’. ATSB hint that the crew hung about at 1500 feet then ‘dive’ to the next limiting height and ‘drive’ up to the next descent point – Bollocks. Do that in any ‘performance’ aircraft – let alone a swept wing jet and you are looking for trouble. I digress.

On my old chart the NDB approach is ‘tight’ – the approach path points directly at an 800 foot high chunk of terra firma; and, leaves you at 2.9 miles to conduct a visual circling approach; except there is no circling permitted South of runway 05 or 23. A 76 ton aircraft at 130 knots inside of three miles, in the dark, pissing rain with nothing but rising terrain ahead – off a ‘D&D’ style of approach – Nah; don’t think so. Lets’ take a look at my old chart again. At 10 miles almost due West of the hills (797’ terrain @ 7200 [6080’ = ONE nautical mile = 30 seconds at 120 knots] feet ESE of the airport) the NDB approach begins at 1500’ AMSL; that leaves 5 miles to run to the IAF at 900’ – at 140 knots a rate of descent :: to 700 fpm is stable and easily do-able. This fetch’s the aircraft to five miles and enough room to break left or right and join the circuit. So to a visual night circuit, in the rain, think about it for a moment. To land 05 the crew loose sight of the runway – (break right) - left turn to pick up a three mile final – acceptable. To make final leg on the 23 direction is almost unacceptable; a long left turn, followed by a right to base followed by another right hander to final – the runway out of sight until base leg to the FO and out of sight to the Capt. until late base/ final. Not a 'visual approach' at all.- Not too bad in good conditions – but tricky in bad. 

Ah well; at least the GPS approach system and equipment is available to use now. A straight in runway approach to 5/600 feet is right and proper for heavy jet transport in this day and age. Most sensible. What is not acceptable is the ATSB dumbing down and presenting, in bad English, a valuable safety lesson.

ATSB – “This resulted in the aircraft’s altitude being lower than what the pressure altimeter was indicating to the pilots.” – Seriously, who writes and edits this crap?

Right – back to my knitting.

Toot – toot.
K, agree with you entirely, but I cant help thinking our system in OZ may set things up somewhat.
I remember an incident in Europe some years ago with an Airline I was involved with, where a crew got distracted with workload and ended up on an ILS approach with standard set. All over Europe, transition altitude varies, from 3000Ft in Uk to the ground in Russia.Sop's varied around the place from using QNH to god forbid QFE. Think of SOP, normally approach checks would be completed around 30 miles out, a key gate of around ten thousand feet, or around ten minutes to the FAP. trouble is some transitions at 3000 ft gets a bit cramped for an altimeter set and crosscheck.

It was decided that when cleared to an altitude the Pilot flying would set local QNH, the support pilot would remain on standard until transition, where the call would be made "transition", "set QNH....." from the told card and "crosscheck." The theory being that an error in Altimeter setting would be more likely to be "caught" if there was a split in altimeter readings, and if not at least the pilot flying would have the correct setting on his altimeter for the approach.

Its an easy enough error to make, tired, hassled by ATC, crap weather, the thing I find hard to accept is they ignored several GPWS alerts without having a good look at why? perhaps with split altimeters they may have picked it up. At the end of the day, I can remember years ago when all non precision approaches in OZ were circling, CAsA wouldn't align them because they felt it would encourage pilots to bust minima. A stable approach does not necessarily have to be in a straight line, it can commence from mid down wind or in a turn, Think Hong Kong, 90 degree offset ILS, from the minima a curved turn to final, all nicely stable. Have pilot skills been so eroded by the auto magic that pilots are now incapable of flying a visual stabilised approach?
Even so.

Some good points made there TB; which is why I made mention of the ‘transition’ notes on the ‘Jepp’ and the lack of information regarding the same in the ATSB report. Whatever SOP the crew used – as you say, 10,000 feet/ 10 minutes is a good place to be ‘set-up’ for an instrument approach – time and space to get the loose ends tidied up – the briefing and TOLD things of the past, nothing to do but fly the approach – routine, done a million times a day all over the world regardless of transition. Same - same a ‘stable’ approach; this crew were clearly capable of conducting the approach – and got it right the second time. There can be little doubt over crew competency – but; we need some in depth information, detail related to just how and why the local pressure was not set.

ATSB – “The flight crew did not complete the approach checklist before commencing the non-precision NDB approach into Kosrae, resulting in the barometric pressure setting on the altimeters not being set to the local barometric pressure.”

Yes – But- Why? I believe we should have been offered a detailed explanation in the ATSB report – an analysis – good enough to use for training. It is a ‘rare’ event this one, the incorrect altimeter setting ‘persuasive’ enough to lead to cancelled EGPWS warning; serious stuff. The NDB approach and circling would be occupying the aircrew – particularly when the crew believe all the checks are complete and consigned to the past – routine again – check complete – forget about it –and, on to the next event. The notion to complete one check list item – out of sequence (later) is fraught with peril, particularly where the next event is a demanding one.

Well, the whole event may well be a rare animal – one we hoped was extinct. It did happen, which opens the door for a repeat – I just think the why’s and wherefores are worthy of examination. It all ended happily this time (nod to the gods) but it should never have happened at all. ATSB should be moving to ensure that it never happens again, through correct, thorough detailed analysis of exactly why the event occurred. That flight came as close to disaster as it is possible to get – remind me again – at what height does the EGPWS kick in with a ‘terrain – to low’ warning?

Oh, don’t mind me; the curiosity curse strikes again; what sequence of events and circumstance could promote a departure from basic routine, SOP and habit – then persuade a crew to cancel a ‘terrain’ warning? Then there’s the Rad Alt to back up the call – more puzzles. Me, I’d be reaching for the taps before the lady had finished saying her piece – right or wrong – we’re out of here – TOGA and horsepower – lots of.

"For want of a nail the shoe was lost " etc…..

Toot - toot.
My two bob’s worth.

Agree with the above – however the following lines from the ATSB put an eccentric spin on what actually happened, and they are arse about face:-

1) - ATSB – “The crew's belief that the EGPWS alerts were due to a decreased navigational performance and not terrain proximity led to the crew’s decision to inhibit the first EGPWS alert and not correct the flight path.”

2) - “The flight crew initiated a missed approach when they lost visual contact with the runway”.

Turn those two statements about, in sequence:-

1) – ATSB - “The flight crew initiated a missed approach when they lost visual contact with the runway”.

2) - ATSB – “The crew's belief that the EGPWS alerts were due to a decreased navigational performance and not terrain proximity led to the crew’s decision to inhibit the first EGPWS alert and not correct the flight path.”

Suddenly, it all starts to make ‘operational’ sense – the crew appear to have been in visual contact with the ‘land’ (one may even guess the runway) when the EGPWS warnings were discarded – fair enough some would say – particularly if the ATSB had dug about a bit to see if spurious EGPWS warnings were a ‘feature’ of the approach conducted. The crew could actually ‘see’ where they were -. The missed approach was initiated when the crew lost ‘visual contact’ and the missed approach procedure was executed. Once again – fair enough – good airmanship – lost visual + EGPWS warnings – no messing about ‘go around’ initiated.

Another small, but troubling item ignored by ATSB is the actual ‘value’ of the islands NDB as a primary navigation tool. From the CPL ground school days any instrument pilot who can’t name the four potential ‘dangers’ to navigation which can be produced by a NDB/ ADF system should not be allowed to fly. We have a coast line + high hills + Sunset /Night + Rain – all of which affect the NDB/ADF system how? ATSB don’t mention the power and range of the NDB or any noted diminished performance due the effects of where it is situated or the time of day.  I wonder, does the operating company mention these old times killers?

Just small points which, IMO the ATSB should have covered – if only to ‘eliminate them from our inquiries’ so to speak. But then, I’ve just read the load of bollocks provided on behalf of Qantas and the 737 into Canberra.

Send that bucket this way when you’re done with it son; meanwhile - I’ll get the beers in. My two bob, spent as pleased me best.
I solemnly swear I am up to no good…

The bump of curiosity started itching again; Kosrae, the NDB/DME approach and the ATSB report demanding a good scratch. It is the ‘dive and drive' comment (aspersions) which create the irritation – it is just so wrong, you have to wonder why the ATSB set about their work in the manner they adopted. Passing strange I call it. Rough research on a beer coaster follows:-

Lets take it as a given that one way or another – the flight arrived at the ten mile fix at 1500 feet, properly configured for the approach leg. Consider that at 10 nms on an ILS the ‘averaged’ height is around the 2500 foot (AGL) mark (give or take) the Sydney 34 ILS has you at 1600’ @ 5 nms. The approach flown at Kosrae is a laid back affair with 1000 foot advantage and five additional miles – when compared to an ILS approach. The approach profile begins  ‘below’ a standard 3˚ height/distance profile; which excludes any need to be shoving the nose down, trying to slow up and maintain the profile – quite the reverse, you can actually maintain height and 'fly' to intercept the Korsae profile.  If the approach was not off-set that is exactly the way to do it. So why attack the crew with a D&D bull-pooh accusation?

Furthermore, close inspection of the NDB track sets the approach to runway 05 up very nicely; becoming visual anywhere between 5 and 3.5 miles makes for an easy roll onto final – in essence a doddle; however, closer in at 500 feet/2.9 miles is a little tight for a transport jet – with a load of passengers in the back - but you can see why the ground proximity warning would get ‘antsy’. Not a problem if visual.  Landing on the 23 runway is a whole different ball game; but then, when the winds favour the 23 runway – the ‘dry’ season is in – I digress.

Dive and drive approach considerations aside, the real potential threat is the miss-set altimeters (and the vagaries of the NDB). Human factors at work perhaps? Go figure, its an important flight – must be ‘smooth’ and seamless; low transition (5000’?) no SOP for such things and then becoming visual – the temptation to break off early to make a longer, smoother final approach, attention focussed on the landing – that is the next event – the approach is ‘complete’ and forgotten. Then back into IMC – the whole flight deck attitude must change now, from expectation of an easy night landing to potentially an approach to minima, close in and tight. 500 feet @ 2.9 miles ain’t a lot of wriggle room, not in marginal conditions, not with piles of bricks lurking within the cloud, not with the EGPWS bleating; time to go around – and they did. Safe as houses..

I won’t bang on anymore about this – it just annoys me that the ATSB have missed so many of the attending elements to this flight and loaded it all back onto the crew. Not a stellar crew performance I’ll grant you; but the human factors and possibly fatigue played a role in this event – and ATSB dismiss those elements with a totally inaccurate condemnation of ‘dive and drive’; which, by inference is not only technically wrong but most politically incorrect. This from an outfit that claims not to lay blame – Bollocks.

I just hope that a fatal accident which could have been prevented by ATSB doing their job properly and thoroughly never occurs. The smooth, glib, deceptive nature of ‘reports’ disguising the core elements and ignoring the radical causes is becoming a normalized deviance – this, as any safety manager will tell you is not a good thing; not at all.

Save file and close it – forever.

Toot – but then there’s the Canberra incident -  toot.
O&O investigation No: AO-2014-032

Not that the average punter, stakeholder or even DIP would know it but the now No1. longest O&O'd ongoing ATSB AAI went past it's 4th Anniversary without so much as an Annex 13 interim statement; or any recognisable update since 05 May 2017. However apparently the investigation webpage was revisited a week after the 4th Anniversary on 28 February 2018 - WTD... Huh

Blush Slightly embarrassed (because I'd missed it before), I noticed that on the AAI webpage a link for a passing strange 'Explanatory Statement', also dated 05 May 2017 (i.e. spot the disconnects Dodgy ).

  Media release
ATSB issues second interim ATR report: 5 May 2017

Explanatory Statement
Investigation AO-2014-032 - ATR in flight pitch disconnect
Quote:Explanatory Statement - ATSB Investigation AO-2014-032 ATR in flight pitch disconnect
With highly technical investigations, the ATSB considers it appropriate to provide an explanatory statement that describes the nature of the technical investigations in a manner which is more easily understood by readers of this report.


ATR42 and ATR72 aircraft are twin-turboprop, short-haul, regional airliner and cargo aircraft built in France and Italy by ATR, and have been in service around the world since the mid-1980s. They seat between 48 and 78 passengers. The entire fleet of the two aircraft types have operated in excess of 20 million flight hours.

There are currently a small number of both aircraft types operating in Australia.

2014 incident

On 20 February 2014, a Virgin Australia Regional Airlines ATR 72 aircraft, registered VH‑FVR, operating on a scheduled passenger flight from Canberra, Australian Capital Territory to Sydney, New South Wales sustained a pitch disconnect while on descent into Sydney. The pitch disconnect occurred when the crew applied opposite inputs to the elevator controls while attempting to prevent the airspeed from exceeding the maximum permitted airspeed for the aircraft type. The pitch uncoupling mechanism activated and the elevators deflected in opposite directions, resulting in aerodynamic loads above the design strength of the tail structure, causing significant damage. 

The “pitch uncoupling mechanism” (PUM)

The elevator consists of a left and right control surface and is located at the top of the tail structure on ATR aircraft. It is operated by the pilots pushing or pulling on the control column in the cockpit, which raises or lowers the nose of the aircraft (known as pitch). During normal operation, the left and right elevator deflect in the same direction and in equal amounts.

There is also a mechanism called the pitch uncoupling mechanism (PUM), located between the right and left control surfaces in the tail of the aircraft. In the event of one of the elevators becoming jammed, the PUM can be triggered to have the elevators operate independently of each other. The PUM is activated by the pilot (operating the pitch control for the elevator not jammed) applying significant pressure to the control column in either direction. The pilot is then able to operate the elevator on the non-jammed side.

If significant pressure is applied in the opposite direction on each of the control columns, the PUM may also be triggered. An inadvertent activation of the PUM due to opposing control inputs is what occurred in 2014.

Flight crew procedure

Generally, flight crew procedures prohibit the simultaneous inputs by both pilots on the control column. Established handover/takeover communication protocols reduce the risk of any inadvertent dual input.

The Work of the ATSB 

The ATSB has undertaken an extensive investigation into the safety factors and issues behind the incident. The investigation has considered design, engineering and certification aspects of the aircraft, as well as operational, maintenance, training and regulatory aspects.

On 15 June 2016 the ATSB released its first interim investigation report that identified a safety issue concerning the potential for PUM activation to exceed the strength of the aircraft.

During the continued investigation of the occurrence, the ATSB has obtained an increased understanding of the factors behind this previously identified safety issue. This has identified that there are transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads capable of exceeding the design strength of the aircraft structure. The ATSB also identified that these transient elevator deflections were not considered during the certification process. The ATSB considers that the potential consequences are sufficiently important to release a further interim report that expands on the identified safety issue, prior to completion of the final investigation report. Readers are cautioned that new evidence may become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence.

In order to ensure the veracity of the analysis of the evidence leading to the identified safety issue, the ATSB engaged the UK Air Accidents Investigation Branch (AAIB) to conduct a peer review. The AAIB conducted an analysis of the evidence relating to the safety issue and concluded that their findings were consistent with those provided by the ATSB.

Stakeholder engagement and cooperation

The role of the ATSB is to identify safety issues and communicate them to the relevant organisation(s) to address. Since 2014, ATSB has worked closely with ATR (the aircraft manufacturer), the European Aviation Safety Agency (EASA), the French Bureau d’Enquêtes et d’Analyses (BEA), the United Kingdom Aviation Accident Investigation Branch (AAIB), the Civil Aviation Safety Authority (CASA), Toll as the Australian operator of the Australian ATR42 aircraft, and Virgin Australia as the operator of the ATR72 aircraft. Each of these stakeholders has a specific role in relation to the continued safe operation of these aircraft and has taken the following action to address the safety issue:


ATR has continued to provide data to ATSB and cooperate more broadly to undertake further aeronautical engineering and assurance work to determine if the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. Specifically, ATR has commenced a detailed engineering analysis of the transient elevator deflections that occur during a pitch disconnect. Indications from ATR is that this work will be completed in July 2017.

On 5 February 2016, as a result of this occurrence and a briefing from the ATSB, ATR released an All Operators Message. The message informed operators of ATR 42/72 aircraft of revised maintenance and operational documentation relating to the pitch control system and pitch disconnect occurrences.


EASA is the issuer of the aircraft’s type certificate and, as such, is the global regulator for the continued safe operation of the word-wide ATR fleet.

While acknowledging the safety issue identified by the ATSB, on 20 December 2016 (and updated on 21 February 2017), EASA issued a related safety information bulletin (SIB) that contained the following statement:

At this time, the safety concern described in this SIB is not considered to be an unsafe condition that would warrant Airworthiness Directive (AD) action ... P2 - So what's the bloody hold up? Confused  

As the global regulator for the aircraft type, EASA is closely monitoring the detailed engineering analysis of the transient elevator deflections being carried out by ATR.


CASA has advised that they continue to work closely with both EASA and the Australian airline operators of the ATR aircraft, in relation to the continued safe operation of the aircraft type in Australia. ATSB has been advised that this has included both continual dialogue with and specific audits of the airline operators to assure that sufficient pilot training and operational procedures are in place to prevent the recurrence of this event. P2 - Wonder if those audits were conducted in accordance with the recently amended CASA surveillance manual - see Aiding & abetting; or under the busses?? - or as per the McComic black letter regulatory captured days; that brought us strange dichotomies like the PelAir 2009 MAP/SAR vs the Airtex MAP/SAR and AAT embuggerance... Rolleyes     
Virgin Australia and Toll

Virgin Australia Airlines advised that, in response to this occurrence, they have taken action to reduce the potential for pitch disconnects and to manage the risk of adverse outcomes from such occurrences. These included:
  • reviewing and revising (where necessary) policy and procedures associated with descent speeds, handover and takeover procedures, overspeed recovery and on ground pitch disconnects
  • incorporation of a number of factors surrounding the event into training material and simulator checks
  • improved pilot awareness through Flight Crew Operations Notices, manufacturer’s communications (All Operators Messages) and ongoing training and checking
  • updated maintenance requirements following a pitch disconnect.
Toll Aviation and Toll Aviation Engineering advised that, as a result of this occurrence, they issued a safety alert to their flight crew and aviation maintenance engineers, which included copies of ATR and EASA service bulletins. This alert advised that, in the event of a pitch disconnect, the aircraft was to be grounded until the appropriate checks had been carried out.

Toll has also developed and delivered enhanced training to their flight crews focused on handover/takeover procedures, unexpected turbulence and high-speed scenarios, and the pitch uncoupling system. Toll have also conducted detailed inspections associated with major  maintenance procedures.

Safety recommendations

While welcoming the safety action taken to this point, in particular ATR’s engineering analysis, the ATSB retains a level of concern as to whether the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. As a result the ATSB recommends that:
  • ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.
  • EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.
  • CASA review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect, to determine whether the aircraft can safely withstand the aerodynamic loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that CASA take immediate action to ensure the ongoing safe operation of Australian‑registered ATR42/72 aircraft. P2 - Funny how for CASA immediate means sometime in the next century... Huh

Readers of this report are encouraged to read this report in conjunction with, the interim report released on 15 June 2016 report and an update on the ATSB website on 10 June 2014.

A final report is expected to be published in August 2017 (P2 - Must be a typo...err maybe HVH 's motley minions meant August 2027... Big Grin ) and will include the results of the further testing and assurance activity being conducted by ATR, and will also include operational, maintenance, training and regulatory aspects associated with the incident.


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Last update 05 May 2017

Oh well, good to see that HVH and his minions are upholding the Beaker record for making the ATSB the premier international top-cover experts for effective obfuscation of potentially embarrassing aviation accident investigations.

For classic example please refer to the ongoing OI search for MH370:

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Oh but that's right.. "nothing to do with us your honour" ... Undecided    

MTF...P2 Cool
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ATCB lining up the ducks on YMEN DFO accident -  Dodgy  

A rehash of where HVH's topcover bureau is currently at with the combined investigations surrounding the tragic Essendon DFO accident: AO-2017-024 & AI-2018-010 

Quote:Updated: 9 February 2018

The investigation into this accident has been completed and a draft report is in the final stages of completion. The report will soon undergo a review by the ATSB’s Commission and by Directly Involved Parties (DIPs), which is a process that enables checking of factual accuracy and ensures natural justice. It has been necessary to extend the completion date for this investigation due to a number of factors, including accommodating the involvement of international DIPs, who have up to sixty days to comment under international conventions.

As with any ATSB investigation, if a critical safety issue is identified during the course of an investigation, it is immediately brought to the attention of the relevant parties so that appropriate safety action can be taken.

Last update 28 February 2018


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
General details
Date: 21 February 2017
Investigation status: Active

Investigation phase: Evidence collection
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre
Investigation type: Safety Issue Investigation
State: Victoria

Report status: Pending

Expected completion: 3rd Quarter 2018

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Last update 20 April 2018

And from the Airports thread:

Senate Report released -
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Finally, in the Senate today the RRAT Legislative committee inquiry tabled their report into the Airports Amendment Bill 2016:


Airports Amendment Bill 2016 [Provisions]
19 March 2018

© Commonwealth of Australia 2018
ISBN 978-1-76010-747-5

View the report as a single document - (PDF 315KB)

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And from off the UP, Old Akro & Mr Peabody voice their frustrations:

Quote:OA: This accident has been over speculated. We need the ATSB to do its job and publish the report.

In Feb the ATSB put out a media release essentially saying that the report was done but release was delayed because of a requirement to give interested parties time to comment with the inference that this involving international parties was increasing this period to 60 days. This 60 day period has now elapsed by 30 days and still no report.

The exact same update was issued on the same day for the 3 September 2015 incident at Mt Hotham with VH-OWN & VH-LQR- an incident that occurred 32 months ago. .

The list of pending reports has grown to 109.

This is from the ATSB's current strategic plan:

" The Government’s recent Budget measures, and the ATSB’s organisational change program, position the ATSB to reduce its investigation backlog and increase its capacity to complete complex investigations within 12 months, which is a key deliverable of the ATSB."

The ATSB is clearly failing to do its job by any measure.

Mr Peabody: I think we will be waiting quite a while for this report to come out; according to the ATSB investigation status the report is still at "Final Report: Internal Review". That means it likely hasn't even gone to the DIPs yet, if it had the status should be "Final Report: External Review".

And yes they do appear to work at a cracking pace!! Snail wise I mean.

In a 'passing strange' coincidence I noted the following addition to the ATCB AAI webpage: 

Quote:What happened

In October 2009, the operator of Essendon Airport (now Essendon Fields Airport) received an application from the Hume City Council (HCC) to construct a radio mast on top of the council office building at Broadmeadows, Victoria. The application was made under the Airports (Protection of Airspace) Regulations 1996 (APA Regulations) which was only applicable to leased, federally-owned airports, such as Essendon. The application identified that the building and existing masts had not been approved under the regulations. The regulations required any proposed construction that breached protected airspace around specific airports to be approved by the Secretary of the then Department of Infrastructure and Transport (Department). Protected airspace included airspace above a boundary defined by the Obstacle Limitation Surface (OLS). The Secretary was required to reject the application if the Civil Aviation Safety Authority (CASA) determined that the application would have an ‘unacceptable effect on safety’.

CASA’s initial response to the HCC application stated that the building and existing masts represented a hazard to aircraft and should be marked and lit, while the proposed radio mast represented a further hazard and, as such, would not be supported. The advice was considered inadequate by the Department, who instructed CASA that they required advice that either the application for the mast had an unacceptable effect on safety, or it did not. CASA subsequently determined that the application did not have an unacceptable effect on safety, and in addition, advised the Department of specific lighting and marking requirements to mitigate any risk presented by the mast. The Department approved the HCC application on 28 February 2011 conditional on appropriate marking and lighting being affixed to the radio mast and building. The ATSB has since been advised that the radio mast has been removed due to reasons unrelated to aviation safety.

What the ATSB found

The scope of this investigation was limited to the processes associated with protecting the airspace at leased, federally owned airports, and in particular the application of safety management principles as part of that process. The investigation used the HCC application for examining the APA Regulations processes, and as a result identified an issue specifically associated with that application. However, the investigation did not consider whether or not the aerial on the HCC building was unsafe.

The Airports Act 1996, which was administered by the Department, was the principal airspace safety protection mechanism associated with a leased, federally-owned airport’s OLS. The Australian Government had committed to using a safety management framework in the conduct of aviation safety oversight (that is, a systemic approach to ensuring safety risks to ongoing operations are mitigated or contained). In contrast, the conduct of safety oversight of an airport’s airspace under the Airports Act used a prescriptive approach (that is, the obstacle was either acceptable or unacceptable). This approach met the requirements of the Airports Act, but was not safety management-based. With respect to the assessment of the HCC application under the Airports Act, a safety management approach was not used.

What's been done as a result

The Department, now known as the Department of Infrastructure, Regional Development and Cities, has advised that it will confer with key stakeholders in the APA Regulations process regarding relevant risk management practices. The intent is to implement a more systematic approach to risk management, guided by the Commonwealth Risk Management Policy.

The Department has also identified the need to reform the current airspace protection regime based around the Airports Act. In a paper titled ‘Modernising Airspace Protection’, the Department identifies that current airspace protection regulation under the Civil Aviation Act 1988 and the Airports Act requires improvement, and has initiated public consultation regarding reforms into this particular regulatory system.

Safety message

A safety management system approach is considered ‘best practice’ by the International Civil Aviation Organization and has been adopted by Australia as the core method of aviation safety oversight through the State Aviation Safety Program. The Airports Act processes need to adopt safety management principles to the assessment of construction applications involving breaches of prescribed airspace, but rather, used a prescriptive regulatory approach. Construction proposals can impinge on aviation safety margins, such as those represented by the OLS. A fully informed, safety management-based approach should be used to ensure that safety is not compromised.

Safety analysis
Safety issues and actions
Sources and submissions

This bit is IMO simply gob smacking in the observed subservience by CASA to what was then Murky's Department: 

"..CASA’s initial response (sic)...while the proposed radio mast represented a further hazard and, as such, would not be supported. The advice was considered inadequate by the Department, who instructed CASA that they required advice that either the application for the mast had an unacceptable effect on safety, or it did not. CASA subsequently determined that the application did not have an unacceptable effect on safety, and in addition, advised the Department of specific lighting and marking requirements to mitigate any risk presented by the mast..."

Reference safety issue: AI-2013-102-SI-01

Quote:The use of risk management principles when considering an application under the Airports (Protected Airspace) Regulations

Issue number: AI-2013-102-SI-01
Who it affects: Airports managing protected airspace associated with their runways
Issue owner: The Department of Infrastructure, Regional Development and Cities
Operation affected: Aviation: Airspace management
Background: Investigation Report AI-2013-102
Date: 03 May 2018

Safety issue description

The Department of Infrastructure, Regional Development and Cities adopted a prescriptive approach to the Hume City Council building application within the obstacle limitation area of Essendon Airport, which was in accordance with the process prescribed under the Airports (Protection of Airspace) Regulations 1996, but did not require the application of risk management principles to the department’s consideration.

Proactive Action

Action organisation: Department of Infrastructure, Regional Development and Cities
Action number: AI-2013-102-NSA-063
Date: 03 May 2018
Action status: Monitor

In response to this safety issue, the Department of Infrastructure, Regional Development and Cities (Department) advised that:

The Department notes the ATSB comments that the approach to the application was in accordance with the relevant applicable regulations i.e. the Airports (Protection of Airspace) Regulations 1996 (APA Regulations). The Department also notes that under APA Regulations r. 14(2) the Secretary must approve applications unless they interfere with the safety, efficiency or regularity of air transport operations.

As outlined in the report, the Department stresses that the primary responsibility for providing safety advice rests with CASA, given that under APA Regulations r. 14(6) the Secretary must not approve a proposal for a controlled activity if CASA has advised the Secretary that carrying out the controlled activity would have an unacceptable effect on the safety of existing or future air transport.

While the Department does consider relevant risks (including to safety, efficiency and regularity) in considering applications under the APA Regulations, the Department agrees that in the future a more systematic approach to risk management should be implemented in relation to applications being assessed under these regulations. To this end, the Department will be guided by its internal 2015 Risk Management Framework, which aligns with the 2014 Commonwealth Risk Management Policy. The Department will document its risk management approach to airspace protection applications during 2018.

The Department will also work with key stakeholders to understand and document relevant risk management practices within those organisations (particularly CASA) that impact on the application processes and advice provided to the Department for the purposes of the regulations.

A significant change since the 2010 incident has been that in October 2015 the Victorian Government amended the Victoria Planning Provisions to include mandatory consideration of National Airports Safeguarding Framework Principles and Guidelines in planning processes around the state’s airports and airfields. This is outlined at: www.dtpli.vic.gov.au/planning/plans-and-policies/planning-for-airports/the-national-airports-safeguarding-framework.

This amendment will assist in early identification of potential airspace intrusions and facilitate communication between the relevant regulators, airports and developers. Further information about the National Airports Safeguarding Framework Principles and Guidelines is available at: www.infrastructure.gov.au/aviation/environmental/airport_safeguarding/nasf/index.aspx

The Department continues to work with industry and State, Territory and local governments to improve awareness of airspace protection issues and planning processes.
The Department is currently reviewing the airspace regulations as they will sunset in April 2019 under the Legislation Act 2003 and will also take into account the ATSB’s findings on this matter.

ATSB response:
The ATSB welcomes the above proposed safety action concerning introducing a risk based approach to decision making. The ATSB will monitor the progress of implementing this safety action in future amendments to airspace regulations.
Current issue status:
Safety action pending

[Image: share.png][Image: feedback.png]

[i]Last update 03 May 2018[/i]


The above safety issue response, from the current iteration of the Dept, would appear to suggest that finally we have a Dept Secretary that acknowledges the inherent deficiencies of the regulations surrounding airspace and airport protection in both the CA and Airport Acts. 

However IMO it is still totally unacceptable that this investigation has been O&O'd at HVH HQ for the better part of half a decade, only to be dragged out now when other investigations may potentially draw attention to the ATCB's apparent inability to independently investigate and make safety recommendations to help industry participants proactively mitigate safety risk issues... Dodgy    

MTF...P2  Cool

The ATSB died the day that Alan Stray left. What was a once highly reputable organisation was then destroyed by the bureaucrats hiring a completely unqualified, moronic, out of his league money counting farkwit called Dolan (Beaker). The moron made a mockery of the ATSB by making smart intelligent Investigators redundant, ignoring proven investigative methodology such as the Reason model, focusing on budgets and absolutely screwing up investigations such as Pel Air and MH 370. Six years of failed leadership under Beaker and his ass licking minions caused irreversible damage. The introduction of lightweight pithy reports containing waffle and complete shite became the norm. Beard on/beard off numpty.

Then along came HiVis Hood (HVH). The ‘bride in waiting’. Lined up as the fall guy for Pel Air by the CAsA’s Screaming Skull and Farkwitson, he never rose above third in the line of command. So he dodged the sword and popped up at the monopoly business that can’t make a profit, ASA. Here he stayed until also realising that he was not to become the new CEO, that role gifted to yet another moron - Electric Blue Harfwit. HVH then heads to the ATSB as chief and commander. His legacy? Another bad joke in which reports have become even more ludicrous, sanitised and dare I say, poofterised, and Hood spends his time blogging and counter-commenting on criticism of his stupid organisation. Emotional fool. So, in short, the ATSB is a worldwide embarrassment.

To have Beaker pop up mi mi mi-ing on 60 Minutes only adds to the embarrassment. He stuttered and stammered as real experts highlighted how Beaker and his Beakerites are clueless fucktards couldnt find a semen stain on a mattress. They should find a smoking hole and disappear down it forever.

“Absolutely unsafe skies for all”
Goggles old mate,

God I've missed your succinct Prose.
ASASI Melbourne conference

Hi-vis Hood took the stage early today at the ASASI conference in Melbourne. Very dapper in expensive suit and no sign of the vest. Interesting thing is that Australia has a plethora of skilled and competent investigative guru’s that are part of the organisation, so only god knows why HVH with his ‘correcting the record’ methodology and failures of the Pel Air and MH370 investigations is there? Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???


‘ASASI - genuinely safer skies for all’
(06-02-2018, 09:39 AM)Gobbledock Wrote: ASASI Melbourne conference

Hi-vis Hood took the stage early today at the ASASI conference in Melbourne. Very dapper in expensive suit and no sign of the vest. Interesting thing is that Australia has a plethora of skilled and competent investigative guru’s that are part of the organisation, so only god knows why HVH with his ‘correcting the record’ methodology and failures of the Pel Air and MH370 investigations is there? Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???


‘ASASI - genuinely safer skies for all’

"..Perhaps he mistook ‘reach out’ for ‘reach around’ and is in the wrong building???.." - Top shot Gobbles, luv your work... Wink 

If your around tomorrow perhaps you could get us a blow by blow of the Dr A's hoodoo voodoo prezo -  Rolleyes

1130 - 1210 Just Culture from a Regulators perspective - Jonathan Aleck, CASA 

Maybe we can get it on podcast?

MTF...P2  Tongue  
P2 requested a Sunday update on this hilarious CAsA topic;

1130 - 1210 Just Culture from a Regulators perspective - Jonathan Aleck, CASA

Will see what can be arranged good sir. I imagine Dr Voodoo’s speech will last around 10 seconds, and be something like this;

“All aviators are criminals, lock them up in jail and throw away the key”. Up next, Dr Voodoo’s new inclusion in the Civil Aviation Act; ‘pre recognition’. The art of predicting an aviation offence before it has even been committed and then punishing the yet to offend offender;

HVH's 1 in 60 bollocks on O&O'd investigations -  Dodgy  

Resplendent in high viz and fresh from a training session for this year's CEO toga party sleep-out, HVH treads the light fantastic with the latest spin'n'bollocks excuses for investigation backlog... Rolleyes  

From Annabelle in the Oz today Wink :

Quote:[Image: 629b3ef53bbc8a10e7875ffe57d3540c]
Air investigator ATSB vows to speed up complex probes. ATSB Chief Commissioner Greg Hood. Picture: Dylan Coker

ATSB vow to speed up probes

ATSB chief Greg Hood says the air investigator is ‘actively working’ to finish complex investigations in a ‘timelier manner’.

The nation’s air investigator says it expects to finish its complex investigations in a “timelier manner” after a program aimed at clearing a backlog of reports.

The latest figures show the Australian Transport Safety ­Bureau expects to publish 30 per cent of complex investigations within 12 months in 2017-18, against a target of 90 per cent.

ATSB chief commissioner Greg Hood said the ATSB was finishing complex investigations in an average of 16 months but was “actively working” to improve the timeliness.

The “Back on Track” program, aimed at clearing a backlog of reports, had been “productive”. Some 30 investigations that were behind time were now finished, while a further five to eight were expected to be done by the end of the financial year.

“Back on Track has required a diversion of significant resources away from our business as usual operations and therefore the percentage of complex investigation reports that have been completed remains around 30 per cent for this 2017-18,” Mr Hood said.

“I remain confident that when the Back on Track program is completed and these diverted resources return to business as usual operations, the ATSB will be positioned to complete its investigation reports in a timelier manner.” Mr Hood also pointed to other measures aimed at getting investigations completed more promptly, including moves to hire more transport safety investigators and be more selective in what it investigates.

While the headcount had gone down by about 25 per cent since the ATSB became an independent statutory body in July 2009, a recent budget boost had enabled an extra 17 transport safety investigators to be recruited.

“These investigators are currently being trained and a number have already had the opportunity to deploy to accident sites,” Mr Hood said.

“The process of establishing investigator competencies generally takes 18 months to complete, so we anticipate that we will begin to see the benefits of these additional resources in the next financial year results.”

As well, the ATSB would use its database to pinpoint cases with “the greatest potential for improving transport safety”.

The ATSB had started 120 investigations this financial year, compared with 162 investigations in 2016-17. “There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity. We are also placing emphasis on addressing accidents and incidents that recur through safety education.”

Hmm...no comment -  Dodgy

MTF...P2  Cool

HVH has his yearly sleepout for the homeless on June 21. I’m not sure who will be ‘correcting the record’ on his behalf while he is out of the office with other CEO’s sleeping on the street. A noble cause, however it’s just a shame that his compassion for humanity doesn’t extend to the survivors of the Pel Air ditching or the families of the MH370 victims.

I wonder if he will be sleeping in his hi-vis vest, a Toga and a hand knitted blanky? I just hope that whoever he ends up ‘spooning’ with doesn’t get frightened by that pointy object in their back!

“Safe cuddles for all”
O&O investigation: AO-2015-108 1029 days to completion - UDB!  Dodgy

Via the ATSB website today:

Quote: Final Report
Download final report
[DownloadPDF: 3.16MB]
Listen to this PDF[img=10x0]https://www.atsb.gov.au/Assets/readspeaker_small_blue.png[/img]
Alternate: [DownloadDOCX: 5.74MB]

What happened

On 3 September 2015, several multi-engine turboprop aircraft converged on the airspace above Mount Hotham Airport, Victoria, as part of a multi-day charter involving several operators. While conducting a number of area navigation (RNAV) Global Navigation Satellite System (GNSS) approaches, the pilot of a participating Beech Aircraft Corp B200 (King Air) aircraft, registered VH‑OWN, descended the aircraft below the minimum altitude and exceeded the tracking tolerance of the approach after experiencing GPS/autopilot difficulties. The pilot twice climbed the aircraft without following the prescribed missed approach procedure and manoeuvred in the Mount Hotham area. During this manoeuvring, the aircraft came into close proximity to another King Air, registered VH‑LQR, which had commenced the same approach. Both aircraft were in instrument meteorological conditions and unable to sight each other. Significant manoeuvring was also observed as VH‑OWN was on final approach to the Mount Hotham runway. All aircraft landed safely at Mount Hotham without injury to passengers or crew.

What the ATSB found
Difficulties in operating the GPS/autopilot resulted in the pilot of VH‑OWN experiencing an unexpected reduction in the level of supporting flight automation, and a significant increase in workload, while attempting to conduct RNAV (GNSS) approaches into Mount Hotham Airport. This increased workload affected both the pilot’s ability to follow established tracks such as the published approach and missed approach, and his ability to communicate his position accurately to other aircraft and the air traffic controller.

Although radar coverage in the area was limited, there were opportunities for the air traffic controller to identify when VH‑OWN was having tracking difficulties during all three approaches, and when VH‑OWN tracked towards the expected position of VH‑LQR. However, this position information was not effectively communicated, resulting in a missed opportunity to prevent a potential controlled flight into terrain and/or collision with VH‑LQR.

What's been done as a result
The pilot of VH‑OWN underwent flight testing by both a delegate of the Civil Aviation Safety Authority (CASA), and by a flying operations inspector employed by CASA, who recommended remedial training. Independent of this investigation, in February 2017 it became mandatory for all aircraft operating under instrument flight rules to be fitted with Automatic Dependence Surveillance – Broadcast, further increasing surveillance capability nationally, including in the Mount Hotham area.

Additionally, and independent of this investigation, the Department of Defence radar system, capable of surveillance in the Mount Hotham area, is scheduled for upgrade in late 2018. The radar system upgrade is likely to enhance the national air traffic system through the increased compatibility between that radar and the Airservices Australia surveillance system.

Safety message
Maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced. Additionally, as the responsibility for separation from other airspace users and terrain in Class G airspace lies with aircrew, it is imperative that pilots maintain the skills to navigate accurately, and interpret and utilise traffic information to maintain safe separation. From an air traffic control perspective, the occurrence highlights the safety benefit of communicating any apparent tracking anomalies and/or conflicts to the involved pilots.

Mount Hotham runway
[Image: ao2015108_picture-4.jpg?width=382&height=286&sharpen=2]
Source: Mount Hotham Airport and Resort

P2 comment: IMO parts of the following extract rings some alarm bells... Huh

Quote:The following day, the pilot of OWN, along with a Civil Aviation Safety Authority (CASA)‑approved testing officer, conducted a test flight in OWN which included a practice area navigation RNAV (GNSS) approach in daylight visual meteorological conditions. While the aircraft reportedly did demonstrate a minor tracking anomaly when approaching the final approach fix, this did not replicate the situation of the previous day. Further opportunity to test-fly the aircraft and/or the GPS was hampered when the pilot of OWN destroyed the GPS removable data card before the ATSB had commenced an investigation, making it impossible to replicate the conditions of the occurrence flight. This action was taken after the pilot was reportedly told the data card was likely corrupted.

The pilot of OWN voluntarily suspended RNAV (GNSS) operations until he could undergo independent flight testing by CASA. This testing by CASA then resulted in a recommendation that the pilot complete remedial training before undergoing a further flight test. Following the second flight test, the pilot was deemed proficient and competent to resume operations. At no time during the two test flights were any anomalies with the GPS and/or autopilot recorded by either the occurrence pilot or the CASA-approved testing officers. CASA, however, advised that no formal testing of the aircraft or its equipment was conducted during those two flights beyond observation of functionality.

Also coming out of HVH HQ today... Dodgy

Via the ATCB twitter guy/gal:
Quote:The ATSB is requesting your feedback on the effectiveness of its engagement and communication.   Help us improve transport safety.  Visit the ATSB website to start our stakeholder survey:  http://www.atsb.gov.au/newsroom/news-items/feature-news-items/survey-2018/ 
[Image: DgqKI45UYAAWIeC.jpg]
10:47 AM - 27 Jun 2018

Err...no comments - they're all in the survey... Rolleyes

MTF...P2  Cool

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