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Closing the safety loop - Coroners, ATSB & CASA
#31
Aviation safety: The auto-dependency spectrum??

Opposite ends of the spectrum? - Duck'n'dive:
Quote:Flight below minimum permitted altitude involving Cessna 441, VH-EQU

Near Wollongong Airport, New South Wales, 3 August 2015

[Image: VH-EQU.jpg]
Versus...well duck'n'dive??  Undecided  


Courtesy Flight.org blog... Wink
Quote:[Image: melbourne-airport-flight-800x415.jpg]
11
Oct
SHEED, MESEN and Melbourne’s RW34. A Look Back at Virgin Australia’s Boeing 777 Flight Path Incident.
4 comments -

It’s been a little over 12 months now since the ATSB were informed of an incident involving a Virgin Australia Boeing 777 and an unstable approach to Runway 34 at Melbourne (YMML, MEL). Given the impending update from the ATSB, now is a good chance to reflect on the incident before the final report is published.

This article seeks to uncover a means in which to mitigate occurrences of similar unstabilised approaches elsewhere, and we’ll also compare the procedure as flown on the Boeing 777 to that of the Boeing 737 (for which similar incidents are a rarity).

Today in the Australian, international aviation safety legal expert, Joseph Wheeler is back with yet another thought provoking article, this time in relation to the Emirates crash landing in Dubai - see HERE for the latest on AP on the developing story on this accident:
Quote:Emirates EK521 Dubai accident puts focus on autoflight systems
  • Joseph Wheeler
  • The Australian
  • 12:00AM August 5, 2016
It may be too early to narrow down the causes that contributed to the destruction this week of an Emirates Boeing 777 aircraft in Dubai, but aspects of the accident warrant attention given similarities with others in recent years.

The event bears at least a superficial resemblance to the crash of Asiana Airlines flight OK214 at San Francisco Inter­national Airport on July 6, 2013.

There, a variant of the Boeing 777 family crashed on landing due to a mismanaged approach. ­According to the US National Transportation Safety Board, certain safety issues were identified which contributed to the disaster.

If initial reports are correct — that Emirates flight EK521 was attempting a go-around or missed approach when it landed on its belly — then many of the matters implicated in OK214 could be relevant to this latest incident.

Among these factors are the design complexity of the 777’s auto­flight system. The NTSB recommended that reduced design complexity and improved systems training could help reduce the type of errors made by the pilot flying in the Asiana crash.

Other findings indicate there was an overuse of automation at Asiana. The US aviation regulator has since introduced guidance and a regulatory change to support the need for pilots to regularly perform manual flight so their skills do not deteriorate.

It will be interesting to note as an Emirates investigation proceeds, whether this issue was considered to contribute to the EK521 events and whether UAE laws and guidance were amended when the US FAA rules were amended.

The only casualty in the Emirates accident was a firefighter. How did someone who helped save so many following the evacuation of EK521 come to lose his own life in the process?

While no firefighters died in their response to the Asiana crash, one passenger did when the firefighting crew failed to check for vital signs of a Chinese teenager and subsequently drove over her.

One of the NTSB recommendations was that officers placed in command of an accident be given aircraft rescue and firefighting (ARFF) training.

The arriving incident commander placed an officer in charge of the fire attack for OK214 who had not received ARFF training, and this was considered to have introduced unnecessary challenges.

There was, in fact, no guidance in place or protocol to ensure the safety of passengers and crew at risk of being hit or driven over by a vehicle during ARFF operations.
Among contributing causes in the Asiana crash, according to the NTSB are “(1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training … increased the ­likelihood of mode error …” and “(5) flight crew fatigue which ­likely degraded (the pilots’) performance”.

In light of media reports after the Flydubai accident at Rostov-on-Don, Russia on March 19 that implicated pilot fatigue as a contributing cause, this factor will also be watched with interest by the aviation industry following the events that led to EK521’s destruction.

As recently as this week British media published leaked documents from Flydubai pilots suggesting they were unsafely urged to work beyond their flight and duty time limitations even when they had warned their employers it would be unsafe.

All eyes will be on the outcome of a UAE General Civil Aviation Authority investigation into EK521 with professional interest, to see if fatigue played a role.

Joseph Wheeler is the principal of aviation and aerospace law firm IALPG and aviation counsel to Maurice Blackburn lawyers and the Australian Federation of Air Pilots.

Of course it is all idle speculation at this stage but JW does bring into the mix some very interesting observations on the possible liability issues associated with these high profile accidents, where it can be shown that the relevant authorities have not taken on-board or proactively risk mitigated identified safety issues from past accident investigations.

Also of interest, & perhaps another potential hole in the Swiss cheese, with the Dubai Emirates accident is again a Flight.org article which Ventus linked to in the AP 'Accidents - Overseas' thread mentioned earlier:
Quote:[Image: boeing-777-going-around.jpg]
12
Apr
Low Missed Approach Altitude Restrictions
2 comments

A question concerning a recent change to the missed approach procedures in Dubai UAE (OMDB) has raised some interesting points about the 777 in this flight regime: high thrust, low altitude, high pilot workload, and ATC procedures that would seem to be not too well thought out.
  
Not that our pollies or bureaucrats seem to give a toss but in the interests of 'closing the safety loop' and mitigating safety risk, on what seems to be re-occurring modern day international aviation safety issues, perhaps we need to identify where we (Australia) sit on the auto-dependency spectrum... Confused
MTF...P2 Cool
Reply
#32
In the interests of brevity, it is merely reaping what you sow.
The AIOS harvest is more and more looking like a bumper crop in the making.
The stats are adding up, one by one.

Perhaps we need a new "specific" category of incidents and accident.

"AIIA's" = Automation INDUCED Incidents and Accidents"

As someone is very fond of saying: Tick - Tock.
Reply
#33
Solemn reflections while out walking in the forrest

What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly.

The 80's was the decade of midair crashes. TCAS was introduced in the late 80's into the early 90's and again with outstanding results. Problem identified and problem solved, mostly.

The 80's and early 90's was also quite a popular time for weather related accidents, particularly windshear, and Windshear, Detection and Alerting Systems underwent a technological improvement that has seen countless accidents avoided. Problem identified and problem solved, mostly.

The 2000's has seen two trends. Firstly runway overruns became more popular than a Politician at a trough. Very popular. The second has been runway incursions and accidents. Asiana's 777 at San Fran landing short in 2013 is memorable, FlyDubai earlier this year eating pavement was truly disturbing and now the EK crash. It's too early to fully speculate on the EK crash although some likely causes are starting to shine through. I will leave that to other discussion threads. No two accidents are the same, so you can't necessarily group all of these airport/runway accidents together under one root cause, however my observations indicate that there could be two causes or contributing factors to numerous airport/runway accidents in the past 15 years;
1) Growth in air traffic and airport usage at select airports and their associated airpsace.
2) Operational pressure;
- Budgets budgets budgets! Pilots pressured to remain on schedule and not cause 'financial penalties' due to performing go-arounds, hence pushing the envelope.
- Pilot fatigue due to companies squeezing more out of them.
- Poor and/or degrading airport infrastructure due to a lack of dedicated finances.
- High oil costs for many years and tight profit margins which in turn puts pressure on pilots to save costs.
- Cutbacks to training program's, SIM time, even some Pilots lack of flight hour experience in the larger commercial jets.

Anyway, that's my two-bob worth. I could be wrong, and after all I am just an ageing old man. But I do know one thing - unless the EK aircraft was in a really really unstable config it is a brave crew who hit the joystick while sinking at a reasonable rate of knots over very low altitude right above the piano keys in 50 degree weather.

"Safe sandpits for all"


#bringbackalan
Reply
#34
(08-05-2016, 08:09 PM)Gobbledock Wrote: Solemn reflections while out walking in the forrest

What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly.

The 80's was the decade of midair crashes. TCAS was introduced in the late 80's into the early 90's and again with outstanding results. Problem identified and problem solved, mostly.

The 80's and early 90's was also quite a popular time for weather related accidents, particularly windshear, and Windshear, Detection and Alerting Systems underwent a technological improvement that has seen countless accidents avoided. Problem identified and problem solved, mostly.

The 2000's has seen two trends. Firstly runway overruns became more popular than a Politician at a trough. Very popular. The second has been runway incursions and accidents. Asiana's 777 at San Fran landing short in 2013 is memorable, FlyDubai earlier this year eating pavement was truly disturbing and now the EK crash. It's too early to fully speculate on the EK crash although some likely causes are starting to shine through.

I will leave that to other discussion threads. No two accidents are the same, so you can't necessarily group all of these airport/runway accidents together under one root cause, however my observations indicate that there could be two causes or contributing factors to numerous airport/runway accidents in the past 15 years;

1) Growth in air traffic and airport usage at select airports and their associated airpsace.
2) Operational pressure;

- Budgets budgets budgets! Pilots pressured to remain on schedule and not cause 'financial penalties' due to performing go-arounds, hence pushing the envelope.
- Pilot fatigue due to companies squeezing more out of them.
- Poor and/or degrading airport infrastructure due to a lack of dedicated finances.
- High oil costs for many years and tight profit margins which in turn puts pressure on pilots to save costs.
- Cutbacks to training program's, SIM time, even some Pilots lack of flight hour experience in the larger commercial jets.

Anyway, that's my two-bob worth. I could be wrong, and after all I am just an ageing old man. But I do know one thing - unless the EK aircraft was in a really really unstable config it is a brave crew who hit the joystick while sinking at a reasonable rate of knots over very low altitude right above the piano keys in 50 degree weather.

"Safe sandpits for all"


#bringbackalan

Closing the safety loop #34 - Gobbles said:

"..What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly..."

On the subject of the introduction & history of GPWS, I note the following excellent article from Bloomberg on the man who invented that life saving technology... Wink
Quote:Thanks to This Man, Airplanes Don’t Crash Into Mountains Anymore

[Image: feat_bateman-1.jpg]The wreckage of Alaska Airlines Flight 1866, a Boeing 727, smolders as recovery workers search for the bodies of 111 victims on Sept. 7, 1971, in Juneau, Alaska.
Photographer:AP

Don Bateman’s terrain mapping device has nearly eliminated the largest cause of death in jetliner accidents.

By Alan Levin | August 10, 2016

Giant flocks of black birds circled the wreckage of an airliner that had struck an Alaska mountain two weeks earlier, killing all 111 aboard. In a small plane overhead, a young engineer directed his pilot to follow the same path the jet had taken toward the craggy terrain.

With seconds to spare, an alarm went off. Don Bateman’s plane climbed to safety, but he was frustrated. The electronic device he invented to warn pilots that they were about to hit the ground didn’t leave enough time to have prevented the large airliner from crashing.
“I was disappointed,” Bateman, now 84, recalled of the day in 1971 when he flew over the remains of Alaska Airlines Flight 1866, which had slammed into a fog-shrouded ridge. “We needed to do better.”

That’s exactly what Bateman and his small team of engineers at what is now Honeywell International Inc. did. The device presaged today’s mobile mapping applications, dramatically reduced what had been by far the worst class of air crashes and made Honeywell billions of dollars.

[Image: feat_bateman-2.jpg]
Don Bateman with a Honeywell plane the company used to test his safety devices at Paine Field in Everett, Wash.
Photographer: Mike Kane/Bloomberg
Advertisement


“I would give Don individual credit for having saved more lives than any other individual in the history of commercial aviation,” said Earl Weener, a member of the U.S. National Transportation Safety Board and former chief engineer for safety at Boeing Co.

Before retiring in June, Bateman and his band of colleagues dabbled in the world of Cold War espionage, hid the true cost of their endeavor from their corporate masters and endured skepticism from the very airlines whose planes were being lost. In spite of repeated changes in corporate ownership and the blunt-spoken Bateman’s occasional threats to quit, he worked on his mission to save lives with the same group for almost six decades, colleagues said.

Eventually Bateman’s Enhanced Ground Proximity Warning System became required in most commercial planes around the world, dramatically reducing accidents in which perfectly good aircraft with trained crews plowed into the ground or bodies of water, almost always in poor visibility.

In the 1960s and 1970s, there was an average of one such fatal accident per month, according to the AviationSafetyNetwork website. It was by far the largest cause of death in jetliner accidents.

[Image: feat_bateman-4.jpg]
President Obama awards Bateman the National Medal of Technology and Innovation in 2011.
Photographer: Win McNamee/Getty Images

Since the U.S. government began requiring an upgraded version of the device on all but the smallest aircraft starting in 2001, there hasn’t been a single such fatal crash on a U.S. commercial passenger plane equipped with it or competing devices. There have been a few overseas, often when pilots ignored or shut off the devices.

President Barack Obama awarded Bateman the National Medal of Technology and Innovation in 2011.

Bateman was always fascinated with airplane crashes. As an 8-year-old school boy in 1940 in Saskatoon, Canada, he and a friend sneaked out of class after two military planes collided and crashed nearby. As punishment, his teacher made him write a report on what happened.

“That was my introduction to aircraft accidents,” he said recently. The carnage he saw that day helped motivate him years later.

After taking a job with Boeing in Seattle, he joined a small aviation firm called United Control in 1958. Airplane accidents continued to fascinate him and he began “making little books” of notes on them. One type stood out.

In the arcane world of aviation terminology, these crashes were called Controlled Flight into Terrain, or CFIT. It was a vexing problem: Basic navigation should have kept pilots from crashing. But the cockpit navigation technology of that era wasn’t intuitive and it was too easy to get disoriented, especially at night or in bad weather.

“In my mind it became a big issue, even though there wasn’t much being done about it,” Bateman recalled.

In the 1960s, Bateman worked with Scandinavian Airlines System, now SAS AB, which had suffered a CFIT crash in Turkey in 1960, to invent a mechanism to warn pilots when they flew too low. It involved a new instrument on planes that used radio waves to determine a plane’s distance from the ground. It helped stem the accident rate and, after a series of crashes, the U.S. Federal Aviation Administration required it starting in 1974.

But it was prone to false alarms and had a glaring weakness: It couldn’t look forward, so was of little use if a plane was flying toward steeply increasing ground, such as a mountain.

For years, Bateman tinkered with the device to improve it. He also consulted with NTSB investigators, poring over accident reports.

“He would come to me and say what do we know about this accident?” said Jim Ritter, director of the NTSB’s Office of Research and Engineering, who was a technician at the time. “The whole time, the gears were spinning and he was trying to make things safer.”
[Image: Bateman%20Toaster%20Chart.png]
Bateman had been imagining a far better solution as early as his flight over the Alaska crash site. If he could create a database of all the world’s terrain, the device would see mountain tops and cliffs from miles away. But this was before personal computers and global-positioning services.

Even worse, much of the world’s topography was considered secret at the time, a vestige of the Cold War.

Then in 1991, in the chaos created by the breakup of the Soviet Union, the detailed maps it had created of the world starting in the 1920s were for sale -- if you knew where to buy them.

Bateman asked Frank Daly, the director of engineering at the Sundstrand Corp. division that had swallowed United Control, for his blessing to purchase the data from the U.S. government’s Cold War enemy.

“He thought I was crazy,” Bateman said.

They wound up sending one of his employees, Frank Brem, in search of maps in Russia and elsewhere. “There isn’t a terrain data store in downtown Moscow,” Daly recalled. “But he would go out and find the right people.”

A bigger problem than navigating the black market was the millions of dollars it was costing for the still unproven technology. “We probably weren’t as open with senior management about that process,” Daly said. He sometimes hid costs in other accounts.
[Image: feat_bateman-3.jpg]
A demonstration of a prototype infrared technology from Honeywell at Morristown Airport in New Jersey in 2010.
Photographer: Emile Wamsteker/Bloomberg

By the early 1990s, Bateman had developed working prototypes of the new system. Now the company had to sell it.

For pilots and safety officers, it was a marvel. Ed Soliday, then director of safety at United Airlines, had been prodding Bateman to improve the warning device. One day in the early 1990s, Bateman called and said he thought he had what Soliday wanted.

“Once I flew the thing with Don, it was like an epiphany,” Soliday recalled. “I was sold. I thought if we could make it work, this was a huge breakthrough.”

If a plane was flying toward a mountain, a screen popped up automatically marking the high ground in yellow and red on a map. If pilots didn’t respond, it began a series of increasingly dire warnings. Once a collision became almost imminent, a mechanical voice implored, “Terrain, terrain. Pull up! Pull up!” Compared to the earlier system, it was almost fool proof.

There are 45,000 units on aircraft today, worth more than $4 billion at list prices
But many of the more cost-conscious corporate chieftains at airlines weren’t convinced, according to Bateman and Daly.

A meeting at American Airlines was particularly grim. Daly was on the sales call at the airline’s headquarters with his then chief executive officer. Their host, a senior executive at the airline, was hostile.

“He was almost apoplectic and said, ‘We don’t want another box. We don’t want to have to replace the existing system,’ ” Daly said. “Here I am justifying spending tens or hundreds of millions of dollars and my boss has just been soundly beaten on the shoulders by the customer.”

Soliday had more success at United. The airline agreed to help Bateman’s team test it so it could be certified by the FAA, he said. Most other carriers balked. It took another high-profile fatal crash to change their minds.

What the Pilot Sees
[Image: Mark_V_EGPWSim_bro-1.jpg]The current version of Bateman’s device, Honeywell International Inc.’s Enhanced Ground Proximity Warning System, uses a color-coded map display to show pilots where dangerous high ground lurks ahead. Hazards grow in danger from yellow to red. A solid red area means a collision will occur within 30 seconds if pilots don't act. The device also has warning horns and can instruct pilots to “pull up!” in an emergency.

As American Flight 965 neared Cali, Colombia, from Miami on the evening of Dec. 20, 1995, a pilot accidentally entered the wrong data into the plane’s flight computers. The crew didn’t notice as it began a slow left turn toward mountains lying invisible in the darkness.

The Boeing 757 was equipped with the earlier version of Bateman’s warning device and its mechanical voice began warning of “terrain.” But 13 seconds later, after the pilots added full throttle to climb as steeply as possible, it rammed into a ridge. All but four of the 163 people aboard died.

Within days the airline wanted the new device, which would have issued an alert far earlier and likely prevented the crash, Bateman and Daly said. First American and then United agreed to voluntarily install them. Other carriers followed. The FAA began requiring them in 2001.

In the end, the products spawned by Bateman’s device were a financial boon to Honeywell. There are 45,000 units on aircraft today, worth more than $4 billion at list prices, according to the company.

Both Bateman and Daly wonder whether the decades-long effort to develop and improve the warning system would be possible in today’s risk-averse corporate world.

“Today new projects need to be blessed by many people,” Daly said. “You need to have hard evidence. They just would not speculatively fund something like this, especially when we were being resisted by the aircraft manufacturers, the airlines.

“But Don’s faith, the genius of his team and a little support from the company -- and it happened.”

As Gobbles alludes in his post the introduction of lifesaving risk mitigation technology, like GPWS & TCAS, was due in large part to many findings & safety recommendations from effective AAI (Aviation Accident investigation) as per ICAO Annex 13 throughout the 70s, 80s & early 90s. Since that time we've seen the onset of safety issues revolving around automation dependency. Subsequently there has been many proactive safety recommendations attempting to mitigate this now repetitively identified safety issue.

Unfortunately in Australia our State AAI, the ATSB, is yet to clearly identify 'automation dependency' as a significant safety issue in modern day 'next generation' RPT aircraft.  

Quote:SafetyWatch
[Image: safetywatch_icon_1.png]
The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. The ATSB Commission urges the transport community to give heightened attention to the risk areas featured below. These are the areas where Australia’s aviation, rail and maritime communities can make safe transport systems even safer. 

SafetyWatch gives you information about each safety concern, strategies to help manage risk areas along with links to safety resources. 

The ATSB will add or remove topics over the coming months to reflect current information on safety trends and occurrences. 

Subscribe now to keep up-to-date with news from the ATSB or follow us @ATSBinfo on Twitter. 
 
Click on a photo for more information.
[Image: Reduced-visual-cues.jpg][Image: marinepractices.jpg][Image: safeworkrail.jpg][Image: dataerrors.jpg][Image: Non_controlled-Aeros.jpg][Image: gapilots.jpg][Image: maritimepilotage.jpg][Image: underreporting.jpg][Image: approachtoland.jpg]
 

Related: SafetyWatch
 

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This is despite the quite disturbing findings in previous Senate Inquiries like:
Pilot training and airline safety; and Consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010
&..
Aviation Accident Investigations
The former inquiry, at Recommendation 9, actually called for the relevant agencies to review the findings & recommendations to come from the AF447 Final Report:
Quote:2.299    The committee recommends that the Civil Aviation Safety Authority (CASA), the Australian Transport Safety Bureau (ATSB) and Australian aviation operators review the final findings of France's Bureau of Investigation and Analysis into Air France 447, including consideration of how it may apply in the Australian context. Subject to those findings, the committee may seek the approval of the Senate to conduct a further hearing in relation to the matter.
However like the vast majority of well considered Senate & Government non-partisan review findings, these potential risk mitigation recommendations were completely ignored by CASA, ATSB, Airservices Australia & Murky's department.
Therefore rather than being at the forefront in aviation safety, Australia is now severely lagging behind the rest of the world and in some cases our aviation safety agencies are consistently becoming part of the causal (Reason model) chain... Confused
Shame on you Malcolm, Barnbaby & miniscule 4D Chester, shame! Blush
MTF...P2 Tongue
Reply
#35
CAsA & ATsB out of the loop on RPA/UAV safety - Confused

Remember this??





This was the QON & the ATSB somewhat flippant answer:
Quote:Senator Fawcett, David asked:

Senator FAWCETT: … Early this year just north of Perth a Dash 8 had a very near miss with a reasonable-sized UAV. I understand ATSB has made comment on that incident. But, more broadly, the question I am interested in is how many incidents are being reported to you through the various reporting mechanisms that you have, whether it is micro or larger UAVs. Secondly, what input, if any, are you having into the current NPRM that CASA has on the streets around looking at new rules for UAV operations?

Mr Dolan: The first half of your question I think we would have to take on notice, unless someone has the material in front of them. But we are tending to look at all significant events involving UAVs, just because it is one of those growing territories, at least to some establish-the-facts sort of level. I would have to consult with my colleagues to establish what we have been doing with CASA on the specific question of their new rule suite.

Senator FAWCETT: I am happy for you to take that on notice. I would also like you to take on notice ATSB's position, with the breakdown of incidents that have occurred—just from what I have seen in the media, the majority appear to be the smaller UAVs that your amateur can buy from whatever kind of shop—on the concept that anything less than two kilograms essentially does not present a risk and therefore should be unregulated, and whether in the light of incidents that have occurred you are comfortable with that approach.

Mr Dolan: I am happy to give you a response on notice.


CHAIR: Then will you come back to the committee—or through the secretary or through the department or through the minister—and explain to the Australian public and this committee what their protection is from the growing plethora of unmanned vehicles in the air?

Answer:

The ATSB has received 19 reports relating to UAVs over the last 3 years (although two may have been model aircraft). Twelve of these were medium (2 to 150 kg), one was small (150g to 2 kg) and six are unknown (likely to be either small or medium).

The ATSB received a briefing on the NPRM at the last ATSB/CASA Bi-annual meeting on 4 June 2014. The ATSB did not consider it necessary to make a submission on the NPRM.

The types of incidents reflect manned aircraft incidents (apart from i & vi):

i. 5 datalink/communication failures

ii. 5 engine failures

iii. 1 airframe failure

iv. 1 birdstrike

v. 3 near collisions with aircraft (two of these may have been model aircraft)

vi. 1 collision with a person resulting in minor injuries

vii. 2 UAV operating in a CTAF without making calls and/or in circuit area

viii. 1 UAV operating near a controlled aerodrome outside VMC

Refer to SEQoN 236.
 
And this was where we last left the vexed issue of UAV/RPA regulation on Aunty Pru:
(07-08-2016, 03:29 PM)Peetwo Wrote:
(07-07-2016, 11:40 AM)kharon Wrote: Drones and the like.

This topic is getting some traction, particularly now with ‘sales’ expected to increase 10 fold.  It got some attention at the BRB last evening.  It’s not a ‘hot’ topic, not yet at least, but the different ‘styles’ of risk management were discussed. The FAA appear to be taking a strong line, registration and airworthiness checks, CASA a more laid back approach where responsibility is abrogated through the familiar hand washing process. One of the almost unanimously agreed points was that no matter what the official approach taken, the ‘rogue’ element and those who wilfully intend to misuse the UAV will do so, regardless.

The conversation then turned to ‘numbers of’ – in the long term.  Just how many of the wretched things can we expect.  Consensus seemed to be that at the moment, it’s a ‘fad’ which will hit a peak and diminish as interest wains and wrecks increase.  Sensible money seems to be bet across a three horse race; the sane, safe, legal productive use of an excellent tool by responsible adults: the dedicated aero-modeller types who have never yet created a problem to anyone; and, the dedicated Darwin award crowd who also like lasers and spotlights.  The also rans are those who will purchase not a tool or a thing of interest but a trendy ‘product’ to amuse ‘junior’ for a while until it is discarded and finds it’s way into the nearest skip, broken and forgotten as easily as it was purchased.

One thing was agreed, UAV’s are here to stay in one form or another; it only remains to be seen how ‘government’ will respond – after the fact with retrospective knee-jerk; or, proactively looking carefully at the risks.

We shall see – for mine, the shotgun is always handy.

Toot toot.



Hmm...I'm a little bit dubious of this...

"...Australia can be confident that the biggest aerial innovation since the jet engine is being introduced safely and deliberately. Nobody knows this better than CASA — and when CASA promotes the benefits of more commercial micro drones in Australia, we should all listen..."

From his track record so far Skidmore has shown no inclination to giving a flying fig (or UAV) for minority industry groups and/or their commercial concerns, it is simply not part of his vocabulary - Dodgy   

Moving back to the Gold Coast incident two days ago, here is an update via the GC Bulletin:


Quote:[Image: 024d1a46bc5502e0beb13d969e23834e?width=1024]
The helicopter was flying at 60m on Wednesday when it nearly collided with the drone. Picture: Westpac Lifesaver Rescue Helicopter Service.

Call from drone pilot training after near miss with Gold Coast chopper
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/70373654dd04500200fef506aea12bd0?t_product=GoldCoastBulletin&t_template=s3/chronicle-tg_tlc_storyheader/index&esi=true&td_noGallery=true&td_device=desktop[/img]Alison Marks, Gold Coast Bulletin
July 8, 2016 10:20am

It may be a case of.."damned if you do, damned if you don't"; however going off the track record of the Department & it's aviation safety agencies, I am somewhat suspect that Murky & his minions are obfuscating their responsibilities in a further attempt to limit the government's public liability on such issues as the rapidly growing plethora of small (<2kg) UAVs. That is they are once again divorcing themselves from the safety loop. Huh

Today's Oz article by Binger does nothing to dispel my suspicions... Dodgy :
Quote:Drone deregulation: fatalities will be a case of ‘when, not if’

[Image: 7e3b11bbb3929a953c19661171a36a07?width=650]Scott Goodkin cuts up a carrot with the spinning blades of a 2kg drone. Picture: Lyndon Mechielsen
[Image: mitchell_bingemann.png]
Reporter
Sydney
@Mitch_Hell
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
Professional drone operators are putting pressure on the government to dump new laws that would deregulate the commercial operation of remotely piloted aircraft by the end of this month.

Peak group Australian Certified UAV Operators held a demonstration in Brisbane this week to underline its concerns about the rule changes, at which photographic drone pilot Scott Goodkin used the spinning blades of a drone to sever a raw carrot.

ACUO has enlisted the International Aerospace Law and Policy Group to help it put its case to government to fight the legislation, which will allow commercial operators to fly without a licence drones weighing less than 2kg from the end of this month.

The group thinks deregulating the operation of commercial drones will lead to an increase in civilian accidents.

“This amendment allows people to fly drones up to 2kg in weight, without any training, insurance, registration or certification. It will open Pandora’s box in terms of new dangers for airlines and the general public,” ACUO’s president Joe Urli said.

Operators must still obey standard flight rules, which are not to fly within 5.5km of an airport, above 400 feet or within 30m of buildings, railways or vehicles, and always to have line of sight of the drone.

The Civil Aviation Safety Authority requires that a list of these rules is included with the sale of any drone but ACUO says these are neither strict nor clear enough in explaining the risks.

IALPG principal Joseph Wheeler said the legislation was a step backwards for aviation regulation and that it would put Australia’s enviable aviation safety record in jeopardy.

“While the rest of the world are tightening restrictions on drone technology, Australia has put in place a level of deregulation which will end in a safety nightmare when, not if, the first fatalities ­happen,” Mr Wheeler told The Australian.

“Allowing the untrained, uncertified, uninsured and unproven to commercially offer services to the public for money, using high-powered, off-the-shelf (or homemade) drones, is reprehensible.”

A CASA spokeswoman said the amendments would cut costs and red tape for low-risk drone ­operations while continuing to prioritise safety.

“Requiring all commercial operators to be trained, qualified and certified to operate regardless of drone size would be an unnecessary regulatory burden on people carrying out low-risk RPA (remotely piloted aircraft) operations, including private model and recreational flyers,” she said.

Last year CASA issued 15 infringement notices for breaches of drone safety rules and has issued seven notices so far this year. Two investigations are under way.

Recent research by RMIT University showed technical problems were the cause of 64 per cent of drone-related accidents between 2006 and this year. The paper’s author said it would be necessary for stricter safety regulations to be put in place because Australian skies were used increasingly by commercial drone operators.

ACUO wants the regulations to revert to original rules to protect controlled airspace, aerodromes and airports from errant drones. It also wants all commercial operators to be properly trained, qualified and certified to operate, regardless of drone size.

 
MTF...P2  Cool
Reply
#36
Here we go again - Confused

Headline: Jetstar find a un-manifested elephant in A320 cargo hold Big Grin

Background

Courtesy Aunty Pru (search 4 IP), Planetalking, ABC AM & ATSB... Wink   

(08-23-2016, 07:48 PM)Peetwo Wrote:
(05-14-2016, 10:49 AM)Peetwo Wrote: Ben Sandilands getting up a head of steam - Rolleyes

Following on closely from the PT Cobham BAE-146 blog piece & the 50 odd comments that followed, Ben Sandilands has yet another 'serious' Jetstar incident to sink his teeth into to again highlight the appalling duplicity & selective bias by the inept, seemingly captured big "R" regulator CASA.

This ATSB investigation will also be interesting in that it could be regarded as the first real test for the soon to be Chief Commissioner Hoody to insure a totally non-PC'd final report is produced, warts & all. Huh       

For background here is a rehash of the 'other' Jetstar incidents that were also covered by AP & PT... Wink  
(12-05-2015, 09:51 AM)Peetwo Wrote: AAI in a parallel universe - Will Aviation Safety again be the victim of Bureaucratic obfuscation & Political expediency.. Huh

Quote:Two serious Jetstar incidents under ATSB investigation

From the 'Closing the safety loop' thread & yesterday's ABC radio 'World Today' program:
Quote:WILL OCKENDEN: The Australian Transport Safety Bureau (ATSB) isn't the only one looking into this matter.

The aviation regulator, that's the Civil Aviation Safety Authority, or CASA has taken the unusual step of running its own investigation in parallel to the ATSB.

Peter Gibson is from CASA.

PETER GIBSON: We, of course, as the regulator, as the safety regulator need to look at immediate safety issues, be satisfied that they've been dealt with, that the causal factors have been understood by the airline and that the airline has taken the appropriate actions.

So that's why you've got two parallel investigations
.

WILL OCKENDEN: What could be the outcome of a CASA investigation?

PETER GIBSON: Well, we're making sure most importantly that Jetstar is putting in place changes that will ensure these sorts of mistakes aren't made again.

Vivid memories of the last high profile 'parallel' investigation and we all know how that turned out - Dodgy

Wonder if the operator will voluntarily ground all A320 operations until all the safety issues are effectively risk mitigated to the satisfaction of the regulator? - Yeah right & Elephants can fly Big Grin (see pic above)

[/url]  
Continued from ABC World Today program:
Quote:BEN SANDILANDS: These are really serious investigations.

WILL OCKENDEN:
That's Ben Sandilands, an aviation writer and commentator for the crikey.com.au blog, Plane Talking.

He says the other incident, 10 days later on the 29th October, was far more serious.

BEN SANDILANDS: A Jetstar flight to Perth actually really struggled to take off from Melbourne airport at all. It was very nose heavy, clearly had gone too far down the runway to stop and that could have been a very serious incident.

WILL OCKENDEN: The Australian Transport Safety Bureau says it's investigating both incidents to find out how the so-called "aircraft loading event" occurred.

It's classified the incidents as "serious".

Ben Sandilands agrees.

BEN SANDILANDS: They moved people around on the flight so that they could land in the proper configuration in Perth. On the other incident, which was a Brisbane to Melbourne flight, they were out by more than, well, almost two tonnes in the weights and balances on the aircraft and so they had to adjust their landing calculations for Melbourne.

WILL OCKENDEN: They're supposed to do this before they take off. Is there any indication why those checks weren't done?

BEN SANDILANDS: None whatsoever. What is extraordinary and I've been talking to a number of pilots this morning who just cannot believe that something that is fundamental to a small tier country airline service could be messed up so badly by a scheduled airline.

It is beyond belief that an airline in Australia would push back and begin a flight without actually knowing how many people were really on board and indeed the other elements of the calculations as to where they were seated.

That's fundamental. That is the sort of stuff that airlines stopped making a mess of back in the 1950s and 1940s.

Ben Sandilands again with a follow up article:
Quote:[url=http://blogs.crikey.com.au/planetalking/2015/12/04/comment-why-action-should-be-taken-against-jetstar/]Comment: Why action should be taken against Jetstar

Ben Sandilands | Dec 04, 2015 5:48PM |
 
P2 comment: The mention of Nick Xenophon is extremely relevant because at a pivotal point in the Pilot training Senate Inquiry, when NX was zoning in on the dodgy safety culture of Jetstar (*1) - somewhat conveniently?? - CASA with very little warning took the bold step of grounding Tiger - Dodgy

(*1 - Remember "Toughen up Princesses" & Ben Cook Darwin base Fatigue Special Audit report?)  

OK...so one more time round the Mulberry bush..   Cool

&... TICK TOCK goes the Miniscule clock??

Ben S courtesy of Planetalking today:

Quote:Why Jetstar's latest incident should alarm flyers
The ATSB says a 'serious incident' is one that could end in a crash, and Jetstar has just had another one

Ben Sandilands
Jetstar’s tail strike incident at Melbourne Airport this week puts another red flag over the Qantas subsidiary’s operations and the unwillingness to date of the supposed safety regulator CASA to ground or restrict its flights.

However the ATSB appears to have fast tracked its inquiry into an incident that imperiled the lives of those on the 180 seat passenger jet bound for Hobart, indicating a final report will be provided by this November...

Update on ATSB Jetstar loading incidents investigation.

From the ATSB today:
Quote:Updated: 23 August 2016


Completion of the draft investigation report has been delayed due to competing team member priorities and workload, and to allow additional investigative work to be finalised.

This additional work includes:
  • obtaining and consolidating additional evidence
  • analysis of evidence held and the development and test of investigation findings.
When complete, the draft report will be released to directly involved parties (DIP) for comment and on the factual accuracy of the draft report. Feedback from those parties over the 28-day DIP period will be considered for inclusion in the final investigation report...

Yesterday:

Quote:Loading related event involving Airbus A320, VH-VQC, Sydney Airport, NSW, on 29 October 2016

 
Investigation number: AO-2016-145
Investigation status: Active
 
[Image: progress_1.png] Summary
The ATSB is investigating a loading related event involving a Jetstar Airbus A320, VH-VQC, at Sydney Airport, New South Wales, on 29 October 2016.

While unloading the aircraft, ground crew detected a baggage container in the cargo hold which had not been recorded on the loading manifest.

As part of the investigation, the ATSB will interview the flight and ground crew and gather additional information.

A report will be released within several months years -  Big Grin
 
General details

Date: 29 Oct 2016
 
Investigation status: Active
 
Time: 15:25 ESuT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Sydney Airport
 
Occurrence type: Loading related
 
State: New South Wales
 
Occurrence class: Operational
  
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Feb 2017 
 
Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A320-232
 
Aircraft registration: VH-VQC
 
Serial number: 3668
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Gold Coast, Qld

Destination: Sydney, NSW
 
 
 
[Image: share.png][Image: feedback.png]

Last update 01 November 2016

Rolleyes - Wonder how long it will be before miniscule DDDD NFI Chester comes out swinging on behalf of Jet * saying that I'm merely scaring the travelling public -  Shy

Quote:DARREN CHESTER:
No, I don’t think that at all, Fran. I think it’s quite irresponsible and inaccurate to be scaring the travelling public with unfounded claims about safety issues. Now…




MTF...P2  Tongue
Reply
#37
Unbelievable that this mob are still allowed to fly. I started looking through the ATsB's incident data base and lost count of the amount of loading incidents, incorrectly positioned containers, damage to aircraft from ground equipment, unsecured containers.......it just doesn't end.

TICK TOCK indeed
Reply
#38
The Ghosts of Canley Vale revisited -  Angel
(08-15-2015, 02:37 PM)Peetwo Wrote:
(08-15-2015, 11:29 AM)crankybastards Wrote: Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

Quote:K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.

I note off the UP that the tragedy & travesty of the unresolved, definitely obfuscated VH-PGW fatal accident at Canley Vale has once again resurfaced... Undecided

For the record Confused :
Quote:Lumps

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

[url=http://www.pprune.org/members/133764-old-akro]Old Akro

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.


[url=http://www.pprune.org/members/41806-lead-balloon]Lead Balloon

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.


[url=http://www.pprune.org/members/331778-lumps]Lumps

Originally Posted by LeiYingLo 
Quote:Which is what any competent twin pilot knows to do and would've done in the first place

Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?


Old Akro

Quote:
Quote:Which is what any competent twin pilot knows to do and would've done in the first place.

The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.

[url=http://www.pprune.org/members/9979-adamastor]Adamastor

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.


[url=http://www.pprune.org/members/333707-thorn-bird]thorn bird

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.


Adamastor

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Quote:
Quote:Is your assertion the pilot should have landed at YSRI?

No, it is not.

Quote:
Quote:There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.
 
Agreed.

Quote:
Quote:I knew this young man very well, he was well trained…

I knew him too. It was a tragic loss, and yes, it is still raw.

Quote:
Quote:You arm chair experts are quick with your condemnation…

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Quote:
Quote:Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.
 
OK can anyone else see the common thread here? Here we have a perfect example of why it is important that we have a totally independent Annex 13 AAI that is free to investigate and establish the facts without external or internal ulterior motives for obfuscation and possible cover-up... Dodgy


MTF...P2 Cool
Reply
#39
(12-05-2016, 09:34 PM)Peetwo Wrote: The Ghosts of Canley Vale revisited -  Angel
(08-15-2015, 02:37 PM)Peetwo Wrote:
(08-15-2015, 11:29 AM)crankybastards Wrote: Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

Quote:K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.

I note off the UP that the tragedy & travesty of the unresolved, definitely obfuscated VH-PGW fatal accident at Canley Vale has once again resurfaced... Undecided

For the record Confused :
Quote:Lumps

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

Old Akro

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.


[url]
Lead Balloon

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.

[/url]
[url][url]
Lumps

Originally Posted by LeiYingLo 
[/url][/url]
Quote:Which is what any competent twin pilot knows to do and would've done in the first place
[url][url][url]

Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?

[/url][/url][/url]
[url][url][url]
Old Akro

Quote:
[/url][/url][/url]
Quote:Which is what any competent twin pilot knows to do and would've done in the first place.
[url][url][url]

The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.
[/url][/url][/url]
[url][url][url]
Adamastor

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.

[/url][/url][/url]
[url][url][url][url]
thorn bird

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

[/url][/url][/url][/url]
[url][url][url][url][url]
Adamastor

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Quote:
[/url][/url][/url][/url][/url]
Quote:Is your assertion the pilot should have landed at YSRI?
[url][url][url][url][url]

No, it is not.

Quote:
[/url][/url][/url][/url][/url]
Quote:There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.
[url][url][url][url][url]
 
Agreed.

Quote:
[/url][/url][/url][/url][/url]
Quote:I knew this young man very well, he was well trained…
[url][url][url][url][url]

I knew him too. It was a tragic loss, and yes, it is still raw.

Quote:
[/url][/url][/url][/url][/url]
Quote:You arm chair experts are quick with your condemnation…
[url][url][url][url][url]

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Quote:
[/url][/url][/url][/url][/url]
Quote:Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.
[url][url][url][url][url]

I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.[/url][/url][/url][/url][/url]
http://[url][url][url][/url][/url][/url]
http://[url][url][url][/url][/url][/url]
Reply
#40
(03-17-2017, 08:55 AM)Peetwo Wrote: Update 17/03/17: Widow condemns CASA as 'incompetent' & 'dysfunctional' - Confused

Reference posts:

(03-13-2017, 07:47 PM)Peetwo Wrote:
(03-13-2017, 05:34 PM)Peetwo Wrote: Next I note that NSW Deputy Coroner today handed down his findings on the tragic 2013 Dromader fire fighting accident near Ulladulla. From AAP via the Oz:
Quote:Pilot died after 'inadequate' inspection
  • Jodie Stephens
  • Australian Associated Press
  • 4:32PM March 13, 2017
A waterbombing pilot fighting a NSW blaze was killed after his plane's wing broke off mid-flight as a result of cracking and corrosion that was missed during an "inadequate" inspection months earlier, an inquest has found.

David Black, 43, died when his M18 Dromader aircraft crashed in an isolated and mountainous area of the Budawang National Park, in the state's south, on October 24, 2013.

The experienced pilot was preparing to attack a bushfire when the left wing of his aircraft suddenly broke off, causing the aircraft's rapid descent, Deputy State Coroner Derek Lee wrote in his inquest findings released on Monday.

Mr Black left behind his wife of 12 years, Julie, and three young children.

"David and Julie had worked together as a team, industriously, to reach a stage in life where their business was successful, their family was nurtured and cared for, and they were simply able to enjoy life," Mr Lee wrote.

"To lose David in sudden circumstances is heart-rending."

The plane Mr Black was flying was owned by his company, Rebel Ag, which provided aerial support to the NSW Rural Fire Service.

It was tested and inspected just over two months earlier by two companies, Aviation NDT and Beal Aircraft Maintenance, but Mr Lee said the work was inadequately done.

He wrote in his findings that testing by Aviation NDT used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority.

Further, the plane's wings were not removed during a visual inspection by Beal Aircraft Maintenance, meaning that corrosion and cracking on one of the left wing's attachment lugs was not detected.

By the time Mr Black crashed in October, the Australian Transport Safety Bureau found that cracking on the inner surface of the lug had reached a critical length of 10.4 millimetres and at least 32 secondary micro cracks were also identified.

The engineer behind the visual inspection, Donald Beal, told the inquest the manufacturer's service bulletin did not mandate removal of the wings, so he didn't see any need to remove them.

Mr Beal also said there was ambiguity about what visual inspections actually involved, Mr Lee recalled in his findings.

At the NSW Coroner's Court on Monday, Mr Lee recommended that CASA consider issuing a directive that wings be removed during inspections of M18 Dromader planes.

He also recommended they consider a different way of calculating fatigue damage, which did not just rely on flight hours but also looked at other factors that age an aircraft, such as its speed and the weight of loads that it carries.

A CASA spokesman said they would consider the recommendations carefully.

Update to NSW Deputy Coroner report.

Quote:Firefighting plane that crashed killing pilot had maintenance issues, inquest finds
ABC Online
 - ‎1 hour ago‎

The Sydney court heard Mr Black's plane was inspected on the 8th of August, 2013, using an alternative, less sensitive procedure that was not approved by the Civil Aviation Safety Authority (CASA). In his report, the Coroner asked: "Was the August 2013 ...

Safety inspection failed to detect fatal corosion in plane's wing
dailytelegraph.com.au
 - ‎5 hours ago‎

State Coroner Derek Lee found on Monday that an inspection of the plane conducted 11 weeks prior to the crash used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority. Cracking and corrosion ...



Courtesy the Oz today:

Quote:Solo mum keeps business afloat
[Image: f8547f3311a984d7be2aab4157fa6906]
Julie Black has been flying solo for the past 3½ years in more ways than one.

Quote:..After the accident, Ms Black had to replace the Dromaders with Air Tractors, and find a chief pilot, as well as juggling the raising of her children. “The business is still going. It is still employing people and maintaining services to our clients,” she says.

Ms Black vowed to never put pilots in Dromaders again and has since bought four Air Tractors for spraying.

“It has been extremely hard when you are used to working with someone in a partnership for 17 years, and been able to tag-team between work life and home life,’’ she says.

“When you have lost that 50 per cent and you are now 100 per cent on your own … all our decision making was done ­together.

“Now I lie in bed and night and wonder if I have made the right ­decision and what would David have thought about whatever the issue is at hand.’’

‘Incompetent’ CASA slammed

[Image: 0a625cf601361427ae833bdb52aa1f3a]
Quote:...Ms Black said the inquest by the deputy State Coroner Derek Lee showed the crash involving a Polish-built M18 Dromader was a textbook example of the Swiss cheese theory of accidents. This theory postulates that holes develop because of human error and dysfunction, and eventually they link up to cause serious accidents.

“In this accident when you go back and you look at all the holes that were lining up over a matter of 13 years, this aircraft was doomed. Had we known that we obviously would never have flown it,” Ms Black said. “When you go back through the ATSB report you can see the holes developing right back to 2000. In just about every single one of those holes CASA is involved. How CASA originally said you could use a flawed testing system (the eddy current technique) is unbelievable. It was contrary to what both the manufacturer and the FAA had mandated as the correct testing method.”

Ms Black’s solicitor, Mark Gray-Spencer of GSG Legal, said the evidence presented to the inquest clearly showed CASA failed to identify the fact that the maintenance company, Beal Aircraft Maintenance, and its non-­destructive testing company, Aviation NDT Services, was using the wrong method to test the attachments on the Dromader wings.

“Aviation NDT used an eddy current technique to test the wing attachments which was contrary to what both the manufacturer and the FAA said should be used. Both had advised that Magnetic Particle Testing had to be used,” Mr Gray-Spencer said.
“Six weeks after the approval from CASA for the eddy current technique was sent to Neil Joiner (of Aviation NDT Services), CASA issued an airworthiness directive (AD) stating that you had to use magnetic particle testing. This was inconsistent with the eddy current technique approval. The maintenance organisation should have looked at the AD and realised their procedure was not OK.”

An AD is a legislative instrument issued under federal law.

“For 13 years, from the issuing of the AD until the accident, the wrong testing was used,” he said...

And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
   
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  - Dodgy  

P2 comment: Gutsy lady Ms Black! Angel - Welcome to the ranks of the IOS... Wink


MTF...P2 Cool

Ps "K" this may have to be moved to the 'Closing the safety loop' thread... Wink

(03-18-2017, 06:41 AM)kharon Wrote: A complimentary round trip ticket.

P2 – “And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
 
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  -  

P2 comment: Gutsy lady Ms Black! - Welcome to the ranks of the IOS...

Welcome indeed. One of the reasons people can sit at home watching horrific stories of carnage, destruction, tragedy, fire or even aircraft accidents on the TV while eating their dinner is that it ain’t ‘personal’. Nowadays, folk rush off to ‘counselling’ after they’ve had a splinter removed from their arse and tell everyone who will listen about the trauma and how they intend the sue the council because the park bench surface was not ‘safe’. Why? Well it’s now ‘personal’. It’s the same with ‘CASA contact’; until the filthy spectre has tapped you on the shoulder; it ain’t personal. But when it does……Problem is that from the minister down, no one, except those affected ‘get it’. The vast majority of aircrew and engineers have never had the dubious pleasure of dealing with CASA other than in the routine way of medicals and such. DAME’s, Chief pilots, etc. all have had ‘the experience’ even then that’s a mixed bag: and, the 'go along to get along' syndrome has resulted in some truly awful aberrations; I digress. See Thorny’s post – HERE – for just a small part of the problem.  

P2 - “Ps "K" this may have to be moved to the 'Closing the safety loop' thread...

It probably should be mate; but you know as well as I the CASA response to coronial recommendations; they are treated as opinion. What did we examine when we did the analysis; some thirty or so cases? We selected just a few to provide a range and for all the good that hard work has done, we could have stayed in the pub; (practiced your darts).

HITCH - (Oz Flying)
“Only by the reaction to these truths can we judge the commitment of the Federal Government. However, we need to lift our chins and plod on; we have more hope of reform with the advisory group than we would have without them.

Hitch and probably the GAAG understand the truth of it; but, what else can they do? The ‘CASA’ experts who have royally buggered the system and wasted hundreds of millions while getting paid handsomely to do so now expect ‘help’ from industry experts, who are not only doing it all ‘for love’ but taking time, resource and energy away from their own interests. Do they have to cooperate? Well I suppose they do; but its not the first time and it most certainly will not be the last time an industry advisory panel has laboured – in vain. History children, history. Not too far back – Pel_Air?, Forsyth? Ring any bells?

FWIW, I reckon the minister and CASA are taking the Mickey – again; same old tune, same old result. One may fervently hope for the best but it always most sensible to expect and prepare for the worst.

We wish Mrs Black well and any small support we can offer. The first part of this story is tragic and life changing; the second part is in the lap of the gods. Personally, I would not abandon all hope just yet, but I wouldn’t be holding my breath either.

Toot toot.
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#41
A closed safety loop - found one!  Wink

Caught this via the NT News:


Quote:[Image: 2ae2462476247d616361309cf4c359c6?width=1024]


Chopper crash could have been multiple fatality if not for fuel tank standards changes

JASON WALLS, NT News
January 20, 2018 1:00am

THE helicopter crash in Central Australia which left two men with spinal injuries this week could have been a multiple fatality if not for changes to fuel tank standards sparked by a series of earlier deadly crashes.

The design of the Robinson R44 model helicopter involved in the crash was changed after three similar crashes in NSW resulted the deaths of eight people between 2011 and 2013.

In the most recent incident, which bears eerie similarities to Wednesday night’s crash, the pilot and three passengers were killed when the chopper they were in rolled onto its side after striking trees.

The deaths were attributed to a fire which started when the helicopter’s aluminium fuel tank leaked “following an otherwise survivable impact”.

That incident led to action from the Civil Aviation Safety Authority, which now requires a bladder-type fuel tank to be fitted in all R44s in Australia as well as other fuel system improvements.

There are 52 R44s registered as operating in the Northern Territory and Wednesday’s crash is the third in the NT since 2016 involving an R44 or its two-seater counterpart, the R22.

None of those crashes have been fatal and no injuries were reported in the two previous incidents.

An Australian Transport Safety Bureau spokesman said it was too early in the investigation to say conclusively whether the fuel tank change prevented the deaths of all those on board on Wednesday.

“However, it is expected that the mandated change to bladder-style fuel tanks for all R44 helicopters in Australia would have reduced the risk of a post-impact fire in this occurrence,” he said.

The 46-year-old woman injured in Wednesday’s crash was flown to the Royal Adelaide Hospital on Friday in a serious but stable condition.

The 32-year-old pilot and his 32-year-old passenger already in hospital in Adelaide were in a stable and serious condition respectively. The other passenger, a 35-year-old man, suffered minor injuries.

 I am sorry to burst the 'NT News' scoop bubble but if they'd bothered to dig a little deeper they may have discovered that the identified safety issue predated those (2011-2013) NSW reoccurrences for the better part of 15 years (now 2 decades). And if it wasn't for the lobbying of certain fatal victims NOK (like the Cousins in WA) and the efforts of a certain Senate Committee, we may have been witness to another fiery fatal Robbo accident... Angel

Reference: Sunday Ramble - Beyond the pale 

Quote:..Some on here will remember that at Budget Estimates in May 2013 (i.e. 2 months after the tragic Bulli tops accident), the matter of the R44 post impact fire accidents were the subject of Senate questioning. Here is a copy of a post of mine off the UP from that time:



Quote: Wrote:Yep the list is growing and the stench is rising!

--------------------------------------------------------------------------------

You can add the Cousin's to that list...remember this from sub16:



Quote: Wrote:“We have been to Martin Dolan Chief Commissioner ATSB, Albanese, John McCormick, Local Member John Castrilli - who did write a letter to CASA on our behalf but that was it! John McCormick insulted us in his response stating that "CASA is unaware of any other accidents involving this company’s aircraft". Oh My God how insulting to our intelligence. So in their eyes Kenny's Mob have never been involved in other incident!

How many fatalities does a Company need to have to be anything recorded as an ACCIDENT! At the inquest the CEO of Heliworks was questioned about his Statutory Declaration and had he completed - he disclosed he did not complete it and the Company had told him what to write! How could that be admissable in a court of law?

They were aware that this cowboy operation existed out at the Bungles but once again NO ONE would do a thing to stop them...............

It took 2 yrs 7 mths after the accident for the inquest to be held and we did not get the final report until a further 6 months!! Over 3 years!!”

Then

“Well we had our inquest which was an absolute joke and embarrassment for the fact that so many documents were not produced / lost / created etc and no one did a thing about it. Our Coroner Ms Fricker left a lot to be desired and the fact that in the 2 years 7 months not one person in the court room excluding us had even visited the accident site or gone out to witness just what happens out there. We came away just blown away with the fact that so many things were dismissed/ allowed/undisclosed and were allowed to be.

That smell of money I think well and truly came into play!!!
I personally lost all respect for our government representatives, law, safety authorities after sitting in that court room for 5 days and listened to excuses on their behalf...instead of reasons to rectify and was horrified after the evidence given that it was declared and accident.

As I said in court this was an Accident waiting to happen and will occur again!!The coroner in her report even noted the number of helicopter accidents just since the inquest - approx 4 month....and not one recommendation was handed down. She used the words like Breached and Failed to comply in her report and yet not one
recommendation.”

Carolyn Cousins. (mother of Jessica Cousins) Slingair Robinson 44 Bungle Bungles 14

September 2008 4 fatalities

Although according to Beaker this accident was a high-energy impact:



Quote: Wrote:Mr Dolan: There had been a number of post-crash fires associated with R44 helicopters. In the vast majority of those cases they represented high-energy impacts, which is to say accidents that were unlikely to have been survivable and which would have led to a post-crash fire in almost any helicopter.

Senator XENOPHON: So you are saying that the retrofitting would not have made any difference?

Mr Dolan: That would be our general assessment.

Senator XENOPHON: Take it on notice, because I have a few other matters to raise. You are saying that, from a causation point of view, even retrofitting the helicopters with that protective bladder, it still would have been a fatal accident?

Mr Dolan: On the facts that were available to us. We are not aware of any previous to Cessnock. I do not think we are aware of any of the low-energy collisions leading to that sort of thing. There were, as you say, a number of high-energy collisions that would have led to a ruptured fuel tank in any helicopter and therefore a great likelihood of a post-crash fire. Those are the sorts of accidents that generally are not survivable.

But on the evidence in the bureau report it would appear that there was a strong possibility the pilot at least survived the crash impact only to be overcome by the post impact fire, from the report:

Medical and pathological information
The post-mortem examinations for all occupants of the helicopter described varying degrees of injuries consistent with the high vertical velocity impact. All sustained extensive thermal injury.

The pilot’s post-mortem report indicated that he was found ‘...a slight distance from the damaged aircraft.’

You will notice that the post-mortem didn't appear to explore how the victims died i.e. did they succumb to their impact injuries or the 'extensive thermal injuries'. Nor was IMO the post-survivability issues properly explored by the ATSB. It was almost as if the ATSB accept that if a chopper comes (in particular a Robbo) down hard it will inevitably burn!

Yes 004 it will be interesting to watch and I bet there will be a couple of interested Senators tuned in as well..given the QONs outstanding on the subject of post-impact fires and R44s

Here's the links for the high energy post-impact fire fatalities to which Senator X refers:
http://www.atsb.gov.au/media/1533519/ao2008062.pdf

http://www.atsb.gov.au/media/1361537/aai...79_001.pdf

http://www.atsb.gov.au/media/24556/aair2...46_001.pdf

And here is a link for the report from the Jaspers Brush tragedy - AO-2012-021 - that included these two safety issues:


Quote: Wrote:Fitment of rubber, bladder-type fuel tanks to R44 helicopters

And in ICAO Annex 13 Ch 6 under Safety  Recommendations  it is stated...

"..6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO..."

So what is the ATSB excuse for sitting on these SRs until now (over two years after the fact)?? No this is just another cynical attempt to gain credibility where none is due..
FFS get rid of the Muppet.   [Image: angry.gif] 
   
Errr (grumble..grumble - Angry ) - no comment! Dodgy



MTF...P2 Cool
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