The search for investigative probity.

Popinjay and Hoody taking the piss on ICAO Annex 13 final report compliance??

Via the Dicky King thread:

(12-01-2023, 06:32 PM)Peetwo Wrote:  [Image: chalk-cheese-1.jpg]

Chalk & Cheese: S is for? - Surveillance.

As a clear chalk and cheese comparison, I refer to another ATSB systemic investigation - AO-2018-078. In regards to CASA oversight, the following is the overview summary (page 29):

Quote:The Civil Aviation Safety Authority (CASA) had two primary means of oversighting a specific operator’s aviation activities: regulatory services and conducting surveillance of its activities. They also used a scale of prioritisation, based on risk, to determine where to focus resources. This prioritisation was based on several factors, such as the sector of operation, organisational changes and challenges.

To maintain oversight across Australian operators (authorisation holders), CASA had a number of certificate management teams in different locations, made up of CASA officers, including flying operations inspectors, safety systems inspectors, and airworthiness inspectors. Each of these teams oversighted multiple authorisation holders. At the time of the accident, the team responsible for the oversight of Airlines of Tasmania comprised of one certificate team manager, three flying operations inspectors, four airworthiness inspectors and one safety system inspector. The team had oversight of 58 AOC holders, 50 aviation maintenance organisations and four delegates.

This oversight summary is strangely remiss in the AO-2022-009 report, despite (I would have thought) being equally applicable??

In the meantime from the BRB, here is the 'King Aviation Swiss Cheese' model for the Miniscule to refer... Big Grin

[Image: Swiss-Cheese.jpg]

In reference to the 'Previous investigations with surveillance and hazard identification findings', listed in the  AO-2018-078 investigation, I checked for the applicable section for 'CASA Oversight': 

AO-2017-057

 
Quote:Regulatory oversight

Overview

The stated mission of the Civil Aviation Safety Authority (CASA) is ‘To promote a positive and collaborative safety culture through a fair, effective and efficient aviation safety regulatory system, supporting our aviation community.’

CASA was responsible, under Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia, including by:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

CASA had documented a regulatory philosophy that included maintaining a risk-based approach to decision making, and being consultative and collaborative with industry, while balancing consistency with flexibility in its work.

CASA had two primary means of oversighting a specific operator’s aviation activities:
  • regulatory services, by assessing applications for the issue or variations to its AOC and associated approvals (including approvals of key personnel)
  • conducting surveillance of its activities.

CASA used a scale of prioritisation based on risk to determine where to focus resources. This prioritisation was based on a number of factors, such as the sector of operation, organisational changes and challenges.

In order to maintain oversight across Australian operators, CASA had a number of certificate management teams (CMTs), made up of CASA officers, including flying operations inspectors (FOIs) and airworthiness inspectors (AWIs), in different regions of Australia. Each of these teams oversighted a number of AOC holders. The majority of the oversight of Rossair was conducted by an Adelaide-based team.

AO-2017-005:

Quote:Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section 9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

The two primary means of oversighting a specific operator’s aviation activities were:
  • assessing applications for the issue of or variations to its AOC and associated approvals (including approvals of key personnel)
  • conducting surveillance of its activities.

AO-2009-072:

Quote:Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the
safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section
9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;
(d) developing effective enforcement strategies to secure compliance with aviation safety standards;
(da) administering Part IV (about drug and alcohol management plans and testing);
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance, including assessment of safety‐related
decisions taken by industry management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in order to monitor the safety
performance of the aviation industry, to identify safety‐related trends and risk factors and to promote
the development and improvement of the system;
(h) conducting regular and timely assessment of international safety developments.

The two primary means of oversighting a specific operator’s aviation activities were:

 assessing applications for the issue of or variations to its AOC and associated approvals
(including key personnel and the training and checking organisation)
 conducting surveillance of its activities on a regular basis.

Up until 2004, CASA oversight of the operator’s jet AOC was conducted by the Bankstown
general aviation (GA) field office276 and oversight for the operator’s turboprop operation was
conducted by the Brisbane air transport office. In August 2004, responsibility for oversighting the
turboprop AOC was transferred to the Bankstown office. The Bankstown office retained oversight
responsibility for the operator when the two AOCs were merged in October 2006.

This section briefly overviews the processes involved in assessing variations and conducting
surveillance, and then discusses CASA’s oversight of specific aspects of the operator’s activities.
The section focusses on CASA’s oversight of flight operations activities conducted under the
operator’s AOC during 2005–2009, with some events prior to 2005 discussed when relevant.

Curious to how far back this standard format for the 'CASA Oversight' summary in ATSB systemic operator investigations, I went to the biggest CFIT investigation in this century IE 'Collision with Terrain - Fairchild Metro 23 aircraft, VH-TFU 11km NW Lockhart River Aerodrome, Qld 7 May 2005'

Quote:1.18 Regulatory oversight of Transair and Aero-Tropics

1.18.1 The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act
1988, for the regulation of aviation safety in Australia. Section 9 of the Act
included the following:

(1) CASA has the function of conducting the safety regulation of the
following, in accordance with this Act and the regulations:

(a) civil air operations in Australian territory;
(b) the operation of Australian aircraft outside Australian territory;
by means that include the following:
© developing and promulgating appropriate, clear and concise
aviation safety standards;
(d) developing effective enforcement strategies to secure compliance
with aviation safety standards;
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance,
including assessment of safety-related decisions taken by industry
management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in
order to monitor the safety performance of the aviation industry, to
identify safety — related trends and risk factors and to promote the
development and improvement of the system;
(h) conducting regular and timely assessment of international safety
developments.

The two primary means of oversighting an operator’s aviation activities were
assessing applications for the issue of or variations to its Air Operator’s Certificate
(AOC) and associated approvals (including key personnel and training and
checking organisation), and conducting surveillance of its activities on a regular
basis.

The only exceptions to this standard format that I have been able to find so far are Croc-o-shite and the VARA ATR broken tail accident reports:

Quote:Anyone else see the ironies of the examples that the ATSB has picked on?? Wonder why they didn't include the VARA ATR-72 broken tail accident?? Oh that's right they farmed that part of the investigation off to a 'Case study: implementation and oversight of an airline's safety management system during rapid expansion':  Update: ATSB PC accident investigation AO-2014-032

Quote:Overview of the investigation

As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems.

The ATSB collected a significant amount of evidence and conducted an in‑depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

As part of its investigation, the ATSB:

interviewed current and former staff members of the operator, regulator and other associated bodies
examined reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
reviewed other investigations and references where similar themes have been explored.

This stitched up Hooded Canary investigation waffled along aimlessly for 3 years until it was subsequently discontinued: 

Quote:Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.


"...The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations..." - Unless of course you're the 'Croc Wrangler'??? -  Dodgy

Before we move on from the Hooded Canary's successful cover-up of the flawed CASA oversight of the VARA ATR operation, remember this? Ref:  Update: ATSB PC accident investigation AO-2014-032 

 

It is interesting to note that in the rather lengthy 1st interim report, the following was stated:

Quote:Investigation activities to date
To date, the ATSB has collected information about, and analysed the following:
  • the sequence of events before and after the pitch disconnect, including the post-occurrence maintenance and initial investigation by Virgin Australia Regional Airlines (VARA) and ATR
  • flight and cabin crew training, qualifications, and experience
  • the meteorological conditions
  • VARA policy and procedures
  • VARA training courses
  • VARA’s safety management system
  • VARA’s maintenance program
  • the aircraft’s systems
  • the relationship between VARA and the maintenance organisation
  • maintenance engineer training, qualifications, and experience
  • the maintenance organisation’s policy and procedures
  • the maintenance organisation’s training courses
  • the maintenance organisation’s quality and safety management
  • the Civil Aviation Safety Authority’s (CASA) surveillance of VARA
  • CASA’s approvals granted to VARA
  • CASA’s surveillance of the maintenance organisation
  • CASA’s approvals granted to the maintenance organisation
  • ATR’s flight crew type training
  • ATR’s maintenance engineer type training
  • ATR’s maintenance instructions for continuing airworthiness
  • known worldwide in-flight pitch disconnect occurrences involving ATR 42/72 aircraft.

So the CASA Oversight had been completed and apparently analysed, yet the findings and analysis were not included in the final report... Dodgy

Back to the 'Croc-o-shite' report and the bizarre omission of the 'CASA Oversight' standard format. The following is a very alarming Oz article (TY CW -  Wink ) from 14 July this year:

Quote:Accusations of safety breaches show failure to rein in Outback Wrangler Matt Wright

[Image: 7e5e36794c172f8f67513f22d7da20f1?width=1280]

The Civil Aviation Safety Authority had investigated scores of incidents involving celebrity croc-wrangler Matt Wright and his company Helibrook in the decade preceding the fatal chopper crash that killed Netflix star Chris Wilson.

The Australian has obtained, under Freedom of Information laws, CASA documents which – despite being heavily redacted – reveal the regulator has been aware of suspected safety breaches involving Helibrook for about 12 years.

Wright burst onto CASA’s radar after the first series of his reality television show Outback Wrangler hit screens in 2011.

When those first four episodes – produced for National Geographic and bankrolled by Screen NSW – were broadcast, a member of the Northern Territory Government’s crocodile management program contacted CASA and “raised concerns” about Wright’s “aviation operations”.

After reviewing the footage, investigators alleged Wright and his co-star Michael Burbidge had possibly committed up to 14 safety breaches, during a six-week period, while filming in late 2010.

That assessment was based solely on what CASA could see in the final cuts.

[Image: 9f6041a3083c1494f0371c2192837c18]

The possible offences – involving five different choppers – included reckless operation of an aircraft, low flying, carrying firearms, carrying live animals, not wearing seatbelts, not restraining cargo, unapproved modifications and conducting commercial operations without an air operator‘s certificate.

But before the ink was dry on CASA’s report Wright was back in the spotlight after the NT News published a front-page photo of what was alleged to be someone shooting a crocodile from a helicopter he was flying.

CASA did not investigate the April 2013 incident but NT Parks and Wildlife did.

A witness alleged that shots were fired from the helicopter as it hovered over the mouth of Shady Camp, 110km southeast of Darwin, which is known for its high concentration of crocodiles.

‘‘(I) spotted these guys about a kilometre away shooting a croc outside the river mouth, winching it up and flying to shore and land,” he told the newspaper.

But Wright, who said he was taking a client heli-fishing and on an adventure tour, denied they had shot towards the water, adding that there might have been a few gunshots heard earlier when they were shooting pigs over land.

‘‘We were just flying over looking at all the boats on the water,’’ he said.

[Image: NED-9632-NT-Times-Cover_KAO5p2raU.jpg]

‘‘We saw a barra caught in the shallows and he (the client) jumped out and grabbed it, and we flew to the bank to secure it.’’

The client, David Blanck, refused to comment on the gunshots but said he had jumped out to grab the fish.

‘‘We saw a barra and I asked Matt what he thought, and he said ‘jump in and get it’, and that is pretty much what we tried to do,’’ he said.

‘‘I jumped down, got it and tied it to the skid with a bungee cord, and flew to the bank and took photos.”

The Parks and Wildlife Commission investigated but cleared the men of any wrongdoing after seeing a picture of a barramundi they had caught.

[Image: 296c1215ab58eac8dfa708347b681c55]

When the story was published, Wright was angry and Burbidge, who owned the chopper, allegedly stormed into the NT News building and had a go at the paper’s editor.

A year later, in a separate alleged shooting incident, the owner of a fishing charter business reported seeing two R44 helicopters flying low, near the mouth of the Finniss River, while those on-board discharged what appeared to be automatic firearms. The man alleged to police that one of the pilots was Wright.

He said the choppers were hovering and circling around as if looking for something, possibly pigs, and firing volleys of shots in quick succession.

He further claims that bullets were landing within 100m of him and others who were fishing in the area, causing them to fear for their lives.

When the fisherman called triple-zero the operator said that she also could hear the shots being fired.

“He could hear the whizzing of bullets and they ducked their heads into the boat,” CASA recorded.

Police contacted Wright to arrange an interview but his travel schedule made it hard.

When CASA contacted him, he said the complaint was “untrue”, “didn‘t happen” and that he “had no knowledge of this incident”.

Wright said his log book was not up to date and he couldn’t remember his movements that day but if he was in the area, he would have been 10 nautical miles back from the Finniss River and that the fisherman “complains about that sort of thing all the time”.

“As soon as he sees helicopters and hears shots he brings him (Wright) into it,” the investigator recorded Wright as saying.

“It is bullshit and he is sick of it.

“This is not helping his AOC application and he does not need this.”

CASA decided there was insufficient evidence of wrongdoing.

In the midst of these accusations the rising star was having a blast with his Hollywood actor mate Gerard Butler who was Down Under filming Gods of Egypt.

In March 2014 Wright took the star of 300 on a bespoke outback adventure that involved buffalo hunting, heli-fishing and airboat rides.

When Butler returned to the US, he giddily shared a home video of Wright’s wild chopper flying during an appearance on Jimmy Kimmel Live.

The 20-second clip shows Wright’s black Robinson R44 hurtling towards Butler and others, before aiming its rotor towards the men and spinning above their heads for a terrifying few seconds before landing a few metres away on the beach.

“This guy is quite a famous adventurer in Australia,” the Scottish actor told Kimmel.

“I don’t want to say his name because it was … There was a lot of stuff I couldn’t even put on this video by the way. This is the tame stuff.”

As the footage began to roll, Butler told the host “this is how we were flying about”.

“We didn’t even upload the best bit of this where we were spinning around at 70 miles per hour and him in the chopper right above us,” he said.

Sources close to the incident say that when the footage, filmed at the Peron Islands, was made public, Wright was “wild” that Butler had shared the private clip.

Experienced helicopter pilots have told The Australian that the chopper’s perceived proximity to the people on the beach appeared to breach CASA regulations and that for several seconds the chopper was within “the dead man’s curve”.

“Any cough or splutter from the engine would’ve killed them all,” a source said.

But after reviewing the footage and interviewing Wright, CASA found no breaches had occurred.

[Image: a60ea7ed1145f31e9b625bffd4bd3645]

In any case, by the time CASA became aware of Butler’s video, investigators had their hands full with another alleged incident involving that same chopper, registered VH-MEB, after receiving a tip-off that it had drowned.

“Yes that is correct that MEB did go underwater the other day when I was on my way back to the shack,” Wright emailed a CASA investigator in June 2014.

“Wasn‘t a good weekend that one as I also had a major on the airboat about three days earlier.

“But with MEB I had landed on the beach to have a quick flick before starting work that afternoon.”

Wright said that when he went to start the chopper again, there was “no power”.

“It was a diode of the starter relay that had stopped working so by the time the engineer got there it was too late with the incoming tide and water was lapping up around the belly and we could not get it started at that stage.

“I know this isn‘t going to help my current investigation but there wasn’t much I could do to prevent this one Pete and I’ve lost my machine that I still have to pay (Mick Burns) out for it as the insurance didn’t cover the total cost, so this one has hurt a bit.”

[Image: 481abd7fab7a255326579464a084a682]

Wright told CASA that he was alone when it happened and that the helicopter’s Maintenance Release – where flying time is recorded – had floated away.

Burbidge flew out to retrieve the wreckage via sling load beneath his Squirrel.

Days later Wright sold the written-off chopper to his mentor, cattle baron and former reality television star Milton Jones, who later changed its registration to VH-NTH.

A year before MEB went underwater, Wright had slung a 23-year-old man with cancer – Jett Brewster – beneath it “for some sightseeing”.

CASA was alerted when the November 2013 edition of North Australian Fishing and Outdoors magazine published a story about it with photos.

The article, written by his Outback Wrangler co-star Wilson, said that “Jett dangled airborne below the chopper for more than 30 minutes as Matt flew across some of the vast landscapes of the Top End”.

When CASA interviewed Wright and Brewster, who passed away last month, both said the slinging had only been for five minutes along the shoreline and Wright said he didn’t think he needed authorisation because it was a “private operation”.

“He had done it because Jett wanted to experience what he (Wright) did for work,” the CASA investigator recorded of his conversation with Wright.

“He (Wright) thought ‘why not as Jett did not have long to live’.”

In August 2015 CASA asked Wright to show cause why it should not – in light of previous incidents including the Butler video – vary, suspend or cancel his Air Transport Pilot Licence or Commercial Pilot Licence.

In March 2016, CASA decided – after considering Wright’s response and representations made on his behalf – not to vary, cancel or suspend his licenses.

“Rather, in this instance, I have decided to counsel you,” the acting regional manager wrote in a 10-page Notice of Counselling letter.

Only two pages of this letter were not redacted before it was released to The Australian.

[Image: 8be6d0f68df84037924f86ab8ad5f991]

“Therefore the purpose of this letter is to formally record that you have been counselled during our face-to-face meeting in the Darwin CASA office on 9 March 2016,” it concluded.

[Image: 5d5a4e827a1055335dc3ecac79f6a7d4]

But Wright’s aviation issues were far from over.

In April 2017, a helicopter sub-hired from Wright’s mate and former business partner Troy Thomas crashed in Western Australia, injuring passengers and sparking CASA and Australian Transport Safety Bureau investigations.

The Robinson R44, registered VH-SCM, crashed into the water after taking off for a charter flight from the top of a boat at Talbot Bay.

Thomas’s company Horizontal Falls Seaplane Adventures owned the chopper but was operating under Wright’s AOC.

The pilot and two passengers, who suffered minor injuries, had to exit the helicopter underwater and swim 50m to shore before being treated at hospital.

Then in August 2017, pilot Jock Purcell crashed one of Helibrook’s Robinson R44s, registered VH-LGN, in the NT with three passengers on board.

In December that year, CASA called Wright again after the newlywed regaled the Herald Sun with a story, about how he had told his wife Kaia to jump from a hovering helicopter to chase a pig, which was then printed in an article about their outback romance.

In 2018, CASA launched a noncompliance investigation into Helibrook after receiving complaints about five alleged incidents of “unsafe behaviour” in helicopters associated with Broome-based Horizontal Falls Seaplane Adventures, which was still operating under Wright’s AOC.

The complaints to CASA included reports and videos of “deliberate and systematic low-flying and vessel-harassment”, unsafe behaviour by a helicopter in relation to a seaplane, an illegal landing on Cockatoo Island and reports of a helicopter departing Broome in thick fog.

“This organisation is conducting itself in a manner which demonstrates a systemic and belligerent disregard of legal and safety obligations over an extended period,” one complaint alleged.

A pilot, with “several thousand hours of experience” told CASA he was “aghast” when he saw a helicopter take off from Broome with “zero visibility”.

“Other pilots were watching and shaking their heads,” he wrote. “I have photographs of this morning that proves the conditions were nowhere near legal.”

WA National Parks and Wildlife had also ordered one of the pilots to attend mediation with them.

CASA said the activity in the videos “depicted helicopters engaging in manoeuvres which placed the aircraft in situations of varying risk profiles” but ultimately concluded that the complaints could not be substantiated.

In late 2018, Wright turned up at Airwork Helicopters in Caboolture, north of Brisbane, where he reportedly told students that “CASA had sent him back to flight school”.

[Image: NED-9629-TAUS-Helibrooks-timeline-of-tur...hZjyov.svg]

In May 2019 CASA sent Wright a “notice of decision to vary commercial pilot licence”.

A couple of months later, CASA sent him a “notice of decision to vary conditions on commercial pilot licence”.

Both letters were fully redacted before being released to The Australian.

[Image: 858c0d4f084f306cd74715036489314e]

At the turn of the decade, in 2020, Helibrook’s affairs took a turn for the worse, after a seemingly benign incident involving an R44 with the registration VH-XHB.

In August 2020, Helibrook reported to CASA and the ATSB that “while repositioning for refuel, the helicopter landed hard” at Wright’s Top End Safari Camp and that the pilot was the only person on board.

“The pilot was not injured and the helicopter sustained moderate damage to the undercarriage,” a CASA report from September 2020 states.

As a consequence, CASA deemed that “no further CASA action is recommended with respect to the company” and did not investigate further.

Nothing more would have come of it if it had not been for Wilson’s fatal crash two years later.

On February 28 last year, Wilson was killed when Helibrook’s VH-IDW, which he was slinging beneath, crashed during a crocodile egg collecting mission at West Arnhem Land. Pilot Sebastian Robinson was critically injured and is still recovering from severe spinal injuries.
During their investigation NT Police publicly appealed for anyone who had flown on board the destroyed chopper, which was also used for charter flights, to submit their photos and footage.

[Image: a83baed34d2e146e843ad0fc6c78fe9e]

Lo and behold tourists who had been on VH-XHB when it crashed in 2020 also came forward and reported that an alarm sounded before the chopper fell about 10 metres and made a hard landing.

At the time Wright, who was not the pilot, was informed one of the tourists had recorded a video of the incident.

It will be alleged that after viewing the footage, Wright asked the tourist not to share it with anyone, before providing the passengers involved in the incident with free alcohol and refreshments.

Since Wilson’s death, which is still under intense scrutiny, CASA has launched another five investigations into Helibrook.

Of those, one is about the fatal crash and another relates to alleged “unsafe behaviour reports”.

Helibrook’s operations were voluntarily suspended last year but Wright, who still has his pilot licence, is still flying.

CASA said it was inappropriate to comment “noting other ongoing matters under investigation”.

Wright declined to comment.

If you believe it is remotely possible that the ATSB was not aware of any of these disturbing tales of regulatory safety breaches involving both the Matt Wright and Troy Thomas commercial, airwork and private operations - I've got a lovely bridge in Sydney Harbour going cheap... Big Grin 

Why go to such lengths to cover up the CASA negligence to properly oversight the Matt Wright and Troy Thomas cowboy outfits?

The following is one BRB hypothesis doing the rounds. Under ICAO Annex 13, APPENDIX I - FORMAT OF THE REPORT, para 1.17 it states:

Quote:1.17 Organizational and management information.

Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator. the air traffic services, airway. aerodrome and weather service agencies: and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices. and regulatory framework.

It then says under 'Analysis':

Quote:2. ANALYSIS

Analyse, as appropriate, only the information documented in I. - Factual information and which is relevant to the determination of conclusions and causes.

From a legal perspective, by the ATSB leaving out 'CASA Oversight' in the context section, means that there is no need to properly analyse the obvious complete lack of surveillance of the Helibrook AOC and approvals.

Why they would do this? Possibly to avoid any embarrassment when the report and safety issues are reviewed by ICAO?

Incidentally the safety issues from the Croc-o-shite report are still yet to be given an issue date and/or to listed on the ATSB safety issues and actions database - WTD? 

MTF...P2  Tongue
Reply

Popinjay's Croc-o-shite report: The systemic investigation that wasn't??Dodgy

Courtesy CH9 ACA:


Popinjay (from 02:35): "The helicopter was likely not refuelled..."

Plus via the ABC:


Quote:Celebrity crocodile wrangler Matt Wright has been committed to stand trial in the Northern Territory Supreme Court on a charge of attempting to pervert the course of justice.

The charge is related to alleged events following a helicopter crash which killed his friend and television co-star Chris "Willow" Wilson in 2022.

Mr Wright, 44, was not present at the time of the crash and has strenuously denied all allegations.

Both Mr Wright and Mr Wilson starred in the National Geographic television series Outback Wrangler and Netflix show Wild Croc Territory.

Mr Wright appeared in the Darwin Local Court this morning for a brief committal hearing, where he was supported by his wife and legal team.

He faces a string of other charges, including fabricating and destroying evidence, which will be heard in the Darwin Local Court in June next year.

"I'm hopeful the remaining charges will all be withdrawn once this charge is dealt with next year," Mr Wright said in a statement.

In a brief hearing following Mr Wright's, helicopter pilot Michael Burbidge pleaded guilty to a charge of destroying evidence.

He was not piloting the helicopter that crashed.

Charges against Mr Burbidge of attempting to pervert the course of justice, fabricating evidence and making a false declaration were withdrawn.

Former NT Police officer Neil Mellon also pleaded guilty to a charge of destroying evidence, while his other charges — attempting to pervert the course of justice and making a false declaration – were withdrawn.

He will return to court in March for submissions and sentencing.

Separately, Mr Mellon faces 32 unrelated allegations including disclosing confidential information, unlawfully accessing data, obtaining benefit by deception and numerous weapons charges.

His separate matter will next be heard in the Darwin Local Court in February.

This week Mr Wilson's widow, Danielle Wilson, filed a separate civil suit against Mr Wright's company and Australia's aviation safety regulator over the fatal chopper crash.

An application filed with the Federal Court lists Helibrook and the Civil Aviation Safety Authority (CASA) as respondents.

The ABC understands Ms Wilson seeks damages, interest, costs, interest on costs and other orders as the court sees fit.

"In a brief hearing following Mr Wright's, helicopter pilot Michael Burbidge pleaded guilty to a charge of destroying evidence.."

...Former NT Police officer Neil Mellon also pleaded guilty to a charge of destroying evidence, while his other charges — attempting to pervert the course of justice and making a false declaration – were withdrawn.

He will return to court in March for submissions and sentencing.

Separately, Mr Mellon faces 32 unrelated allegations including disclosing confidential information, unlawfully accessing data, obtaining benefit by deception and numerous weapons charges..."


Related posts from the UP:

Quote:Ascend Charlie

Quote:CASA-approved safety management system was not being used to systematically identify and manage operational hazards,”

What a surprise.

Quote:The ATSB also found that CASA delegates removed crucial conditions from crocodile egg collecting authorisations, making it more likely the sling person would be killed if the helicopter’s engine failed.

There will be some world-class ducking and weaving going on in CA$A.



Cloudee

Quote:Originally Posted by Nescafe

Not a bad description for an operator that fudges maintenance, drains fuel from a crashed helicopter to divert blame and harasses a pilot in his hospital bed, allegedly.

Old mate was in court today. A couple of accomplices have pleaded guilty to destroying evidence from the crashed chopper. NT news today.

Michael Burbidge pleads guilty to destroying evidence after chopper crash that killed Chris Wilson

Prosecutor Steve Ledek asked that the details of the offending be suppressed to ‘preserve the state of the evidence’ against Outback Wrangler star Matt Wright in the Supreme Court.

Next from "X", I note that lawyer Peter Carter (from Carter Capner Law, Brisbane) was interviewed, on channel 7 'Sunrise', in regard to the Croc-o-shite legal wrangling:

Quote:Watch Peter Carter, director of Carter Capner Law on Sunrise talking about Outback Wrangler Matt Wright facing court over a series of charges involving the fatal helicopter crash that killed his Netflix co-star Chris Wilson.

#aviation #helicopter #accident #legal #lawyer

Note Carter's references to Chris Wilson's widow and her chances of success in suing CASA rather than the operator... Rolleyes

In what would be close to world record time for the ATSB to complete a systemic investigation, with all of this legal criminal and potential civil action, makes it even more 'passing strange' that the ATSB released the final report when they did??

This brings me to an earlier ABC article (13 Jan 2023) that timelines some more aberrations and disconnections with the Croc-o-shite cover-up investigation:

Quote:Australian Transport Safety Bureau upgrades investigation into NT helicopter crash that killed Chris 'Willow' Wilson

[Image: d9a1ff95791146837ba6226c551ca18e?impolic...height=485]

Key points:
  • The ATSB originally anticipated the release of findings in late 2022
  • Its investigation coincides with multiple court cases relating to the crash, including one involving celebrity crocodile wrangler Matt Wright
  • Mr Wright "strenuously denies" any wrongdoing in relation to the crash



Transport bureau upgrades investigation

The date of release for the ATSB report has been pushed back, the authority confirmed, due to the investigation being "upgraded to a systemic level investigation".

A systemic response is the ATSB's second highest level of investigation, topped only by a "major investigation" which would potentially involve a "large number of casualties".

An ATSB spokesman said the authority could not go into specifics on why the investigation had been upgraded as it was still ongoing, but said investigations were upgraded to systemic "when they are expanded to consider factors relating to organisations, processes, systems, cultures" and more.

A description on the ATSB's website said systemic investigations "have a broad scope and involve a significant effort collecting evidence across many areas".

"The breadth of the investigation will often cover multiple organisations," the description said.

"Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes."

Hmm...wonder what?/who? made Popinjay upgrade the investigation nearly a year in?

Some key date info: in late 2022 Popinjay advised “before the end of the year”; Jan 2023 he extended and upgraded it to “before” April 2023, then released it late NOV 23.

Basically, Jan 2023 - Popinjay makes a 3 month extension, it’s actually released 11 months after based on his BS ‘systemic’ excuse for the delay. The outcome is a report that doesn’t analyse systemic issues.

Regardless, it appears that the AAI aspect is secondary to everything else, and is being manipulated for other needs - there’s a lot in this and it’s very ‘murky’??

Next, in reference to my previous post:  [/url]

[Image: Swiss-Cheese.jpg]

Why did the rushed final report not include:  [url=https://auntypru.com/forum/showthread.php?tid=217&pid=14040#pid14040]Chalk & Cheese: S is for? - Surveillance.
 

Meanwhile in WA, despite the many systemic issues including negligent CASA oversight, the Coroner has refused to open up a proper inquest into the tragic R44 accident in Broome that took the life of Amber Miller:

Quote:No coronial inquest into fatal Broome chopper crash in which a 12-year-old girl and the pilot died

Key points:
  • A WA Coroner has decided not to hold an inquest into the death of Amber Jess Millar, who died in a helicopter accident in Broome in 2020
  • The 12-year-old girl and pilot Troy Thomas were killed in an accident that shook the Kimberley town
  • Jess' parents Clint and Fiona Benbow can appeal the decision but have declined to comment


   

Now watch the first 27:19 minutes of this Senate Estimates session:


MTF...P2  Tongue
Reply

Popinjay leaks Skerrit Ghost review; & CASA author ATSB corporate plan?

Remember this?

(11-10-2023, 08:02 AM)Peetwo Wrote:  Miniscule Dicky King trainwreck interview: Skerritt the panacea for Transport Safety agencies??  Dodgy

Via Su_Spence saga thread:

(11-09-2023, 06:14 PM)Peetwo Wrote:  Miniscule Dicky King weighs in on CASA ineptitude on Broome R44 fatal??Rolleyes

Via LinkedIn... Wink :



Australian Aviation
53,678 followers
2h •

Transport Minister Catherine King has defended CASA’s handling of the company responsible for 2020’s fatal crash of a Robinson R44 helicopter which killed a young girl.

The minister told ABC Radio in Perth this week that CASA “can’t be everywhere” in response to questions from host Nadia Mitsopoulos over whether the crash, which took the life of 12-year-old Amber Jess Millar (pictured), could have been prevented had CASA been more proactive.

https://ow.ly/xgqe50Q5Mti

Link for the transcript of the Perth (trainwreck) ABC radio interview:  https://minister.infrastructure.gov.au/c...-abc-perth

Note this was the sub-heading for that interview:

Quote:INTERVIEW

Tuesday 07 November 2023

Subjects: Crash in Daylesford, Electrifying Perth's buses, sustainable aviation fuel

Note there is no mention about CASA's failings in the Broome R44 fatal, this is despite the transcript revealing that this was the dominant interview subject matter:

Quote:NADIA MITSOPOULOS: Okay. Catherine King is with me, the Minister for Infrastructure, Transport, Regional Development and Local Government. Let’s stay on the issue of aviation, because you would be familiar with that chopper crash in Broome a few years ago that killed the pilot, Troy Thomas, and 13‑year‑old Amber Millar.

Now the Australian Transport Safety Bureau did a report into that crash, it described the pilot as having a risk‑taking appetite. It also found six unreported incidents and accidents involving Mr Thomas. Are you confident there are no more matters to be canvassed concerning Troy Thomas?

CATHERINE KING: Well, what I will say is that it’s really important that we have an independent Civil Aviation Safety Agency that focuses on safety, and the ATSB, whilst they did not find any findings against CASA, what I’ve asked CASA to do is to look at this incident, make sure that there is any other lessons that they would learn from that, and if there’s anything further they need to do, that they need to do so.

I’ve met over the phone with Clint and Fiona, so –

NADIA MITSOPOULOS: Who are 12‑year‑old Amber’s parents?

CATHERINE KING: Unimaginable, unimaginable, and I’ve got a 15‑year‑old, I think all of us can just imagine, you know, what we would feel in those circumstances, and have put them in touch with the head of CASA, Pip Spence, they’ve been talking to her and they’re in touch fairly regularly.

CASA has said publicly, obviously had the pilot survived the accident, they would have taken action against the pilot, but that unfortunately they’re not able to do, he lost his life in that incident as well. They’ve said that really clearly that’s what would have happened.

But again, it’s whether there was any further action in terms of the maintenance of this craft, whether there’s more, broader systemic things that they think they need to do. So they’re continuing to look at that, but ATSB have finished its investigation and didn’t find any direct findings against CASA, and really what ATSB will do, and they’re the investigators, will look at whether there’s any systemic failures that need further work.

NADIA MITSOPOULOS: Isn’t the failure here, and I appreciate ATSB has completed their report and they’ve done what was asked of them, isn’t the issue here the fact that there were another six unreported incidents and accidents? I mean this involved a chopper going into the water, one of those incidents involved somebody being injured. I mean, I guess what people are trying to understand is how can that happen, that five or six incidents go unreported.

CATHERINE KING: Well, exactly. To some extent I would say it is absolutely incumbent on everyone in aviation, if there are incidents that occur, like we all have to operate safely. It is difficult for the ATSB or for CASA to be aware of something if it’s not reported.

NADIA MITSOPOULOS: But what about if CASA was more proactive, maybe they would have learnt about it, because the problem is they are reactive not proactive.

CATHERINE KING: Well, I think you could say that about all of our safety systems to some extent, but what I –

NADIA MITSOPOULOS: That’s not good.

CATHERINE KING: – what I’d say with this is they can’t be everywhere. Like they just can’t, you know, we can’t have investigators everywhere, but what we can have is eyes on the industry everywhere, and that is incumbent on all of us, if we see something, report it, if we see that there’s unsafe action, or you think there is unsafe action in the industry; general aviation is a big sector, it is everywhere, in small airports, small properties, all the way across the country, it is really important that people report incidents if they think something is happening and report that to CASA so they can investigate, cause they just can’t be everywhere.

NADIA MITSOPOULOS: But there’s no presence of CASA in the Kimberley. That’s been ‑  and whenever we talk about this I get ‑ and I’ve already got text messages coming in from people saying that there’s no eyes on the aviation industry in the Kimberley. Is there anyone from CASA there?

CATHERINE KING: I’d have to go back and check that, but what I would say is we are all eyes, so wherever you are, you are an eye on the industry, and so it’s important to report that to CASA. CASA, as I said, are still looking at whether there are other things they need to do. One of the things also –

NADIA MITSOPOULOS: Could they be more proactive?

CATHERINE KING: I think ATSB did not find that, but what I would –

NADIA MITSOPOULOS: But I’m asking you.

CATHERINE KING: No, no, and what I would say is I have got at the moment John Skerritt who used to head up the Therapeutic Goods Administration, I appointed him when we were last in government, it’s a regulatory agency around the safety of medicines and products. He has now left the TGA, and he is undertaking a piece of work for me across CASA, ATSB and AMSA, which is the Australian Maritime Safety Agency, to look at a couple of things. First is sustainable funding models, so we need to make sure we’ve got enough resources so that they can do their jobs, and also to look at the regulatory environment in which they operate in.

So he’s having a look at that for me at the moment, and certainly if there’s anything further that we need to do, or if CASA identifies anything further they think we need to do, then I am up for that.

NADIA MITSOPOULOS: It’s 17 past 10. I’ve got the Infrastructure and Transport Minister, Catherine King, with me. So are you aware that CASA is putting another two staff in WA, are you aware of that?

CATHERINE KING: Because they’re independent of me, they have a separate board and they are independent of Government, they organise their own operational arrangements, so they wouldn’t inform me about what they’re doing, but if they are doing that, then that is a good thing. That would be a matter for the board and for the CEO to determine that.

NADIA MITSOPOULOS: Does it surprise you that CASA’s not had a presence up there?

CATHERINE KING: I think that –

NADIA MITSOPOULOS: And we know there are problems with the aviation industry.

CATHERINE KING: Yeah. Well, if there’s – and certainly if there are systemic problems, particularly up north that CASA is identifying, and that is a good thing, if they’re putting more staff up there, then that is a good thing.

NADIA MITSOPOULOS: What type of new evidence would warrant a fresh inquiry into this issue?

CATHERINE KING: I’m not an investigator, and it really wouldn’t be something that would be ‑ that’s not for me to determine. What I have said, you know, and in the discussions we’ve had with Pip Spence, particularly the head of CASA, is, you know, if there are things that they identify they can do better, then they need to look at that, and you know, talk to me about what they need to be able to do that, and so that’s really where that’s up to at the moment.

NADIA MITSOPOULOS: The Coroner here has refused a public inquest into that fatal crash, and it was hoped he would also look beyond just that crash and safety issues generally in the particularly tourism aviation industry. Did you make any representation to support a Coronial inquest?

CATHERINE KING: It would be inappropriate for me to do that. They are obviously independent, they’re part of the WA judicial system as well, it would be inappropriate for me to do that.

NADIA MITSOPOULOS: Are you meeting with the Benbow family while you’re in Perth?

CATHERINE KING: Not while I’m in Perth, but as I said, I have met with them, they’ve met via phone with staff from my office, and we’ve put them in touch with Pip Spence.

NADIA MITSOPOULOS: Are you concerned about the mounting – well, there is concern at CASA regarding short staffing, bloated work backlogs, key unions involved with CASA, their members walking off the job; are you concerned about CASA’s ability to do their job properly, because these are very serious concerns, when people go on strike, you got to listen.

CATHERINE KING: They’re currently in EBA negotiations at the moment, so I do ‑ they are in Enterprise Bargaining Agreement negotiations at the moment, so some of that commentary has that as a backdrop, so but what I –

NADIA MITSOPOULOS: So are you saying it’s not genuine, the concerns?

CATHERINE KING: – would say is there’s an EBA negotiation happening at the moment, but the other thing that is happening, as I said, is we’ve asked John Skerritt to have a look at the sustainable funding models for the safety agencies across my portfolio.

NADIA MITSOPOULOS: And what about aviation in the tourism industry; does that need to be specifically looked at?

CATHERINE KING: Well, I mean it’s very broad, and so really, you know, there are a lot of general aviation operators in the tourism sector, and they all have requirements under CASA regulations, I mean they all do have those.

So if there are people who are operating outside of the regulations, then you know, that is something that is of concern to us, and as I said, in this particular incident CASA has said very clearly, had the pilot survived, then there would have been ‑ they would have taken some action against him.

NADIA MITSOPOULOS: I appreciate what you’re saying, but isn’t the question here who is checking them? You can have all the regulations you want, but they’ve got to be enforced, and the whole criticism here is about the lack of oversight, no one’s checking.

CATHERINE KING: And you cannot have a CASA officer at every airport, in every single plane right the way across the country. That is why it is incumbent on the sector itself to report; if people see anything they need to report. Obviously CASA needs to be able to do its job, it needs the resources to do its job, and that’s my job –

NADIA MITSOPOULOS: But it needs to be more proactive, doesn’t it –

CATHERINE KING: – to make sure that’s the case.

NADIA MITSOPOULOS: – to be looking at the industry. I’m not saying you have an officer in every plane, but there’s been virtually no presence in WA.

CATHERINE KING: But I would say that it, you know, like they do investigate, you know, they do investigate. But again, if there are things that need to be done to improve, not just CASA’s presence, but what they are doing in terms of general aviation more broadly, then, you know, I’m up for that, and part of what John Skerritt will be looking at is to look at whether the systems are working as they should be, not just at CASA but across all of my safety agencies.

(ABC Radio audio link - HERE. The Miniscule DK interview starts at approximately the 01:36:30 mark.)

Looking through previous episodes of the Nadia Mitsopoulos morning radio program, I note that last week she focused on the Broome R44 crash that killed 12 year old Ambar Miller: https://www.abc.net.au/listen/programs/p.../103036226 (from 05:15 minutes)

Quote:The parents of 12-year-old Amber Millar who died in a helicopter crash in Broome in 2020 are devastated the WA Coroner has decided not to hold an inquest in to the tragedy.


DK quotes: ".. I have got at the moment John Skerritt who used to head up the Therapeutic Goods Administration, I appointed him when we were last in government, it’s a regulatory agency around the safety of medicines and products. He has now left the TGA, and he is undertaking a piece of work for me across CASA, ATSB and AMSA, which is the Australian Maritime Safety Agency, to look at a couple of things...as I said, is we’ve asked John Skerritt to have a look at the sustainable funding models for the safety agencies across my portfolio. ...part of what John Skerritt will be looking at is to look at whether the systems are working as they should be, not just at CASA but across all of my safety agencies..."

No doubt in my mind that the Miniscule did not originally intend to spill the intel on John Skerritt appointment. This spill was purely as a result of a tenacious reporters relentless questioning on the major deficiencies and duplicity of CASA rotary wing operator/pilot oversight in the topend. (Refer this post for background on Su_Spence's sensitivity around this: Su_Spence's conflicted 'stating the bollocks' on Top-End Madness??)

From Google trolling I came across this Dept webpage: Australian Transport Safety and Investigation Bodies Financial Sustainability Review

Quote:Our transport safety bodies are world-renownedBig Grin - yeah right) and the Australian Government is committed to ensuring they stay operationally fit-for-purpose and are sustainably funded to carry out their responsibilities.

The Australian Transport Safety and Investigation Bodies Financial Sustainability Review (the Review) will review the operations, consider potential efficiencies and options for cost recovery of the following bodies;
  • Civil Aviation Safety Authority (CASA)
  • Australian Transport Safety Bureau (ATSB)
  • Australian Maritime Safety Authority (AMSA)

The Review will be undertaken over six months.

About the Review

The objectives of the Review are to identify, report and make recommendations on:
  • The extent to which agencies’ operations and associated funding arrangements/mechanisms are fit for discharging their legislative and regulatory responsibilities, and whether any changes should be considered by Government.
  • Government and non-government funding sources of safety and investigation bodies, together with current and future funding requirements (based on the efficient cost of delivery), including regarding any expected changes to each agency’s operating environment.
  • Assessment of options for government and non-government funding sources, including through cost recovery, and their likely sectoral impacts.
  • Opportunities for operational efficiencies, and how they could be implemented, including whether opportunities exist to implement risk-based frameworks or scale operations to adapt to changing circumstances.
  • Any legislative or regulatory amendments required as a consequence of other recommendations made.
  • The Reviewer will consult with relevant government and industry stakeholders. The Reviewer will provide a report to the Minister for Infrastructure, Transport, Regional Development and Local Government following the conclusion of the Review for consideration.

Terms of Reference

Read the Terms of Reference.

Hmm...wonder why such a significant review has not been made public nor mentioned by Betts, Su_Spence and CO, or questioned on by the Senate RRAT committee in the Supplementary Budget Estimates? The sinister answer is on the ToR webpage:

 
Quote:Date published: 24 October 2023

Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference

Document Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference—PDF (220.7 KB)
Document Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference—DOCX (129.49 KB)


So the ToR wasn't published till the day after the RRAT Senate Estimates hearing and is still yet to be brought to the attention of industry and taxpayers, including the identity of the anointed Reviewer John Skerritt??

Of also 'passing strange' interest is there are 2 versions under 'Governance'/'Who will conduct the Review?'

From the ToR:

Quote:1.3 Governance

1.3.1 Role of the Reviewer

The Review will be conducted by a Reviewer with appropriate expertise in public sector financial, operations and
governance to be appointed by The Hon Catherine King MP, Minister for Infrastructure, Transport, Regional
Development and Local Government (the Minister).

The Reviewer will be responsible for the delivery of the final report to Government by early 2024, including
recommendations addressing the scope outlined above.

Secretariat support for the Review will be provided by the Australian Department of Infrastructure, Transport,
Regional Development, Communications and the Arts (the Department).
 

And from the review webpage:

Quote:Who will conduct the Review?

The Review is being undertaken by an eminent person with extensive expertise in public sector financial, operations and governance appointed by The Hon Catherine King MP, Minister for Infrastructure, Transport, Regional Development and Local Government (the Minister).

The Reviewer will be responsible for the delivery of the final report to Government by early 2024, including recommendations addressing the scope outlined above.

The Reviewer is being supported by a secretariat team within the Department of Infrastructure, Transport, Regional Development, Communication and the Arts.

Spot the difference?

I wonder when the review webpage was 1st made public?

Finally, the 'Reviewer':

Quote:Reviewer

Professor John Skerritt

[Image: prof-john-skerritt.jpg?itok=OpgwrxZS]

Professor John Skerritt is a respected regulatory leader with extensive experience in strategic policy, operational and financing models for regulatory systems. He has led a number of regulatory functions across health, agriculture, veterinary and fisheries, and land and natural resource protection and emergency management areas. This includes supporting and implementing the results of major government reviews, modernising regulatory policies and operations including business and digital transformation, developing strengthened compliance and enforcement schemes as well as playing a lead role in the national and international harmonisation of regulation and regulatory practice.

He has extensive senior government experience, including 24 years in three Deputy Secretary/Deputy CEO roles - within the Australian Department of Health (including 10 years as Head of the Therapeutic Goods Administration), the Foreign Affairs and Trade Portfolio and within the Victorian Government.  Professor Skerritt also has significant experience on boards of international and national organisations, including as board chair and as chair of board audit committees.

Prof Skerritt is a Professor and Adjunct Professor respectively at the universities of Melbourne and Sydney and has a PhD and a University Medal from the University of Sydney, and international qualifications in management from London Business School and IMD Switzerland.

Hmm...didn't notice any references to transport safety, aviation or maritime safety investigation??  Dodgy

Still no official announcement from miniscule DK or her Department, however I did notice the Senator Gerard Rennick did make a Instagram post referring to Skerrit Ghost Review: https://www.instagram.com/p/CzaSI57rPh2/...hare_sheet 

Quote:Can you believe this?

Skerritt has landed some plum job chairing a committee that will be nothing but a flick and tick exercise.

The RRAT Senate committee should be reviewing Infrastructure, not some unelected bureaucrat, especially Skerritt.

I have also discovered that DK was in fact not the 1st to leak the existence of the "Australian Transport Safety and Investigation Bodies Financial Sustainability Review". In fact the first person to make/leak (30 August 2023) an unofficial announcement of the review was Popinjay himself, in the current ATSB Corporate Plan:

Quote:Corporate Plan 2023-24

[Image: R51L1553_Angus_Mitchell-2_250.jpeg?itok=E5bpyc_Q]

I am pleased to present the Australian Transport Safety Bureau (ATSB) Corporate Plan for the period 2023-24 to 2026-27.

This Corporate Plan has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. The Corporate Plan is also consistent with the Statement of Expectations 2023-25 (SOE) for the ATSB, as notified under Section 12AE of the TSI Act, by the Minister for Infrastructure, Transport, Regional Development and Local Government.

The SOE sets out clear expectations relating to the ATSB’s governance, strategic direction, key initiatives, and stakeholder engagement, such that the ATSB’s resources be used in an efficient, effective, economical, and ethical way, following best practice principles and guidelines. I look forward to continuing to work with the Government to ensure the ATSB remains well positioned to meet these expectations.

I note there have been calls stemming from several inquiries and associated reports seeking to extend the ATSB’s services through an expanded remit. The ATSB will continue to provide input into such inquiries although any decisions to change the ATSB’s operating parameters are a matter for Government. My priority, since becoming Chief Commissioner in late 2021, has been to ensure the ATSB is funded adequately to perform the role defined by its existing remit. In this context, the ATSB will actively participate in the recently announced Australian Transport Safety and Investigation Bodies Financial Sustainability Review, which will consider and evaluate the ATSB’s current operational and funding arrangements.

In the past 12 months the ATSB has continued to demonstrate itself as a highly-capable agency releasing a number of complex and industry-significant investigation reports that carry wide-ranging safety learnings to the relevant transport modes. One such example is the ATSB’s final report into the collision with terrain of a Lockheed C-130 large air tanker during the 2019-20 Australian bushfire season. That investigation produced multiple key safety lessons relating to the tasking and operation of large air tankers – an operation becoming more prevalent in Australian firefighting.

Another fine example from the last 12 months was our final report into an investigation of a rail collision in Far North Queensland, which resulted in multiple safety actions being taken. The collision occurred due to a brake pipe not being properly connected when the train was coupled, and our investigation also made findings around survivability aspects in how the locomotive was manufactured. Pleasingly, this led to action being taken by the operator, the industry standards board, and the locomotive’s design owner.

In the marine sector, we also finalised a significant investigation into the sinking of a pair of tugs in Devonport, Tasmania, after they were impacted by an Australian-flagged bulk carrier, when its crew failed to select the correct steering setting during a turn in the port’s swing basin. This investigation made findings – and resulted in safety action by the operator – relating to bridge resource management, a key component of all safe marine operations. It also reflected on the response by the port operator, with more safety lessons emerging for that side of the industry as well.

As a relatively small, operationally-focused agency, the ATSB needs to anticipate change and adapt to ensure we are meeting the needs of government, industry, and the travelling public. Accordingly, during 2023 we launched our inaugural strategic plan, detailed later in this report. This plan was developed from extensive work with staff from across the agency. It clearly identifies the key objectives, strategies, and actions to be given priority over the short to medium term, with a focus on:
  • enhancing our products and stakeholder engagement for improving transport safety
  • fostering organisational resilience
  • affirming our role as the national transport safety investigator.

One area of that plan which has already yielded significant benefit has been a greater utilisation of audio-visual content. Through an expansion of the ATSB’s digital media production capabilities, we are able to develop more animations and videos to support our report releases. These products not only provide a better understanding for the audience already engaged in our reports; they also bring more people into the safety conversation, with high engagement levels across social media, and a high utility for television and online media outlets.

Over coming years, the strategic plan will aim to further improve the ATSB’s ability to provide greater value for persons and organisations seeking to use our products to take safety action.

Based on my interactions with a range of peer international safety investigation bodies since joining the ATSB, it is evident the agency remains highly regarded, and among the world’s leading transport safety agencies. I remain fully committed to continuing to work innovatively and collaboratively with all relevant stakeholders to enhance and amplify our contribution to improving transport safety, both domestically and internationally.

Angus Mitchell

Chief Commissioner and Chief Executive Officer
   
"recently announced" - Yet it took another month for EWB's Dept to publish the details of the review, a further month to publish the ToR, then  a further 2 weeks for EWB's crew to unofficially publish that Skerrit had the job and for DK to publicly leak both the existence of the review plus the identity of the imminent reviewer??

As a significant sidebar, in the course of tracking when the ATSB Corporate Plan was first created, I visited the document properties for the PDF version of the CP: https://www.atsb.gov.au/sites/default/fi...023-24.pdf

Quote:Document properties
File name: ATSB Corporate Plan 2023-24.pdf
File size: 733 KB
Title: -
Author: Lloyd Petty
Subject: -
Keywords: -
Created: 8/29/23, 10:13:37 AM
Modified: 8/29/23, 10:13:54 AM
Application: Acrobat PDFMaker 23 for Word
PDF producer: Adobe PDF Library 23.3.20
PDF version: 1.6
Page count: 24
Page size: Varies
Fast web view: Yes
 

Note that the author's name is Lloyd Petty, this individual is a long term employee for CASA with his most recent listed on LinkedIn as:

Quote:Civil Aviation Safety Authority
7 yrs 9 mos

Manager, Resource Planning & Reporting


Why is a CASA officer writing the four year 'strategic plan' for a supposedly fully independent government statutory agency?

MTF...P2  Tongue
Reply

[Image: SYDEX-media_image001.jpeg]

Popinjay starts the BLAME GAME on Gold Coast Midair??Dodgy

The following despicable ATSB cover-up propaganda, is attributed to Popinjay...  Angry

Quote:Interim transport safety report one year on from Gold Coast helicopter collision

[Image: AO-2023-001%20News%20Item%20Image.jpg?itok=1AHbNKWk]

The Australian Transport Safety Bureau has released an interim report detailing contextual information established as part of its ongoing investigation into the mid-air collision between two helicopters on the Gold Coast one year ago.

The report is intended to update the industry and public on the progress of the ATSB’s independent ‘no blame’ investigation, which is conducted with the goal of improving transport safety.

“To date, the ATSB has undertaken extensive work to understand and recreate the events of the day in order to identify and examine the context and risk controls that existed at the time,” Chief Commissioner Angus Mitchell said.

“The ATSB analysis framework looks at a hierarchy of factors arranged in their relative proximity to an event, and this investigation has so far concentrated on elements closest to the event: individual actions, vehicle/equipment performance, local conditions, and risk controls.”

This work has included interviews with key personnel and witnesses, the examination of both helicopters, maintenance logs, and postmortem information, a review of industry understanding of seat belt fitment, and analysis of ADS-B and radar flight tracking information, CTAF recordings, and video imagery.

“A large amount of the evidence gathered through this work is detailed in today’s interim report, and investigation into and analysis of many of these areas is ongoing,” Mr Mitchell said.

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites.

“A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” he said.


“It is important to note while this is a substantive and comprehensive interim report, the ATSB is yet to make formal findings as to the contributing factors that led to this accident as we are continuing our analysis of that evidence.”

Moving forward, Mr Mitchell said the investigation would consider whether any systemic factors contributed to, or increased risk in the accident.

“This will include consideration of the design of the operating environment and operating procedures, the onboarding and implementation of aircraft, change management, and the regulatory environment and input,” he explained.

The ATSB’s final report, which will include analysis, findings, and any recommended safety actions, is on track for an anticipated completion in the third quarter of 2024.

“This was a tragic accident, and it is our responsibility to make findings and drive safety actions, which reduce the likelihood of a similar occurrence in the future,” Mr Mitchell said.

The interim report notes several steps which have already been taken in response to the accident.

After reviewing its processes and procedures, Sea World Helicopters has implemented a new ‘pad boss’ traffic advisory role, added air traffic systems to each of its helicopters’ avionic systems, increased communication protocols, and taken steps to make its helicopters more visible.

Separately, the ATSB issued a Safety Advisory Notice in September, targeting aircraft lifejacket manufacturers and national aviation certification authorities.

“During this investigation, our investigators identified a potentially common lack of understanding in the broader helicopter tourism community about how constant wear lifejackets should be worn in conjunction with seatbelts,” Mr Mitchell explained.

“This correlated with a discovery that some passengers’ seatbelts were not fitted correctly in this accident, in part due to interference from their lifejackets – although we have not attributed this to the tragic outcomes in this case.”

Read the interim report: Mid-air collision involving Eurocopter EC130B4, VH-XH9, and Eurocopter EC130B4, VH-XKQ, Main Beach, Gold Coast, Queensland, on 2 January 2023

Publication Date 02/01/2024

The part in bold and underlined, what the hell was Popinjay bringing this up for?? The following is the ultimate effect that unbelievable ill informed, disassociated statement has had... Dodgy

Courtesy Skynews, via YouTube: 

Quote:

Gold Coast helicopter crash: ATSB reiterates ‘zero policy’ approach to drugs

Aviation safety officials have reiterated a 'zero tolerance' approach to drugs after the pilot of a fatal crash in the Gold Coast was found to have traces of cocaine in his system.

The Australian Transport Safety Bureau issued its interim report on the incident on Tuesday.

Two Sea World tourist helicopters collided midair on January 2 2022.

The collision killed four people, including the pilot of one of the helicopters.

A further nine were injured.

The report also revealed that some seatbelts on the aircraft were not fitted correctly.

UDB! Popinjay needs to resign NOW!  Angry

[Image: BSN-Blog-4.30.19.jpg]

MTF...P2  Tongue
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The finger pointing illustration sums up our dysfunctional system of aviation governance.
P2’s forensic analysis has once again prised open the lid on the can of worms that is government by independent bodies whose functions were once within Departments with responsible Ministers at head with direct oversight. The Westminster tradition with its proper, principled and pragmatic feature of the most direct line of responsibility between the governed and the governors has been discarded with predictable and now very obvious consequences. The Public Sector, that which used to be the Public Service, is a fat revolving door operation with some pointing of fingers in the blame game as P2 so ably exposes. But beyond that they are all conscious that this can’t go too far lest Ministers are forced to step in which could, just conceivably, place at risk the whole colossal gravy train and the salary factories of Canberra.
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First BRB Indaba.2024..

By demand, item #1 – the Gold Coast mid air. It comes with a warning 'beware the fury'. That fury being fully justified (IMO) the blame ducking shambles the ATSB and CASA have developed almost beggars imagination; it certainly beats logic and good 'over-sight' of an operation. Maybe some readers will understand 'what' exactly is involved with bringing a 'new' type' onto an operating certificate; under a CASA rule set. It ain't a stroll in the park; not by a long, long mile it ain't. Brutal amounts of paperwork being the least of it; management pressure to keep the ball rolling; - in short its no game for light weights. However, seems the CP got the job done, signed off and fully approved. Bar the one flaw; the one which proved to be fatal. Perhaps ATSB (with the aid of the useless, (expensive) German (expensive) tech video stropathon can define some very, very basic rules (cast ion stone, covered in blood) about why no one picked up the potential for 'conflict' between incoming and out going aircraft. One glance at the ATSB diagram clearly defines the oversight the busy CP (forgivably) made. But there is no excuse for CASA: their own words and tenet.

See-and-avoid’, as a means of separation and collision prevention for two or more
vehicles, is an ancient principle and one that in the maritime environment predates
aviation by many centuries.

2.1.2 In the early history of aviation, see-and-avoid was the only means for avoiding collision,but as aviation advanced, its limitations have become apparent. Since the early days of flight, additional measures have been sought to reduce the risks of mid-air collision. In parallel with aviation, the maritime industry has adopted, where circumstances have warranted, many of the same means to avoid collisions on the water.

2.1.3 In modern aviation, see-and-avoid is the last line of defence, but usually not the only mechanism for avoiding a collision or an Airprox event

These questions should have been addressed by CASA early in the piece; discussed and 'sorted' prior to any operational approval; once again, take a look at the diagram provided and spot the obvious error. (No Choc Frogs). The company i.e. the CP would be very reluctant to 're-draft' and have 'accepted' and pay for an amendment to their manuals and procedures. CASA would have upped the ante and the charges and taken the God's own time to 'accept' the new procedures; the cost in time, work and money prohibitive. So, least said, soonest mended. Result – inevitable..........

After the Lord Mayors parade; the sweepers. Those left to sweep up the mess; a.k.a. The ATSB. If our wee bearded Popinjay (media hog) had any idea of what the professionals in 'air safety' thought of his antics; he'd probably buy a bigger hat, with a bias (and little in the way of cattle to match the ensemble). Deliberately, without a qualm, he gets into the brainless media and promotes the notion that 'chemicals' had a part to play in the event. BOLLOCKS – in Spades, redoubled. BOLLOCKS........

This bumptious, unqualified, self promoting, camera loving, kangaroo bothering weasel is so captured and so willing to spin and weave the CASA narrative into 'the media' that it is embarrassing' in the extreme. The BRB cannot believe that he has not been asked to 'depart' the fix and go back to translating 'Indon' weather forecasts, or whatever. Independent ?? Competent?? Honest??-  BOLLOCKS.........

I ask you, once again, study the diagram presented and define what the inevitable conclusion of that arrival and departure plan would be – sooner or later. With 20/20 hindsight the answer screams off the page; the company 'missed' it – CASA missed it – the ATSB have bamboozled the world into looking away from the realities. Bloody media so busy grabbing 'headlines' have missed the whole load of horse pooh – following Lord Mayors parade; like kids in a lolly shop.

[Image: AO-2023-001%20News%20Item%20Image.jpg?itok=1AHbNKWk]

Now I have to face and manage a hostile crew; perhaps Popinjay would accept an invitation to attend. Only be about two dozen there, and answer the only question that matters – WTD...

That is all, duty done – P7 wants to invite Spence along. Nope – they outlawed pilgrims v Lions hundreds of years ago – didn't they? Be fun though, sure enough.......

Toot – toot,,,,,,
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Popinjay Supp Estimates 23-24 AQON (so far)??Rolleyes 

Via RRAT Supp Estimates webpage:

67. ATSB - Date Minister was advised of Mr Mannings term expiring

290. ATSB - involvement in the process of filling Board appointments announced in August and October

291. ATSB - Chief Commissioner Angus Mitchells involvement in retiring members or proposed appointments to Board

Quote:Senator Bridget McKenzie asked:

Was the Chief Commissioner, Angus Mitchell consulted or asked for his view on either the
retiring members or proposed appointments?

Answer:

Yes.

292. ATSB - Details of Chris Mannings appointment to Board

293. ATSB - Details of Mr Wilsons appointment to Board

296. ATSB - Chief Commissioners review of 2021-22

Quote:Senator Bridget McKenzie asked:

1. Chief Commissioner ’s review 2021–22 states that ATSB ‘flagged our ongoing concern
about collisions between trading ships and small vessels on the Australian coast’ following
an incident in February 2020. What additional actions have been taken to mitigate the risk
of these collisions?
2. In 2021-22 the ATSB failed to meet the performance criterion that ‘85% of safety issues
[are] addressed in the previous financial year’. Given that only 74% of safety issues were
addressed in 2021-22, what needs to happen to meet this performance criterion?
3. In 2021-22 the ATSB missed its target median times to complete short (8 months),
defined (16 months) and systemic (22 months) investigations. How can ATSB investigations
be completed within the target times?
4. Despite a substantial increase in air traffic, the ATSB received approximately $500,000
less in government funding in 2021-22 compared to 2020-21. Did this impact the agency’s
functions?

Answer:

1. There were three collisions between trading ships and small vessels between 2015 and
2018 and a further collision between a fishing boat and bulk carrier on 29 February 2020
(investigated by the Australian Transport Safety Bureau (ATSB) as MO-2020-001). That
investigation (and others previously) highlighted the importance of maintaining an
adequate look out and the value of surveillance technology to increase traffic
awareness. The ATSB continues to monitor such occurrences and notes that there have
not been any collisions related to inadequate look out over the last few years.

2. The ATSB is a ‘no-blame’ safety investigator and does not have any power to enforce the
addressing of safety issues identified during ATSB investigations. However, the ATSB
does work with safety issue owners to encourage appropriate safety actions, both
during an investigation and afterwards. Some safety issues take time to address,
especially when new regulations are involved. As such, safety issues will continue to be
addressed in later years. For 2021-22 this particular measure was not met as a number
of safety issues identified in that year rolled over into 2022-23 where they were
addressed. This is reflected in the 2022-23 ATSB Annual report which shows that for the
2021-22 year, 85 per cent of safety issues had been addressed.

3. The ATSB has been actively targeting the performance of investigation times, and this is
reflected in the 4-year decreasing median for Short and Defined investigations shown in
the 2022-23 ATSB Annual Report. Measures in place are restricting the number of active
investigations to an average of two per investigator, adherence to a project
management approach to investigations, and an even distribution of investigations
across three directors. In 2023, the ATSB strategic plan led to a dedicated Short
investigation team (to conduct the majority of office-based short investigations), and a
dedicated Data Recovery team, Safety Analysis and Research, Marine investigation team
and Rail investigation team. While there will always be some variability in the length of
investigations depending on complexity (especially the larger systemic investigations),
the above measures are expected to continue to reduce the median time of
investigations in the forthcoming years.

4. To ensure, as far as practicable, that the ATSB can resource the investigations it takes
on, the ATSB limits the number of investigations to an average of two per investigator
(although investigators work across multiple investigations). With the ATSB’s present
resourcing this accommodates approximately 90 investigations a year across aviation,
marine and rail. There are currently no budget measures associated with industry
growth, however the Australian Government provided an additional $4.6 million in the
2023-24 Budget (in addition to its ordinary annual appropriation) to allow ATSB to retain
a staffing base of 110 ASL and conduct safety investigations across all modes of
transport within its remit. The Government has commissioned a Review of Operations
and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies
,
announced in the 2023-24 Budget, which is expected to make recommendations to
Government relating to agency resourcing.

298. ATSB - Locations of Commissioners and staff of ATSB

299. ATSB - Independent investigation of transport accidents in 2021-22

300. ATSB - Safety data recording analysis and research in 2021-22

Quote:Senator Bridget McKenzie asked:

What proportion of time and budget did the ATSB work on safety data recording, analysis
and research in 2021-22? 

Answer:

The ATSB does not break down its activities/resources into specific streams that would allow
it to isolate the resources allocated directly on safety data recording, analysis and research
in 2021-22.

301. ATSB - Fostering safety awareness knowledge and action in 2021-22

Quote:Senator Bridget McKenzie asked:

What proportion of time and budget did the ATSB work on fostering safety awareness,
knowledge and action in 2021-22? 

Answer:

The ATSB does not break down its activities/resources into specific streams that would allow
it to isolate the resources allocated directly on fostering safety awareness, knowledge and
action in 2021-22.

MTF...P2  Tongue
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Chalk & Cheese: French TV AS350 Helicopter mid-air v Seaworld midair?

The following 2015 Argentinian AAI final report, was recently brought to my attention by Aerossurance on LinkedIn:

Quote:French TV AS350 Helicopter Accident in Argentina (UPDATED with final accident report)

The mid air collision of two Airbus AS350 (H125) helicopters on 9 March 2015 resulted in the death of all 10 people on board during the filming of a French TV programme, Droppedfor TF1 in Argentina. The accident highlights the importance of risk assessment, planning and preparation for any aerial activity.

Two AS350s were involved, both from different local government bodies: LQ-CGK and LQ-FJQ. At least one is reported to have been a Helicopter Emergency Medical Service (HEMS) aircraft loaned to the film makers. Of the 10 people onboard, 3 were French sports stars, 5 French TV personnel and two local pilots. The accident happened near Villa Castelli in La Rioja province in north-west Argentina.  The area is in the foothills of the Andes and is about 1300m above sea level.
[Image: argentine-collision.png]
Moments Before the Mid Air Collision (Credit: JIAAC)

The Bureau d’Enquêtes et d’Analyses (BEA) has issued a statement:

Quote:
The BEA has been notified of the accident that occurred between two Airbus Helicopters AS 350’s in the province of Rioja in Argentina yesterday, Monday 9 March. The two helicopters, registered respectively LQ-FJQ and LQ-CGK, had eight French passengers and two Argentinian pilots on board.
In accordance with international provisions the BEA, representing the State of Design and Manufacture of the helicopters, will participate in the Safety Investigation that has been initiated by its Argentinian counterpart, the JIAAC (Junta de Investigación de Accidentes de Aviación Civil).
Two investigators from the BEA, accompanied by a technical adviser from Airbus Helicopters and a technical adviser from Turbomeca, are travelling to Argentina today.

Flight International have commented on video footage of the accident
Time have published a piece critical of the production company and French reality TV in general. https://www.youtube.com/watch?v=u1iKgZzPyXU



UPDATE 22 June 2015: NTSB has issued a report on another fatal accident, this time a Loss of Control – Inflight at night, while filming a reality television show for the Discovery Channel, involving Bell 206B N59518 in California 0n 10 Feb 2013: NTSB faults pilot, inspector in reality TV helicopter crash.  The filming was organised by the production company EyeWorks USA, which has since rebranded itself as 3 Ball Entertainment.

UPDATE 10 August 2015: In the case of the US accident, it is now reported that an out of court settlement has been reached. 
UPDATE 24 August 2015:  Another accident has occurred in the US and is covered in an article that looks at safety in TV.
UPDATE 13 December 2015: Another TV helicopter accident in Argentina is reported: MTV helicopter crash kills two in Argentina
JIAAC Safety Investigation Final Report
UPDATE 17 December 2015: The JIAAC accident report on the March 2015 collision has been issued.  The accident investigators stating” In an operation classified as aerial work, which involved the transport of passengers and air-air filming activity, there was an in-flight collision between the two participating aircrafts”. The collision was caused by the combination of  the following factors:
  • Location of the helicopter that was filming (LQ-FJQ), from the “outside”, in the path of both aircrafts, that significantly limited the visual contact of the pilot who had to move forward in flight in order to film the target (LQCGK);
  • Lack of a formal assessment of the safety risks for an unusual operation (filming and flight in proximity), which prevented the identification and analysis of the dangers inherent to that operation, and the adoption of mitigation actions, requirement not  equired by the current regulations;
  • Deficiencies in the operation planning that led to the accident, including the failure of observing the “see and be seen” concept or an evasive maneuver if visual contact is lost between both aircrafts;
  • Lack of formal procedures in accordance with the nature of the operations performed;
  • The use of aircrafts whose public identification prefix does not imply providing logistics and aerial support for filming of a completely private nature;
  • Ambiguity in the observance of regulations related to air operations of public aircrafts;

[Image: argentine-mac.png]



Mid Air Collision (MAC) Safety Resources

UPDATE 9 March 2019: Aerossurance has previously published:
Also:
 
Here is the French BEA English translated version of the JIAAC final report: https://auntypru.com/wp-content/uploads/...n_15-1.pdf

It took the Argentinians 284 days to complete this systemic investigation. The ATSB Seaworld fatal chopper accident is already at 435 days with no recent update indicating a final report will be published anytime soon... Dodgy

Given the obvious similarities/parallels, I wonder will this report feature in the ATSB final report?  Rolleyes

MTF...P2  Tongue
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Like Chalk & Cheese: Homendy vs Popinjay (the latest Can'tberra Village idiot) - Blush

Via the NTSB, Baltimore bridge collision accident:


Quote:31,100 views Streamed live on Mar 27, 2024

NTSB Chair Jennifer Homendy briefs the media on the NTSB investigation of a cargo ship striking and subsequent collapse of the Francis Scott Key Bridge in Baltimore, Maryland.

Compare that to this load of bollocks and self-serving BS... Dodgy


Plus on the release of the Prelim report, released 35 days past ICAO Annex 13 compliance for release of a AAI Prelim report:


Quote:“The ATSB has released this preliminary report to detail the circumstances of this tragic accident as we currently understand them, but it is important to stress that we are yet to make findings,” said ATSB Chief Commissioner Angus Mitchell.

“Our findings as to the contributing factors to this accident, and the analysis to support those findings, will be detailed in a final report to be released at the conclusion of our investigation.”

Mr Mitchell said the preliminary report details factual information, including the accident’s sequence of events.

“The factual information detailed in this report is derived from interviews with survivors of the accident, including the surviving pilot and passengers, and witnesses; analysis of video footage and images taken by passengers on board both helicopters, onlookers on the ground, and CCTV from nearby buildings; examination of the wreckage of both helicopters; and a review of recorded radio calls and aircraft tracking and radar data.”

The preliminary report details that the helicopters were operating from two separate helipad facilities about 220 metres apart, a pad within the theme park, and a pad to the south at the operator’s own heliport, adjacent to the park. The 5-minute scenic flights were to follow the same counter-clockwise orbit, with the inbound helicopter, registration VH-XH9 (XH9) on approach to land at the heliport to the south and the outbound helicopter, registration VH-XKQ (XKQ) having departed the pad to the north from within the theme park.

The two helicopters collided at an altitude of about 130 feet, 23 seconds into the departing XKQ’s flight.

The main rotor blades of helicopter XKQ entered the forward cabin of XH9. XKQ broke apart in mid-air and impacted shallow water next to a sandbar. The pilot and 3 passengers were fatally injured, and 3 passengers were seriously injured. The helicopter was destroyed.

Helicopter XH9 sustained significant damage to the forward cabin, instrument console, and main rotor blades. The impact turned XH9 to the left, and the pilot continued with the momentum of that movement, completing a 270° descending turn to land on the sandbar below them near to XKQ. The pilot and 2 passengers were seriously injured, and 3 other passengers had minor injuries.

The helicopters were operating in non-controlled airspace where pilots use a common traffic advisory frequency (CTAF) to make radio calls to announce their position and intentions, and, as required, to arrange separation with other aircraft.

The report details the radio calls made by the pilot of the returning helicopter XH9, and that as they tracked south over the Broadwater, that the pilot saw passengers boarding XKQ as it was preparing to depart.

The pilot of XH9 recalled that their assessment was that XKQ would pass behind them, and that they did not recall the pilot of XKQ making a standard “taxiing” call announcing their intention to depart.

“This does not necessarily mean that a taxi call was not made, and the ATSB investigation will undertake a detailed analysis of the nature of the radio calls made,” Mr Mitchell noted.

The report also details that the pilot of XH9 did not see XKQ depart from the park helipad.

While video footage taken by passengers in both helicopters on mobile phones contained images of the other helicopter, this does not mean that the other helicopter was visible to either pilot.

“The investigation will look closely at the issues both pilots faced in seeing the other helicopter,” Mr Mitchell said.

“We have already generated a 3D model of the view from the pilot’s seat from an exemplar EC130 helicopter which we will use as part of a detailed visibility study to help the investigation determine the impediments both pilots faced in sighting the other helicopter.”

Mr Mitchell said the investigation will also look more broadly beyond the issues of radio calls and visibility.

“The ATSB will also consider the operator’s procedures and practices for operating scenic flights in the Sea World area and the process for implementing the recently-acquired EC130 helicopters into operation, and will review the regulatory surveillance of the operator and similar operators.”

The investigation would also look at the use of traffic collision avoidance systems (TCAS). There was no requirement for the helicopters to be equipped with a collision avoidance system, and while both accident helicopters were fitted with TCAS, those systems had not been fully integrated in the accident helicopters (as they had with the operator’s other helicopters), and according to the operator’s pilots were of limited benefit when operating near and on the helipads.

“This will be a complex and comprehensive investigation.

“However, if at any time during the course of the investigation the ATSB identifies a critical safety issue, we will immediately share that information with relevant parties so they can take appropriate safety action.”

And for the anniversary interim report, this manufactured Popinjay bollocks press release:

Quote:Interim transport safety report one year on from Gold Coast helicopter collision

[Image: AO-2023-001%20News%20Item%20Image.jpg?itok=1AHbNKWk]

The Australian Transport Safety Bureau has released an interim report detailing contextual information established as part of its ongoing investigation into the mid-air collision between two helicopters on the Gold Coast one year ago.

The report is intended to update the industry and public on the progress of the ATSB’s independent ‘no blame’ investigation, which is conducted with the goal of improving transport safety.

“To date, the ATSB has undertaken extensive work to understand and recreate the events of the day in order to identify and examine the context and risk controls that existed at the time,” Chief Commissioner Angus Mitchell said.

“The ATSB analysis framework looks at a hierarchy of factors arranged in their relative proximity to an event, and this investigation has so far concentrated on elements closest to the event: individual actions, vehicle/equipment performance, local conditions, and risk controls.”

This work has included interviews with key personnel and witnesses, the examination of both helicopters, maintenance logs, and postmortem information, a review of industry understanding of seat belt fitment, and analysis of ADS-B and radar flight tracking information, CTAF recordings, and video imagery.

“A large amount of the evidence gathered through this work is detailed in today’s interim report, and investigation into and analysis of many of these areas is ongoing,” Mr Mitchell said.

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites.

“A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” he said.

“It is important to note while this is a substantive and comprehensive interim report, the ATSB is yet to make formal findings as to the contributing factors that led to this accident as we are continuing our analysis of that evidence.”

Moving forward, Mr Mitchell said the investigation would consider whether any systemic factors contributed to, or increased risk in the accident.

“This will include consideration of the design of the operating environment and operating procedures, the onboarding and implementation of aircraft, change management, and the regulatory environment and input,” he explained.

The ATSB’s final report, which will include analysis, findings, and any recommended safety actions, is on track for an anticipated completion in the third quarter of 2024.

“This was a tragic accident, and it is our responsibility to make findings and drive safety actions, which reduce the likelihood of a similar occurrence in the future,” Mr Mitchell said.

The interim report notes several steps which have already been taken in response to the accident.

After reviewing its processes and procedures, Sea World Helicopters has implemented a new ‘pad boss’ traffic advisory role, added air traffic systems to each of its helicopters’ avionic systems, increased communication protocols, and taken steps to make its helicopters more visible.

Separately, the ATSB issued a Safety Advisory Notice in September, targeting aircraft lifejacket manufacturers and national aviation certification authorities.

“During this investigation, our investigators identified a potentially common lack of understanding in the broader helicopter tourism community about how constant wear lifejackets should be worn in conjunction with seatbelts,” Mr Mitchell explained.

“This correlated with a discovery that some passengers’ seatbelts were not fitted correctly in this accident, in part due to interference from their lifejackets – although we have not attributed this to the tragic outcomes in this case.”

Read the interim report: Mid-air collision involving Eurocopter EC130B4, VH-XH9, and Eurocopter EC130B4, VH-XKQ, Main Beach, Gold Coast, Queensland, on 2 January 2023

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites. - “A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” This statement led to further defaming of the dead Chief Pilot:


Hmm...don't believe Homendy would be so stupid as to be led down that particular 'blame game' rabbit hole... Rolleyes

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