The search for investigative probity.
Closing the FRMS safety loop?  -  Dodgy

(01-13-2018, 07:41 AM)kharon Wrote: A most inconvenient ditching.

"...There had to be a reason for the bizarre, extraordinary behaviour of CASA following the Norfolk ditching event. The life and career of one small, insignificant human became as nothing when compared to the truly shocking notion that the world may discover how seriously flawed the regulator, the regulation and the management of aviation truly was then. It will come as no surprise that nothing – absolutely nothing has changed since then; unless you count the slow, irresistible slide deeper into the pit. Do I feel sorry for the ‘good eggs’ in the CASA basket? No, I do not. ‘They’ could have spoken out, they have had ample opportunity and much encouragement to do so. Resignation and silence – honourable? Oh, I think not..."

Extract from 'Accidents - Domestic' thread post #256:

HVH: “By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,”

Is that like the ATSB closing safety loops on serious safety issues that having been identified, in some cases nearly 2 decades ago, & despite political and aviation safety bureaucratic rhetoric, are yet to be effectively risk mitigated... [Image: dodgy.gif]

Examples from the same decade refer here: Closing the safety loop - Coroners, ATSB & CASA

And most recently and still live... [Image: dodgy.gif]
FRMS/SMS a lip service exercise - Part VII & FAA IASA audit, FRMS & an 'inconvenient ditching'?

In Senate Estimates the 'closing the safety loop' as a term of reference was first adopted by Senator Fawcett in the 2012 Budget & Supplementary Estimates.

From Senate Hansard:

Quote:Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

& answer to Supp Estimates QON 157 (note that this was 6 days before the AAI inquiry began):

Question no.: 157
Program: N/A
Division/Agency: (ATSB) Australian Transport Safety Bureau
Topic: Closing the loop on ATSB safety recommendations
Proof Hansard Page/s: 77-78 (16/10/12)

Senator FAWCETT asked:

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak:
It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.


One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed, not addressed, no longer relevant or withdrawn.

A safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required.

The ATSB policies and procedures for identifying and promoting safety issues, including through the issuance of a formal recommendation, is outlined in its submission to the Senate References Committee Inquiry into Aviation Accident Investigations.

The ATSB’s Annual Plan and part of the ATSB’s Key Performance Indicators specifically relate to a measurement of safety action taken in response to safety issues; in the case of ‘critical’ safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.

As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for following up on recommendations and safety issues identified by the ATSB, as provided for in the Memorandum of Understanding between the agencies. Aviation safety agency heads will continue to monitor the present arrangements to provide an adequate system for addressing issues identified through ATSB investigations.

Coming back to the - unclosed loop - 2 decade old identified safety issue of fatigue, as a passing strange coincidence the following was a short passage of Hansard, from May 2012, that followed Sen Fawcett's ATSB safety loop questioning:

Quote:Senator XENOPHON: I will try to make it a very quick one. I keep getting complaints from those who are in safety-sensitive positions in aviation about fatigue issues and that the fatigue issues seem invariably to accompany reports of an oppressive workplace culture, most recently in terms of air traffic controllers. How does the ATSB deal with the particular issues of fatigue management and the performance consequences of workplace culture, given the subjectivity inherent in those concepts? Do you see a role in ATSB monitoring the performance of the fatigue management systems or do you see it as a purely regulatory function? Do you think that the regulatory agencies are doing enough about fatigue risk management? I am happy for you to take it on notice.

Mr Dolan : With your indulgence, I can answer it quite quickly.

CHAIR: Yes, get to the point.

Mr Dolan : Fatigue, when it is detected as a contributing factor in any investigation we undertake, we will look to fatigue management systems to see whether they can be improved to better manage the risk of fatigue in the system. I do not have any evidence in front of me that would allow me to give you an additional comment on the adequacy of regulatory oversight. We have not seen anything that would say it is inadequate. P2 comment - Err (vomit - Confused ) BOLLOCKS!!

Senator XENOPHON: Thank you.

Also of much historical interest was this passage from earlier in the ATSB session:

Quote:Senator XENOPHON: It has been suggested to me that, with the ATSB's pursuit of no-blame results in reports, on the one hand they are delayed by seeking high levels of consensus amongst interested parties and, on the other hand, they could potentially end up lacking human factors reporting as to risk, rendering the reports almost as historical records rather than safety enhancement tools. Could you comment on that? Is the amount of time spent on consulting interested parties detracting from the timeliness of publishing reports? I know there are some tensions here in terms of due process and fairly helping people. I have tried to set out what the concern is.

Mr Dolan : I hear two elements to your question, so I will take them sequentially. The key process of consultation is done at the point where we have a draft report. So we have examined all the facts, we have done our analysis and we have formed provisional views. We circulate a draft report under the protection of our act—so not to be released—to what we call directly involved parties. If it is domestic, we expect any comments within a month and we emphasise that we are principally seeking any corrections of factual inaccuracies in our report. We are also seeking, where we have identified a safety issue, information on any action that the relevant party may have taken in response to the identified issue. The focus is on getting something done in response to our findings. That process normally takes a month plus another week or two to make sure that the relevant concerns that may have been raised with us are integrated into the final report. I do not see it as a major constraint on our timeliness.

Senator XENOPHON: You do not think it constrains you in terms of providing more depth in human factors analysis?

Mr Dolan : That was the second part, as I was saying, of the question. There is the specific timeliness thing, an appropriate level of review to make sure that the rigour and the factual accuracy of our reports is in place, which I think is important, and it also goes to procedural fairness. Although we are a no-blame organisation, people can read our reports as pointing the finger, even though we do not intend them to. So there are no surprises for those involved.

The second point is that I am startled that there is a belief out there that we do not have human factors at the core of what we do. Our entire investigation and analytical model is based on fundamental principles of human factors—understanding human error, understanding how to minimise it, accepting that you can never remove it, and looking therefore at how you capture errors and make sure they are dealt with in the system. I am not sure, in addition to that, how much I can say.

Senator XENOPHON: I will possibly put some questions on notice about Airservices Australia. In relation to that issue of human factors, it was not a criticism; I am just saying that was a concern that has been expressed to me by those in aviation. I am thinking of the Air France 447 investigation, which of course the ATSB has nothing to do with—that terrible loss of life over the Atlantic.

Mr Dolan : We are watching it with interest.

Senator XENOPHON: No doubt you are looking at it with interest. You correctly emphasised factual information. With Air France 447, I think there is still a final report down the track?

Mr Dolan : The report is due for release next month, as I understand it, from Mr Troadec of the BEA.

Senator XENOPHON: That whole investigation seems to be looking at human factors. It seems increasingly clear that the 'what' does not so much clarify the 'why'. To what extent will the 447 investigation influence the way that air safety investigators around the world conduct their work, or is it just an instance of human error?

Mr Dolan : I suppose this might help you in explaining my puzzlement. I have had conversations from time to time with my French counterpart, Mr Troadec. I would totally agree with you that some of the key issues in Air France 447 relate to human factors—understanding why some of the various actions that were clear from the flight data recorder and the cockpit voice recorder, once retrieved, happened. The reason I remain puzzled is that the 'why' is at the heart of what we are trying to do. We normally get the 'what' in the initial occurrence report. The time we take is to try to understand the 'why' and whether anything needs to be done as a result of us having determined the 'why'.

 Q/ Can anyone else see the irony of the 'Beaker' weasel words?  Dodgy

Again remember that this was approximately 5 months before the Senate PelAir inquiry began; and a year before the diabolical findings of that inquiry were made public; and about 13 months before AIPA presented their Parliamentary Brief on fatigue and the proposed disallowance motion on the CAO 48.1 legislative instrument... Confused

Extract from PelAir MKII FR:

Quote:...On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation...

& from Oz Aviation 8 December 2014:

ATSB to reopen Pel-Air ditching investigation

December 8, 2014 by

[Image: Norfolk-AO-2009-072.jpg]Westwind VH-NGA ditched off Norfolk Island in 2009. (ATSB)

The Australian Transport Safety Bureau (ATSB) will open a fresh investigation into the ditching of a Pel-Air Westwind corporate jet off Norfolk Island in 2009.

The decision to reopen the case was made following a critical review of the original inquiry by the Transportation Safety Board of Canada (TSB), which found the ATSB did not follow proper process and had poor oversight during the investigation.

“A new investigation team will review the original investigation and associated report in the light of any fresh evidence and relevant points raised in the TSB review and other recent aviation reviews,” the ATSB said in a statement on Monday.

“At the same time, the ATSB Commission will continue to methodically and carefully work its way through the broader findings and recommendations of the TSB review, with the aim of ongoing improvements to the future work of the ATSB.”

A Senate committee also the released a scathing assessment of the original investigation.
Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss told Parliament last week he had asked the ATSB to reopen the case.

To be continued: Next I will again fast forward to the PelAir MK II Final Report to factually expose how the ATSB has once again obfuscated it's stated responsibilities to the re-investigation (see above) and the primary purpose for ICAO Annex 13 Aviation Accident Investigation. IMO the PelAir FR, in particular on the downplaying of fatigue & SMS identified safety issues, provides further proof that the ATSB is still continuing in the role of providing top-cover for the regulator CASA, the Department and indeed the Minister... Dodgy

MTF...P2 Cool
P2 -"IMO the Pel-Air Final Report; in particular; the downplaying of fatigue & SMS identified safety issues, provides (IMO) further proof that the ATSB is still continuing the role of providing top-cover for the regulator CASA, the Department and indeed the Minister"..

Nah! – wrong way round P2. The minister is always the first protected; otherwise – what use are ATSB and CASA – if not to protect the shiftless, lazy, only interested in retaining power government. Many governments have had an opportunity to resolve the three decade long problem of ATSB, CASA and the “safety” argument. All failed; beaten by a bunch of ‘expert’ opinion which they have never gainsaid or even bothered to question. Why would they – they’re safe behind the Iron Ring. That class of top cover costs a fortune and the tax payer meets the bill – all in the name of “safety” of course.

Excuse me, I need to vomit – copiously..
Chopper water crashes - A point of comparison?

References: ATSB - AO-2018-026 & Accidents Domestic post #277



To be fair the ATSB investigation into the tragic 'collision with water' accident of Eurocopter EC120B, VH-WII has barely begun. However given the less than 2 week timeframe difference and the obvious similarities in accident scenario (overwater/helicopter/fatalities etc.) there is  IMO a perfect opportunity to conduct a 'point of comparison' review of just how the NTSB and ATSB go about business on two relatively high profile fatal AAIs... Rolleyes

Here is the ATSB AAI summary so far:


The ATSB is investigating the collision with water of Eurocopter EC120B, VH-WII, which occurred near the Hardy Reef pontoon, north-east of Hamilton Island, Whitsunday Islands, Queensland on 21 March 2018.

At about 1543 Eastern Standard Time, the helicopter was on approach to land on the pontoon when it collided with the water.

A team of four Transport Safety Investigators have been deployed to the accident location to commence the evidence collection phase of the investigation. Investigators will interview witnesses, pilot and passengers, examine any available recorded data, review operational and maintenance records and technical documentation amongst other investigation activities.

The evidence collection phase will also define the size and scope of the investigation and determine the expected timeframe for the completion of a final report.

Preliminary information about this accident is expected to be released in late April 2018 to provide an overview of the evidence collected.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Witnesses are encouraged to contact the ATSB, through our webpage or phone 1800 992 986.

Note that all ATSB investigations now provide a reference link for the stage the investigation is at:

Status: Active 
[Image: progress_0.png]

Phase: Evidence-Collection Read more information on this investigation phase

This is a recent HVH led initiative supposedly to be more transparent and to keep interested parties better informed.

The other recent initiative is the introduction of this statement:

"...Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken..."

Call me cynical but this statement is almost totally obsolete as the amount of 'Critical Safety Issues' (CSI) ever issued by the ATSB prior to the release of a final report could, I believe, be counted on one hand. 

This statement is IMO little more than a lipservice exercise to recognise the ATSB's tick-a-box compliance to ICAO Annex 13. Note that the ATSB identifying a CSI does not necessitate (as per most ICAO signatory States) the direct and immediate promulgation of a 'safety recommendation'... Dodgy       

This brings me to the NTSB AAI progress so far:

Quote:UPDATE: NTSB Investigation of New York City Helicopter Crash 3/13/2018

NEW YORK (March 13, 2018)—The National Transportation Safety Board continued its investigation Tuesday into the March 11, 2018 crash of an Airbus Helicopters AS350B2 (N350LH) into New York’s East River.

The helicopter was substantially damaged when it impacted the river and subsequently rolled inverted during an autorotation, killing five passengers and injuring the pilot.

The pilot had contacted the LaGuardia Airport air traffic control tower for entry into the Class B airspace while flying at an altitude of 2,000 feet. Approximately five minutes later, the pilot declared “Mayday” and stated that the helicopter’s engine had failed. Visual meteorological conditions prevailed for the scheduled 30-minute aerial photography flight that was operated by Liberty Helicopters under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from Helo Kearny Heliport (65NJ), Kearny, New Jersey.

Parties to the NTSB investigation are the Federal Aviation Administration, Liberty Helicopters and the Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA France). Airbus Helicopters and Safran Helicopter Engines are technical advisors to the investigation.

Significant activities today included:

- Physical examination of the accident helicopter at New York Police Department’s Aviation Unit headquarters in Brooklyn by airworthiness, powerplant, and survival factors investigator.
- Engine was prepared for removal and teardown
- Helicopter structure and systems examined by airworthiness investigators.
- Rotor and flight control systems examination initiated
- Survival factors investigators examined and documented passenger restraint system
- Investigators interviewed Liberty Helicopters’ chief pilot
- Interviewed witnesses and rescue personnel
- Interview with accident pilot to be scheduled
- NTSB’s Transportation Disaster Assistance team consulted with NYPD regarding personal effects.
- Recovered electronic devices, including a Go-Pro camera, which is being sent to the NTSB laboratories in Washington for readout.
- Recovered Appareo Vision 1000 from helicopter. Unit and memory card were placed in water for transport to NTSB laboratories. The Vision 100 could provide data on pitch, roll, and yaw as well as position, vertical speed, ground speed and altitude and ambient sound.

Imagery of the ongoing NTSB investigation are available at the NTSB's Flickr page at and video is available at the NTSB's YouTube Channel at

Contact: NTSB Media Relations
490 L'Enfant Plaza, SW
Washington, DC 20594
Eric Weiss
(202) 314-6100

The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.

& 2 days later:

UPDATE: NTSB Investigation of New York City Helicopter Crash

NEW YORK (March 15, 2018)—The National Transportation Safety Board continued its investigation Thursday into the March 11, 2018, accident in which an Airbus Helicopters AS350B2 (N350LH) impacted New York’s East River.

The helicopter was substantially damaged when it hit the water and subsequently rolled inverted during an autorotation, killing five passengers and injuring the pilot.

Significant activities of the investigation include:

- Interviewed Liberty Helicopters personnel, including the accident pilot
- Conducted a teardown of the helicopter’s engine; no evidence of abnormalities was found
- Examined structure of helicopter; no evidence of pre-impact breakup
- Examined flight controls and found no pre-impact failure or malfunctions
- Interviewed witnesses to crash; interviews continue
- Obtained air traffic control voice and weather data, which is being reviewed in Washington
- Examined float system on helicopter, and this examination continues

NTSB investigators are seeking videos that show different angles or aspects of the accident sequence. Broadcasters or witnesses with video are asked to contact the NTSB at

Then 6 days later the NTSB provided another update, announcing the issuing of an urgent Safety Recommendation:

Quote:NTSB Issues Urgent Safety Recommendation to Prohibit Flights that Use Unsafe Harness Systems


The National Transportation Safety Board Monday called on the Federal Aviation Administration to prohibit commercial flights that use passenger harness systems that do not allow for easy release during emergencies.

The urgent recommendation stems from the ongoing NTSB investigation of a fatal accident in New York City involving an Airbus Helicopters AS350B2 helicopter. The helicopter impacted the East River during an autorotation maneuver after the pilot reported a loss of engine power. The helicopter subsequently rolled inverted. The pilot, who was not wearing a harness, only manufacturer-installed lap and shoulder belts, escaped from the helicopter with minor injuries. Five passengers who wore the harnesses in addition to the safety belts remained inside the helicopter and drowned.

“While we applaud the FAA’s intention to move forward on banning these types of doors-off flights, the FAA has not outlined how or when they plan to take action,’’ said NTSB Chairman Robert L. Sumwalt. “And definitive action needs to be taken.”

The doors-off aerial photography flight was scheduled for 30 minutes and was operated by Liberty Helicopters under the provisions of Title 14 Code of Federal Regulations Part 91.  

[Image: blobid1_1521482501134.jpg]

NEW YORK (March 13, 2018) --Harald Reichel, an Aerospace Engineer with the NTSB's Office of Aviation Safety, examines the engine of a Liberty Helicopters' helicopter that crashed in the East River here Sunday, March 11, 2018. The NTSB's Go Team has formed an operations group, airworthiness group, powerplants group and a survival factors group to conduct the NTSB's investigation of the crash. Reichel is the chair of the powerplants group. A weather group and air traffic control group were also formed using NTSB investigators in Washington. (NTSB Photo by Chris O'Neil)

The additional harness system consisted of a nylon fall-protection harness tethered via a lanyard to the helicopter. The harnesses allowed passengers to move securely within the helicopter, including sitting in the door sill, while airborne. The harness system was not installed by the helicopter manufacturer; it was comprised of off-the-shelf components that were provided to the passengers by FlyNYON, the company that sold the experience to the passengers. Under normal circumstances at the conclusion of each flight, FlyNYON personnel would release a locking carabiner located on the back of the passengers’ harnesses.

Despite being given a briefing on how to remove these additional harnesses using a provided cutting tool, none of the passengers were able to escape after the helicopter rolled over into the water. The pilot’s manufacturer-installed restraint system was required to comply with 14 CFR section 27.785©, which states that “Each occupant’s seat must have a combined safety belt and shoulder harness with a single point release.” The harness system provided to the passengers on the accident flight was not evaluated by the FAA.

The NTSB has a long-standing concern with safe egress for passengers aboard helicopters. As a result of a helicopter accident that occurred in 2008, the NTSB found that three of the surviving passengers’ unfamiliarity with the type of buckles on the restraints in the helicopter significantly hindered their ability to release their restraints when they attempted to evacuate the cabin under emergency conditions. In the 2008 accident, passengers received a briefing that described how to operate the rotary restraint, but the surviving passengers said they became confused with its release when the accident occurred.

NTSB weblinks:

Quote:Related News Releases
Related Reports

MTF? - Definitely, standby for updates...P2 Big Grin
Update: AO-2018-026 - Prelim report released.

Via the ATSB:

Sequence of events

The ATSB is still determining the final sequence of events in the lead-up to the accident. The limited information provided in this preliminary factual report is based on the evidence collected to date, including witness accounts. The final sequence of events will be determined by the collection, analysis and examination of further evidence.

On 21 March 2018, at about 1500 Eastern Standard Time,[1] the pilot and four passengers of a Eurocopter (Airbus Helicopters) EC120 B helicopter, registered VH-WII and operated by Whitsunday Air Services Pty Ltd, departed Hamilton Island Airport, Queensland, on a charter flight. The flight included flying over coral reefs and beaches, then landing on the Hardy Reef floating helicopter landing site (HLS) (Figure 1). The HLS (pontoon) was located about 72 km north‑north‑east of the Hamilton Island Airport situated between Hardy Reef and Hook Reef, in the Great Barrier Reef Marine Park Area. After landing, the passengers were to be ferried from the HLS by a small boat to ‘Reefworld’, a large pontoon used to view aquatic life and a base for water sports. This was the second flight that day, by the pilot in VH-WII, to Hardy Reef. The earlier flight was conducted without incident.

Figure 1: Proximity of Hamilton Island Airport to the Hardy Reef HLS
[Image: ao2018026_figure-1.jpg?width=463&height=...&sharpen=2]
Source: Google earth, modified by the ATSB

While approaching the pontoon, at about 1535, the pilot reported noticing a warning message illuminate in the upper vehicle and engine multifunction display (refer to section titled Helicopter information). As this was a high workload phase of flight, the pilot was unable to verify the nature of the warning. However, in response, the pilot elected to conduct a go-around. When the helicopter was at an altitude of about 40 ft (12 m) above the pontoon, the pilot recalled feeling a ‘thud’ and the nose of the helicopter yawed sharply left (anticlockwise from above). In an attempt to arrest the yaw, the pilot reported that he made a number of control inputs, which included lowering the collective[2] and pushing the cyclic[3] forward and to the left. The pilot was unable to regain control of the helicopter and it collided with the water. A passenger reported that soon after impact with the water, the helicopter rolled onto its right side in a mostly inverted orientation.

The pilot and two of the rear passengers exited the helicopter soon after the collision. After swimming free from the upturned helicopter, the two passengers reported donning their life jackets from a waist belt mounted pouch.[4]

The remaining rear passenger was evacuated by one of the surviving passengers and the front passenger (in the copilot seat) was evacuated from the helicopter by the pilot. At about that time, personnel from Reefworld arrived and assisted with first aid and resuscitation until emergency services arrived. The two passengers that were unable to exit the helicopter unassisted were fatally injured. The two other passengers sustained minor injuries, and the pilot was uninjured.

The helicopter was observed in a semi-submersed state for some time after the occupants had been evacuated and was drifting inverted in a northerly direction away from the landing pontoon. The helicopter’s emergency float system was not deployed (refer to section titled Helicopter information).

On 26 and 27 March 2018, under water sonar operations were initiated by the Queensland Police Service in an attempt to identify the helicopter wreckage location. The sonar detected what was believed to be a man-made object in about 58 m of water (Figure 2) about 1.2 km north‑north‑west of the landing pontoon. The location was consistent with the tidal flow and wind conditions at the time of the accident. The length of the object was about 11 m, which was also consistent with the length of VH-WII.

Figure 2: Sonar image of a man-made object with a scale against the sonar shadow
[Image: ao2018026_figure-2.png?width=463&height=...&sharpen=2]
Source: Queensland Police Service, modified by the ATSB

Pilot information

The pilot held a current Commercial Pilot (Helicopter) Licence and had completed a flight review on 7 March 2018. The pilot also held a Class 1 Aviation Medical Certificate which was valid until 24 May 2018. Distance vision correction was to be worn and reading correction was to be available while exercising the privileges of the licence.

Helicopter information

The Eurocopter (Airbus Helicopters) EC120B ‘Colibri’ is a five-seat helicopter fitted with a single Turbomeca Arrius 2F turboshaft engine. The helicopter incorporates several of Eurocopter’s trademark technologies including a 3-bladed Spheriflex® main rotor head and their 8-bladed Fenestron® anti-torque tail rotor.

Cockpit instrumentation includes a dual screen vehicle and engine multifunction display. The display monitors and displays a number of operational parameters including information on engine and electrical systems, fuel quantity, and outside air temperature.

The pilot and copilot (or front passenger) positions have high-back energy absorbing seats with four-point safety restraints. Doors adjacent to the front seated occupants can be jettisoned. In the rear, there is a three-person capacity energy absorbing bench seat fitted with three-point safety restraints, and a sliding door located adjacent to the left rear seated passenger.

VH-WII (Figure 3) was manufactured in 2009 and first registered in Australia on 18 February 2010. Whitsunday Air Services Pty Ltd has been the registered operator since 19 May 2015.

VH-WII was fitted with landing gear skids equipped with an emergency float system.[5] The skid floats were capable of inflation when the float deployment lever safety pin was removed and the lever was activated by the pilot. The float deployment lever was attached to the helicopter’s collective and could only be triggered if the safety pin was removed.

Figure 3: VH-WII
[Image: ao2018026_figure-3.jpg?width=463&height=...&sharpen=2]
Source: CQ Plane Spotting

Operator information

Whitsunday Air Services Pty Ltd conducts a significant number of flights to the reef and surrounding area utilising a fleet of helicopters and fixed-wing aircraft fitted with various floatation systems. A Civil Aviation Safety Authority air operator’s certificate (AOC) was re-issued to the operator on 17 April 2015, valid until 30 April 2018. The AOC stipulated that the certificate holder was authorised to conduct charter and aerial work operations in the EC120 helicopter in Australian territory.

Meteorological information

The nearest Bureau of Meteorology weather station was located at Hamilton Island Airport. At 1530 on the day of the accident, the routine report of the meteorological conditions at the airport indicated that the wind was 24 kt (45 km/h) from the south-east.

Hardy Reef floating helicopter landing site

The Hardy Reef floating HLS consisted of two pontoons (Figure 4). The pontoons were capable of accommodating two helicopters each. The pilot of VH-WII was attempting to land at ‘pontoon 2’, the most northern pontoon.

The operator’s HLS instructions noted that birds were a known hazard on the pontoons. Further, pilots were instructed to verify the wind conditions by observing the flags at Reefworld, but they could approach and land at the pontoons in any direction, depending on wind direction.

Figure 4: Hardy Reef HLS and bird hazard (inset)
[Image: ao2018026_figure-4.png?width=463&height=...&sharpen=2]
Source: ATSB

Ongoing investigation

The ATSB investigation is continuing and will include consideration of the following:
  • an underwater survey using a remotely operated vehicle to establish if the man-made object located by sonar is the accident helicopter
  • depending on the outcome of the under water survey, the ATSB may recover the wreckage for inspection and recovery of recorded information
  • helicopter maintenance history
  • helicopter performance and handling characteristics
  • pilot qualifications, training, experience and medical information
  • preperation of passengers, including briefings, for possible emergencies
  • survivability of the accident
  • operator policies and normal and emergency procedures
  • Civil Aviation Safety Authority operator surveillance records
  • environmental influences
  • similar occurrences in Australia and internationally.
The ATSB will continue to consult the engine and airframe type certificate holders. Accredited representatives from the United States National Transportation Safety Board (NTSB), the French Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA), and their advisor Airbus Helicopters, have been appointed to participate in the investigation.

The ATSB acknowledges the support of the Queensland Police Force, Cruise Whitsundays, the management and staff of the Reef View Hotel and Palm Bungalows, and Hamilton Island Enterprises for their assistance during this investigation.
The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.
  1. Eastern Standard Time is Coordinated Universal Time (UTC) +10 hours.
  2. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
  3. Cyclic: a primary helicopter flight control that is similar to an aircraft control column. Cyclic input tilts the main rotor disc, varying the attitude of the helicopter and hence the lateral direction.
  4. The pilot was already wearing a life jacket as part of the standard operating equipment specified by the operator, however, elected not to inflate his lifejacket.
  5. Emergency floatation system: inflatables fitted to the helicopter to provide water buoyancy in an emergency.


MTF...P2 Cool
Update: Via the Oz

Quote:Pilot felt thud then lost control
[Image: f9e9b4ccd5c67d25e4ba11b6bbeed5d3]12:00amMichael McKenna
The pilot of a helicopter that crashed off Queensland saw a warning light come on and felt a thud before losing control.

Helicopter pilot felt thud then lost control in fatal crash

The pilot of a tourist helicopter that last month crashed off north Queensland, killing two American retirees, saw a warning light come on and then felt a thud before losing control.

In its preliminary report, the Australian Transport Safety Bureau said yesterday it was yet to determine the cause of the March 21 crash of the five-seater helicopter as it returned from a flight over reefs on the Whitsundays.

Hawaiian tourists Peter Hensel, 79, and his wife, Sue, 65, were both killed. Mrs Hensel’s daughter and son-in-law, Emily and Bobby Sheets, escaped from the crash with minor injuries.

The pilot was unharmed.

According to the report, the pilot of the five-seater Euro­copter EC120B — operated by Whitsunday Air Services — reported seeing a warning light come on the “upper vehicle and engine malfunction display’’ as he approached a helicopter pontoon at Hardy Reef.

“As this was a high workload phase of flight, the pilot was unable to verify the nature of the warning,’’ the report said. “However, in response, the pilot elected to conduct a go-around. When the helicopter was at an altitude of about 40ft (12m) above the pontoon, the pilot recalled feeling a ‘thud’ and the nose of the helicopter yawed sharply left (anticlockwise from above).

“In an attempt to arrest the yaw, the pilot reported that he made a number of control inputs.

“The pilot was unable to regain control of the helicopter and it collided with the water.’’

The pilot and two other passengers were able to get out.

The report said the pilot and a passenger then pulled the couple from the wreckage.

Staff from a nearby pontoon administered CPR until emergency services arrived but they could not be saved. The Hensels had been on their dream honeymoon after getting married in December.

Queensland police have since located the wreckage.

Hardy Reef, about 40km northeast of Hayman Island, is a popular ­diving and snorkelling site with a large pontoon used by daily dive boats and two smaller pontoons offering a landing platform for helicopters that offer scenic flights over the Whitsundays and surrounding reef.

Investigators will now seek advice on whether the wreck should be brought to the surface.
Hmm...wonder if the HVH will go with cap in hand to the invisible miniscule for extra resources/funds to recover this submerged wreck? Rolleyes

MTF...P2 Cool
P2 - "Hmm...wonder if the HVH will go with cap in hand to the invisible miniscule for extra resources/funds to recover this submerged wreck?"

Reckon they’d have to; considering previous history – the float deployment is worth a spare thought or two. Also (in ignorance) curious about why the ‘go-around’? Warning lamp – Thud – Deck asap I’d have thought – but Choppers is different – so I’ll just hold off until the ATSB eventually tell what went wrong.

No, I’m not going to go and finish my knitting – get ‘em in GD, there’s a good chap….
Hmmmm, a puzzling case indeed. I’m a bit perplexed by the pilots account of what he perceived took place, nonetheless it’s still a touch early to put the all the jigsaw pieces together.

Surely ‘he who corrects the record’, Commisioner Hood, will assist in retrieving the drowned whirlybird. Do they make waterproof (not ‘water soluble) hi-vis vests? If not, do not worry, Inspector Hood will be there wearing nothing but a brief ‘banana hammock’ and loads of 30+ sunscreen. I just hope he takes care in the water as there are a lot of starfish up that way......

‘Safe deep sea water retrieval for all’
In a sane hemisphere -Rolleyes

Via the NTSB safety compass:

Quote:The Age of Reason
May 1, 2018 ntsbgov Leave a comment
By Chairman Robert L. Sumwalt

Some scholars play a critical role in founding a whole field of study: Sigmund Freud, in psychology. Noam Chomsky, in linguistics. Albert Einstein, in modern physics. In the field of safety, Dr. James Reason has played such a role. In this field, no single name is better known.

Dr. Reason turns 80 today, and if you’re reading this, it’s possible that you owe your life to his ideas.

NTSB reports have frequently cited Dr. Reason’s work, and I personally quote him liberally in my talks to industry and safety stakeholders.

His contributions to safety have been influential not only in transportation and workplace safety, but also in fields as varied as healthcare, nuclear power, and fraud prevention.

His books include Human Error; Organizational Accidents; Managing the Risks of Organizational Accidents; Organizational Accidents Revisited; The Human Contribution: Unsafe Acts, Accidents, and Heroic Recoveries; and A Life in Error: From Little Slips to Big Disasters.

He views safety as a system, and accidents as the result of any individual’s mistakes in combination with other failings in the system. People are fallible, but that doesn’t make accidents inevitable.

Focusing on a safer system, instead of only an individual’s mistakes, can help diminish individual error (for example, through better training and procedures). More importantly, studying the system reveals much more of “what went wrong” – and will go wrong again if not corrected, because other individuals will make mistakes.

Dr. Reason came up with a handy analogy for his view, called the “Swiss Cheese Model of Accident Causation.” (Just say “Swiss Cheese Model” to a safety or risk management professional, and they’ll probably nod knowingly.)

In this model, layers of protection against an accident, each of which has weaknesses, are visualized as slices of cheese riddled with holes. An accident occurs when the weaknesses, or holes, align.
[Image: swiss-chese-model.png?w=474]Swiss cheese model by James Reason published in 2000. Source:, open-access, CC Attribution 2.0 Generic
We’re all living in the Age of Reason. It’s a good age in which to live, one during which accidental deaths and injuries have been on the decline.

The continuous improvement of safety depends on safety professionals living with what Dr. Reason called a “chronic unease.” The paradox of safety is that the moment we think we’ve arrived, we introduce another hazard: complacency.

However, even in the chronically uneasy profession of safety, we find cause to celebrate every now and then. So, on that note, Happy 80th birthday to Professor Emeritus James Reason, on behalf of safety professionals everywhere—and on behalf of all those he’s saved, from every walk of life.

Of course here in Dunceunda land we've gone 'beyond all sensible Reason' (BASR - Dodgy  

Regardless - Happy 80th birthday Jimmy Reason - Big Grin
ATSB, airports and the search 4 IP -  Shy  

(P2 comment - Please excuse the thread drift but much like the recent Ben Cook contributions, courtesy of Oz Aviation, you'll soon see the significance) 

From a long time fellow follower and airport aviation safety expert Dan Parsons  Wink , via Twitter (see HERE) -


..This post has taken me a long time to write. I don't like to be this critical and negative but I want to shine a light on some (still fairly) recent decisions made in Australia relating to aerodrome standards.

[Image: DcjInBjWAAAnuPt.jpg]
9:00 AM - 7 May 2018

Missed Opportunities: We Should be Doing Better

Dan Parsons

May 7, 2018

Over the past year or so, I've written about a couple of topics that seem to have converged into this post. Airport professionalism, the application of aerodrome regulations (twice), runway strip standards and accidents were topics I recently explored and after doing so more research I stumbled across a couple of incident investigations in Australia that bring these previous articles together.

The thesis of the article is that incident investigations are letting us down and we are not learning all the lessons that we could be from events that, but for chance, didn't end up in catastrophe.

Yes, this is going to be a critical post. I'm not criticising individuals, I'm critising the system and if there are factors of which I am not aware, then I am also blaming the system for obscuring them from me for I think I've done a reasonable level of due diligence.

The purpose here is to call for better from our aviation safety system. To highlight, the missed opportunities that could one day bite us and to shine some light on some recent decisions and reports that, I believe, to be reducing aerodrome safety standards without appropriate analysis, communication and review.

Down a Runway Strip Rabbit Hole

Following the relative success of my post on the Pegasus runway excursion in Turkey, I started to do a bit of research to see if there were any related events. I soon discovered an ATSB report issued May 2017 relating to an incident that occurred in January 2017.

The incident involved a BAe-146 (or RJ-85 or AVRO 146, or whatever you call it) landing on the runway strip of an unsealed runway at a remote mining aerodrome in Western Australia. Obviously, the aircraft should have landed on the runway but in a nutshell, dust obscured part of the runway/runway strip and the pilot flying mistakenly lined up on the runway strip. Luckily, they landed without further incident and taxied via the runway back to the apron.

Some Valid Analysis

The ATSB conducted an occurrence investigation given the actual outcome of the incident and issued its findings as part of an Aviation Short Investigations Bulletin. The report focussed on the positioning of aiming point markers outside the runway strip.

Given that the runway is unsealed and aiming point markings cannot be provided, the aerodrome operator had elected to establish aiming point markers abeam the aiming point location.

This particular aircraft operator flies into four other unsealed runways who have also established aiming point markers abeam their aiming points. The problem identified by the investigation is that some of these other airports have placed the markers within the runway strip (i.e. close to the runway) and the incident airport placed them outside the runway strip.

This difference contributed to the pilot's assumption that the runway strip to which they were aligning themselves was the runway. They identified parallel lines of cones and a least one aiming point marker immediately adjacent to the runway - dust was thought to be obscuring the other side's marker.

The investigation goes further to suggest that the outside the runway strip positioning is less desirable than the within the runway strip location due to greater use of peripheral vision required to maintain a scan of the runway and the markers.

These points, and in particular this last issue, show the strengths of the ATSB's long history of human factor expertise.

Falling Short

However ... I believe the report falls short in two areas.

The first is relatively minor. With the best of intentions, the report attempts to analyse the regulatory background to these markers but makes a few errors. It confuses markers and markings and as such, makes incorrect interpretations of the regulatory requirements. It also takes a few standards out of context and this leads to incorrect conclusions. If this was the limit of the failings in this report, then I probably would still not have been happy with the report and have written a long post on the correct interpretation of these standards but as it is, I think there is a bigger problem here.

As I was reading the report, I kept asking myself about the PAPI (Precision Approach Path Indicator) system. The fact that the event involved a jet aircraft on an unsealed runway already had me primed for this question. Aerodrome standards nerds in Australia know that CASR 139.190 requires aerodrome operators to provide PAPI (or VASIS) on runways used by jet-propelled passenger transport aircraft.

For me, if PAPI had been installed on the runway strip then this event would not have occurred. The pilot would have identified that they were lined up on the runway strip and altered course to line up with the runway. If they couldn't identify the runway then they would go-around and wait for the dust to clear.

Where Are the PAPI?

So, why was this requirement not raised in the report? This seems to me like a significant regulatory oversight that needs to be addressed. I did search for an exemption but could not locate one on the CASA website.

I asked some friends for help and was pointed to the federal register instead. There I found CASA EX171/16 which was issued less than two months before the event. This instrument is a blanket exemption from the VASIS requirements for runways that are used by jet-propelled charter aircraft. As a mining aerodrome, this flight was most likely a charter flight albeit probably a regularly scheduled flight operating from airline like facilities (at least at the Perth end).

I'm not privy to the decision making process relating to this exemption. One would hope that it was the result of thorough safety analysis before it was signed and promulgated. And further, one would hope that this sort of decision would feature in any subsequent incident investigation where it might have impacted the event.

Am I Asking Too Much?

Maybe I am. After all, PAPI doesn't provide horizontal guidance. But I believe that it was a fundamental question for the investigator to ask about the PAPI as part of the investigation. Its presence on the runway strip would have alerted the crew to their misalignment.

Why Do We Do Investigations?

The ATSB proudly conducts investigations not to apportion blame but to "prevent the occurrence of future accidents". So, here we are discussing whether this investigation will achieve that goal and unfortunately we have proof that it didn't. However, again, we are lucky that the event passed with no significant injury or damage.

The Preventable Incident

This time an EMB-135LR landed just short of a runway in Queensland and took out some runway lights.

The analysis included in the investigation was again good from a human factors and flying operations point of view but it did not ask the aerodrome-standards-related question of where was the PAPI/VASIS? It got really close by identifying that this airport was the only one flown to by the operator that did not have a VASIS and that it was the first time the pilot had flown a jet to a runway without a VASIS. It even listed the absence as a finding but failed to follow up on that point.

I am honestly stumped as to why the decision to exempt these airports from a safety requirement that was in place within the previous year was not discussed. This is the second of two events that could have been averted, directly or indirectly, had the previous regulatory requirement been met. But the analyses and lessons contained in the reports don't seem to delve far enough into the aviation system. They are limited to the front-end operators and not the airport or the regulator and these are truly missed opportunities.

We Deserve More from Our Aviation System

I know that root causes and incident investigation analysis stops where the money stops but I thought the scope of investigations would be broad enough to identify systemic issues including the regulator/regulations. The points I have raised above would not have added substantial time or costs to these simple investigations but the benefits could have been significant.

If you'll indulge me; had the issue of jet operations into runways without VASIS been flagged in May 2017 and a recommendation to CASA to identify aerodromes that were not complying with the previous regulatory requirement, then the later August 2017 event might not have occurred at all.

And since the issue still hasn't been raised, are we simply waiting for the next jet landing incident to occur? We might be lucky and it won't. We might be lucky and it will be like these to events with no significant adverse outcome. Or we might not be lucky at all.

We Can All Do More

I'm not content to simply have a whinge at people that are unlikely to read this post. Instead, these issues can impact any of our investigations. It is easy, firstly, to look at the outcome of an incident and apply resources based on how bad it was. No bad outcome = simple investigation or no investigation at all.

But these events are gifts. Instead, look at what could have reasonably happened.

Thanks to the lack of a bad outcome, you now have access to all the people involved, they are likely to want to contribute to the investigation and you have the potential to highlight the good behaviours and strengthen them while addressing deficiencies that you might identify as well.

I know resources are limited and time frames can be tight but always try to ask "why?" a few more times just to make sure you don't have a bigger issue lurking, ready to bite.

MTF...P2  Cool
Smart young man is Dan. The Gobbledock recalls the greenhorns early days at Fort Fumble. From there he progressed through several airports and now is in the Sandpit. It’s a pity that some, if not all of his former CAsA bosses, couldn’t have spent their time starting at the ground level in one of numerous aviation related disciplines and gotten their hands dirty. That way at least some of the buffoons managing our great nations safety regulator would have at least some experience of the ‘real’ industry. But no, we have Carmody, Aleck, trough swilling bureaucratic tossers holding the reigns, tossers who wouldn’t know an Oleo from a gable marker....

Go hard and go strong Dan.
ANAO open audit into HVH's ATSB -  Rolleyes

The Mandarin reported less than a week ago that there was potentially going to be an audit conducted on the ATSB but now it is confirmed... Huh

Quote:Efficiency of the investigation of transport accidents and safety occurrences

Due to table: April, 2019

Infrastructure, Regional Development and Cities

Australian Transport Safety Bureau

Please direct enquiries through our contact page.

The objective of this audit is to examine the efficiency of the Australian Transport Safety Bureau’s (ATSB’s) investigation of transport accidents and safety occurrences.

Audit criteria

The ANAO proposes to examine:

  1. Has the ATSB put in place efficient processes for the investigation of transport accidents and safety occurrences?
  2. How well does the ATSB’s investigation efficiency compare to its own previous performance as well as relevant international comparator organisations?

Hmm...I can almost visualise an AP submission on the horizon... Big Grin 

MTF...P2  Tongue

Hmm...I can almost visualise an AP submission on the horizon... Big Grin

And I can already smell HVH drafting a ‘correcting the record’ document in response to next years audit report!
VH-ANK Lutana: 70 years on and the lessons lost? -  Undecided  

Via the ABC News online... Wink 

Victims of the VH-ANK Lutana plane crash remembered 70 years on
ABC New England 
By Jennifer Ingall and Haley Craig

Posted about an hour ago

[Image: 10192522-3x2-700x467.jpg]

PHOTO: Pieces of the plane can still be seen at the crash site 70 years later. (Supplied: Libby McIntyre)

"It's very quiet. You can hear the wind in the background. There are lots of pieces of molten plane, bits of glass, aluminium ... no birds, it's just a quiet resting place."

These are the reflections of Libby McIntyre up high on the mountainside of the Liverpool Range in northern New South Wales, at the site where VH-ANK Lutana crashed in 1948, killing the 13 people on board the plane.

Libby McIntyre's grandmother Margaret McIntyre, the first woman to be elected to the Tasmanian Parliament, had her parliamentary career cut short when the Australian National Airlines plane she was a passenger on crashed into Mount Crawney near Nundle.

Ms McIntyre made the trek to the crash site with her niece Lucy Sharman to mark the 70th anniversary of the tragedy.

[Image: 10192528-3x2-700x467.jpg]

PHOTO: Libby McIntyre at the site where her grandmother was killed 70 years ago in the crash of the Lutana on Mount Crawney, near Nundle in NSW. (Supplied: Susie Bell)

[Image: 10192588-3x2-340x227.jpg]

PHOTO: Sir Rupert Shoobridge, president of the Legislative Council, with Margaret McIntyre in 1948 shortly after her election as Tasmania's first female MP. (Supplied: Libby McIntyre)

"To see still 70 years on all those little bits of metal, there's a wheel housing, bits of fuselage — someone else found a button today,"

"It wasn't eerie. For me it was the thought that it must have been terrifying for those people in the last minutes," she said.

VH-ANK Lutana crashed on a cold winter's night. There were no survivors, and to this day no-one really knows how the pilot got so far off course.

[Image: 10183592-3x2-700x467.jpg]

PHOTO: Search and rescue crews onsite in 1948 just days after the crash. (Supplied: Civil Aviation Historical Society Collection)

The flight from Brisbane to Sydney didn't arrive as scheduled at 8.55 pm on Sunday September 2, 1948. The alarm not raised by Sydney air traffic control until 10 minutes later.

The best source of the known details about the crash come from Air Crash Volume 2, written by the late Macarthur Job.

He wrote it took several days for the crash site to be located, after it was sighted from the air by another airline pilot, East West's Captain John Neuss, flying from Tamworth to Sydney.

A subsequent investigation found: "The aircraft had struck first the tops of 50 foot trees on the mountain summit, the initial impact being taken on the starboard propeller, the nose and wing tips," Mr Job wrote.

The plane then continued over the summit, and down the ridge for 400 yards, plunging into trees.

[Image: 10192566-3x2-700x467.jpg]PHOTO: The wreckage of the plane lies in steep, wooded terrain in the Liverpool Range. (Supplied: Susie Bell)

"This more violent impact sheared off the port wing, overturning the aircraft, before it dashed itself against the mountain slope and burst into flames."

The burnt out remains of the Lutana were found 87 nautical miles north-west of its last reported position at Williamtown, leading investigators to conclude the pilot was not where he thought he was.

Captain John Drummond was in fact crossing the Liverpool Range when the plane struck Mt Crawney.

Mr Job wrote that an inquiry following the crash found the pilot and crew inexplicably diverted from their flight path, and were let down by navigation instruments and "untrustworthy maps."

The Department of Civil Aviation was criticised for "not using the modern scientific aids discovered and used during the war … such as radar."

The crash of VH-ANK Lutana was a turning point in civil aviation and led to many safety improvements.

[Image: 10183608-3x2-700x467.jpg]

PHOTO: The propeller of the Lutana was still embedded in the ground at the Mt Crawney crash site in 1968. (Supplied: Vic Hatfield)

Twenty years after the crash, John Neuss visited the site along with good mate Vic Hatfield.

Mr Hatfield said the site was still rugged and hard to find. The men flew over it in a glider the day before the visit to get their bearings.

Even 20 years later, there was still evidence of wreckage: the propeller, an exhaust pipe, even part of a wing high in a tree branch.

"A bit of sadness you might say, because 13 people died there very quickly," he said.

In 1983, the propeller was retrieved from the site and mounted as part of a memorial by the Lions club in the tiny village of Nundle.

Twists of fate revealed as relatives gather to remember

[Image: 10183616-3x2-340x227.jpg]

PHOTO: Former stewardess, the late Ann Shaw, at the Lutana crash memorial in Nundle. She narrowly escaped the fateful flight. (Supplied: Vic Hatfield)

There are tales of loss and luck among the people left in the wake of the tragedy.

The stewardess rostered aboard the flight, Brenda (Peggy) Wise almost missed it.

She met the plane just as it was taxiing down the runway in Brisbane, relieving Ann Shaw who had been asked by Captain Drummond to be on board for the Sydney leg because Ms Wise was late.

Many years later, Ms Shaw visited the Nundle memorial, saddened but ever grateful fate had stepped in that day.

Peg Higginbotham is the niece of Ms Wise who rushed so unwittingly to her death. Ms Higginbotham said her grandparents were so distressed by the loss of their 23-year-old daughter they raised Ms Higginbotham until she was six years old.

[Image: 10193014-3x2-700x467.jpg]

PHOTO: Peg and Richard Higginbotham reflect on the life of Peg's aunt and namesake Brenda (Peg) Wise who was the stewardess on the Lutana. (ABC News: Haley Craig)

"I was named after my aunt. I didn't replace my aunt, obviously, but my grandmother and grandfather obviously had a very huge hole in their hearts and needed some distraction," Ms Higginbotham said.

"So my aunt was always very present in my life, even though she died before I ever knew her."

Wendy Brown attended the service to mark the 70th anniversary. Her very existence hinges on the fact her parents, then newlyweds, changed flights at the last minute.

"I wouldn't have been born, my five sisters would not have been born, 13 grandchildren would not have been born," she said

"I'm here because they were not on that flight."
[Image: 10193064-3x2-700x467.jpg]

PHOTO: Sisters Tina and Margarite Van Andel unveil the memorial plaque with the names of the 13 people killed in the 1948 crash of the Lutana. (ABC News: Haley Craig)

Sisters Tina and Margarite Van Andel were not aware of the story behind their father Arthur's death on the Lutana until after their mother died. It was simply not spoken about.

"I think she was protecting us from any unhappiness, only focusing on what a good father he was, what a wonderful husband," she said.

Five of the crash victims are buried at the Tamworth cemetery where a new memorial plaque has been unveiled to remember all 13 victims.

As was stated in the ABC's excellent commemoration article, although extremely tragic at the time, there was some very hard lessons learnt from the crash of VH-ANK which helped set the standard for aviation accident investigation for at least the next 50 years. 

Some would argue another CFIT crash 56 years later - ie Metroliner VH-TFU at  Lockhart River on the 7 May 2005 - marks the point in time when there was a serious decline in aviation accident investigation standards. Not because of the efforts of the ATSB tin kickers at the coalface but because of the bureaucratic butt covering from within the executive managements of both CASA and the ATSB... Dodgy    

Refer Ben Cook's PelAir AA series, from - HERE.  Wink  

&.. refer to ICAO's audit report from their Australian audit in November 2017  - : 
Quote:AIG: Fully implement the ATSB’s action plan to ensure that all accident and incident investigation reports are completed within the established timelines. 

So the Search for IP remains elusive... Huh 

However if you were to believe the present ATSB CC HVH (HIGH VIZ HOOD); the serious decline of AAI standards has now been successfully arrested and will shortly be on the up  Rolleyes :
Quote:ATSB provides increased visibility into investigations

[Image: investigation-process_news.jpg?width=463...&sharpen=2]

The ATSB is providing further insight into its investigation processes with the release of real-time investigation status information for all of its active investigations.

In addition to releasing the status of an investigation on its dedicated investigation web pages, the ATSB has also made available detailed information about its investigation phases and methodology.

ATSB Chief Commissioner Greg Hood said the changes were designed to provide a greater level of transparency into the work of the national transport safety investigator.

'The ATSB is a world class transport safety investigator and all of our investigations are undertaken in a meticulous and thorough manner, in accordance with both national and international legislation and standards. While our legislative obligations prohibit the release of restricted information during an active investigation, we strive to provide as much transparency as possible during an investigation.'

Mr Hood noted that the ATSB has traditionally provided more insight into its investigations than many international counterparts, particularly regarding the provision of estimated timeframes for each investigation.

'The dynamic and multifaceted nature of investigations can affect timeframes, which are always provided as an estimation.

'We understand that the length of time it takes to conduct a thorough investigation can sometimes generate frustration and uncertainty for directly involved parties such as next-of-kin, and for the interested general public.

'Australia actually performs very well against international investigation timeframes, particularly with  aviation investigations where our overall completion timeframes were assessed by the International Civil Aviation Organization as being around half of the global average.'

Mr Hood said investigation timeframes are impacted by two primary factors—available resourcing and the unpredictable and often complicated nature of serious incidents and accidents.

'It is important to note that, even if the timeframe of an investigation is extended, if the ATSB discovers a critical safety issue during an investigation we immediately bring it to the attention of relevant parties to be addressed.'

To better reflect the dynamic and multifaceted nature of investigations, the ATSB has now amended its web pages to reflect an expected completion date as a quarter, rather than a month.
Those who would like to be kept informed of ATSB releases can subscribe via [url=]the ATSB website

Bear in mind that those HVH statements (above) were made over 8 months ago; so the question now is, has there been any real tangible improvement in that time? 

Apparently NOT! Well at least according to a small minority of IOS posting on this thread over on the UP Wink


How unsafe is the ATSB?

3 years to release a report on a loss of separation at Melbourne airport....3 years?

This is an ongoing issue with the ATSB who seem unable to release timely final reports into incidents that have all the information readily available and need urgent rectification.

The resolution to this event occurred within days of the event. Anything in this report is now 3 years old. How are we meant in the professional aviation space to rely on anything the ATSB produce when it happened so many years ago we have all moved on. It’s like a news report telling us who was PM 3 years ago.

AO-2015-084, released 06 Aug 2018


Horrifying ATC. 

A trainee with 11 years experience overseas asking a 737 at 1,100ft to slow to minimum speed, who also mixes up call signs. 

Then an instructor telling pilots if they go missed to expedite said missed approach. Whatever an expedited missed approach is I don’t know, I do know mismanagement of energy during go arounds can be catastrophic (FlyDubai anyone). Coordinator then intervened and told trainee that the second 737 should go around. 

Authors seem confused about what a 90 degree turn is with a soft apportionment of blame to the EK pilots for following the taxiway lights. They mentioned a call to HQ and a please explain for why 777 pilots are following lights instead of cutting corners so ATC doesn’t look bad.

The entire report reads like a coverup for AirServices. I can certainly see why they sat on this for a while. No pilots to blame.


In my opinion, extremely unsafe.

i seem to recall that the prelim report for the mismanaged Emirates 777 go-around in UAE was released within 30days of the event and was of decent quality. If one expects level of quality from ATSB we’re dreaming.

I was waiting for a ground staff lightning strike report to develop some policy and procedures whilst operating on the ramp area during thunderstorms, some time back. Took 3 years to get to a final report after about 3 different delays (the prelim was just a statement of facts and took a year to come out)!! WTF! In the meantime, everyone is left vulnerable and exposed.

Much in the same way as you’ve said (if I’ve understood you properly), the final report said nothing of worth. No accountability! Nothing.

Useless bureaucrats!


In relatively recent times the Australian Public service has been besot with organisational paralysis. There is too much introspective focus by them on things that don't matter to us customers like HR, OH&S, LGBT+A-Z equality, etc, etc, which is allowing the boat anchors to thrive at being boat anchors while stifling the abilities of the doers.


ATR pitch disconnect that put cabin crew in the hospital and very close to an airframe in the ground. The final report has been pushed back many times. The last promise of the final report? August 2018. So much for that. This event occured in Feb 2014. Over 4.5 years...yes years ago. 

Something stinks here.


There are plenty of mechanisms in the ICAO Annex 13 to get information into the public domain without delay.

This looks like a paper shuffling exercise gone wrong, but three years? There should be public accountability somewhere in the process...surely?


With the examples given of delayed reports it certainly looks to be a safety issue. Lessons learned need to be gained before the incident is 4-5 years old that is for sure!

In the ymml loss of separation report we can see that both CASA and Airservices knew about the safety issue since 2011, words were said, hands were wrung but nobody wanted to actually make a decision that might be inconvenient.


It is not only the speed of delivery of accident reports but the accuracy of the actual reports themselves. In a number of ATSB GA accident reports that I have reviewed lately I can see errors of fact. To me they stick out like the proverbial. I have emailed ATSB re these items but no reply was the reply. The errors continue unchecked.

Some would say that they do not have the funding for more staff to clear the back log and to proof read the reports. Fine then perhaps ATSB should get less involved in the likes of a South African Convair accident or that of MH370. Both involved manpower and funds.



Staff funding isn’t necessary the issue here. It’s the timeframe to get the new investigators trained up to the required standard which is multiple years. They are going through this currently. 

What concerns me is it’s taking multiple years for key safety alerts/fixes coming out of more serious incidents, by the time they have got to this point either it’s happened again (think AirAsia incident and incident) or loss of life. 

Falling Leaf:

I think you will find that the investigators complete the report in 3 to 6 months. Then the upper management of ATSB, Airservices, CASA, the airline involved kick the report back and forth for the next 2-3 years with different legal threats until the final neutered report, which says nothing and blames no-one, is finally released.

Lead Balloon:

But you can be sure that at Senate Estimates it will be all under control - short term issues that are being managed. Some huffing and puffing for show, from the usual duopoly Senators, and some genuine attempts to get to the truth from the non-major party Senators. 

The machine is broken. Once the machine is broken, it no longer has the corporate integrity to admit it, even if it knew it was broken.


Petropavlovsk …No-one is defending the ATSB Whyalla investigation report – it was less than competent.

But you draw a really long-bow in saying that everything after the Whyalla report was a fiasco.

Did you ever read the ATSB report into the 2003 IL-76 CFIT accident in East Timor?

That one was an absolutely top-class investigation report, and it was acknowledged in the ICAO Journal – see: yushin%20IL-76%20RDPL-34141%20Bacau%20Timor%20Leste%202003-01-31.pdf

The web has got MANY complimentary articles about that investigation. It set the scene for a lot of benchmarks on HOW a complex investigation COULD be managed in a remote location with LIMITED resources EFFECTIVELY to provide a top-class result.And, the report was issued in less than a year of the accident. So, with the right folks, ‘yes’, the ATSB was good at what it did.

Now? Not so sure.

But maybe you need to consider AND acknowledge that the ATSB DID have some very competent investigators at the time of the Whyalla report, who really DID know what they were doing, and ask WHY that’s no longer the case, instead of throwing shit at the good guys who left and then addressing WHY they left? I know a few of them and they are VERY bloody good operators...….and they still work in PNG!

You refer to the PNG AIC…..seen the good work that outfit is doing lately Petropavlosk? Somehow I don’t think so.

Lead Balloon:

Yep - the ATSB used to have a critical mass of competent personnel, competently led (although, in the case of the original Whyalla report, no one with sufficient competence in piston engine physics and chemistry).

ASTB no longer has that critical mass. Just like CASA.

Although it’s true and nice to say that there are some ‘really good people’ working in these organisations - some of whom I count as friends - the fact remains that the organisations are busted. The machines are busted. They are less than the sum of their parts and - what’s worse - governments no longer know how to fix them.

Hmm...I feel an O&O thread update coming on... Rolleyes

MTF...P2  Cool
70 years on and the lessons lost? - Part II.

Using the findings/recommendations of the 70 year old VH-ANK Lutana plane crash would it be possible to do a simple comparison to modern day/21st century Australian aviation safety standards to assess whether the past identified safety issues have been properly safety risk mitigated?

As an example let's rewind to 2010 when the issue of CFIT accidents in radar monitored CTA was brought to our attention in the case of ATC approach control into Launceston airport. The following is a (posthumous -  Angel ) extract from a 3 August, 2010 Ben Sandilands (Planetalking) article:

Quote:A sarcastic and opinionated look at air space reform

With no certainty at this stage as to which miserably mean spirited and visionless conservative party will win the August 21 election, it might be reasonable to tidy up a critical element in the radar and air space controversy that Dick Smith recently ignited. The central issue is that of dragging Australia into world’s best […]
AUG 03, 2010

[size=large]With no certainty at this stage as to which miserably mean spirited and visionless conservative party will win the August 21 election, it might be reasonable to tidy up a critical element in the radar and air space controversy that Dick Smith recently ignited.

The central issue is that of dragging Australia into world’s best practice, and using active air traffic control, by air traffic controllers rather than busy pilots, to separate passenger airliners from other aircraft when using Australian airports.

It is a no brainer, but in a nation where pilots, airlines and regulators ferociously resisted black box flight recorders and weather radar, if not the use of radio and enclosed cockpits nearly 100 years ago, anything is possible when airline greed and pilot complicity coincide.

This is the recent political history of air space reform.

In 2004 John Anderson, the Minister for Transport in a Howard Government, issued a ministerial direction that radar control would be used to separate airliners approaching and departing a number of regional airports, including Launceston, where there was not just a serious incident on May 1, 2008, but subsequently, the release of a deficient ATSB report that made no safety recommendations and tip toed around the air space management issues it should have addressed.

Anderson was ignored.

Before the 2007 Federal election the Shadow Transport Minister, Martin Ferguson said:

[Image: Ferguson-600x72.jpg]

Ferguson (in my opinion) was the tool of the airlines and the change resistant culture of aviation regulation in Australia.Dick Smith has shared with me a letter he wrote to the Prime Minister Julia Gillard recently concerning that policy switch, and his fear that if re-elected, a Labor government would NOT introduce the active separation of airliners using Launceston Airport. In that letter he says:

[Image: DS-extract-600x200.jpg]

On July 21 we reported the ministerial direction made by the current Infrastructure and Transport Minister, Anthony Albanese, that active control be provided 24/7/365 at Launceston.

On July 25 we reported that as indicated in the documentation from CASA that Minister Albanese relied upon, this was not the case, and on July 26 we reported that it really was the case. What we didn’t report at the time was that ‘some unfortunate errors in press release writing’ had caused the misunderstanding. My view is that in fact CASA was trying to pull the wool over Albanese’s eyes, by framing its recommendations to conform with change resistance in air space reform in this country, and that Albanese is not John Anderson, and that this was a serious error of judgement somewhere along the path from the air space regulation office in CASA to the Minister’s minders. Thus we have now reached a position where if re-elected Labor will do what Albanese promised to do, which is an historic advance for air safety in this country, and that if the Coalition is elected to government its Minister for Transport will carry out what it previously promised to do, but failed to enforce under John Anderson...

Now fast forward to 2015: Dick Smith says radar systems at Hobart and Launceston airports a safety risk

&.. 2017:  Dick & TASWAM revisited.

Now although "K" in the post following rightfully lambasted Dick for over reaching and in the process losing credibility (Wolf! Wolf! -  Wink - there was an underlying 'safety' message that unfortunately IMO still remains live and not appropriately risk mitigated: 

Quote:..The real story is the ADS-B system; or the lack thereof. ATCO not trained, tested and qualified to use a very expensive, controversial system is not, of its self ‘dangerous’; but, as the story tells; they ain’t qualified – so they don’t use it. This, stand alone points directly at the truly dreadful state the ASA is in, it highlights the unseen additional stress and strain on the ATCO and speaks volumes on the total disorganization within the hugely expensive, loss making monopoly the ASA is. It is truly disgraceful that the ADS-B system is ‘running’ but ASA cannot fully exploit the efficiency benefits the system ‘could’ provide. 

Smith – “Mr Smith told the minister that if nothing changed, there would be a serious accident and it would take a royal commission to bring about better safety.”

Bollocks; counterproductive, emotive Bollocks. There is a great waste of time, public money and operating costs; it is a massive haemorrhage of resources and money – all trackable back to the large, shiny, expensive offices of a handful of ASA management types. Dick is wasting credibility and opportunity barking up the wrong tree; the Senate committee is not. The RRAT is reading the audits, analysing the programs and asking, quite correctly, WTF have you been playing at? A hundred million dollars a year monopoly, going broke, beggars belief; retrenching, not training ATCO, bringing in consultants to do the in house work payed by industry, that and taking long lunches and cozy weekend get a ways needs to be examined; in detail... 

Couple the "K" post with the series of ATCO ATSB REPCON's, recently brought to our attention by the ABC and Bumaye on the BITN thread (references starting from here: Fatigue and 'just culture' in a Harfwit world; & from Bumaye here: Another REPCON from ATSB website on ATC night-shift fatigue issues.) you begin to get a picture of how big and how close the holes are to aligning in the mouldy old (Airservices obfuscated and CASA oversighted) ATC Swiss Cheese... Confused  

MTF...P2  Cool
WTD? - The bollocks Ballina investigation: AO-2017-097

Via Oz Flying: 

Quote:[Image: Ballina_Byron]

Close Call at Ballina prompts See-and-Avoid Warning
5 September 2018

A close call at Ballina Byron Gateway Airport in September last year has prompted the Australian Transport Safety Bureau (ATSB) to issue a warning about the importance of see-and-avoid separation.

Cessna C208 Caravan VH-SJJ and Robinson R22 VH-MFH came into conflict on runway 06 on 19 September 2017 when the Caravan departed for Nambucca Heads whilst the helicopter was descending to the runway ahead of it. The instructor in MFH elected to land on a grass area beside the runway to avoid a potential colllision with the departing aeroplane.

According to the ATSB report released today, the Certified Air/Ground Radio Operator (CAGRO) advised the Cessna pilot of the Robinson's operation, but the desire to depart before an approaching A320 landed distracted the pilot.

The pilot of SJJ reported that although he had a clear view of the runway ahead, he did not see the helicopter at any stage.

"The CA/GRO acknowledged that the C208 pilot already had traffic information on the inbound Airbus and advised, ‘...on your right hand side there is helicopter JKH, also...’ and following a four-second pause, ‘...conducting operations runway 06, helicopter MFH’. At 1106:55, the C208 pilot responded ‘thanks for that and SJJ is entering and rolling runway 06’", the ATSB reported.

"At this time, MFH was on short final for runway 06 at approximately 200 ft above the runway and approaching a point that was about two thirds of the way along runway 06. The instructor realised that the C208 was departing and transmitted that MFH was ‘runway 06 for the runway’. That call partly over-transmitted on the C208 pilot’s response to the CA/GRO.

"The instructor took control of the helicopter and vacated the runway to the north followed by a call to advise their location at the‘northern grass.’ The C208 pilot continued the take-off and departure to Nambucca Heads."

The ATSB later commented at the Cessna pilot entered and departed the runway "prior to positively identifying the helicopter on short final."

In the Safety Message included in the report, the ATSB highlighted the importance of a good visual look-out at non-controlled airports.

"Pilots are reminded to apply effective see-and-avoid principles when operating at or near non-controlled aerodromes. While broadcasting on and monitoring of the CTAF is the key way for pilots to establish  situational and traffic awareness, it is also important to maintain a constant visual lookout to validate any operating assumptions and avoid traffic conflicts."

The full report on the incident is on the ATSB website.


A year for that bollocks? Surely not? The paperwork must have got lost in some lazy ass bureaucrats in-tray for at least the last 11 months? If HVH and his executive think that load of codswallop is going to pull them out of the fire I can sell them the Sydney Harbour Bridge going cheap - FFS! How utterly embarrassing... Blush

While on the HVH led ATSB and it's continuing search for IP, I note that the ANAO have now opened up their ATSB performance audit for outside submissions/contributions:

Quote:Efficiency of the investigation of transport accidents and safety occurrences
Due to table: April, 2019

Infrastructure, Regional Development and Cities

Australian Transport Safety Bureau

Contribute to this audit

The ANAO welcomes members of the public contributing information for consideration when conducting performance audits. Performance audits involve the independent and objective assessment of the administration of an entity or body’s programs, policies, projects or activities. They also examine how well administrative support systems operate.

The ANAO does not have a role in commenting on the merits of government policy but focuses on assessing the efficient and effective implementation of government programs, including the achievement of their intended benefits.

The audit you have selected is currently collecting audit evidence and is seeking input from members of the public. We particularly value information that deals with significant matters or insights into the administration of the subject of this audit. Information can be submitted either by uploading a file, or by entering your information into the comments box below.

While your contribution will be considered, and handled with care, you will not automatically receive feedback about your contribution. However, if you provide your contact details, you may be contacted regarding your contribution.

Please note that contributions are intermittently monitored. We aim to consider all contributions within 14 days of receipt.

We anticipate accepting contributions to this audit until Tuesday 18 December 2018.

  Hmm...where do I start??  Dodgy

MTF...P2  Cool

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