[Peetwo]

Analysis – deemed non essential.

The 777 event is deemed ‘an incident’.  The A330 event is defined as a 'serious' incident.
There’s a head scratcher for starters.  I expect the difference is because the EPGWS chimed in.  But it’s the ‘result’ section of both ‘summary’ reports that makes me despair of ATSB.

Q - In response to this occurrence Qantas updated their training material for visual approaches and enhanced similar material in their captain/first officer conversion/promotion training books. In addition, targeted questions were developed that required check pilot sign off for proficiency. Finally, visual approaches were included as a discussion subject during flight crew route checks for the period 2013–2015.

The ATSB “Safety message” cracks me up; Qantas have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.  

VA - The ATSB has been advised by Virgin Australia International Airlines that the SHEED approach is no longer available for use by its Boeing 777 crews.

The ATSB “Safety message” cracks me up; VA have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.

But I like the VA response, cut and dried, don’t use that approach.  It is at least succinct, does it address the deeper implications?  We’ll never know, VA sorted it out, internally and once again without any need for ATSB or CASA assistance.  

Q - Incident March 2013; report release June 2015.   ATSB, two years + a bit to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion. 

V - Incident Aug 2013; report release June 2015.   ATSB just a shade under  two years to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion.

ATSB were superfluous, not required in either incident.  Both matters were resolved in house, by experts, at a pace in keeping with the needs of the airline to keep operating.  No one engaged in real world, real time operations can be ducking about, waiting 24 months for a ‘safety’ analysis ; they have to crack on.

The point I’m struggling to make is that both incidents were, potentially serious accidents.  The airlines involved moved swiftly, positively and effectively to mitigate the immediate risk.  Bravo, well done, but no more than we could reasonably expect from first class air carriers.  The ATSB didn’t help too much, nor did the complex 'safety' regulations, or those who wrote them.

Where ATSB fail miserably is in the area where one could reasonably the ATSB to be of real value for money.  There are some deep, esoteric and subtle elements in the ‘chain’ of events leading up to the incidents; these have not been analysed, therefore there is no ‘deep and meaningful’ academic assessment of the peripherals, which may have assisted either airline to ‘modify’ their thinking.  There is nothing published which may assist the ASA to modify their thinking and perhaps make some changes to the Melbourne terminal airspace.  After a two year study, costing gods only know what, I’d have expected something adding value.  It’s a pity the airlines can’t publish their reports; they may be worth reading.

In short Minister, we got ripped off - again.  

Toot toot.  

...& Minister while your there, could you please tell the Muppet to publish your SOE...FCOL

Hey "K" choc frog post that one..

Just to help you out mate, here are the two farcical safety issues that are published on the non-user friendly bureau website - gotta say why do they bother :

Guidance material


Issue number: AO-2013-130-SI-01

Who it affects: Virgin Australia International Airlines B777 pilots

Issue owner: Virgin Australia International Airlines

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-130

Date: 15 July 2015

Safety issue description

The presentation of the runway 34 visual approach in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint.

Proactive Action

Action Organisation: Virgin Australia International Airlines

Action number: AO-2013-130-NSA-031

Date: 15 July 2015

Action status: Closed

Virgin Australia International Airlines has advised that the SHEED approach to runway 34 at Melbourne is no longer to be used by its Boeing 777 crews. 
 
Current issue status:
Adequately addressed

Status justification:
The action by Virgin Australia International Airlines eliminates the risk associated with the safety issue.
 

Visual approach guidance


Issue number: AO-2013-047-SI-01

Who it affects: Flight crew

Issue owner: Qantas

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-047

Date: 09 July 2015

Safety issue description
Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the intended approach.

Proactive Action

Action organisation: Qantas

Action number: AO-2013-047-NSA-032

Date: 09 July 2015

Action status: Closed

Qantas advised that in response to this occurrence they:

Updated the material for visual approaches in their flight training library.

Enhanced the material for visual approaches in the captain and first officer conversion/promotion training books including targeted questions that required check pilot sign off for proficiency.

Added visual approaches as a subject for discussion during flight crew route checks for 2013/2014 and 2015.
 
 
Current issue status:
Adequately addressed

Status justification:
The ATSB is satisfied that the safety action adequately addresses this safety issue.
 

Ok all good, nothing to see or learn from here, move along & Beakers BASR ("Beyond All Sensible Reason") methodology strikes again - please can someone save our bureau from this muppet??

The following quotes/excerpts are taken from the AIPA submission 8 to the Pel-Air cover-up Senate Inquiry.  A submission I might add that is well worth taking the time to read in it's entirety 

First this on the standards of the ATSB reports:

From bottom of page 8: ...In 2011, we raised our concerns in our Supplementary Submission to this Committee during the Inquiry into Pilot Training and Airline Safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 in this way:

“Are ATSB Reports serving their intended safety purpose or are they too late and too superficial to be anything other than records of bureaucratic activity?
AIPA is of the view that recent major reports are not serving their safety improvement purpose due to a lack of depth, particularly in regard to HF, and a lack of timeliness. We believe that, without the technical and HF insight that is required for complete understanding of complex failures, it is difficult to defend against an inaccurately or inadequately described problem.

Similarly, if nobody really remembers the problem or they think it has already been solved before a report is issued several years after the event, then the report has lost its value (other than a record of activity). The roadblocks to timely publication must be eliminated.

AIPA believes that there needs to be a formal system for multilateral industry assistance to the ATSB to supplement its resources, particularly in regard to specialist operational and technical knowledge.”16

It is through that prism that AIPA provides its comments....

Then on the ATSB BASR approach to identified safety issues & safety recommendations:








Finally the following quote from AIPA's ASRR submission perhaps highlights the view of many of Qantas pilot's (at least) in regards to having & maintaining a fully independent State AAI:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was
being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety.

Current knowledge, post the Senate Inquiry, suggests not.

AIPA believes that the ATSB has a very clear duty under the TSIA to independently and
holistically examine the aviation safety system. Pandering to the ego or behaviour of any
stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.

Recommendation 3


AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

Hmm...no further comment required, except to say...."Dear Minister, READ & ABSORB"

MTF...P2