ATSB reports [Archive] - PPRuNe Forums

Sarcs

5th Aug 2013, 11:50

If nothing else, and the terms of reference for the review of the ATsBeaker by the TSB Canada aren't expanded (as they should be), there is perhaps a lot to be learnt from the TSB in regards to its structure, true independence and its stated Mandate, not to mention the fact that the purse strings are not held by the Minister of Transport:
Mandate

The Canadian Transportation Accident Investigation and Safety Board Act (http://laws.justice.gc.ca/en/C-23.4/index.html) provides the legal framework that governs TSB activities. Our mandate is to advance transportation safety in the marine, pipeline, rail and air modes of transportation by

conducting independent investigations, including public inquiries when necessary, into selected transportation occurrences in order to make findings as to their causes and contributing factors;
identifying safety deficiencies, as evidenced by transportation occurrences;
making recommendations designed to eliminate or reduce any such safety deficiencies; and
reporting publicly on our investigations and on the findings in relation thereto.
As part of its ongoing investigations, the TSB also reviews developments in transportation safety and identifies safety risks that it believes government and the transportation industry should address to reduce injury and loss.
To instill confidence in the public regarding the transportation accident investigation process (http://www.tsb.gc.ca/eng/enquetes-investigations/index.asp), it is essential that an investigating agency be independent and free from any conflicts of interest when investigating accidents, identifying safety deficiencies, and making safety recommendations. As such, the TSB is an independent agency, separate from other government agencies and departments, that reports to Parliament through the President of the Queen's Privy Council for Canada. Our independence enables us to be fully objective in making findings as to causes and contributing factors, and in making transportation safety recommendations.
In making its findings as to the causes and contributing factors of a transportation occurrence, it is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board does not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board’s findings. No finding of the Board should be construed as assigning fault or determining civil or criminal liability. Findings of the Board are not binding on the parties to any legal, disciplinary, or other proceedings.
There is also a part that differentiates the TSB mandate from other transport related Federal agencies. And this helps to maintain the integrity of the TSB independence from these agencies i.e. no weasel worded MOUs for this lot:
The TSB and other organizations

The TSB's mandate is distinct from those of other organizations such as Transport Canada (TC), the National Energy Board (NEB), the Royal Canadian Mounted Police (RCMP), the Canadian Coast Guard (CCG), and the Department of National Defense (DND), all of whom play a role in the transportation field. As an independent federal agency, the TSB is not associated with any of these organizations, although we do work in cooperation with them when conducting investigations and making safety recommendations.
Transport Canada is concerned with developing and administering policies, regulations and services for transportation systems in Canada with respect to federally regulated marine, rail and aviation transportation modes. The National Energy Board is responsible for regulating pipelines under federal jurisdiction. This differs from the TSB's mandate of advancing transportation safety in the marine, pipeline, rail and air modes of transportation through the conduct of independent investigations, the identification of safety deficiencies, and the making of recommendations to eliminate or reduce such deficiencies.
When the TSB investigates an accident, no other federal department (except the Department of National Defense and the Royal Canadian Mounted Police) may investigate for the purpose of making findings as to the causes and contributing factors of the accident. Transport Canada and the National Energy Board may investigate for any other purpose, such as regulatory infractions.
In terms of methodology it would appear that the TSB has a point of difference to Beaker in regards to the importance of the safety recommendation system:
Recommendations

The Transportation Safety Board of Canada (TSB) is responsible for advancing transportation safety. One of the ways it does this is by making recommendations to federal departments and other organizations to eliminate or reduce safety deficiencies.
Under our Act (http://laws.justice.gc.ca/en/C-23.4/index.html), federal ministers must formally respond to TSB recommendations and explain how they have addressed or will address the safety deficiencies. Using an Assessment Rating Guide (http://www.tsb.gc.ca/eng/recommandations-recommendations/rg.asp) (which includes definitions for the status of recommendations (http://www.tsb.gc.ca/eng/recommandations-recommendations/rg.asp#sor)), the Board evaluates the responses and their overall effectiveness. Each response is assessed as Fully Satisfactory, Satisfactory Intent, Satisfactory in Part or Unsatisfactory. Progress made to address TSB recommendations is assessed by the Board on an ongoing basis.

For recommendations and assessments made before January 1, 2005, please refer to our annual reports (http://www.tsb.gc.ca/eng/publications/index.asp#reports).

Marine recommendations (http://www.tsb.gc.ca/eng/recommandations-recommendations/marine/index.asp)
Pipeline recommendations (http://www.tsb.gc.ca/eng/recommandations-recommendations/pipeline/index.asp)
Rail recommendations (http://www.tsb.gc.ca/eng/recommandations-recommendations/rail/index.asp)
Aviation recommendations (http://www.tsb.gc.ca/eng/recommandations-recommendations/aviation/index.asp)
It is also worth reading the Canadian Transportation Accident Investigation and Safety Board Act (http://laws.justice.gc.ca/en/C-23.4/index.html) for a quick compare with the TSI Act 2003!:ok:

Kharon

5th Aug 2013, 21:05

Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered.

Send the Navy, I'm sure the boys and girls not on 'transport duties' could do a bang up job and enjoy the outing. I expect the experience and training opportunity would/ could be of some value for money.

Yeah I know, back to my knitting...:ugh:

004wercras

5th Aug 2013, 22:38

Herr Kharon, you are correct. There are numerous legal implications for the unauthorised removal of the boxes that are currently gathering barnacles and being used to camouflage many varieties of orange reef fish. I will try to locate the specific dot points (now that the third test is finished :() . Suffice to say the 'evidence' would be classified as useless, tainted and potentially interfered with should the Styx Houseboat take up anchor, stealthily remove said boxes and whisk them away to the land of the maple leaf for a robust examination.

Also the downside is that although the boxes are at a moderate depth I don't believe they are deep enough to have been adequately preserved, such as with the AF boxes (something to do with presuure, oxygen levels, technical stuff like that). Perhaps Herr Sunfish the keen aviator, diver, and font of much knowledge could expand on this topic?

Interesting and succinct research and analysis Herr Sarcs. Also of interest is the following for comparison;

TSB Director, Investigations - Background as a pilot, director of flight operations and has hands on experience as an investigator. :ok:

TSB Director, Operational Services - Background in HF, he has a doctorate in the subject, and also has hands on investigation experience. :ok:

ATSB Commissioner Beaker - Comcare, workers comp, Ausaid and Agriculture and Fisheries, mi mi mi mi and likes playing with large pots of money. :(

I just hope that when the Maples visit they don't get dragged into the whirlpool of pooh and end up taking some of the residual stained matter back to the TSB and infect some of their own people with 'beyond Reason methodology', mi mi mi, poor investigative techniques and bureaucratic bull**** 101.

Sarcs

6th Aug 2013, 02:10

Kharon:Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered.
I think what you say is essentially true "K", however I also think it depends whether the ATsBeaker have officially 49erd the OBR:
49 OBR ceasing to be an OBR under declaration of ATSB
(1) The ATSB may, by published notice, declare that a recording, or a
part of a recording, identified in the notice is not to be treated as an
OBR on and after a date specified in the notice.
(2) If the ATSB decides not to investigate the transport safety matter
to which an OBR relates, the ATSB must, by published notice,
declare that the OBR is not to be treated as an OBR on and after a
date specified in the notice.
(3) If:
(a) the ATSB decides to investigate the transport safety matter to
which an OBR relates; and
(b) the ATSB is satisfied that any part of the OBR is not relevant
to the investigation;
the ATSB must, by published notice, identify that part and declare
that part is not to be treated as an OBR on and after a date specified
in the notice.
(4) The ATSB cannot revoke or vary a notice published under this
section.
(5) When an OBR, or part of an OBR, ceases to be an OBR because of
a notice published under this section, then any related OBR
information also ceases to be OBR information.
Now if the box has been officially 49er'd then I think (Creamy can probably confirm this) then it could be fair game for anyone to retrieve??:rolleyes:
It is also interesting to note that essentially an OBR only covers the CVR by definition and the Civil Aviation Act like-wise only places protections on the CVR. So the question there is: Would the FDR (by no protection) be also fair game if it was a stand alone unit? :confused:

004wercras

6th Aug 2013, 02:43

I thought '49erd'was a term use for The Skulls treatment of some of his fellow drivers at CX :hmm:

Creampuff

6th Aug 2013, 06:31

If the recording or part of the recording on the CVR has been the subject of a Notice under s 49, the recording or the part of the recording the subject of the Notice is not treated as an OBR from the date specified in the Notice.

I can find only one s 49 Notice on the ATSB website. It does not relate to an aviation investigation.

I suspect the ATSB’s (Orwellian) reasoning will be that although the ATSB didn’t think it was worth retrieving the CVR from NGA, the ATSB is not satisfied the recording is not relevant to the investigation of the ditching. Therefore, it must remain an OBR subject to the TSI Act forever ….

But lots of people seems to be labouring under the misconception that because the CVR contains an OBR, no one (other than the ATSB) is allowed to touch or remove the CVR or listen to what’s on it in any circumstances.

The offences in the TSI Act are for adversely affecting an investigation (s 24) and for copying OBR information or disclosing OBR information (s 53). (There are also exceptions.)

If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken? If the person doesn’t copy what’s on it, or disclose to anyone what the person heard, the person hasn’t breached s 53. The person hasn’t adversely affected the ATSB’s investigation, even if the ATSB wanted to pretend it’s keen to know what’s in the OBR. Indeed, if the ATSB wanted to pretend it’s keen to know what’s in the OBR, the person could help the investigation by delivering the CVR to an independent body – surely the ATSB would have no hesitation in authorising an independent body to have access to the OBR, under s 52, so as to confirm what a great report the ATSB produced.

If the person puts the CVR back in the hull, Sunfish could then dive down and remove it from the hull (with the owner’s permission) listen to what’s on it, and then put it back without copying or damaging the OBR, and without disclosing what he heard. Then Sarcs goes for a swim ….

Eventually, lots of people would be able to wink knowingly at each other … ;)

Horatio Leafblower

6th Aug 2013, 07:28

If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken?

If the wreck has been abndoned, who owns it?

If the insurance company is asserting ownership over it, surely they can be forced to move it from the crown land it is presently cluttering up?

(Can't complain about fuel leaks and pollution I suppose... :oh: )

Sarcs

6th Aug 2013, 23:44

Phelan:
Election squabbling buries air safety recommendations (http://proaviation.com.au/news/?p=1576)

Liberal Senator David Fawcett says Transport Minister Anthony Albanese has failed to respond to the damning findings of the Senate Inquiry into the ATSB’s and CASA’s responses to the Norfolk Island ditching on November18 2009.
ATSB today confirmed that there would now be no action on the critical recommendations until after the election.
The Senate Committee’s report with 26 safety-related recommendations was released on 23 May, 2013. It highlighted serious concerns with the processes and conduct of both government agencies, and its recommendations were aimed at rectifying what it described as “the serious deficiencies that the committee had identified.”

The committee’s first recommendation was that the ATSB retrieve the accident aircraft’s flight data and cockpit voice recorders “without delays.”
The report said: “The committee understands that retrieval of the recorders would be particularly useful in this instance [and] that the ATSB has certain responsibilities, set out in ICAO Annex 13, when it comes to retrieval of aircraft involved in accidents. It is an assumption throughout Annex 13 that, where a FDR [flight data recorder] exists, the accident investigation body will prioritise its retrieval.”
Air safety specialists believe that the aircraft’s flight data and cockpit voice recorders could be recovered with relative ease, saying they do not understand why this recommendation is being ignored, especially as further delay might damage the equipment.
Also recommended were a reopening of the original investigation with a focus on organisational and systemic issues, a drastic rearrangement of the structures within which ATSB and CASA operate, the establishment of an ICAO Annex 13 independent panel to oversee ATSB investigations and reporting, and a referral to the Australian Federal Police to investigate whether CASA breached the Transport Safety Investigation act by withholding critical documents during the investigation.
During estimates hearings in May this year, Senator Fawcett specifically highlighted the risk of Government inaction before the caretaker period began, causing an unacceptable delay to implementing the recommended aviation safety reforms.
When asked during Estimates on May 29 if the department’s brief to the Minister would occur in sufficient time so that Mr Albanese could respond before the caretaker mode, Department Secretary Mike Mrdak replied:
“We already have officers in the department – and clearly me and senior officers – who have carefully read the report now. I have had discussions with my senior officers. We envisage being in a position to provide some initial advice to the minister, I expect, certainly within the next week to 10 days in relation to it. I envisage having conversations with the Civil Aviation Safety Authority CEO and the head of the Australian Transport Safety Bureau in the coming days to ascertain their views, to enable me to provide a comprehensive view to the minister, I would hope by the end of next week.” [two months ago.]
Senator Fawcett points out that the report was tabled on May 23, allowing the Minister a three month window to respond and that given its damning findings Minister Albanese should have made this his top priority, particularly given his promise that ‘nothing is as important as aviation safety.’
“Even the announcement today of an external review of the ATSB by the Canadian Transportation Safety Board (TSB) was not made by the Minister but by the agency in question, said Senator Fawcett, referring to ATSB announcement on August 2 that the transportation is safety board of Canada (TSB) will conduct an independent external review of the ATB’s investigation processes and publish the results. The review was announced jointly by TSB Chair Wendy Tadross and ATSB chief commissioner, Martin Dolan.
Sen Fawcett remains unimpressed: “This raises serious concerns about the efficacy of any resulting report unless the Minister ensures that the terms of reference (ToR) and Australian management of the audit are transparent and independent.”
We asked the ATSB whether a decision been made on recovery of the flight data and cockpit voice recorders of the Pel-Air aircraft, whether recovering the recorders would be an ATSB or departmental decision, and whether the investigation will be reopened as recommended in recommendation 9. We also asked if the Canadian review was a part-response to the Senate recommendations.
The ATSB would not comment on the recorders or reopening the investigation, but a spokesman said: “We’ve been in discussion with the Transportation Safety Board of Canada for some time, and it’s about benchmarking and comparison of our systems of investigation. This is an initiative of the ATSB’s chief commissioner and the TSB’s Chair, and the TSB has agreed that their benchmarking review will have regard to the Senate committee’s findings, so we’ll take those into account.
“In regards to your specific questions, it is the responsibility of the Government to respond to the recommendations of Senate committees. The ATSB has provided input to the preparation of a government response. The caretaker conventions that are now in place mean that a government response will not be finalised until after the federal election.“
Senator Fawcett again called on Minister Albanese to ensure that this review of the ATSB has the confidence of the aviation industry and the public by adopting Recommendation 8 of the Senate report:
8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation orocesses as identified in the Senate report including the Canley Vale accident.”
Can't really add anything to that!:D:D

Up-into-the-air

7th Aug 2013, 01:06

Here the "...flood of reports..." we did not see in July comes:

Aviation Short Investigation Bulletin - Issue 21 (http://www.atsb.gov.au/publications/2013/ab-2013-117.aspx#.UgGUoDU_61o.twitter)

see the comments: @flyingoz

Creampuff

7th Aug 2013, 03:46

Regarding Senator Fawcett’s comments quoted by Mr Phelan, the sentence that’s missing from Senator Fawcett’s comments is again the one that starts:If elected on 7 September, a Coalition government will move immediately to ….

004wercras

7th Aug 2013, 08:55

Great to see that 'safety' is a non essential item that really isn't worth a pint of panther piss during periods of caretaker governments.
May I also suggest that all road enforcement rules including the operation of speed cameras, along with aviation rules also not count during 'caretaker mode', that rape and murder receive a dispensation and that tax not need to be paid during caretaker mode.
Anything else? Oh yes, why not shut down the electricity and water grids along with sewerage treatment during caretaker mode??
Absolute f:mad:wits

VH-FTS

7th Nov 2013, 21:29

The latest round of ATSB reports are a bit of a joke and don't provide any real information to improve safety. However, this one takes the cake:

Investigation: AO-2013-128 - Collision on the ground involving a Cessna 172R, VH-IMS, at Sunshine Coast Airport, Queensland on 2 August 2013 (http://atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-128.aspx)

A Cessna hits a light pole while taxing and it is worthy of the ATSB to investigate? Reading the report, they much have given it to an intern to investigate.

"The pilot learnt a valuable lesson" - what a crock of crap.

In another report about a TCAS RA the outcome is that pilots need to maintain situational awareness - no ****e Sherlock. They knew about each other, the SA was there, how about some real recommendations.

Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole?

Jack Ranga

7th Nov 2013, 21:39

Well, they should submit that report for judging. A possible award for such an industry changing revelation. My congratulations to whomever approved this investigation. Rome burns but they are holding their focus like the steely eyed missile men they are. :D

VH-FTS

7th Nov 2013, 21:44

I'd be very surprised if reports weren't submitted, especially as ATC we notified of the situation (according to my source). But then again, a Q400 tail scrape must be a bigger problem for the ATSB than an in flight fire...

Old Akro

7th Nov 2013, 22:24

The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.

TWT

7th Nov 2013, 23:59

Still waiting for the final report on this one :cool:

Investigation: AO-2011-102 - Collision with terrain involving Aérospatiale helicopter, AS355F2, VH-NTV, 145 km north of Marree, near Lake Eyre, SA on 18 August 2011 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-102.aspx)

VH-XXX

8th Nov 2013, 02:01

Still waiting for the final report on this one

We all know what that one is going to say. I feel like sometimes they take a long time to release them when the words of the truth are difficult to put on paper.

Although the reasons for the flight path have not yet been determined, the ATSB is concerned about the conduct of visual flight rules (VFR) flights in dark night conditions – that is, conditions with minimal celestial illumination, terrestrial lighting cues or visible horizon. The ATSB is reviewing the regulatory requirements and guidance for the conduct of night VFR flights, and the training and ongoing assessment of pilot skills to conduct such flights. The ATSB is also preparing an ‘Avoidable Accidents’ educational report focussing on night VFR accidents.

walschaert valve

8th Nov 2013, 03:00

TWT - 14th November I understand, received a note from the ATSB today

TWT

8th Nov 2013, 05:49

Thanks very much for that walschaert-valve !
I am amongst a lot of people that will be very glad to find out more on that one.

Kharon

8th Nov 2013, 19:18

FTS #24 –"Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole?

I could completely understand a report like the A 380 incident, or AF taking a couple of years; big, multi discipline, multi jurisdictional investigation. Forensic, engineering, design, operating and future solutions take time and I'm glad they do. That sort of stuff needs to be spot on.

Looking back at coroner recommendations and ATSB reports is a tedious business, but when you do the home work a couple of things stand out. One of the most appalling (IMO) is the lack of educational information passed on to the troops. OK, there has been a fatal, not only do we need to know the what, why and how of the thing; we need to know how to prevent the thing happening again. Take CFIT for example; the FSF and other serious safety bodies have done some great work, produced invaluable material and made it freely available. Will it prevent all CFIT?, of course not; but those who take their responsibilities seriously, will have taken an hour of two, watched the video, read the material and are now aware of the risks.

The light weight, compromised, technically pathetic dribble presently being served up to industry achieves nothing but an increasingly large pile of glossy 'feel good' stuff, which probably convinces the public that ATSB has it all in hand, bit like the adverts on TV. "Buy one of these and all your dreams will come true". Problem is, some mugs do believe it.

The shameful travesty of Pel Air puts the current iteration of the ATSB in the class of snake oil salesmen. I hope they manage to straighten up their game before the whole sorry mess is exposed, yet again, at yet another inquiry into yet another preventable accident. Prevention has always been better, cheaper and more effective than cure. Stuff the budget, man up, do your job and regain the faith and trust of industry.

"Ave, Imperator, morituri te salutant" Suetonius reports that Claudius replied "Aut non" ("or not")......Translation here (http://en.wikipedia.org/wiki/Ave_Imperator,_morituri_te_salutant)....:

Sarcs

8th Nov 2013, 20:42

Glad to see the mods have merged these two threads it kind of sets a background to the demise and hit to the reputation of the once proud aviation safety watchdog, the ATSB/BASI.

The bureau, much like Fort Fumble, has always had its detractors but even the critics would (once upon a time) grudgingly admit that on the whole the ATSB generally get it right and make a worthwhile contribution for the betterment of aviation safety. However IMO in the last 5 years they have seriously lost their way. The evidence of this was very much on display throughout the Senate Inquiry (hence *Recommendation 8). Also, as posters on here are noticing, through the quality of the reports being produced. The mantra now appears to be…politically correct and on budget.

*R8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Note: Beaker attempted to placate the Senators by bringing in the Canucks but Senator Fawcett rather scathingly struck back with this comment in a press release…
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation processes as identified in the Senate report including the Canley Vale accident.”

Some would say this decline of the bureau can be tracked back to the Lockhart River investigation with the subsequent Coroner’s findings through to the Miller review. However IMO, despite all those troubling times, the bureau on the whole could still hold their heads up high till at least the middle part of 2008.

Perhaps to highlight this there were two important report publications put out by the ATSB in 2008-09, one was the decade review; Australian Aviation Safety in Review: 1998 to 2007 (https://www.atsb.gov.au/media/1287834/ar2008079r.pdf)and the other (internationally recognised) wasthe worldwide review of commercial jet aircraft runway excursions (http://flightsafety.org/files/RERR/ATSB%20Report.pdf).

In the foreword of the Aviation Safety Review the former and last Executive Director Kym Bills (rather proudly) had this to say:
It has been an exciting and progressive year for air safety in Australia. The December 2008 release of the National Aviation Policy Green Paper established the future direction of the aviation industry, asserting the Government’s position on air safety in Australia as the number one priority. This includes the establishment of the Australian Transport Safety Bureau (ATSB) as a statutory agency with a Commission structure to enhance its independence. Legislative amendments to the Transport Safety Investigation Act 2003 to give effect to the governance changes have been passed by Parliament and the new Commission will come into place on 1 July 2009.

I am delighted to release the third edition of the ATSB’s Australian Aviation Safety in Review. The format of this edition departs from that of the first two editions to provide a range of new information not previously presented. The report provides an overview of the aviation industry with a focus on safety data derived from aviation occurrences reported to the ATSB. It covers a
10-year period (1998 to 2007) and describes trends and analysis of both aviation incidents and accidents.

The first chapter deals with the structure and size of Australia’s aviation sector, including the number of aircraft registered and numbers of pilots and engineers licensed, and the amount aviation activity in different sectors. The next two chapters delve into measures of aviation safety. Chapter 2 examines the trends across 10 years for the number of fatal accidents, accidents and incidents, and their rate expressed as a proportion of annual flying hours. Chapter 3 takes a closer look at the nature of aviation occurrences (incidents and accidents) in Australia through an analysis of what occurred. Chapter 4 looks at why they occurred. That is, what human actions and technical failures contributed to the occurrences. Aviation occurrence reporting requirements and procedures are described in Chapter 5, and in Chapter 6, the special topic covered is the issue of birdstrikes in airline operations.

The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety.

I commend the report to you.

Kym Bills
Executive Director
Australian Transport Safety Bureau

Note: I wonder on reflection whether KB would have made the same statement today?? And does he feel somewhat betrayed by the turn of events that was to occur since the end of his tenure at the ATSB??
The other report/review is still highly regarded internationally as a reference for jet runway excursions and is incorporated into an ICAO/FSF report on Reducing the Risk Runway Excursions (http://www.icao.int/safety/RunwaySafety/Documents%20and%20Toolkits/fsf-runway-excursions-report.pdf).

As an example of the worth of this excellent proactive report and the knock on safety benefits, lessons learnt etc..etc our fellow Canuck comrades, the TSB Canada, have just released a final report into a Quebec runway excursion by an American Airlines 737: Aviation Investigation Report A10Q0213 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2010/a10q0213/a10q0213.asp).

Note: This excellent and very informative report is worth taking the time to read and you will find that in the web portal format is extremely easy to navigate around. You will also observe that the ICAO/FSF is listed as a reference and that the ATSB database on similar B737 incidents is referred to in appendix G.

Extract from Safety Action section of this report:Safety action taken
American Airlines

In April 2011, as part of its pilots’ recurrent training, human-factors class, American Airlines introduced a simulation and discussion of this Boeing 737 runway excursion. This training is given to company pilots to educate them on the possibility of a runway excursion due to a nosewheel steering problem on landing roll-out after a normal approach and landing.
Safety concern

Despite efforts in analyzing past nose-gear steering, low-slew rate-jam events and carrying out post-event valve examinations, the cause of these uncommanded steering events remains uncertain. The safety review process completed by the manufacturer and based on a quantitative, cycle-based occurrence rate of 1 X 10-7, classified this event as an extremely remote probability, and gave it an acceptable risk level, combined with a major severity level. An occurrence rate of 1 X 10-7 meets the Federal Aviation Regulations (FARs) certification requirements. Additionally, an acceptable level of risk does not require further tracking of the hazard in the Federal Aviation Administration (FAA) Hazard Tracking System. Consequently, other than flight data analysis and valve examination, the manufacturer has not taken further action following the 11 known nose-gear steering rate-jam events that have occurred over the past 21 years.

Rate of occurrence determines whether a manufacturer needs to take safety action. In order to determine the rate of occurrence, there is a need to capture as many events as possible. This capture allows identification of possible safety deficiencies, and aids in the application of risk-mitigation strategies. Since no defences have been put in place to mitigate the risk of a runway excursion following a rate jam, damage to aircraft and injury to aircraft occupants remains a possibility.

The present known low rate of nose-gear steering rate jams may be explained by the fact that, directional control difficulties on take-off or landing would not often result in an excursion and/or damage or injury, and therefore would not be reported. The lack of reporting may also be due, in part, to the fact that operators, flight crew and maintenance personnel have not been made aware of the possibility of rate-jam events, nor have they been provided information on how to recognize, react or troubleshoot. The rate of occurrence would have to show a significant increase to validate corrective action, as safety action is based on FARs certification and in-service fleet following requirements.

Despite technological advancements in recording devices, many Boeing aircraft do not record nosewheel steering system parameters. Boeing models affected include 707/720, 727, 737, 747 (some models), 757, 767, and 777.

The cause of these low-slew, nose-gear steering rate jams over the past 21 years remains uncertain. A lack of recognition and reporting prevents adequate data collection, analysis, and implementation of risk-mitigation strategies if necessary.
The Board is concerned that, in the absence of information as to the cause of uncommanded steering events due to nose-gear steering rate jams, there remains a risk for runway excursions to occur.
The safety action section shows the benefits or flow on affect of compiling worldwide information, including the ATSB review and draws attention to a possible safety issue on B737 aircraft that will now be noted (at least) on the TSB database. It also reinforces the ICAO/FSF initiative to create a Runway Excursion Database.

So the question is can our bureau recover from the Beaker years and return to some of its former glory as a proactive AAI organisation at the forefront of contributing to aviation safety worldwide, or are we to continue with these politically correct, fiscally accountable, dribble of reports that have no substance or relevant safety recommendations attached?? If it is the latter then industry and taxpayers deserve a refund and our once proud safety watchdog should be disbanded! Minister it is your call but please take account of the disturbing findings in the PelAir inquiry and action a government response to the partisan Senators recommendations ASAP…:rolleyes:

PAIN_NET

8th Nov 2013, 21:37

2008 AART - Recommendation 1: The Minister and CASA commit to achieving completion of the development of the priority Regulatory Parts by submitting all drafting instructions to OLDP by the end of 2008 and full implementation of these Parts by 2011.
2008 Senate - Recommendation 2 The committee recommends, in accordance with the findings of the Hawke Taskforce, that CASA's Regulatory Reform Program be brought to a conclusion as quickly as possible to provide certainty to industry and to ensure CASA and industry are ready to address future safety challenges.
2011 Senate – Recommendation 4 (2.281) The committee recommends that Civil Aviation Safety Regulation (CASR) Part 61 ensure that all prospective regular public transport (RPT) pilots be required to complete substantial course-based training in multi-crew operations and resource management (non-technical skills) and human factors training prior to, or in reasonable proximity to, initial endorsement training; the committee recommends that the Civil Aviation Safety Authority (CASA) expedite, and assign the highest priority to, the implementation of CASR Part 61.
2011 Senate -Recommendation 7 (2.288) The committee recommends that the Civil Aviation Authority (CASA) expedite, and assign the highest priority to, the implementation of Civil Aviation Safety Regulations (CASR) Part 141 'Flight Training Operators' and Part 142 'Training and Checking Operators'.
2011 Senate -Recommendation 10 (3.146) The committee recommends that the Minister for Infrastructure and Transport provide a report to Parliament every six months outlining the progress of the Civil Aviation Safety Authority's (CASA) regulatory reforms and specifying reform priorities, consultative processes and implementation targets for the following 12-month period.
2013 Senate - Recommendation 13 (6.58) The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.
The ever more pressing need for the regulators to complete the 25 year gestation of the Australian regulations is most clearly apparent in safety recommendations from coroners, ATSB and industry, held in abeyance, dependent on the reformation. Lockhart River occurred in 2005, since then many coroner recommendations have relied on promised reforms to the pertinent regulation. Reformed regulation to minimise as far as legislatively possible, the percentage chances of accident reoccurrence. This has not transpired, despite scores of recommendations related to fatal accidents. Further, there is an almost complete lack of educational information distributed which may, from the lessons learnt, prevent a future occurrence.

"K" – I have persuaded P1 to release the draft notes of one contribution made to a final report being prepared. I regret the 'Venn' report cannot be provided. I am asked to remind all that the document provided is not to be relied on legally, is only a draft of working notes, remains unedited (unaccredited) and is provided solely to promote discussion. It has been parked on Zippyshare, usual caveats. DOWNLOAD NOW button only, click once to avoid the spam etc.

Working draft – Coroner inquiry. (http://www29.zippyshare.com/v/90135155/file.html)

P7. a.k.a. The Old Man (TOM)....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/wink2.gif

Centaurus

9th Nov 2013, 11:17

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers

Interesting observation re the vast experience needed nowadays to write a report. I am sure it has changed now in the RAAF but during my time there in another era, accident investigations were over and done with within one month to three months.

Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could.

One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around.

Kharon

9th Nov 2013, 19:51

C#35 –"One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around."

I'm always surprised that the fundament hasn't given up the uneven battle and collapsed, given the number of escape tunnels dug. The acquisition of 'wriggle room', safe cocoons, legal escape pods: etc. It's an art form now, applauded, rewarded and actively encouraged by the experts above. Circuit breakers of the world united.....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/pukey.gif

Old Akro

9th Nov 2013, 22:07

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.

It takes years of experience to apply a wind vector as a tailwind before & after a 180 deg turn? Or produce different wording for the transcripts of radio calls between the initial, preliminary and final reports?

Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review.

Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports.

This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k.

Kharon

10th Nov 2013, 18:26

OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).

"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.

The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.

I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.

When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.

It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.
The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..

Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did.

Senator FAWCETT (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees/commsen/98f7b3fb-d58d-4773-88bc-1abd63ed7d6a/0003;query=Id:%22committees/commsen/98f7b3fb-d58d-4773-88bc-1abd63ed7d6a/0000%22): Does this report make any recommendations for improvements?

Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.

Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.
I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions....

Sarcs

11th Nov 2013, 02:15

In all the 'white noise'...mumbling and stumbling of mi..mi..mi Beaker:yuk: and the shear arrogance and blatant Sociopath behaviour of the DAS := in the AAI inquiry, you kind of forget about the worthy contributions from 3rd parties.

Geoff Klouth in representing AIPA was one of these and he gave a rather unique perspective as he is an operational Captain and a former Senior Transport Investigator with the ATSB.:D

However I think GK's contribution in a 'private' capacity at the pilot training inquiry was more noteworthy. Shame:ugh: his contribution, along with many others, was white washed by Albo's Great White Elephant Paper (the GWEP)..:{

So for Kharon's benefit, & anyone who is interested, here are some links to highlight GK's contribution to the last 2 inquiries...:ok:

Rural and Regional Affairs and Transport References Committee - 22/10/2012 - Aviation accident investigations (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Fcommsen%2F98f7b3fb-d58d-4773-88bc-1abd63ed7d6a%2F0003;query=Id%3A%22committees%2Fcommsen%2F98f 7b3fb-d58d-4773-88bc-1abd63ed7d6a%2F0000%22) – AIPA Hansard

RURAL AFFAIRS AND TRANSPORT REFERENCES COMMITTEE - 15/02/2011 - Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;adv=yes;db=COMMITTEES;id=committees%2Fcommsen%2F 13622%2F0001;orderBy=date-eLast;page=1;query=Dataset_Phrase%3Acommsen%20Date%3A01%2F05 %2F2010%20%3E%3E%2031%2F12%2F2011%20Dataset%3AcomSen,estim) – Geoff Klouth Hansard

Mr Geoff Klouth (PDF 51KB) (https://senate.aph.gov.au/submissions/comittees/viewdocument.aspx?id=58e45bae-0f41-4809-b0a9-62870f0d2577)
Supplementary Submission(PDF 43KB) (https://senate.aph.gov.au/submissions/comittees/viewdocument.aspx?id=f66cc9d1-5e31-4084-b439-ffe4b702f248)

Pilot training and airline safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 (http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Rural_and_Regional_Affairs_and_Transport/Completed%20inquiries/2010-12/pilots2010/index) – Inquiry page.

Up-into-the-air

11th Nov 2013, 02:16

Here is another "quality" report by atsb - Just released (http://vocasupport.com/?p=2357)

Worth the $150K sarcs??

T28D

11th Nov 2013, 03:29

That is about an hours work, really sad that the ATSB is reduced to this level of reporting.

Kharon

11th Nov 2013, 03:41

K Bills "The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety."
Kym Bills (http://au.linkedin.com/pub/kym-bills/30/540/7bb)- Current
· Chair at Australian Centre for Natural Gas Management
· CEO at Western Australian Energy Research Alliance
· Board member at National Offshore Petroleum Safety and Environmental Management Authority

I wonder if he ever looks back at what he built, probably not. Come home Kym – all is forgiven;your Mum's worried, the dog won't eat, the cat's out of the bag and there's hell to pay with the Senate. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/wink2.gif

Sarcs

12th Nov 2013, 03:47

To be fair to the ATSB the two (best described as desktop investigations) ****e reports under the spotlight were both part of the October edition of the short investigation bulletin (Aviation SIB – Issue 23 (http://atsb.gov.au/publications/2013/ab-2013-166.aspx)). I should clarify I do not question the bods on the ground that they are only doing what they are told, with the allocated (limited) resources given to them. However I am very sceptical about the true motives behind the ATSBeaker short investigation process??

Maybe Old Akro has hit the nail on the head…“The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.”

So what exactly is the bureau methodology behind the short investigation process?? Ok if you refer to the ATSB page Terminology, investigation procedures and deciding whether to investigate (http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx) and under Background it says…

“Following the initial assessment of a notification, a decision is made whether or not to conduct an investigation. Some occurrences may be subject to a limited scope Short (http://www.atsb.gov.au/publications/safety-investigation-reports.aspx?mode=Aviation&disp=L5) fact gathering investigation. These short investigations are published periodically in Short Investigation Bulletins (http://www.atsb.gov.au/publications/publications-list.aspx?publicationType=Aviation%20Short%20Investigation%2 0Bulletin), which include about 10 individual reports each issue. Refer to the investigation levels in Classifying (http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx#fn2).”

….then under Classifying and the heading ‘Three Ways to action’ it goes on to say..

“2. A report of an occurrence that may not warrant a full investigation but which would benefit from additional fact gathering for future safety analysis to identify safety issues or safety trends.”

…further down the page under ‘Pros and cons of the second approach’…

“The advantage of the second approach is that a richer data set for a greater number of occurrences is generated with minimal resource overhead which, in turn, is likely to result in improved future research and statistical analysis outcomes. These short, fact gathering investigations also provide an opportunity to upgrade to a full investigation when the initial fact gathering suggests that the issues are more complex and warrant more detailed examination and analysis.” {Note on above in bold : Wonder how many times that has actually happened??}:confused:

It is worth comparing the difference in methodology for the classification of investigations with the TSB Canada: TSB Canada- (http://www.tsb.gc.ca/eng/lois-acts/evenements-occurrences.asp)Occurrence Classification Policy (http://www.tsb.gc.ca/eng/lois-acts/evenements-occurrences.asp)

Similar methodology perhaps :rolleyes:..but subtle differences in the wording plus the TSB don’t label investigations as ‘short’, ‘long’ or ‘otherwise’ and on the whole their policy is much more straightforward and transparent.:D

Okay so does the bureau system achieve the stated objectives or is it, as OA said above, a matter of bumping up the numbers to meet KPIs?:=

Well without a detailed knowledge of the ATSB database and how the individual short investigations are tagged it is very hard to assess. But going on the wide and varied quality of the short investigations I am somewhat suspicious!!:cool:

My bigger concern though is that this system may mask what could be future or developing significant safety issues. By pigeon-holing a serious incident to a less resourced short investigation, therefore (by definition) a shorter summarised final report, are the ATSB running the risk of minimising what could be in other jurisdictions (internationally) a trending significant safety issue???:ugh:

Hmm..perhaps someone can pick out some examples of the potential for the ATSB investigation classification policy masking significant safety issues from the SIB list??:ok:

ATSB ASIB Archive (http://www.atsb.gov.au/publications/publications-list.aspx?publicationType=Aviation%20Short%20Investigation%2 0Bulletin) (hint a good place to start is item 9):E

Sarcs

13th Nov 2013, 20:31

Section 25A of the TSI Act reads...

"25A Responses to reports of, or containing, safety recommendations

(1) This section applies if:

(a) the ATSB publishes a report under section 25 in relation to
an investigation; and
(b) the report is, or contains, a recommendation that a person,
unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action.

(2) The person, association or agency to whom the recommendation is made must give a written response to the ATSB,within 90 days of
the report being published, that sets out:

(a) whether the person, association or agency accepts the
recommendation (in whole or in part); and
(b) if the person, association or agency accepts the
recommendation (in whole or in part)—details of any action
that the person, association or agency proposes to take to
give effect to the recommendation; and
(c) if the person, association or agency does not accept the
recommendation (in whole or in part)—the reasons why the
person, association or agency does not accept the
recommendation (in whole or in part).

(3) A person commits an offence if:

(a) the person is someone to whom a recommendation is made in
a report published under section 25; and
(b) the person fails to give a written response to the ATSB
within 90 days setting out the things required by
paragraphs (2)(a), (b) and (c) (as applicable).
Penalty: 30 penalty units.

(4) Subsection (3) applies to an unincorporated association as if it were
a person.

(5) An offence against subsection (3) that would otherwise be
committed by an unincorporated association is taken to have been
committed by each member of the association’s committee of
management, at the time the offence is committed, who:

(a) made the relevant omission; or
(b) aided, abetted, counselled or procured the relevant omission;
or
(c) was in any way knowingly concerned in, or party to, the
relevant omission (whether directly or indirectly or whether
by any act or omission of the member)."

Remember this..??:confused: Flight control system event involving Cessna 210N, VH-JHF (http://www.atsb.gov.au/media/4216840/ao-2011-115-final.pdf)

Well...

AO-2011-115-SI-01 - 'time expired' (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-115/si-01.aspx)

AO-2011-115-SI-02 - 'time expired' (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-115/si-02.aspx)

'Tick..tock!':E

Jabawocky

13th Nov 2013, 21:12

I have to agree with T28D, although he is being generous with the hour. Much was a copy and past exercise of others work.

When the insurance assessor arrived on site, the helicopter engine was started and performed without fault. No fuel contamination was found. Other than the damage sustained in the accident, the helicopter was reported to have been well maintained and in excellent condition.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.

Hang on a minute, can I rewrite this in under 5 minutes and let ppruners be the judge of whether my version would make a better conclusion.

When the insurance assessor arrived on site, the helicopter engine was started and performed without fault. No fuel contamination was found. Other than the damage sustained in the accident, the helicopter was reported to have been well maintained and in excellent condition.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.

At the time of the accident, the conditions conducive to carburettor icing existed, and despite the popular myth than an engine will run rough, this is not true if the Fuel/Air ratio's are consistent across all cylinders and simply the engine power is reduced due to a significant loss in mass air flow to the engine.

Safety message to pilots: At the onset of a power loss and noting the insufficient carburettor heat by indication of the instrument, if the non normal state is unexplained, (i.e. heat was applied but instruments show otherwise) treat the instruments as correct and suspect an imminent engine failure, take appropriate measures immediately. Do not continue the flight until the anomaly is resolved.

Safety message to engineers, and pilots: Know your systems and the critical nature of certain elements and ensure they are 100% functional. Trust your instruments

Took 5-10 minutes, and perhaps provides a better safety message.

Another waste of a report, and possibly only achieves one thing, KPI's. Attribution to AKRO :ok:

Jamair

13th Nov 2013, 21:36

So Insurance Assessors do ATSB investigations now?

Old Akro

13th Nov 2013, 22:05

Jaba

You forgot to add..."when in doubt about weather conditions or other operational considerations, call your local insurance representative"

Unbelievable.

What's the bet the insurance assessor is ex CASa or BASI and left because he got sick of the young preppies that didn't know anything.

Up-into-the-air

13th Nov 2013, 22:48

The ABC chopper report has been released

Investigation: AO-2011-102 - VFR flight into dark night involving Aérospatiale, AS355F2 (Twin Squirrel) helicopter, VH-NTV, 145 km north of Marree, SA on 18 August 2011 (http://atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-102.aspx)

Sarcs

14th Nov 2013, 01:06

Not too many surprises there I guess??:confused:

It is interesting that the ATSBeaker have issued yet another SR (AO-2011-102-SR-59 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-102/ao-2011-102-si-02.aspx))to Fort Fumble, that would be 5 for 2013. Considering prior to March (refer here: Safety Recommendations for 2013 (http://www.atsb.gov.au/publications/recommendations.aspx?mode=Aviation&ads=01/01/2013&ade=14/11/2013&mode=Aviation&recommendationType=Interim Recommendation,Recommendation)) there was only one SR issued to FF within the last 5 years, that is somewhat of a world record for ATSBeaker.

Speaking of Beaker just heard him mi..mi..mi-ing on the wireless:yuk::yuk: talking about that particular SR (above)...hmm wonder if he is aware the two mentioned in my previous post have expired???:rolleyes:

Remember this..??http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/confused.gif Flight control system event involving Cessna 210N, VH-JHF (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fmedia%2F4216840%2Fao-2011-115-final.pdf&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions-91%2F)

Well...

AO-2011-115-SI-01 - 'time expired' (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Finvestigat ion_reports%2F2011%2Faair%2Fao-2011-115%2Fsi-01.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions-91%2F)

AO-2011-115-SI-02 - 'time expired' (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Finvestigat ion_reports%2F2011%2Faair%2Fao-2011-115%2Fsi-02.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions-91%2F)

'Tick..tock!'http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/evil.gif

Paragraph377

14th Nov 2013, 11:10

Nice pick up Sarcs. No doubt Beaker is churning out the work knowing for several months now that his mi mi mi empire would end up coming under the spotlight. I'm still looking forward to the Canadians releasing the results of their review next year. Not sure why though as nothing will get done with the findings.
It will be interesting to see the outcome of Truss's initiative next year with the 'independent' review. No doubt the report will be handed to the minister in which the government will respond to each recommendation with 'the government acknowledges that recommendation'. The usual carefully crafted responses in which the government doesn't actually agree to implement any changes, it just acknowledges that changes have been recommended.
Political school of bull**** 101.

Time will tell, but none of this would have been made possible without the growing number of IOS (and don't forget that Mr Truss's international panel of experts will themselves receive the opportunity to earn an honorary place among the IOS), or without the savvy Senators who have refused to allow polish to be applied liberally to the turd.

I would recommend that the review panel spend time with the good Senators and discuss the mystique of Australian aviation with them. I suggest Senator Nash's office, that way they can meet pot plant Pete.

Jabawocky

14th Nov 2013, 11:26

A positive spin.

CASA and ATSB make ASA look outstanding :ok:

Kharon

14th Nov 2013, 19:06

Well, in all probability, the pilot probably stacked the chopper, we probably should have sent the insurance investigator (QBE 1) who would have probably made it probable that the chopper was probably pranged. But no matter CASA will probably redefine "probable darkness" and all will probably be well. But it's probable that we have conned the ABC, probably shut down the probability of bad press, which cannot in any probable cause case, end up with my resignation. Mi Mi "That's a great relief, glad we have the beyond reason probability model and a simpering nodding interviewer who probably swallowed the guff".

Long live short reports, long waits and great KPI bonuses. Thank the gods for the remote control button, new TV's are expensive.

Sarcs

16th Nov 2013, 05:30

Having now read the report (AO-2011-102), scrolled through numerous media articles and video coverage, including the ABC 7:30 report (Report on ABC helicopter crash urges overhaul of regulations (http://www.abc.net.au/7.30/content/2013/s3891292.htm)), I'm quite disturbed by some very interesting parallels coupled with some déjà vu(flashbacks) to episodes in the Senate Inquiry and previous Senate Estimates.:=:=

{Note: The 7:30 vid is well worth watching but warning you'll have to put up with large sections of Beaker fumbling along mi..mi..mi-ing:yuk:. However it is not quite as bad as his appearances at the Senate inquiry/Estimates or the 'head buried in the sand' interview on 4 corners..see here- 4C Beaker interview (http://mpegmedia.abc.net.au/news/fourcorners/video/20120903_Dolan_288p.mp4):ugh::ugh:}

So for a setting the scene here's a quote from the 7:30 Report transcript(my bold):PHILIPPA MCDONALD: The crash and subsequent fire was so intense that Air Transport Safety investigators feared they'd never determine exactly what happened. But an intense two-year forensic investigation uncovered far more than ever anticipated, with vital information provided by the United States Army Aeromedical Research Laboratory.

MARTIN DOLAN: One of the key things they did for us was to feed into some modelling of human perception the flight data that we had for this flight which showed that the sort of increasing bank associated with this helicopter and this accident would probably until very late in the stage not have been detectable without visual reference or without reference to instruments.

PHILIPPA MCDONALD: Investigators believe the pilot experienced what's called spatial disorientation. In the dark of night, with no visible horizon, he couldn't recognise the chopper's spiralling descent in time to recover.

Fellow chopper pilot and friend, David Wilson, knows how spatial disorientation can unhinge the senses.

DAVID WILSON, CHANNEL NINE PILOT: I don't think there'd be a pilot out there today who couldn't say he has never suffered from spatial disorientation. It's a matter of firstly recognising it and then doing something about it because it fights all your senses. You think you're sitting bolt upright, whereas you're actually leaning at 45 degrees.

PHILIPPA MCDONALD: Gary Ticehurst was considered one of the nation's best helicopter pilots and was qualified to fly under the conditions that night. But the Australian Transport Safety Bureau says this tragedy shows aviation regulations need to be tightened.

MARTIN DOLAN: We're saying we're not sure that flight in dark-night conditions, that the standards of safety are necessarily at the level they should be and we're asking the Civil Aviation Safety Authority to take a close look at that.

PHILIPPA MCDONALD: The Civil Aviation Safety Authority says things will change. In future, all helicopters flying at night with passengers will have to be fitted with an autopilot or have a two-pilot crew. This is where the neurons started pinging around, so I then referred to the report and in particular Appendix F – Accidents involving night VFR operations. In table F1 (halfway down the page) there was this entry:

17 Oct 2003
200304282
Bell 407 helicopter, VH-HTD, aerial work (emergency medical services) en route from Mackay to Hamilton Island, Qld. Loss of control en route. Dark night conditions. 3 POB, all fatally injured.

It was then that it all started to gel and drew my attention to a recent post from PAIN post #34 (http://www.pprune.org/pacific-general-aviation-questions/520516-atsb-reports-2.html#post8142320) , that linked to some working notes and this is where it gets interesting :E, from the PAIN notes:
1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003.
Report - R20050002.
Issue date 14 March 2005.
http://www.atsb.gov.au/media/24411/aair200304282_001.pdf
Recommendation R20050002 (http://www.atsb.gov.au/publications/recommendations/2005/r20050002.aspx)
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS
operations.

ATSB Safety Recommendation.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2)
operational procedures and (3) minimum equipment for conduct of such operations at night.
Ok so if you then download the 2003 ATSB report (link above) and put that report alongside the AO-2011-102 report you will see some remarkable parallels..especially in the areas that deal with spatial disorientation and in the Safety Actions/Recommendations section (pg 71 onwards from 2003 report).

{Hmm..kind of makes you wonder why the ATSBeaker needed to rely on the United States Army Aeromedical Research Laboratory when they had already done the hard work back in 2003.}:confused:

On a final note here is a quote from the PAIN working notes from Coroner Henessy's findings/recommendations:
16. The Coroner supports CASR draft regulations point 61 and 133 becoming final.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.
Starting to join the dots??:cool: More to follow..Sarcs (K2):ok:

Addendum:

CASA SRs for AO-2011-102: AO-2011-102-SI-02 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-102/ao-2011-102-si-02.aspx) , AO-2011-102-SI-03 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-102/ao-2011-102-si-03.aspx)

CASA SRs for air200304282: R20040053 (http://www.atsb.gov.au/publications/recommendations/2004/r20040053.aspx),R20050002 (http://www.atsb.gov.au/publications/recommendations/2005/r20050002.aspx), R20010195 (http://www.atsb.gov.au/publications/recommendations/2001/r20010195.aspx), R20030213 (http://www.atsb.gov.au/publications/recommendations/2003/r20030213.aspx).

Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker...27 months was it??:E

Up-into-the-air

16th Nov 2013, 07:51

Good brief sarcs.

The following is the history of the PART 133 [seven years have passed in this one, since the atsb SR] and still not complete, yet casa are loading the industry with a bunch of rubbish regs in this process:

CASR Part 133 – Australian air transport operations - rotorcraft -
Consultation history

Consultation updates in 2012 CASR Part 133 - Consultation Draft of CASR Part 133 - Australian Air Transport Operations - Rotorcraft (http://www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PARTS133) Comments now closed.

26 Jun 2012 Briefing on CASR Part 133 - May 2012 (http://www.casa.gov.au/wcmswr/_assets/main/newrules/parts/133/download/briefing_casr133.pdf) Updated briefing on CASR Part 133 - May 2012

17 May 2012 Consultation updates in 2009 NPRM 0811OS - Passenger Transport Services, International Cargo and Heavy Cargo (above 8640kgs MTOW) - Rotorcraft (http://www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PC_93266) This NPRM is now available.

6 May 2009 Consultation updates in 2008 NPRM 0807OS - Passenger Transport Services: terminology in and application of new CASR Parts 119, 121, 129, 131, 133 and 135 (http://www.casa.gov.au/newrules/ops/nprm/0807os.htm) This NPRM closed for comment on 6 February 2009.

11 Dec 2008 Consultation updates in 2003 NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft (http://www.casa.gov.au/newrules/parts/133/download/nprm0301os.pdf) NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft has been published. Your comments are invited by 30 May 2003.

27 Mar 2003 Consultation updates in 2002 MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft (http://www.casa.gov.au/newrules/parts/133/index.asp) Draft Chapter 11 titled Airworthiness and Maintenance Control to Manual of Standards - MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft, has been published. Your comments are invited.

6 Aug 2002 Consultation updates in 2001 New technical working draft regulations for CASR 133 maintenance aspects (http://www.casa.gov.au/newrules/parts/133/index.asp) CASR Part 133 maintenance aspects of the regulations have been developed and are available for review.

18 Oct 2001 Consultation updates in 2000 DP 0006OS - Commercial Air Transport Operations — Rotorcraft (http://www.casa.gov.au/newrules/parts/133/download/dp0006os.pdf) DP 0006OS - Commercial Air Transport Operations — Rotorcraft response period has been extended to close on 31 January 2001.

6 Dec 2000 DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft (http://www.casa.gov.au/newrules/parts/133/download/dp0006os.pdf) DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft has been published. Your comments are requested by 8 December 2000.

And still not finished

From the atsb site:

Recommendation issued to: Civil Aviation Safety Authority

Output No: R20050002 Date issued: 14 March 2005 Safety action status:

Kharon

16th Nov 2013, 17:25

Can someone make sure the idiot reporters at the ABC get a copy of Sarcs # 53 where he does their job for them, properly and almost writes their story. What a sorry tale ABC investigative journalism makes, how sad that our national "razor sharp" press cannot research and develop a story that is very much in the nations interest. Why would they bother, it's probably more self indulgent and PC to publicly weep and wail over a lost comrade, rather than to try to understand why he's dead, why the ATSB and CASA are full of it and why entire industry is seriously pissed off. Wakey wakey Aunty....:ugh:

I'll stick my neck out and say that the Sarcs post more clearly defines, in one page the need for reform than all the bloody awful polly chatter, CASA waffle and ATSB probability statements ever printed. Nicely played Sarcs, please accept my vote for the post of the year award. Bravo......Indeed, well done sirrah. :D

Sarcs

17th Nov 2013, 01:23

Aw shucks "K"..:O but..but..but I'm not finished yet!!:8

From the Hansard Rural and Regional Affairs and Transport Legislation Committee 23/05/2012 Estimates (my bold):
Senator FAWCETT: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)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: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)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: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)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: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)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: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)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: (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22handbook%2Fallmps%2FDYU%22;queryty pe=;rec=0)Thank you. History will show that the 'Machiavellian One' completely obfuscated the good Senator's question until it was lost in all the 'white noise' of politics and parliamentary process.

That is of course until it was (in part) brought up again in the PelAir inquiry. The committee, with all available evidence presented, considered this enough of a 'significant safety issue' that they wrote no less than 5 recommendations to adequately address:D:
Recommendation 17
9.18 The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18
9.40 The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42 The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44 The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45 The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
The crash of VH-NTV provides the perfect example of why the PelAir report should not and cannot be flippantly ignored..10 years of procrastination and no lessons learnt!:=

The DAS & Chief Commissioner have closed the loop alright, they've closed the loop so that we are insulated from the rest of the world. How many more clearly preventable deaths will there be while these type of individuals continue to bluff the community with the mystique of aviation safety??:ugh: TICK..TOCK!:{

Sarcs

19th Nov 2013, 07:11

Better late than never I guess??:ugh:

Regulatory requirements for class B aircraft maintenance (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-115/si-01.aspx)

Correspondence

Date received:11 November 2013

Response from:Civil Aviation Safety Authority
Response status:Monitor
Response text:With regard to Recommendation AO-2011-115-SR 050 you have recommended that CASA address the safety issue that the Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer's maintenance schedule exists.

You remain concerned that this safety issue may not be adequately addressed and have issued the recommendation that CASA proceed with our program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type.

I accept this recommendation and CASA will address this issue, work has commenced and again it will involve consultation with industry. As this is likely to be a protracted process; CASA is not in a position to specify a specific completion date at this time.:yuk::yuk:

ATSB action in response:The ATSB recognises the acceptance of the recommendation by CASA. The ATSB will continue to monitor the ongoing work by CASA until the issue has been satisfactorily addressed.:E

Paragraph377

19th Nov 2013, 09:49

Sarcs, your post addendum to #44 had me vomiting over the floor and hiding my head ashamedly from public view. That dual response is nothing short of embarrassing, pathetic, and an outward statement of 'we have done bugger all, intend to do bugger all, so you can all bugger off'.
If that is the best that the CAsA and ATSBeaker have to offer then we are overwhelmingly in deep sh#it.

Creampuff

19th Nov 2013, 19:22

With regard to Recommendation AO-2011-115-SR 050 you have recommended that CASA address the safety issue that the Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer's maintenance schedule exists.Nooooooooooooo. :ugh::ugh::ugh:

Whoever made and supports that recommendation obviously had and have no clue what the CASA maintenance schedule and manufacturers’ maintenance schedules actually contain and require, in the context of the regulatory framework of which they are part.

Sunfish

19th Nov 2013, 19:37

Medal is simply a larger version of beaker. They both believe safety issue can be dealt with by managing them until they vanish under a pile of regulatory BS.

Kharon

20th Nov 2013, 01:43

Estimates Hansard (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Festimate%2F1f4a327 c-3a86-4515-9374-f9c0518e91ae%2F0005;query=Id%3A%22committees%2Festimate%2F1f 4a327c-3a86-4515-9374-f9c0518e91ae%2F0000%22) – 18/11/13. P.71 PDF - P. 67 Hansard.(My bold)

Senator FAWCETT: You recently released a report about the crash of the ABC helicopter, which I commend you for. I am a little disturbed when I look back at the report about the helicopter that crashed off the Queensland coast some years ago—basically it was a controlled flight into water, with the understanding that there had been disorientation. Very similar recommendations came out of that in terms of changing the regulations to look at either augmentation of stability systems or two crew, et cetera. What gives you confidence that we will see action in response to this latest report when clearly nothing occurred in response to your last report? Here is where the pictures were brilliant – Now, I don't know whether the poor man had wind, or if the bloke alongside has just let rip. But I got a top screen shot of his face, (I regret NFP here). The print, now a glossy, framed 8" x 10" is hanged (yes) behind the bar of the BRB favourite water hole; priceless. But I digress:-

Mr Dolan: What gives us increased confidence is that Civil Aviation Safety Regulation part 133 is almost in place and involves for passenger carrying air transport operations a requirement for an autopilot in helicopters.

Mr Dolan: Not under the regulations as they stood at the time, but we are also advised by CASA that they are going to redefine the classification of operations, particularly in relation to aeromedical work. We agree. In 2004 we made a recommendation in relation to autopilots for a range of helicopter activities, not just passenger transport. We will continue to watch to ensure that the intent of that recommendation is met through the regulations CASA is putting into place.

Senator FAWCETT: Sure. As I, hopefully, indicated at the start, I fully support your indication; having flown unaided and aided, I can see that there is clearly a safety benefit in that. My concern is that good intentions did not fix it from 2004 and good intentions will not fix it now. I am interested in what concrete actions ATSB are going to take to try to bring either to CASA or to your secretary or the minister an awareness of where these gaps are such that we achieve a safe outcome.

Mr Dolan: Our starting point will be CASA's response to that particular investigation report on the ABC helicopter you are talking about. We certainly want to understand better the new CASA part 133 and what that means not just for passenger operations but more broadly. Depending on what happens with that, the commission reserves the right to make recommendations after receiving responses from various organisations, but we do not have any power to direct any organisation. We only have the power to recommend.

Senator FAWCETT: Chair, can I clarify: in the previous discussion Senator Xenophon was asking CASA for a copy of the advice that was provided to the previous minister?

CHAIR: For which there is no impediment.

Senator FAWCETT: So I relay the same request to ATSB: that we see a copy of the response to the Senate report into the air accident investigation that was provided to the minister.
Well done Pprune, well done Sarcs and Bravo Senator Fawcett......http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif...:D

Oh - Has anyone woken Aunty up yet??.....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/evil.gif

Sarcs

20th Nov 2013, 23:40

ATSBeaker: ATSB action in response:The ATSB recognises the acceptance of the recommendation by CASA. The ATSB will continue to monitor the ongoing work by CASA until the issue has been satisfactorily addressed. The wet lettuce response from mi..mi..mi Beaker got me thinking how do our Canuck counterparts admin and follow up SRs and is it more effective and possibly more transparent???:rolleyes:

To begin with let's compare the two versions of the respective Acts on the subject of SRs.

TSI Act: 25A Responses to reports of, or containing, safety recommendations

(1) This section applies if:

(a) the ATSB publishes a report under section 25 in relation to
an investigation; and
(b) the report is, or contains, a recommendation that a person,
unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action.

(2) The person, association or agency to whom the recommendation is made must give a written response to the ATSB,within 90 days of
the report being published, that sets out:

(a) whether the person, association or agency accepts the
recommendation (in whole or in part); and
(b) if the person, association or agency accepts the
recommendation (in whole or in part)—details of any action
that the person, association or agency proposes to take to
give effect to the recommendation; and
(c) if the person, association or agency does not accept the
recommendation (in whole or in part)—the reasons why the
person, association or agency does not accept the
recommendation (in whole or in part).
Canadian Transportation Accident Investigation (http://laws-lois.justice.gc.ca/PDF/C-23.4.pdf)
and Safety Board Act (http://laws-lois.justice.gc.ca/PDF/C-23.4.pdf) Section 24:
(5) The Board shall
(a) during its investigation of a transportation occurrence, notify forthwith in writing any minister or person who, in the opinion of the Board, has a direct interest in the findings of the Board of any of its findings and recommendations, whether interim or final, that, in the opinion of the Board, require urgent action; and
(b) on completion of its investigation of a transportation occurrence, notify forthwith in writing any minister or person who, in the opinion of the Board, has a direct interest in the findings of the Board of its findings as to the causes and contributing factors of the transportation occurrence, any safety deficiencies it has identified and any recommendations

resulting from its findings.

Minister to reply
to Board
(6) A Minister who is notified of the findings and recommendations of the Board under paragraph (5)(a) or (b) shall, within ninety days after being so notified, (a) advise the Board in writing of any action taken or proposed to be taken in response to those findings and recommendations, or (b) provide written reasons to the Board if no action will be taken or if the action to be taken differs from the action that was recommended, and, in either case, the Minister shall make that reply available to the public.

&
Extension of
time
(8) Where the Board is satisfied that a Minister is unable to reply to the Board within the period referred to in subsection (6), the period
may be extended as the Board deems necessary.
Well on first assessment there appear to be a number of similarities but to my mind the big difference is that the Canucks cut out the middle man and address SRs direct to the Minister...hmm worth noting that?:cool:

Next do the Canucks just accept the responses as given i.e. the wet lettuce approach (above). Well trolling through the TSBC website I came across a news release, although dealing with rail SRs, would seem to indicate that the TSBC is not afraid to name and shame when they're "not happy Jan"! :E: Transport Canada falls short in response to Board recommendations issued from VIA Rail Burlington accident investigation (http://www.tsb.gc.ca/eng/medias-media/communiques/rail/2013/r12t0038-20131115.asp)

Gatineau, Quebec, 15 November 2013 — Citing a lack of firm action, the Transportation Safety Board of Canada (TSB) is concerned there is no clear strategy in place to address the rail safety issues identified by the Board.

Today, the TSB released its assessment of Transport Canada's response to the three recommendations it made following its investigation into the February 2012 VIA Rail Burlington accident (investigation report R12T0038 (http://www.tsb.gc.ca/eng/rapports-reports/rail/2012/r12t0038/r12t0038.asp)). In that accident, three locomotive engineers died and dozens of passengers were injured when VIA No. 92 derailed at a crossover en route from Niagara Falls to Toronto.

“We think the TSB has made a compelling case for these recommendations. They are definitely aimed at improving safety,” said Wendy Tadros, Chair of the TSB. “Two of these recommendations are on our Watchlist (Following signal indications (http://www.tsb.gc.ca/eng/surveillance-watchlist/rail/2012/rail_2.asp) and On-board voice and video recorders (http://www.tsb.gc.ca/eng/surveillance-watchlist/rail/2012/rail_3.asp)) and their implementation will bring down the risk of another accident like Burlington.”

The first recommendation called upon Transport Canada to require physical fail-safe train controls, beginning with Canada's high-speed rail corridors (R13-01 (http://www.tsb.gc.ca/eng/recommandations-recommendations/rail/2013/rec-r1301.asp)). Transport Canada is taking some action to study the issue, but the TSB cautions that this study needs to result in a clear and definitive action plan to ensure trains will automatically slow down and stop when they are supposed to.

While Transport Canada accepted the second recommendation on in-cab video cameras in locomotives (R13-02 (http://www.tsb.gc.ca/eng/recommandations-recommendations/rail/2013/rec-r1302.asp)), it stopped short of requiring them, and instead as with voice recordings, is encouraging voluntary installation.

The TSB believes a voluntary approach does not go far enough and will not ensure that the vast majority of locomotives in Canada will be equipped with essential recorders.

On the other hand, the TSB is optimistic with the proposed action on its third recommendation. Transport Canada plans to start the regulatory process by March 2014, requiring that crashworthiness standards for new locomotives also apply to rebuilt passenger and freight locomotives (R13-03 (http://www.tsb.gc.ca/eng/recommandations-recommendations/rail/2013/rec-r1303.asp)).

“While it is positive that Transport Canada accepts the recommendations,” added Tadros, “Canadians deserve a clear strategy and timely action plan to implement these recommendations.”

The TSB will continue to monitor progress on these recommendations and will reassess them on a regular basis.
So like chalk and cheese I reckon :rolleyes:...hmm Minister perhaps a slight adjustment to the TSI Act could be warranted here??:E

Kharon

22nd Nov 2013, 19:28

But sir, there is no culture of fear in Canada, it's an alien concept: just try to bully or bull**** a Canadian and see where you wind up. Probably on your arse in a pile of bear pooh. They are used to accountability, sane legislation and for the most part, men of good will running the show. The Canucks will need a refresher course on snake pit survival, seeing through smoke, avoiding mirror induced blindness and their own specialist anti voodoo hoodoo protection team.

Yup, I'd love to see our CASA and ATSB try to run Canadian aviation: I truly would. I reckon I'd still be laughing when booze and old age carried me off. It is truly a happy thought....:D

Sarcs

25th Nov 2013, 23:12

It would appear that mi..mi..mi Beaker (ably coached by McSkull and the GWM) has been working on his googly, not only has he mesmerised Aunty but it seems his spin (ozfuscation style) has bamboozled the poms as well...:ugh::ugh:(my bold): Australia tightens rules for helicopter night flying

Australia is tightening up rules for flying helicopters at night following the release of the final report into the August 2011 crash of a Eurocopter (http://www.flightglobal.com/landingpage/Eurocopter.html) AS355F2 Twin Squirrel helicopter at Lake Eyre in South Australia.
Helicopter air transport operations with passengers at night will be required to have an autopilot fitted or operate with a two-pilot crew.

The helicopter, which was carrying a film crew for Australian broadcaster ABC, crashed, killing the film crew, comprising a reporter and cameraman, and well-known and respected helicopter pilot Gary Ticehurst.

The helicopter was conducting a 30min flight after last light and although there was no low cloud or rain, it was a dark night, according to the Australian Transport Safety Bureau.

After take-off, the helicopter levelled at 1,500ft (460m) above mean sea level, shortly after which it entered a gentle right turn and began descending. The turn tightened and the descent rate increased, resulting in it hitting the ground at high speed with a bank angle of about 90 degrees. The crew were fatally injured and the helicopter destroyed.

The ATSB determined that before departure, the pilot had selected an incorrect destination on the global positioning system. After initiating the right turn, the pilot probably became spatially disorientated. Contributing factors were the dark night conditions, high pilot workload associated with establishing the helicopter in cruise flight and probably trying to correct the incorrect GPS input, the pilot’s limited night flying and instrument flying experience and the fact the helicopter was not equipped with an autopilot.

The ATSB identified safety issues with existing regulatory requirements, whereby flights for some types of operations are permitted under visual flight rules in dark night conditions that are effectively the same as instrument meteorological conditions, but without the same level of safety assurance as provided by requirements under instrument flight rules. {Note: Forgot to add that the bureau identified the same issues a decade ago:=}

New regulations being introduced next year will require all air transport flights in helicopters with passengers operating at night to be equipped with an autopilot or a two-pilot crew. While this extends the range of operations required to have such risk controls, the ATSB notes it does not address the situation for other helicopter operations, namely those not carrying passengers.

Now back to the Adelaide Oval where the Poms are all out for 133 :E and mi..mi..mi..Beaker finished up with figures of 2 for 10! :ugh:

Paragraph377

25th Nov 2013, 23:14

New regulations being introduced next year will require all air transport flights in helicopters with passengers operating at night to be equipped with an autopilot or a two-pilot crew. While this extends the range of operations required to have such risk controls, the ATSB notes it does not address the situation for other helicopter operations, namely those not carrying passengers.
The 'fix' is dependant then upon the new regs next year? And what happens when the new 'regs' (as robustly promulgated by our Capital 'R' Regulator) don't come to fruition for another decade?? Which is the norm by the way. The risks remain and life as they say goes on. Good old Beaker and his wet lettuce move on to the next investigation in which CASA will obviously once again escape unharmed if found to be part of the root cause, or at least be found to have inefficient regulations?

As creamy would say 'talk talk talk'. Mi mi mi Beaker and his tautological outcomes, all folly. As for Fort Fumble they don't like those pesky whirlybirds anyway, the more that crash the less there are to regulate!!

Kharon

28th Nov 2013, 21:33

377 -"Good old Beaker and his wet lettuce move on to the next investigation in which CASA will obviously once again escape unharmed if found to be part of the root cause, or at least be found to have inefficient regulations?"

In vainglorious hope that the Pel Air fiasco has been lost in the mists of time. Tick tock and it won't be too long before the piper must be paid. I wonder if this crew is just too dumb to get out of the rain, or like King Canute reckon they can simply stem the tide. I quite enjoy a good mind boggle; but one step beyond boggle, what then??....:D

Sarcs

29th Nov 2013, 21:44

It would appear that McScreamer is testing the waters..here is an excerpt from his latest missive included in the monthly propaganda from Fort Fumble :yuk::yuk:...
"CASA understands and values the importance of our relationship with the Australian Transport Safety Bureau and we {is that a royal "WE"??:(} have processes in place{ that would be the ubiquitous, behind the scenes Mr ALIU :E} to ensure the outcomes of the Bureau’s investigations are carefully analysed and appropriate regulatory and safety actions are taken {or ozfuscated as the need is required}. Any steps that can be taken to further {ozfuscate} develop our relationship with the Australian Transport Safety Bureau, and other aviation agencies, will be positive both for CASA and further buggerise the aviation safety system."

Hmm :hmm:..kind of like saying to the Minister..." WE understand that you've been forced to do this (TASRR) but WE really have it all under control Minister".:ugh:

However there is the small hurdle of the imminent government response to the Senator's PelAir report/recommendations (IOS elephant :E), so in keeping with the theme of the thread here is a gentle reminder of some of those recommendations:D:D: Recommendation 14
7.15 The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:

advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
provide the ATSB with the relevant review report as soon as it is available.
Recommendation 15
7.16 The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.

Recommendation 17
9.18 The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18
9.40 The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42 The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44 The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45 The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
:ok:

OK slight drift...Para377: As creamy would say 'talk talk talk'. Mi mi mi Beaker and his tautological outcomes, all folly. It would appear that McScreamer and Beaker are swapping ozfuscation notes..from DAS speech at Clive's dinosaur park...

"The recent claims made by some sections of the industry appear to compare the standby requirements specified in the new CAO 48.1 with foreign regulators’ airport standby arrangements. However, these are two very different concepts, and comparing them is tendentious and misleading."

Err..Minister a leopard does not change its spots! :ok:

Kharon

30th Nov 2013, 00:39

Err.. Minister a leopard does not change its spots! That's a Yes Minister – not in my jungle they don't. Thing that really gets the elephants panties in a bunch is that the glove puppet actually thinks that anyone, without a lobotomy that is, could believe the constant flow of carefully polished propaganda....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/pukey.gif

Paragraph377

30th Nov 2013, 10:13

Tick tock and it won't be too long before the piper must be paid.Tick Tock indeed :ok: Government cronyism, cover ups, malfeasance and incompetence is a sort of favourite past time of mine. I have experienced it first hand, under two different countries who operate under the Westminster system, so I have an ongoing interest in the rights of the little bloke.

One thing is for certain in Australia this time around, the stakes are higher friends. There are some very serious aviation concerns being raised about Australian aviation oversight by other highly ranked Aviation entities external to Australia. The concerns are of such a nature that for these entities to mitigate, well I will put it this way, it will become a parlous financial blow to the Australian economy. These powerful entities have and are avoiding this potential mess as best as they can, but the length of rope has finally run out.

The other difference at the moment lays with the Australian Senators work. Sure, they have done a pretty good job up til now, and admittedly there have been inquiries before, but thiS time around the CAsA, the former Alabanese and the now Truss have under estimated the veracity of Xenophon and Fawcett, as well as under estimated the Senators determination, will, conscience and intelligence. If people think the situation in Australia has been ozfuscated into the history pages as well this time around, think again. There is a storm front coming that may even shock the most ardent CASAsexual, onlookers or even the IOS!

Watch this space

Jabawocky

30th Nov 2013, 21:48

Maybe I am missing the point here, I confess to only skim reading the last few posts. Tell me how on earth ANY rule changes would have made any difference to that ABC crash, or any other.

Operating under the IFR you still need to take off, and hand fly at least a little bit, and the crash happens in that phase of flight.

The only rule that will prevent crashes like this is to ban night flight in all instances. And we all know how practical that is.

Is this just a media beat up? Did the ATSB suggest something that was….errr dumb? :confused:

Pinky the pilot

1st Dec 2013, 04:00

Thank you,Jabawocky.:ok:

I was wondering much the same thing but thought that I had indeed missed something.:hmm:

VH-XXX

1st Dec 2013, 04:50

Maybe I am missing the point here, I confess to only skim reading the last few posts. Tell me how on earth ANY rule changes would have made any difference to that ABC crash, or any other.

The pilot of the ABC machine was not instrument rated and never had been from a Civil perspective. Unless I am mistaken he also wasn't current by the company's SOP's. Mandating an IFR rating for dark nights or similar, perhaps two pilots minimum would have enhanced the safety of the flight and the outcome.

Sarcs

1st Dec 2013, 05:20

MP1: Media beat up...no IMO Aunty has missed the point!:ugh:

MP2: It is not whether the ATsB SR is good, bad, a total WOFTAM or (ironically) if it would have made any difference to the tragic outcome of the Aunty Chopper accident :{.

Here's a quote from the tail end of my post #53:
Quote:
16. The Coroner supports CASR draft regulations point 61 and 133 becoming final.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.

Starting to join the dots??http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/cool.gif More to follow..Sarcs (K2)http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif

Addendum:

CASA SRs for AO-2011-102: AO-2011-102-SI-02 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Finvestigat ion_reports%2F2011%2Faair%2Fao-2011-102%2Fao-2011-102-si-02.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html) , AO-2011-102-SI-03 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Finvestigat ion_reports%2F2011%2Faair%2Fao-2011-102%2Fao-2011-102-si-03.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html)

CASA SRs for air200304282: R20040053 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Frecommenda tions%2F2004%2Fr20040053.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html),R20050002 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Frecommenda tions%2F2005%2Fr20050002.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html), R20010195 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Frecommenda tions%2F2001%2Fr20010195.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html), R20030213 (http://apicdn.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-3.html&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Frecommenda tions%2F2003%2Fr20030213.aspx&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports.html).

Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker...27 months was it??http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/evil.gif So if the original SR's from 2001, 2003, 2004, 2005 (as listed above) were more appropriately addressed (instead of ozfuscated :=) then the new ATsB SR issued for the ABC chopper crash wouldn't have been necessary and maybe (big maybe:{) this accident may not have occurred...why you ask? Well because the risk of spatial disorientation would hopefully have been highlighted and learnt from, leading to a risk mitigator like for example better SOPs from the operator; or better currency rules from the operator; or incorporated recurrency training for similar scenarios...the list goes on.

Even if the accident still occurred we would still be a decade ahead and looking at other risk mitigators..:ok:

Paragraph377

1st Dec 2013, 10:06

Sarcs, very very succinctly put :ok:
What we often (or used to have) were good ATSB reports and SR's. These on occasion would be followed up by a Coroner recommendation. So now we have two sources recommending changes within a system that failed. Then as the third link in the chain we have..........Fort Fumble. The lazy, laconic, inept ozfucator. They then decide that the ATSB and Coroner recommendations be, dare I say, 'taken on notice'. In other words nothing gets done, and in a lesson in fate, tautology and Groundhog Day the same accident/incident occurs again (for example study the Robbo fuel tank issue and how innocent people have been burnt alive).
In many instances had the 'R'egulator introduced the SR's as recommended by the ATSBeaker or the Coroner, history may have never repeated itself, lives might have been saved, families could have avoided the heartache and pain that they were caused.

So yes, there is a link between rules and regulations and incidents and accidents. Transair at Lockhart is a prime example of how the risks were identified several years before the accident. Fort Fumble ignored the glaring red flags, sat on their collective asses and then ran like cockroaches when all hell broke loose.

Old Akro

1st Dec 2013, 20:47

In November there were 10 new occurrences vs 8 reports released. October was 24 vs 17. September 19 vs 15. So in the last 3 months alone the backlog of reports has gown by 21.

This is a body with 116 employees and an annual budget of about $25m for an average cost of about $150k each. Surely lack of resource is not the reason.

VH-XXX

2nd Dec 2013, 04:21

Would love to know where to find out more.

116 total.

CEO, CIO, CFO and C something... take away 4 or more.

Payroll, admin, reception, legal, hr... hmmm... 15 (conservatively).

Take away 1.5 for maternity leave.

Take 88% of what's left for annual leave and sick leave.

Take away 1.0% that are on long service leave.

Let's conservatively take away 3 more that sit there collating the monthly lists of incidents, following up etc.

116 - 15 - 1.5 * .88 - 1% - 3 = ~80.

Last 3 months of occurences, 10+24+19 = 53.

That's 53 accidents / incidents in the last 3 months that require detailed analysis.

With 7.5 hours in the public service working day across the remaining conservative 80 employees.

80 employees across Aviation, Marine and Rail. 80/3 = 26.

Based incorrectly on 20 working days per month, we have 60 working days across 3 months for the remaining 26 employees....

3,900 man hours per month.
3900 / 53 = 73 hours per incident per person. 73 / 37.5 hours per week = 1.95 weeks....

1 incident per investigator for 2 weeks.

Hardly enough eh?

So many unknowns... I'll bet there are a string of admins that I haven't accounted for and I'd be surprised if those remaining are all of investigator type qualifications. We also don't know the split if aviation versus rail and shipping.

I'm not surprised at your figures then Old Akro.

Would love to know more!

Kharon

2nd Dec 2013, 18:54

Triple X # 76 –"Would love to know more!". Sen McDonald seems to be a bear on the CASA annual report (see the RAAA for comments on the obscene profit margins); perhaps it's time the ATSB was looked at in a similar light. Some old thoughts:-

Everyone enjoys a good story, well told; it is a deeply entrenched part of human kinds development from its origins. Mostly, human beings relate to a clearly defined entertaining story, the lesson or objective of the story is most apparent and easily understood then.

During some of the darker periods in history, it has not been possible for many authors to tell their story in a clear, concise manner thus the message and lesson must be camouflaged and the informed reader must glean the true meaning by being able to interpret or 'read' the subtext and extract the subtle messaging from under the cover of the outer, defensive layers.

Australian Transport Safety Bureau (ATSB) seems an unlikely candidate for this form delivery; their report with the mundane title 200501977 appears to be the least likely candidate to tell a story which has all the ingredients of a first class thriller. But it has; in spades. Properly read, it provides all the essential elements of a classic; although the purist would decry the lack of a love interest, this is the only element missing.

200501977 contains a modest two hundred and forty six pages which can be skimmed through in about thirty minutes, the readers eyes glazing over somewhere during that period. This is a reader mistake. To properly read the report the reader must first understand the nature of a long running battle between two powerful entities for power, money, influence and kudos. The history of these rival groups is coloured, metaphorically speaking, in blood.

In today's world, the Civil Aviation Safety Authority (CASA) is in the political ascendancy, attracts the media attention, enjoys well filled coffers and basks in the security of public and political confidence. The ATSB is chronically under funded, attracts very little media attention and the general public have only a vague notion that it exists.

And so, the ATSB must be careful to protect it's rice bowl, not rock too many boats and mind it's manners.

How then can the ATSB weave the unpleasant truths about this aviation disaster into the fabric of the public lives, when their very existence is a daily struggle. Their answer is in subtle, cleverly camouflaged writing which, correctly interpreted, inevitably leads the informed reader to the correct answer.

Selah.

Sarcs

4th Dec 2013, 02:02

I wonder if the Canucks (TSBC), while conducting their review of the ATSB, have touched on comparing investigation methodology with this just released TSBC Final Report on a Squirrel accident...

Aviation Investigation Report A12P0079 (http://www.atsb.gov.au/media/4366706/ao-2011-102_final_1_.pdf)

...to the ABC Lake Eyre accident??

AO-2011-102_final_1_.pdf (http://www.atsb.gov.au/media/4366706/ao-2011-102_final_1_.pdf)

Although not perfect in comparison e.g. terrain, day v night etc it does have enough similarities to explore differences in investigative methodology and to review the end result over investigations that were being run over a similar period and timeframe.

NOTE: The following passage from the TSB report is very interesting and also draws some remarkable parallels to the ATSB Final Report and SRs from the 17 October 2003 Bell 407 Cape Hillsborough (http://www.atsb.gov.au/media/24411/aair200304282_001.pdf)accident..:cool:
During the period of January 2000 through May 2012 in Canada, at least12 occurrences involved VFR helicopter flights colliding with terrain in instrument meteorological conditions (IMC). Of those occurrences, 4 involved a loss of control at sufficient height above the surface to result in collision with terrain in an unusual attitude. These 4 occurrences involved 9 persons, 7 of whom were injured, 3 fatally.

Previously, the Transportation Safety Board (TSB) had identified a safety deficiency associated with helicopter pilot instrument flying skills. On 13 November 1990, the TSB authorized the release of the following recommendation (A90-81):Footnote 7 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2012/a12p0079/a12p0079.asp#fnb7)
The Board recommends that:
The Department of Transport require verification of proficiency in basic instrument flying skills for commercially-employed helicopter pilots during annual pilot proficiency flight checks.
On 05 September 2012, the TSB issued the following Board Assessment of Response to A90-81:Footnote 8 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2012/a12p0079/a12p0079.asp#fnb8)
TSB does not dispute TC’s contention that “inadvertent” VFR into IMC events constitute a small percentage of the total VFR into IMC events. However, TSB believes that given the fatality rate of these events, TC’s efforts to date to reduce the causes of VFR into IMC events are inadequate.

Consequently, Recommendation A90-81 concerns itself with refreshing skills, acquired during licence training, which are designed to assist pilots in extracting themselves from a VFR into IMC event. The fact that the majority of VFR into IMC events may be preceded by poor pilot decision making does not diminish the value of maintaining piloting skills intended to deal with such an event.

TC’s response is critical of the 180-degree-turn procedure which is outlined in its TP9982E Helicopter Flight Training Manual. TC explains that, due to a combination of an unstabilized helicopter, a panicked pilot and the inherent difficulty in transitioning to instruments, the successful use of the 180-degree-turn procedure is unlikely. TC’s response suggests that this VFR into IMC situation is exacerbated by the pilot being “without any recency in instrument flight”. TSB understands that the instrument flying instruction as conducted during licence training does not qualify any pilot to fly IFR. However, the training emphasizes that the recommended 180-degree-turn procedure is to be used in an emergency and is characterized as the “safest and most expedient procedure” to transition back to VMC.
TC states that because Canadian regulations do not require day VFR aircraft to be equipped with the instruments necessary to safely fly in IMC, all such aircraft would need to be upgraded to accomplish manoeuvres such as a 180-degree turn. It concludes that implementing Recommendation A90-81 would be prohibitively expensive. TSB appreciates that the instrument flying taught during licence training is designed for a pilot who encounters a VFR into IMC event while flying a helicopter not suitably instrumented for IFR flight. The “basic instrument flying skills”, referred to in Recommendation A90-81, are those taught during licence training which does not require use of an IFR equipped helicopter. Therefore, a universal upgrade of the current day VFR helicopter fleet would not necessarily be required to implement Recommendation A90-81.

TC’s comparison between the U.S. and Canadian commercial helicopter experience operating under VFR into IMC focuses on the limitations of the U.S. air ambulance and a regional sightseeing phenomenon. The FAA’s NPRM, referred to in TSB’s assessment, is entitled Air Ambulance and Commercial Helicopter Operations, and the two referenced NTSB recommendations calling for enhanced training for commercial helicopter pilots resulted from accidents under flat light conditions involving commercial helicopters.

While TC believes there is value in including an instrument flying exercise as part of the licence training, its current analysis sees no benefit in enhancing recurrent training in the manner described in Recommendation A90-81. While it has stated a concern for the fact that 50% of VFR into IMC accidents result in fatalities, it maintains that the status quo in mitigating these risks is the obvious and most effective means of preventing these accidents.

Currently, the risks associated with VFR flight into adverse weather remain substantial and TC has not indicated it plans any action to reduce the risks associated with allowing a non-instrument rated commercial helicopter pilot’s basic instrument flying skills to deteriorate as described in Recommendation A90-81. Consequently the reassessment remains as Unsatisfactory.

Next TSB Action (05 September 2012):
The Board has determined that as the residual risk associated with the deficiency identified in Recommendation A90-81 is substantial and because no further action is planned by TC, continued reassessments likely will not yield further results.
The deficiency file is assigned a Dormant status.

The Canucks have definitely not moved on to beyond all sensible reason and they still heavily rely on past Safety Recommendations i.e. their SR database...:D Hmm now there's a point of difference in methodology!:ok:

Kharon

4th Dec 2013, 18:15

What a pleasure to read the TSB/TC debate; expert opinion and practical negotiated agreement, all designed to prevent recurrent accidents. No waiting 27 months for a response, no 10 year old promises to provide regulatory support, no coroners deceived into making soft, disregarded recommendations.

Sarcs you little gem, you have once again cheered me up. Wouldn't it be nice if someone on the Canuck threads were saying "Gee wiz Martha, those Aussie boys are on the ball".

Heigh Ho.

Sarcs

8th Dec 2013, 22:08

“We have come to a point in time where using common sense, speaking factual truths and asking honest questions have been deemed radical behavior. While in turn, manipulation, thoughtlessness and dishonesty is often rewarded and rules the day.” - G Hopkins

Kharon: Australian Transport Safety Bureau (ATSB) seems an unlikely candidate for this form delivery; their report with the mundane title 200501977 appears to be the least likely candidate to tell a story which has all the ingredients of a first class thriller. But it has; in spades. Properly read, it provides all the essential elements of a classic; although the purist would decry the lack of a love interest, this is the only element missing.
And from the archives of Crikey (2008) a small inconsequential passage of text written by Richard Farmer (no not that Richard Farmer..:rolleyes: ) : Richard Farmer’s political bite-sized meaty chunks (http://www.crikey.com.au/2008/03/26/richard-farmers-political-bite-sized-meaty-chunks/?wpmp_switcher=mobile)

Government and business are not the same. Public administration has gone through a period when governments, Labor as well as Liberal-National, were keen to flick a lot of responsibilities from ordinary departmental administration to what was believed to be a more efficient form based on a private enterprise model. Nowhere was this change more pronounced than in aviation where the once omnipotent Department of Civil Aviation was first merged into an overall Transport Department and then had most of its functions split off into separate corporations. Where once there was a Minister and a Departmental Secretary looking after everything from airports to air traffic control licensing of operators and setting and administering safety standards there are now privately owned airports, Air Services Australia with an eye to its profitability and failing to provide adequate numbers of air traffic controllers, a Civil Aviations Safety Authority setting the rules and regulations and an Air Traffic Safety Bureau still in the Transport Department headed by a chief executive with considerable independent powers. That there is a downside to all this deregulation and private enterprise methods is wonderfully (or should that be horribly?) illustrated in the recent report by Mr Russell Miller into the relationship between CASA and ATSB. The Miller inquiry followed critical comments made by the Coroner in his consideration of the Lockhart River aircraft crash and the report released by the Minister for Infrastructure, Transport, Regional Development and Local Government Anthony Albanese is quite an indictment of how badly the split system actually works in practice. A sensible Minister would put the whole system back under his own departmental control.
Sarcs quote: "Err...no comment!":ok:

VH-FTS

12th Dec 2013, 06:51

The latest round of short investigation bulletins are out. Some are hardly worth a mention, others more serious. The common thread is no real advice, feedback or suggestions are given by the ATSB.

Meanwhile, this one was due to be released in September, but still nothing...

Investigation: AO-2012-024 - Wheels-up landing involving Fairchild SA227-AT (Metro), VH-UZA, Brisbane Airport, 15 February 2012 (http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-024.aspx)

Word on the street this accident was handed over by the ATSB to the organisation involved to investigate themselves. The cause was determined within a day, yet over 18 months on still no mention about why we were all fecked around that morning.

Paragraph377

12th Dec 2013, 10:00

What folly. So 18 months after a Metro goes wheels up at Brisbane there is still no finalised report? Typical of the now incompetent ATSB. No deaths, no hull loss, yet 18 months roll by.
In comparison, just for fun, a NTSB report below. A DC-10, Dallas, almost 30 years ago, complete hull loss and 134 dead. Investigation completed in approximately 12 months!
I know you can't compare apples with oranges but FFS, it is still an unbelievable difference don't you think?

http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR86-05.pdf

Sarcs

17th Dec 2013, 10:24

Phearless Phelan has rehashed a classic article covering the 'other' side of the fence take on the causal chain of the Whyalla tragedy...:D: Hot Spots – Whyalla accident revisited (http://proaviation.com.au/news/?p=1912)

Now most would agree that the ATSB Whyalla investigation was (prior to 2008..:E) not one of the bureau's finest hours in AAI..:ugh: It was also probably about the time that FF began to believe they were untouchable when it came to heavyhanded enforcement action post accident/incident. It was also probably the start of their standard modus operandi of burying an unfavourable third tier operator (LCRPT/Charter)..:{ PP article quote: In a post-accident pattern of behaviour now familiar to the general aviation industry, the Civil Aviation Safety Authority (CASA) launched a series of post-accident “special audits,” interviewing various individuals including a former chief pilot (who had been dismissed six weeks earlier for alleged misconduct not related to his aviation duties); the chief pilot of another operator; and the bereaved partner of the deceased pilot.:yuk::yuk: You can read the rest of the text on FF's actions/shennanigans...best summed up by stating.."GROUNDHOG DAY!" :=

But I diverge...at the tailend of the PP article there is a link which takes you to a critique/analysis of the ATSB Whyalla report, plus a couple of more plausible scenarios for the accident itself:

Pelican's Perch #57: (http://www.avweb.com/news/pelican/182152-1.html?redirected=1)
The Whyalla Report — Junk Science? (http://www.avweb.com/news/pelican/182152-1.html?redirected=1)

Many on here have probably read, or can vaguely remember reading..:E, this John Deakin article but for old time's sake it is well worth refreshing the memory. Needless to say (with a title like that) Deakin does not hold back in lambasting the ATSB final report...:=: In December, 2001, the ATSB (Australian Transport Safety Bureau, similar to the U.S.'s NTSB) published one of the worst accident reports I can remember reading.

In my opinion, the ATSB has taken junk science, pure speculation and profound ignorance to levels seldom before seen. They have not only perpetuated "Old Wives' Tales," but they have invented a few new ones. I'm afraid we'll be hearing about "lead oxybromide deposits" for all eternity. As best I can tell, that term seems to have been INVENTED in this accident report. (Try a search on the Internet for "lead oxybromide"!)
So here is a thought..:confused:..maybe, at the time, the bureau had got too big for its boots?? And then after the resounding pizzling they got over Whyalla followed by their subsequent back-peddling on the Final Report conclusions we had set our safety watchdog on the downward spiral to today's insipid...'beyond all sensible reason' (BASR..:E)..politically correct..penny pinching...lapdog bureau that we have today!

Food for thought: Hmm..maybe if they had swallowed their pride, spent some money and called in the experts we would still have a credible AAI??:ugh:

Paragraph377

17th Dec 2013, 10:50

Sarcs, interesting thought provoking post, and an interesting Phelan article.
I am a bit of a fan of the old bureau days and particularly Alan Stray and Kym Bills, so out of my own general interest I might look around the chook shed to see if any light can be shed on the 'poor investigation'. There could be some valid reason (or non valid reason), a root cause even, for why an investigation pissed off the Coroner so much? As an example, although I have great respect for the NTSB, I have seen surprising reports, some quite crappy in fact, come out of investigations which one could classify as being 'sensitive', or 'political hot potatoes' := I am not alluding to anything untoward by the ATSB, but most certainly 'every action has a reaction', and if the Whyalla report was not of a standard commensurate with the bureau's normal and regular capabilities, quality and high standards then there must be a reason. Perhaps the answers are out there and a little spade work and digging from a different angle and depth is required??

Incidentally, from another thread relating to the Tiger Moth crash off beautiful Straddie, it appears mi mi mi Beaker has opened his ATSB jam jar just a fraction and is providing a few cents more than he normally would for the investigation process to be a little more 'robust'. Perhaps the well manicured bureaucrat is trying to avoid the tendentious commentary he received after the Hempel and PelAir fiasco's? Or maybe the Canucks are out here still and have been advising Beaker on how to conduct a mi mi mi investigation?

Jabawocky

17th Dec 2013, 10:56

No…..Quite simply the ATSB and for that matter CASA have virtually NIL knowledge and understanding of piston engines and their fleet operations.

I doubt this has improved since the Whyalla crash.

I strongly suggest you read the George Braly evidence provided to the SA coroner.

I would suggest you go see Doug Sprigg at Arkaroola re this topic. I suggest also ask why did CASA shut down a engine shop who was about to provide evidence to the coroner over a couple of paint tins in the back of a cupboard that were past their use by date? Funny, they dropped all claims after the Ada Oklahoma evidence was presented.:hmm:

Funny thing CASA / ATSB could not block that.:hmm:

Coincidence? Surely not. Maybe I had too many rums on board when I was educated by Mr Sprigg. But given the victim of such strange action is now a colleague and friend of mine, the dots are lining up.

Smoke=Fire they say.

Paragraph377

17th Dec 2013, 11:22

Very god post Jabba :ok: See folks, it doesn't take long when looking at these matters, even briefly as I have, to see the dazzling effects of a CASA circus show!
Very interesting Jabba, interesting indeed mate. And yes, I do see a lot of 'smoke' surrounding this case.

Jabawocky

17th Dec 2013, 11:50

Study and study harder……. lost more to find.

To be fair, it was not all that hard for ATSB and CASA to bluff their way out of it. Who was there going to do the critical thinking and challenge the BS presented. Sir Doug (deserves a knighthood for this and many other things) singlehandedly exposed the can of worms. History of this would be very different had he not.

I would like to write a book on it, and I best do so in the next year or three while folk remember what happened. I might sell 300 copies even. :}

When I bought JD's ticket earlier this year for a trip down under we joked about a fake name….just so he could sneak into Oz undetected by ATSB/ CASA. At the first course one CASA guy was there, but fortunately he was one of the good guys :ok: We seriously joked about it……I am sure there are some that wish that article never saw the light of global aviation media day.

Kharon

18th Dec 2013, 00:10

Jabba #82 –"Study and study harder……. lots more to find.

To me, it's not the finding as much as how the interpretation is framed. Compare the Pel Air and Whyalla "investigations" and three points shriek at you.

Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'.

The industry would be placed at an increased risk level by accepting and following the 'expert' results.

The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk.

It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away.

Strewth. I'll have a pint of whatever he's drinking; must be bloody good stuff.

T28D

18th Dec 2013, 00:23

Bringing JD out here was a stroke of genius, it is difficult for the alphabet soup ATSB to deny factual evidence from internationally recognised experts no matter how hard they try to obfuscate.

Jabawocky

18th Dec 2013, 02:24

Thanks T28D, but that was for the launch of Advanced Pilot Seminars Australia, not anything to do with ATSB.

George on the other hand did come out here about 7 years back……he must have been ducking and weaving too :}

They were a team effort, George with the Dyno data, and JD with the mightier than sword pen! Great result though! And Doug Sprigg (Sir Doug ;) ) should not be left out of that either.

T28D

18th Dec 2013, 06:24

Just the fact JD was here would grab their attention

Jabawocky

18th Dec 2013, 10:26

It should, but you are smart enough to know that it might be expecting a bit much ;)

Sarcs

19th Dec 2013, 01:16

Jaba: I strongly suggest you read the George Braly evidence provided to the SA coroner.
Yes it is a fascinating read and it was duly noted by the Coroner and ended up being the basis of his very damning findings into the actions, inactions/obfuscation in regards to the ATSB, CAsA and their involvement in the Whyalla crash investigation.

Couple of passages from the Whyalla Coroner's report (http://www.airsafety.com.au/whyalla/d724find.htm) : 12.80. Mr Braly outlined his opinions about the sequence of events leading to the ditching as follows:

'The following is a short summary of the sequence of events that, based on known hard engine operating data and the known objective findings surrounding the fatal crash, is what most likely happened in connection with this fatal crash:

1) The left engine crankshaft failed. The cause appears most likely to be related to improper installation of the connecting rod on the number six cylinder.

2) The pilot feathered the left engine and increased the manifold pressure on the remaining right hand engine from a normal 30" to some larger value in the 34 to 40" MP range. The pilot most likely failed to also increase the mixture on that engine to a suitably rich mixture.

3) The indicated airspeed (IAS) of the aircraft was reduced due to the left engine being feathered and the loss of nearly 50% of the previous available cruise power. The combination of the lowered cruise speed and the increased power on the right engine left the right engine in an environment very similar to a "climb condition". That is, the engine was enjoying minimal cooling air flow due to the reduced cruise speed and suffering from higher than normal power settings, both of which are typical of operating conditions encountered during routine climbs.

4) The crucial operational error was the likely failure of the pilot fully (or adequately) to increase the mixture on the right hand engine during this engine out cruise condition. Had the pilot simply and properly increased the mixture during this critical phase of the flight, as normal training and good engine operating practices would dictate, the right engine would not have failed and the aircraft would have, more likely than not, continued to a safe landing at Whyalla.

5) Something as simple as a small excess overhang of a helicoil tang at one of the spark plugs in cylinder 6 of the right engine could have dramatically increased the susceptibility of that cylinder to pre-ignition. The photographs in the ATSB report do not detail this area of the cylinders in sufficient detail to evaluate this not uncommon cause of pre-ignition.

6) One can readily demonstrate that even a newly built or overhauled TIO-540J2B engine, in perfect mechanical condition will, under the conditions described in paragraphs 2-4 above, operate in light to medium detonation and if left unresolved, that light to medium detonation will steadily raise the cylinder head temperature to the point that pre-ignition begins. After the pre-ignition begins, the engine will suffer catastrophic failure, usually within a matter of one to five minutes, unless the pre-ignition is promptly corrected. The author of these comments invites an appropriate representative of the ATSB to visit the author’s test facility and to observe the operation of the TIO-540J2B engine in any combination of power and mixture settings desired, in order to verify each and every observation about the operation of that engine described in these comments.

7) Notes:

a) The various different cruise mixture settings used by Whyalla and the other operators of these engines described in the ATSB report had no effect what so ever on this crash. At the reported normal cruise power settings, it is virtually impossible to cause one of these engines to detonate or pre-ignite, if the engine and the associated ignition system are in proper operating condition.
b) The climb mixture settings used by Whyalla (as distinguished from the descriptions of the power and mixture settings used by all other operators surveyed by the ATSB) were highly improper and likely caused one or more cylinders on both engines to frequently operate in light or medium detonation during portions of each climb.
c) The description of "deposits" on the pistons set forth in some detail in the report is essentially unrelated to any aspect of the cause of this crash. This extended pursuit of this subject is largely a red herring. For example, the deposits such as are described and displayed in the limited photographs in the ATSB report appear, from those photographs, in actuality, to be rather more accurately described as minimal as compared to most engines with similar operating time. In fact, they generally appear to be so minimal as to support the notion that the Whyalla engines were, in fact, frequently operating for short periods of time (probably during climbs, given the reported Whyalla engine operating technique during the climb phase of flight) in light to moderate detonation and this periodic condition actually cleaned the piston domes of some of the otherwise normal deposits. A better collection of photographs of the pistons and cylinder domes would provide still more accurate information on this subject.
d) In common pilot & mechanic operating terminology, when one "leans" the mixture, one reduces the ratio of fuel to air via use of the mixture control. However, when one thus "leans" the mixture to a condition that most pilots and mechanics would routinely call a "lean" mixture, the mixture remains a stoichiometric rich mixture. (The mixture is chemically a rich mixture until the exhaust gas temperature - - as indicated by the turbine inlet temperature gage [sic] during gradual reductions in fuel flow, - - has reached a maximum value and started to decline.) The confusing terminology in this area is responsible for an enormous misunderstanding in the pilot and mechanic community of the true implications of chemically rich and lean mixtures with respect to the operation of high powered piston aircraft engines. At one point, the ATSB report on this crash attempts to accurately define these terms, but then, in other areas, fails to accurately apply the correct terminology to the operation of the engines in question, and thus, compounds the confusion for pilots and mechanics who may read the report.

In its criticism of the routine use of so called "lean" mixtures, the ATSB fell into the common trap of mis-characterising stoichiometric "rich" mixtures as being "lean" mixtures. Worse, the lay press has grabbed onto this aspect of the report and has compounded the confusion in this area with published reports that completely mischaracterize the issue, blaming the crash on the use of "lean" mixtures, with an express or implied suggestion that the airline operators of this type aircraft were trying to skimp on fuel in order to save money at the expense of operating safety. (C196a, p4-6)
Some of Braly's findings etc (as stated above) were revised somewhat, after some of the assertions and conclusions made in the original ATSB final report were proved to be distorted and not entirely based on fact...:ugh:. However the basic premise of Braly's review was largely applauded by the Coroner and enabled him to totally debunk the ATSB Final Report conclusions in regards to the reasons for the catastrophic double engine failures of VH-MZK.

Mr Braly's hypothesis for the causal chain from the time VH-MZK diverged right reads very similar to John Deakin's analysis article: Reference pg 140 para 12.93:
'At the point where the aeroplane diverged right on page 3 at 1847:15, I think the pilot had been wrestling with problems with the right engine since some point in the climb. I believe at about that time he decided to simply throttle the engine. He could do that, and it’s my opinion that at that point in time he had experienced an episode of pre-ignition on the right engine. Whether or not it had already put a hole in the piston is debatable, but he did not, unlike the gentleman that was shown in the recreation of the data yesterday, the benefit of that sort of instrumentation and he would not have likely been able to stop the event before it did damage to the cylinder and, as indicated yesterday, once that sort of thing starts to happen in the cylinder, even if he throttled the engine, if you later reapply power, it’s going to happen again, assuming he had a hole in the piston already.

It is my opinion that the pilot decided simply to throttle the right engine and, in the process of that, the aeroplane yawed to the right slightly. In my experience teaching multi-engine pilots to fly during training, a momentary lapse in the heading control of the aircraft during major left/right power discrepancies is more common than not, even among good pilots, and I think the right-hand turn data is consistent with that, and a prompt re-correction back on course is consistent with him having done that and then retrimmed the aeroplane by use of the rudder trim control and what not to put the aeroplane back on course.

At that point in time the pilot had an unknown problem with the right engine, but it was still operating, and he had a 250- or 260-hour left-hand engine, and he made the decision to continue on. In the process he would have likely pushed up the power on the left-hand engine to something approaching climb power. He may have in fact used climb power - that would be a common training scenario for a multi-engine pilot, that if you lose an engine, you put the other engine up to climb power. That’s not necessarily the most optimal training exercise, but it’s a common method of teaching multi-engine pilots.

So I believe he increased the power on the left engine as he reduced the power on the right engine, and pressed on.

Some time just before 1901:10 when the MAYDAY was transmitted I think the crankshaft failed on the left engine. When the aircraft hit the water the left engine was feathered - I think the left engine would have virtually auto-feathered from the oil pressure loss. The right engine was still turning and not feathered, which is consistent with the previous power reduction.

I think if he had not already had a hole in the piston at the time - 1847:15 - when he throttled that engine, or when he tried to power up the right engine after the failure of the left, that he would have holed it promptly, because it would have gone back into pre-ignition.

It would have been a very confusing and difficult situation for the pilot.

They simply do not train for simultaneous engine failures, and they certainly do not do it at night with a full load of passengers over water.' (T3221-23)
Very sobering indeed...:(

There is no doubt the Coroner's report is a truly fascinating read (if you've got the time..:rolleyes:), but the devil is always in the detail andwith most Coroner's reports that is contained in the findings and recommendations. In the case of Coroner Chivell his findings & recommendations underlined his frustration and consternation with the obvious bungling, obfuscation and disturbing shennanigans by the ATSB and to a lesser extent Fort Fumble. Perhaps this consternation is best illustrated from paragraph 15.5 (pg 181) to paragraph 15.13 (pg 183) {Note: Remembering that this was prior to the introduction of the TSI Act}.

Coroner report quote paragraph 15.10: 15.10. It follows, then, that I reject any suggestion that the ATSB were constrained or limited by section 19CA of the Air Navigation Act, 1920 in this investigation. In my opinion, the remarks of the Director of the ATSB, Mr Kym Bills, to the Australian Senate on 11 February 2003 reflect this misconception:

'For many years there have, from time to time, been difficult issues in some state and territory coronial inquests. The ATSB has been seeking better mutually cooperative relationships with coroners in the context of the legislation currently before the parliament and will continue to do so.

However, problems remain when the bureau is criticised at inquests for not spending more money on a particular investigation to satisfy legal queries such as those relating to future civil litigation; when the high cost of inquests redirects our resources from higher safety priorities; where a particular inquest encounters difficulties with the Commonwealth no-blame legislation; under which we operate in accordance with international agreements; or where legal certainty is sought from an investigation, whereas the evidence often does not allow this and the ATSB’s focus is on the action necessary for future safety.'

The notion that ‘legal certainty’ (by which I assume Mr Bills means the finding of a fact to the requisite standard of proof) is somehow inconsistent with the ATSB’s role to ensure ‘future safety’ is not in accordance with logic. Surely an investigation must demonstrate, to an appropriate degree of certainty, that an incident has occurred in a particular way before remedial or preventative measures can be taken.
Hmm..interesting and what of the Coroner's well considered recommendations?? Have they been embraced by the regulator and promoted by the watchdog...:confused:...well I'll let some one else be the judge of that...:ugh:

IMO another (in a long line) of missed opportunities to advance our learning from a serious accident tragedy and to ultimately enhance aviation safety has been missed...:=:= As Gobbles quite often..:E..said TICK..TOCK!:{:{

Sarcs

21st Dec 2013, 00:46

Kharon: To me, it's not the finding as much as how the interpretation is framed. Compare the Pel Air and Whyalla "investigations" and three points shriek at you.

Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'.

The industry would be placed at an increased risk level by accepting and following the 'expert' results.

The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk.

It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away.:D:D

Whyalla may or may not have been the catalyst for where we find ourselves today but it is now somewhat academic. A couple of recently released bureau reports, plus Kharon's succinct post above, IMO perfectly highlight the current status quo within aviation safety regulation & accident/incident investigation in this country and add further evidence that we are fast approaching critical mass (the holes are aligning)!:ugh::ugh:

First cab off the rank is the prelim report for the wx related 'Serious Incident' (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-100.aspx) involving two 737s diverting into Mildura due fog at YPAD. Link to my post on the subject (incident) on ANZ&P forum: "From the sublime to the ridiculous???" (http://www.pprune.org/australia-new-zealand-pacific/517250-virgin-aircraft-emergency-landing-42.html#post8215002)

In that post I put my thoughts & disgust :yuk::yuk: in fairly plain language on the ATSB downplayed prelim report...IMO truly disgusting for an incident that has enormous implications to the whole industry not just the airline sky gods!:rolleyes:

Perhaps the more understated comment by wildsky (http://blogs.crikey.com.au/planetalking/2013/12/19/are-the-mildura-fog-incident-warnings-being-ignored/#comment-20240) (Ben's article) points to the true potential knock-on effects of the ATSB (dis)missive, prelim report and their future investigation activities into the incident.

...."I guess this “safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally” and the “research study into the unreliability of aviation meteorological forecasts” will be rolled out eventually as the Government response to:
“Recommendation 24
9.106 The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.”
Despite the Chief Commissioner selectively quoting the Bureau of Met’s Norfolk forecasting reliability data to disguise the real and identified risk levels, the reality was that all of the clues were presented to the ATSB and CASA that we had, and still have, a significant operational problem. Mildura, or many other mainland aerodromes, do have lower risks of forecasting errors than remote islands – but the risk still exists and the Mildura event showed just how quickly things can change from risk to actual danger to life and limb.
Safety forums and research studies are what you do when you don’t really want to do anything – they are nice shows of interest but have no weight in achieving change.
Makes me so glad every time I hear “safety is our number one priority”…:D:D

The next report was also covered by Ben, see here: Virgin 737 cleared to fly through paratrooper drop: ATSB (http://blogs.crikey.com.au/planetalking/2013/12/16/virgin-737-cleared-to-fly-through-military-parachute-drop-atsb/)

On the surface this report was fairly reasonable and it would appear that all DIPs have taken on-board the Bureau's concerns and are progressively addressing the significant safety issues. But again the devil is always in the detail which, as we all know, in bureau reports is (usually) contained in the Safety Issues/Actions section. This particular report has led to the bureau (surprise..surprise..;)) actually promulgating two safety issues on their Aviation safety issues and actions (http://www.atsb.gov.au/publications/recommendations.aspx?mode=Aviation) database, see here:AO-2012-142-SI-01 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-142/si-01.aspx) & AO-2012-142-SI-02 (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-142/si-02.aspx)

Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then?? I know..I know it is all about Beaker's touchy, touchy feely, feely, beyond all sensible reason methodology... But it just leaves the man at the back of the room asking.."what else are the hiding??":confused:

Note: Ironically, in the case of the YMIA incident, even certain DIPs (in this case ASA) are still waiting for the ATSB to follow normal accepted practice and submit safety recommendations to frame a ASA MAP (Management Action Plan).

Reference QON 161 AA 02 CHAIR Maintenance of AWIS (Sen Estimates 18/11/13)....

"....Mr Hood: There are over four million aircraft movements in Australia a year, very few of which cause us significant concern. I think it is fair to say this is a concerning incident. We are cooperating fully with the ATSB. It is our hope that the ATSB will establish all of the facts and make appropriate recommendations, on which we will act...."

Unless the Beaker suggestion of having a 'love in'is to be regarded as a serious SR from the bureau, it would appear that Hoody could be waiting a while...:E FFS the bureau in it's present form is a disgrace!:(

More to follow...:ok:

Jabawocky

21st Dec 2013, 03:31

To be honest, Hoody should just go ask some questions of those involved, formulate a plan with those at the coal face, put it in place and move on. Waiting for the ATSB or CASA would be futile and as beneficial as holding ones breath.

I do think he would get it sorted, but if left to others lord only knows. :uhoh:

Paragraph377

21st Dec 2013, 09:33

The ATSB has gone from downright lame to unimaginably pathetic. Now their solution to 'every event of a safety nature' is to have a 'love in' :mad:
So Beaker, should attendees wear name tags as well? Plenty of bowls of lollies on the table as robust tendentious discussions take place, followed by some dry humping of each other's legs, some back patting and star jumps, a game of UNO and a look at some historic Wright Brothers footage? Then it is 'party over, all go home, nothing left to see here'.
I really didn't think it could get any worse (well perhaps Sunfish's smoking hole is worse), mi mi mi Beaker has lost the plot completely.
Please please ICAO, FAA, Communist Party of China, AOPA, anybody really, come in and fix our Aviation system, please!!!

Kharon

21st Dec 2013, 19:34

There have been three important ATSB reports published lately; the slightly hysterical Tiger go-around at Avalon; the secretive Meat bombs v Virgin; and, the Mildura Met Muddle. Each, in it's own way significant. Once you have read and inwardly digested, just for fun, isolate the individual issues into short sentences and see what sort of picture you get and it ain't pretty. Then, if you can stomach it, line up the considered responses aimed at preventing a reoccurrence of any one of the three potentially serious incidents and time line it from start to finish. The question 'have we done enough to minimise the risks?' is nugatory. 'Have we done anything positive in a timely manner at all?, has the ascendancy: the answer being a resounding NO.

The emerging picture reminds me of the Dorian Gray story, written by Oscar Wilde.

Wiki - Realizing that one day his beauty will fade, Dorian (whimsically) expresses a desire to sell his soul to ensure the portrait Basil has painted would age rather than he. Dorian's wish is fulfilled, and when he subsequently pursues a life of debauchery, the portrait serves as a reminder of the effect each act has upon his soul, with each sin displayed as a disfigurement of his form, or through a sign of aging.

“Words! Mere words! How terrible they were! How clear, and vivid, and cruel! One could not escape from them. And yet what a subtle magic there was in them! They seemed to be able to give a plastic form to formless things, and to have a music of their own as sweet as that of viol or of lute. Mere words! Was there anything so real as words?”. Oscar Wilde.

Today's MG Word - Aphorism. [The] term was later applied to maxims of physical science, then statements of all kinds of philosophical, moral, or literary principles. In modern usage an aphorism is generally understood to be a concise statement containing a subjective truth or observation cleverly and pithily written.

Up-into-the-air

21st Dec 2013, 22:03

K

A new form of mi, mi, mi???

ozbiggles

22nd Dec 2013, 09:33

What was slightly hysterical about the Tiger report?
What was secretive about the parachute report?
Have you got anything except your secretive hysteria?

Kharon

22nd Dec 2013, 18:50

Tiger’s A320 could have become a smoking hole in a suburb on this Avalon airport approach in 2011, and for CASA it was the last straw, causing it to ground the airline two days later.

Ben Sandilands is an experienced aviation journalist and commentator not easily fooled. Have a read of the article – HERE (http://blogs.crikey.com.au/planetalking/2013/12/18/safety-report-details-breach-that-got-tiger-airways-grounded/)– in which the procedure used by the Tiger crew is described as "the final straw", causing CASA to ground Tiger. An ATSB report which can con a bloke like Sandilands into writing such an article smacks of mild hysteria. Grab the YMAV VOR RWY 36 (or RNAV as pleases) and run the executed visual approach 'picture' over the approach (remember visual circuit) see how the flight path sensibly intercepts the IAL procedure for 'final'. Then work out where the circling area limits boundary ends and 'circling minima' then have a look at the IAL not below heights. The Tiger approach may 'arguably' be 'subjectively' claimed as technically illegal, but to say 'operationally unsafe' is a slightly hysterical over reaction, IMO used to justify the CASA politically motivated actions.

Sarcs # 94 (http://www.pprune.org/pacific-general-aviation-questions/520516-atsb-reports-5.html#post8226529) –"Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then??

Now –Sarcs #94 – raises issues which may be described as 'secretive'; making the point that as far as anyone knew, there were no SR issued and no procedures developed to prevent the incident reoccurring the next day. Not to say procedural changes weren't made, just that they weren't made public. Once again look at all the factors leading up to what could have been a very serious accident. Maybe it's just me, but a meat bomb through the front wind-screen, cabin or engine would rate as a fairly significant event. Perhaps even demanding an immediate concerted public effort by all parties concerned. The effort may well have happened, but two years (AO-2011-142 - Nov 5, 2011) of waiting to know how the system was changed to eliminate potential meat bomb FOD is just a bit rich of peak.

Sandilands (http://blogs.crikey.com.au/planetalking/2013/12/16/virgin-737-cleared-to-fly-through-military-parachute-drop-atsb/)- ATSB (http://atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-142.aspx)

Anyway OB, that's my two bob's worth; no matter how I choose to express it.

Sarcs

23rd Dec 2013, 05:06

Well Fort Fumble may have knocked off till next year but it appears the bureau boys'n'gals on the coalface are busy working on Beaker's bonus...:E

Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..:cool::
AO-2013-226 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-226.aspx)
In-flight breakup involving de Havilland DH-82, Tiger Moth, VH-TSG, near South Stradbroke Island, Qld on 16 December 2013
16 Dec 2013
Pending
23 Dec 2013

AO-2013-187 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-187.aspx)
In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013
24 Oct 2013
Interim Factual
23 Dec 2013
The fire fighting Dromader tragedy has also apparently led to the bureau generating a Safety Advisory Notice, see here: AO-2013-187-SAN-005 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-187/safety-issue.aspx)

Also released within the last few days was..

VFR flight into IMC involving de Havilland DH-84 Dragon VH-UXG (http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-130.aspx)

{Note: Interesting point that from accident to Final Report only took 445 days:D:D}

This accident has also generated an addition to the ATSB Aviation safety issues and actions (http://api.viglink.com/api/click?format=go&key=1e857e7500cdd32403f752206c297a3d&loc=http%3A%2F%2Fwww.pprune.org%2Fnewreply.php%3Fdo%3Dnewrep ly%26noquote%3D1%26p%3D8229058&v=1&libId=c513a3dd-214b-4dfc-a5fe-100abf10ce79&out=http%3A%2F%2Fwww.atsb.gov.au%2Fpublications%2Frecommenda tions.aspx%3Fmode%3DAviation&ref=http%3A%2F%2Fwww.pprune.org%2Fpacific-general-aviation-questions%2F520516-atsb-reports-5.html&title=PPRuNe%20Forums%20-%20Reply%20to%20Topic&txt=%3CI%20abp%3D%22874%22%3EAviation%20safety%20issues%20an d%20actions%3C%2FI%3E&jsonp=vglnk_jsonp_13877766130626) database: AO-2012-130-SI-01 (http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-130/si-01.aspx)

But in keeping with the Beaker BASR methodology..:ugh: it was only a significant safety issue and no SR was issued.To be fair I guess it is a bit hard to justify the issuance of an SR over a year after the accident...:= (check highlighted dates in following):
Proactive Action

Action organisation:Airservices Australia
Date:19 December 2013
Action status:Monitor

Following notification of the safety issue by the ATSB, on 11 October 2013 Airservices Australia advised that:

In response to the incident, Airservices conducted a managerial review of In-Flight Emergency Response (IFER) procedures. The review identified potential opportunities for improvement relating to the operational interface and transfer of responsibility between Airservices and AMSA [the Australian Maritime Safety Authority] (i.e. ATC [air traffic control] and SAR [search and rescue] aircraft). As a result Airservices and AMSA have agreed to conduct a comprehensive review of the existing MoU [Memorandum of Understanding] to ensure the effectiveness of collaborative Airservices-AMSA IFERs. The review is anticipated to be completed by the end of Q1 2014 [the first quarter of calendar year 2014].

Proactive Action

Action organisation:Australian Maritime Safety Authority
Date:19 December 2013
Action status:Monitor

Following notification of the safety issue by the ATSB, on 14 November 2013 the Australian Maritime Safety Authority advised that:

AMSA and Airservices have agreed to conduct a comprehensive review of their existing Memorandum of Understanding (MoU), including the air traffic service requirements for support from Search and Rescue (SAR) aircraft, to ensure the effectiveness of collaborative in-flight emergency responses. The review is anticipated to be completed during the first quarter of 2014.
AMSA will also update its SAR procedures manual in consultation with Airservices and if appropriate will issue updated guidance on communications between SAR aircraft and the air traffic service.

ATSB action in response:

The ATSB is satisfied that a joint review of inter-agency agreements, with a focus on coordination of in-flight emergency responses and communication, should lead to improvements that adequately address the safety issue. The ATSB will continue to monitor the safety issue.
Ho..ho..ho..Merry XMAS!:ok:

ps err..what vintage is Santa's sleigh maybe his gingerbeer elf and loadmaster elf better beef up their preflight procedures prior to departure??:(

Frank Arouet

23rd Dec 2013, 05:22

QUOTE AMSA and Airservices have agreed to conduct a comprehensive review of their existing Memorandum of Understanding (MoU QUOTE

I wonder who will write this one up?

Up-into-the-air

23rd Dec 2013, 05:44

My bet is mrdack-iooo!!

The big boss hog certainly will run top-cover on this one.

Maybe he will need to dispatch from an airport!!

Sarcs

28th Dec 2013, 04:50

Hmm..has Beaker inadvertently provided us with a template for a future re-modelled ATsB??

Most of us have been dubious (including Senator X #34 (http://www.pprune.org/8233547-post34.html)) of Beaker's real intentions for calling in TSB Canada, whatever his original intentions it has been enlightening to look at how another TSI agency operates.

The TSBC are a no fuss, principled, extremely competent AAI agency that goes about it's business without fear nor favour nor fanfare...:D

In reference to my previous post: Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/cool.gif:
Quote:
AO-2013-226 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-226.aspx)
In-flight breakup involving de Havilland DH-82, Tiger Moth, VH-TSG, near South Stradbroke Island, Qld on 16 December 2013
16 Dec 2013
Pending
23 Dec 2013

AO-2013-187 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-187.aspx)
In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013
24 Oct 2013
Interim Factual
23 Dec 2013
The TSBC recently released a final report into another tragic in-flight breakup accident, that IMO should set the benchmark for the two ATsB investigations mentioned above....:D:D

Aviation Investigation Report A11W0048 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11w0048/a11w0048.asp)

With equal weight the TSBC systematically examine all the possible causal factors (all the holes in the cheese) and end up with the following in their safety action section:4.0 Safety action

4.1 Safety action taken

4.1.1 The Federal Aviation Administration

On 25 May 2011 the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2011-12-02. Effective on 02 June 2011, the AD applied to Viking Air Limited Model DHC-3 Otter airplanes (all serial numbers) that were equipped with a Honeywell TPE331-10 or -12JR turboprop engine installed per Supplemental Type Certificate (STC) SA09866SC (Texas Turbines Conversions, Inc.) and certified in any category.

The AD was prompted by analysis that showed airspeed limitations for the affected airplanes were not adjusted for the installation of a turboprop engine as stated in the regulations. The AD was issued to prevent the loss of airplane structural integrity due to the affected airplanes being able to operate at speeds exceeding those determined to be safe by the FAA.

The AD imposed a maximum operating speed (VMO) of 144 mph for DHC-3 Otter land/ski aircraft and 134 mph (VMO) for DHC-3 Otter seaplanes. Footnote 17 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11w0048/a11w0048.asp#fnb17)

On 19 August 2011 the FAA issued AD 2011-18-11, which became effective on 03 October 2011. The AD applied to all Viking Air Limited Model DHC-3 Otter airplanes that were certified in any category. The AD resulted from an evaluation of revisions to the manufacturer's maintenance manual that added new repetitive inspections to the elevator control tabs. The AD stated that if these inspections were not done, excessive free-play in the elevator control tabs could develop. That condition could lead to loss of tab control linkage and severe elevator flutter, which could lead to a loss of control. Footnote 18 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11w0048/a11w0048.asp#fnb18)

4.1.2 Black Sheep Aviation & Cattle Co. Ltd.

As a result of this accident Black Sheep Aviation established a system that correlates flight duty times to flight ticket invoice numbers. The information is entered on a new flight duty form which is delivered to company dispatch daily and and entered into company Flight Time/Duty Time/Rest Period records daily.

4.2 Safety action required

In June 2012, there were 6957 commercially registered aircraft listed on the Canadian Civil Aircraft Register, of which 5453 (78.4%) weighed less than 5700 kg. Most commercial aircraft weighing less than 5700 kg are operated under CARs subpart 702 Aerial Work and CARs subpart 703 Air Taxi Operations. These operations accounted for 88% of all accidents, 87% of all fatalities, and 82% of all serious injuries involving Canadian registered commercial aircraft in the past 10 years. If accidents involving commuter operations under CAR subpart 704 are added, the number of commercial air accidents jumps to 94% and the number of commercial air fatalities to 95%. Many of the aircraft operated by these companies are not required to be fitted with any type of flight recorder.

These smaller operators face challenging conditions, such as difficult terrain, and typically operate into smaller, more remote airports with less infrastructure. They often fly smaller, older aircraft with less sophisticated navigation and warning systems, which cause higher workloads for crew. Flight crews working for these operators are often working their way up in the system; they may have less training and experience, and often do not benefit from mentors able to pass on their experience.

In contrast, from 2001 to 2012, Canada's large carriers operating under CARs Subpart 705 have had only 1 fatal accident on home soil. Footnote 19 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11w0048/a11w0048.asp#fnb19) These large commercial carriers are required to have safety management systems (SMS), cockpit voice recorders (CVR), and flight data recorders (FDR). Many of these operators routinely download their flight data to conduct flight data monitoring (FDM) of normal operations. Air carriers with flight data monitoring programs have used flight data to identify problems such as unstabilized approaches and rushed approaches; exceedance of flap limit speeds; excessive bank angles after take-off; engine over-temperature events; exceedance of recommended speed thresholds; ground-proximity warning systems (GPWS)/terrain awareness and warning system (TAWS) warnings; onset of stall conditions; excessive rates of rotation; glide path excursions; and vertical acceleration. Footnote 20 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11w0048/a11w0048.asp#fnb20)

Flight data monitoring has been implemented in many countries, and it is widely recognized as a cost-effective tool for improving safety. In the United States and Europe—thanks to ICAO—many carriers have had the program for years. Some helicopter operators have it already, and the FAA has recommended it.

Worldwide, FDM has proven to benefit safety by giving operators the tools to look carefully at individual flights and ultimately at the operation of their fleets over time. This review of objective data, especially as an integral component of a company safety management system, has proven beneficial in the proactive identification and correction of safety deficiencies and the prevention of accidents.

Several stand-alone lightweight flight recording systems which can record combined aircraft parametric data, cockpit audio data, airborne images and/or data-link messages are currently being manufactured. ED-155 MOPS for Lightweight Recording Systemspublished by the European Organization for Civil Aviation Equipment (EUROCAE) defines the minimum specifications for lightweight flight recording systems. While performance standards and TSOs exist, there is no requirement for aircraft not governed by CARs 605.33 to be fitted with any type of flight recorder, and Transport Canada does not intend to extend those requirements to smaller aircraft.

The development of lightweight flight recording system technology presents an opportunity to extend FDM approaches to smaller operations. Using this technology and FDM, these operations will be able to monitor, among other things, standard operating procedure compliance, pilot decision making, and adherence to operational limitations. Review of this information will allow operators to identify problems in their operations and initiate corrective actions before an accident takes place. In short, a whole new and promising avenue is now available to improve operational control and safety beyond CARs subpart 705 operations. In Canada, some companies have already decided to fit their aircraft with lightweight flight recording systems.

The Board acknowledges that there are issues that will need to be resolved to facilitate the effective use of recordings from lightweight flight recording systems, including questions about the integration of this equipment in an aircraft, human resource management, and legal issues such as the restriction on the use of cockpit voice and video recordings. Nevertheless, given the potential of this technology combined with FDM to significantly improve safety, the Board believes that no effort should be spared to overcome these obstacles.

Given the combined accident statistics for CARs Subparts 702, 703, and 704 operations, there is a compelling case for industry and the regulator to proactively identify hazards and manage the risks inherent in these operations. In order to manage risk effectively, they need to know why incidents happen and what the contributing safety deficiencies may be. Moreover, routine monitoring of normal operations can help these operators both improve the efficiency of their operations and identify safety deficiencies before they result in an accident. In the event that an accident does occur, recordings from lightweight flight recording systems will provide useful information to enhance the identification of safety deficiencies in the investigation.

Therefore the Board recommends that:

The Department of Transport work with industry to remove obstacles and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems for commercial operators not required to carry these systems.A13-01
Tough act to follow...where's your money on the bureau, in it's current diabolical state of disfunction under Beaker, showing the same due diligence of the two in-flight breakup accident investigations listed above?? :rolleyes:

T28D

28th Dec 2013, 05:40

sarcs, maybe I am a pessimist, but your:

Most of us have been dubious (including Senator X #34 (http://www.pprune.org/8233547-post34.html)) of Beaker's real intentions for calling in TSB Canada,

Has been on my mind for some time, is the "fix" in ? one might be a little concerned given the number of Montreal trips and the close association of the witch doctor in Montreal that the "fix" is indeed well and truly "in" we hope not but hope is a slippery thing to hold onto.

Old Akro

24th Jan 2014, 22:27

Just reading the Feb 20 batch of ATSB reports.

Seriously, have they sub contracted this to Mills & Boon? Or is the work experience kid writing them?

I understand the ATSB's new no-fault policy. But surely if there is no learning or lessons from a report - then why are we bothering?

After a mid air collision is the best advice / recommendation we can muster to read a 5 year old ATSB brochure "A pilot’s guide to staying safe in the vicinity of non-towered aerodromes."

And of course the really funny thing is that the ATSB report

http://www.atsb.gov.au/media/4533008/ao-2013-205_final.pdf

has a dead link to its recommended "safety message" document. Are we really paying these people?

I've tried searching the ATSB site on both the title of this publication and its ATSB publication number with no luck. It appears that it has been removed from their website. Really doesn't look like they care much, does it?

Surely a mid air collision at a significant capital city airport airport deserves something more insightful? Where is the value in producing this type of report at all? Why not save the money and just stop doing these mindless investigations?

Up-into-the-air

25th Jan 2014, 00:12

Why are we not surprised?

Maybe we need a list for them

I can start as follows:

Monarch
Whyalla
Benalla
Lockhart River
PelAir
Canley Vale

Like to help with th list?

Jabawocky

25th Jan 2014, 05:39

Good start.

Monarch
Whyalla
Benalla
Lockhart River
PelAir
Canley Vale
Airvan engine failure at night NT.

Pinky the pilot

25th Jan 2014, 06:56

Is Mac Job still around? If so, maybe if enough of us ask him nicely, he may pay the ATSB a visit and give them a few lessons on just how an accident should be investigated and the subsequent report written!

Well.....I can dream....can't I?:confused:

Oh, and bring back the Safety Digest whilst he's at it!

Up-into-the-air

25th Jan 2014, 07:25

The issue of course Pinky is who caused the changes to atsb?? Was it the angry man??

Lookleft

25th Jan 2014, 09:06

As a matter if interest who was the Director at the time of the Monarch accident? Who was one of the senior investigators and why was it an example of the litany of poor investigations conducted? :ugh:

Cactusjack

25th Jan 2014, 09:19

Like to help with the list?
Patience Grasshopper, successive governments and the 'race to the bottom by CAsA and ATSB' are ensuring that the list grows by setting the framework for a giant smoking crater. So perhaps you could add 'TBA' to your list?

TICK TOCK

Lookleft

25th Jan 2014, 09:36

You're a knowledgable person CJ, why is Monarch on that list?

Cactusjack

25th Jan 2014, 10:56

You're a knowledgable person CJ, why is Monarch on that list?
:=:= Naughty boy Lookie, trying to bait Cactus into coming out to play!
Sorry, it's UITA's list, only he can answer that :ok: Besides, I was in Montreal at the time.

TICK TOCK

Lookleft

26th Jan 2014, 04:26

A reply worthy of a CASA delegation at a Senate Inquiry CJ. Seeing as he has given you a hospital pass UITA maybe you can explain why Monarch is in your list of incompetent investigations? No CASA like obfuscations please.

Up-into-the-air

26th Jan 2014, 06:27

Lookie:

Go read the report, ask some questions of non-casa peple that you don't appear to frequent with (based on your comments and answers) [and when you give them]

Then form a real opinion as the whether atsb was correct, or Monarch just joins my list.

You may care to add extras, as I am sure you can do so.

From the IOS - TICK, TOCK

Cactusjack

26th Jan 2014, 08:21

Naughty Lookleft, me a CAsA delegate? Tsk tsk. As UITA suggests, you should do your own research, ask your CAsA buddies, maybe even ask your mate Blackie, or if you ask really nicely Gobbledock may assist you?
I am surprised that you even care to ask what my opinion or UITA's is anyway.
For I merely have an armchair interest in things of an aviation nature.

Say hello to Woger and Doc Voodoo for me :ok:
Cheers

TICK TOCK

Sarcs

26th Jan 2014, 08:59

Warning: Longish post following

UITA: Go read the report, ask some questions of non-casa peple that you don't appear to frequent with (based on your comments and answers) [and when you give them]

Then form a real opinion as the whether atsb was correct, or Monarch just joins my list.
Hmm...took your advice UITA and reviewed the BASI report 9301743 (http://www.atsb.gov.au/media/25055/aair199301743_001.pdf), & subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one...:rolleyes:

Maybe the report wasn't exemplary (for the then BASI standards) and FF eventually rolled over the top of most of the recommendations when reincarnated as CAsA but I really can't see where BASI have been negligent in the Monarch crash investigation...?? :cool:

Ok let's go through the motions and cut to the chase of AAIR199301743 i.e. the Safety Actions section: 4. SAFETY ACTIONS

4.1 Interim Recommendations

During the course of this investigation a number of Interim Recommendations were made.

The IR documents included a ‘Summary of Deficiency’ section in addition to the actual interim recommendation. The texts of the interim recommendations are detailed below, with each IR commencing with its BASI reference number. The pertinent comments from the CAA
in response to the recommendations are also reproduced.

IR930214: The Bureau of Air Safety Investigation recommends to the Civil Aviation Authority that when an operator requests the issue of a Permissible Unserviceability to continue flight operations with inoperative equipment listed as an MEL item, then the terms of the Permissible Unserviceability should provide an extension of all MEL conditions for a specified period.

CAA response:
The recommendation reflects CAA policy. The Authority does not accept the finding in paragraph 5 of the Summary of Deficiency in that the Permissible
Unserviceability could be read as permitting “continued operations with a
significantly reduced level of safety (ie autopilot components removed) than that provided by the Minimum Equipment List”.

IR930223: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority;
1. Review the need for approved maintenance controllers to hold maintenance qualifications appropriate to the position,
2. Restrict persons acting in the position of maintenance controller from acting in other positions that will detract from their ability to adequately perform their maintenance controller duties, and,
3. Review the need to limit periods of validity for certain approvals, such as
maintenance controller, and renew such approvals only when specified criteria are met which demonstrate adequate performance.

The CAA response in part stated:
Interim Recommendation 1 : The Authority has reviewed the need for maintenance controllers to hold maintenance qualifications and we have concluded that this is neither necessary or appropriate. It is essential that anyone approved as a maintenance controller has the ability to plan and co-ordinate maintenance activities but this does not extend to being qualified to carry out the actual work. The Authority believes this would be an unnecessary imposition on industry.
Interim Recommendation 2 and 3 : The Authority agrees in principle and these matters are being addressed.

IR930224: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority reviews its procedures in respect to the issuing of Air Operators Certificates. This review should be conducted with a view to restricting the validity of Air Operators Certificates to a specified period, with the AOC renewal to depend on the operator’s previous performance and the demonstrated capacity of the operator to continue to meet the relevant standards specified in the CAA Manual of Air Operators Certification.

The CAA response in part stated:
While it has been Authority practice in the last few years to issue “open ended” AOCs, recent legal opinion advises that the Authority should issue AOCs for a finite period.

BASI comment:
The CAA “Aviation Bulletin” dated February 1994, states that AOCs issued
without a specific period of validity will have to be renewed on 1 July 1994, with all re-issued AOCs being of a fixed term.

IR930231: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review:
(a) the adequacy of instructions to flight crew for maintaining a safe height
above terrain at night.
(b) the phraseology used in AIP/DAPS IAL 1.5 with a view to making it less
susceptible to misinterpretation.

The CAA response in part stated:
The Authority believes that the requirements for descent below MDA specified in AIP DAPS IAL 1.5 are clearly enunciated and notes that it is more comprehensive than the guidance provided in ICAO documentation or by either the UK or USA.
The Authority will be monitoring more closely the conduct of Instrument Rating Tests and renewals to ensure that where incorrect training is occurring that it is corrected. The subject will also be covered by an educational article in Aviation Bulletin.

Further BASI correspondence to the CAA stated:
The Bureau believes that the DAPS IAL 1.5 ‘Note 1’ does not adequately describe where visual reference must be maintained. To achieve the required obstacle clearance along the flight path it would follow that visual reference must be maintained along that path. Note 1 specifies that ‘visual reference’ means in sight of ground or water, however it does not specify where this ground or water is to be. The Bureau believes that visual reference to ground or water directly along the aircraft’s flight path must be maintained and recommends that Note 1 be expanded to state that ‘visual reference’ means clear of cloud, in sight of ground or water along the flight path and with a flight visibility not less than the minimum specified for circling.

The CAA response in part stated:
There is no objection to the addition of the words “along the flight path” to note 1 as you suggest, and this will be done as part of the next AIP amendment.

IR930234: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review the obstacle terrain guidance information provided for flight crew in ‘other than high capacity RPT operations’. This review should ensure that flight crew have adequate knowledge of the terrain associated with the route flown, including the obstacle terrain information for non-precision and circling approaches.

The CAA responses state in part:
CAR 218 (1) (C) details the qualifications required of a pilot conducting RPT
operations, regardless of whether high or low capacity aircraft are involved. This includes knowledge of the terrain at the aerodromes to be used. This knowledge is normally acquired by conducting the flight required by CAR 218 (1) (b) supplemented by pre and inflight briefings.

The requirement to avoid obstacles by 300 feet is to be complied with using visual reference only, i.e. the pilot must be able to ensure all obstacles lit or unlit are avoided visually. At night this may not be possible. Thus the pilot may only be able to descend when he is aligned with the landing runway and able to use the documented obstacle limitation surface, and,
The CAA will review the practices of other authorities in respect to the provision of terrain information on instrument approach charts with a view to determining whether our current practices need to be changed.

IR930244: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. review the current rates of surveillance to determine whether the target levels of the Annual Surveillance and Inspection Program detailed in the MAOC are being met for all RPT AOC holders; and
2. review the adequacy of the Annual Inspection and Surveillance Program in
the MAOC for RPT AOC holders.

CAA Response:
The Authority notes your recommendations and advises that a review of the Annual Surveillance and Inspection Program is currently being conducted.

4.2 Final Recommendations
With the conclusion of the investigation into this occurrence, the following final recommendations are now made:

R940181: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. develop a system for CAA officers to advise DASR of known adverse financial situations of AOC holders;
2. ensure that surveillance and inspection action responds to reported adverse financial situations of AOC holders with particular reference to their ability to conduct safe operations; and
3. develop a system to provide an ongoing assessment of the safety health of AOC holders as part of routine surveillance activities.

R940182: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority implement as a matter of urgency the ICAO PANS-OPS requirement for an instrument approach procedure which provides for a straight-in approach aligned with the runway centreline at all possible locations.

4.3 Safety Advisory Notice
The following Safety Advisory Notice is issued:
SAN940184: The Bureau of Air Safety Investigation suggests that the CAA review the final outcome of the United States National Transportation Safety Board 1994 study of commuter airline safety with a view to assessing the applicability to the Australian industry of the findings and recommendations.
Note: For those interested in the NTSB 1994 study report mentioned above here is a link: NTSB Commuter Airline Study
(http://libraryonline.erau.edu/online-full-text/ntsb/safety-studies/SS94-02.pdf)

It is also worth noting that the Monarch Airlines crash at Young was extensively referred to in the very comprehensive Regional Airline Safety Study (http://www.atsb.gov.au/media/30782/sir199905_001.pdf) released by BASI in 1999. A further point is that in that safety study report R940181 (mentioned above) was further highlighted/reviewed by BASI. Although where the recommendation ended up is anyone's guess..:=..as the ATsB internet database records no longer go that far back...:ugh:

So UITA please explain to me how the Monarch BASI report is as defective/useless as per the ATsBeaker version of reporting these days...:E

Kharon

26th Jan 2014, 18:06

Sarcs # 118 –" [&] subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one.

Not only with LL, but with CAA this time. Some of the BASI IR are bumptious and have the potential to create more red tape with little increased safety value. Was there (from memory) some fairly heavy political heat surrounding this event?, can't remember – anyone?.

Seems the BASI boys back then at least remembered what accident investigation meant, can't see the Monarch investigators leaving an aircraft in the ocean of not recovering the CVR/FDR equipment.

Australia is a signatory to the Convention on International Civil Aviation (Chicago 1944), which established the International Civil Aviation Organisation. Article 26 of the Chicago Convention obligates the governments of countries that are signatories to the Convention to conduct investigations into aircraft accidents in their territories which involve specific aircraft from other countries which are signatories to the Convention. Article 37 (k) of the Convention recommends that, as far as the law of individual countries permit, member countries should adopt uniform international standards and practices for aircraft accident investigation. The international standards and practices for aircraft accident investigation are described in Annex 13 to the Convention.

Australia has given domestic legal effect to its international obligations under the Convention by incorporating the articles of the Convention within the Air Navigation Act of 1920. Part XVI of the Air Navigation Regulations (ANRs) of that Act provides the legal authority for the Secretary of the Commonwealth Department of Transport to require the investigation of aircraft accidents and incidents occurring within Australia. The authority to conduct aircraft accident and incident investigations is delegated by the Secretary to the Director and other designated officers of the Bureau of Air Safety Investigation.

Australia has by historical practice applied the standards and practices of Annex 13 to all aircraft accident and incident investigations. In doing so, the fundamental objective of the investigation is the prevention of aircraft accidents and incidents.

In accordance with the principles of Annex 13, it is not the purpose of this activity to apportion blame or liability. The sole purpose of the Bureau’s operations is the maintenance and enhancement of flight safety.

It seems to me the 1993 statement below has a repetitive sound: May 7, 2005 qualified and prompted the renamed ATSB to finaly produce their CFIT report. The Monarch CFIT occurred in 1993

The investigation found that the circumstances of the accident were consistent with controlled flight into terrain. Descent below the minimum circling altitude without adequate visual reference was the culminating factor in a combination of local contributing factors and organisational failures. The local contributing factors included poor weather conditions, equipment deficiencies, inadequate procedures, inaccurate visual perception, and possible skill fatigue. Organisational failures were identified relating to the management of the airline by the company, and the regulation and licensing of its operations by the Civil Aviation Authority.

Pages 27 to 28 provide the FOI statement which are worth reading and some consideration. He said at no stage was he aware that VH-NDU was being operated with the RMI and HSI inoperative. If he had known he would have stopped the operation.

To my mind, if the FOI would have known and stopped the operation, then CP who did know all about the equipment situation should not have authorised the flight.

In fairness, I can't see what CAA or BASI could have done more than they did; the FOI statement seems to be 'fair and reasonable'. The CAA response seems to be plausible, if anything for my two bob's worth, the BASI seem to be playing the CAA bashing game just a little too loudly if anything. There is a lot of post event 'posturing' and bum covering going on, but page 30 gives you the clues.

A letter to cancel the approval of the Chief Pilot was subsequently prepared but not sent, as he resigned from that position on 17 May 1993. A new Chief Pilot was approved on the same day.

Memories faded now, but it seems to me this CP eventually ended up working for CASA and has aspired to some 'senior' position, but don't bet the house on that; it was a long time ago.

The chronology starting at page 31 is worth half a coffee and, for me more clearly defines the issues; but here again, the retrospective analysis shows what should have been done before hand; but there are few 'cures' initiated to reduce the probability of this reoccurring again, 10+ years later, in 2005 at Lockhart River. Bad response all around – Yes; poor BASI report – No.

Check paragraphs 1.19.4 (p 36) and 1.19.8 (p 40) valuable in 1993 priceless in 2004. In fact, when you get down to 1.20 (p 41) there is some very good informative data. No, (IMO) we need to remove Monarch from the list of poor investigation.