ATSB to be reviewed by Canadian TSB

[TWT]

Cookies must be enabled. | The Australian (http://www.theaustralian.com.au/news/breaking-news/atsb-under-review-by-canadian-counterparts/story-fn3dxiwe-1226690156228)

[FYSTI]

Australian Transport Safety Bureau commissioner Martin Dolan announced on Friday his agency's methodology and processes will be assessed by Canada's Transportation Safety Board (TSB).
Nothing more than a desk audit. Investigating the politics of ATSB / CASA / commercial & political operators, appear not to be in the terms of reference. I am willing to stand corrected (and amazed!), but I think my bet will be safe that methodology and processes will be within "international best practice" guidelines. Sure, there will be a few grammatical & spelling errors in some of the policy & procedures manuals, and these will be noted in the extensive report.

Sir Humphry would be impressed, never call an an inquiry unless you already know the outcome. Nothing to see here, move along.

[denabol]

Ben's report seems somewhat sharper when it comes to this.

ATSB processes to be independenty reviewed | Plane Talking (http://blogs.crikey.com.au/planetalking/2013/08/02/atsb-processes-to-be-independenty-reviewed/)

The TSB will, it is to be hoped, consider the evidence tendered to that Senate inquiry by the chief commissioner of the ATSB which lead to the committee devoting an entire chapter of their report to their dissatisfaction with his testimony.


At the end it still looks like the ATSB might get pineappled. Can only hope so.

Whether the very bad smell created by the conduct of the ATSB and CASA in relation to the Pel-Air investigation can be removed by the independent and external review by the TSB remains to be seen.
The ATSB statement makes no direct mention of Pel-Air, and doesn’t disclose any response to the recommendations of the Senate committee that was so dismissive of the worth of Dolan’s testimony.
Those recommendations included, in short, the ATSB re-opening the crash inquiry and doing its job fully and diligently.
The TSB’s report will be published.
It isn’t know whether that publication will be preceded by the ATSB reviewing the final draft and having an opportunity to change it.
For the the sake of an external and independent review, it is to be hoped that this will not be the case, lest its independence and externality be cast into doubt.

[004wercras]

It's a con job. Beaker has his head on the line so he commissions an overview of his organisation by the Canadians. The scope of the review will be very very limited, and is a smokescreen. The maples will indeed look at Beakers 'beyond reason' methodology under the guise of 'best practise'.
Now not surprisingly 'best practise' is the key here, as it is not prescriptive nor is it quantifiable or measurable! The Maples will walk away saying something like 'ATSBeaker do indeed employ best practise. They do things differently down under but it is commensurate with their environment'. Beaker will be on fire and an endless stream of mi mi mi mi will fill the halls of Canberra.

Perhaps the Maples will request a copy of Beakers methodology over the Pel Air investigation to see if that was 'best practise'? In reality it probably was - failure to retrieve the wreck saved him precious budget money and it prevented a fully accurate investigation to be completed, that would have had serious implications for the government and CAsA! So yes indeed, it was best practise for Dolans ass to do what he did.

Who is paying for this 'working group of Canadians'? Is it coming from Beakers budget or the Canadians? Either way I am sure some working groups will come out of this little smokescreen and the end report will see some bipartisan collaborative workshops hosted in downtown Montreal.

[Kharon]

Nice bunch of folk the Canucks; happy memories of long cool drinks with short round goalkeepers before, during and after matches. Ice hockey goal keepers are the Canadian equivalent of our rugby hookers, purpose built (by the same company did the harbour bridge) to fulfil a tough role in a hard game. Will they bring their best game - I wonder?

I note Ben Sandilands has done a short piece on the proposed ATSB independent review (http://blogs.crikey.com.au/planetalking/2013/08/02/atsb-processes-to-be-independenty-reviewed/) (sorry madam, no audits this week). He also hints that the "process and procedures" will be 'scrutinised'. It's a pretty safe bet that end of the equation will be squeaky clean; but will the TSB dig deep and see if those policies, procedures and protocols are being executed correctly?. Will they dare to look beneath the shiny bright mudguard of the "beyond all reason" model ? Perhaps we should start sending accurate data to the TSB; a file 3 inches thick explaining just what is wrong; then, if the TSB do not wish to examine the rust under the mudguard we can make it all very, very public. The tar sticks where the brush touches.

I like the Canadians; I just wonder if they have any idea, at all, exactly what horrors are hidden under the skirts of Lockhart, Whyalla, Norfolk, Canley Vale and the other twenty or so abominations foisted on an undefended industry. There are after all only 87 outstanding similar reports....:ugh:

I wonder who's paying for all this?, I wonder at the timing ?, (all blame the last Gumermint) but mostly I wonder how the ICAO states and the Senate can let Pel Air slip away without a word said and then happily countenance a user friendly "review" of process of procedure; we know the process is there FCOL; we don't know why they abused it; or why they cuddled up to the Sleepy Hollow men and become a proven safety liability and embarrassment?. More like revue than review, unless they go for boiler plate 'rear view'.

Yup move on, nothing of any value to see here.

Old Akro (http://www.pprune.org/pacific-general-aviation-questions/520516-atsb-reports.html#post7972276) - If you take the ATSB budget and divide by the number of reports (air, sea & land) the average reports costs more than $200,000. Surely even McKinsey & Co would be cheaper and faster.

[Jack Ranga]

Bit like the report on staffing the Canadian ATC mob did on ASA, lol :D

[halfmanhalfbiscuit]

Lets hope the TSB are smart enough to test the documented processes with the process in practice with such case studies as Pel Air.

[Sarcs]

Biccy other independent and external (read foreign) aviation commentators believe that the TSB will have no other choice but to review the Pelgate investigation and Senate report:E:
The TSB’s review stems from a recommendation made by the Australian Senate Committee on Aviation Accident Investigations in May 2013. The committee was initiated in the wake of an accident involving the ditching of a medical evacuation IAI Westwind jet in November 2009.

The Committee stated in their final report amongst others that parts of the ATSB investigation process [of the Westwind jet accident] lacked transparency, objectivity and due process.
Beaker maybe still in denial but no one else is apparently...:ok:

'Canadian safety investigators to review and compare Australian ATSB processes' (http://news.aviation-safety.net/2013/08/02/canadian-safety-investigators-to-review-and-compare-australian-atsb-processes/)

[halfmanhalfbiscuit]

Sarcs, surely the TSB will be smart enough not to damage their credibility here? Always a danger the NTSB will look at the TSB look at the ATSB.

I guess that is where the clever terms of reference come in.

[Kharon]

We still have the TSB visit to look forward to. Fresh from Willyleaks:- Terms of reference and agenda.

1000 – 1015. Meet and greet team fiasco in the 5 star lobby. Complimentary vomit bags are provided.

1030 - 1130. A selection of teas and biccy's served in the smoking room, to allow pre selection of your favourite playboy bunny competition candidate.

1130 – 1200. Inspection of world class work station, points awarded for spotting out of alignment paper clips and blunt pencils.

1200 – 1230 Con-Car transport to a 5 star restaurant, delays may occur due a shortage of Con-fuel, taxi vouchers will be provided. N.B. There is a 10 page travel warning guide provided in your delegate "Welcome package", you are cautioned not to leave your Con-vehicle, lest the Ills of Society are following on push bikes carrying eggs and chanting rude slogans. One size fits all rubber protection equipment has been provided for your comfort and safety.

1300 – 1500. Lunch; during which a talk on "Disconnected Writing" will be presented by the doyen of structured reports, on special release from our flagship regulatory body. Please note, due to a stress related condition and the "Bunny" theme of this seminar, we ask guests not to make derogatory remarks about the speakers choice of the "male" version bunny costume; the ears are an essential part of the recovery process for this outstanding visionary.

1530 – 1600. Con-Car transport to secluded marina (safety rules apply) where a harbour booze cruise will be provided, terminating at the Luna Park jetty. We ask participants to avoid overt fondling of the topless crew, we is a very PC outfit; we are always careful not to have our guests pictures taken by long lens vigilantes from the IOS, so squeeze discreetly to ensure plausible deniability.

1730 – 1930. A guided tour of our world famous, multi million Smoke and Mirrors facility will be conducted by the Sleepy Hollow spin squad. Time permitting a glimpse into the top secret Snakes and Ladders room may be possible, provided the courier bringing the signed permission from Marickville is not egged by the IOS.

1930 – Return to your 5 star suite followed by a Romanesque themed dinner party, featuring food prepared by the stars of My Kitchen Rules, served by your pre selected playboy bunny. Con-Cars will be available for those wishing to visit various places of interest after dinner.

The Commonwealth expects a fully detailed report to be provided by 1800 the following day, robustly exposing any small flaw detected during our rigorous and exhaustive tour of the great Australian protocols and procedures. Please ensure your invoice in not marked below the current standard consultant charge rate of AUD$ 200 per hour, plus OOP expenses.

Now, we know it's an onerous task but; try to have a nice day Y'all.

Willyleak sponsored by the IOS Salubrious Brotherhood of Whitewash Wallah's Inc.

[004wercras]

After the Beaker has entertained the Maples as per Kharons previous detailed post, and he has mi mi mi mi'd them to death, perhaps the Canadian guests could be scheduled some R&R at Chateau le Nash? Maybe a day spent in the office with this fine lady, pot plant Pete and Nick, Sterle and Fawcett? At least that way the Maples could be provided with a much more transparent overview of how the Fabulous Beaker Brothers actually operate?

After that they could review the work on Canley Vale to date, of course fully review the Pel Air joke and then take a trip back a couple of years to the Lockhart investigation?
I am sure that if the Maples did just the above they would find that they need to station a permanent workforce in Australia just to sift through the 5 years worth of Beaker mi mi mi?
Please please bring back Alan Stray :ok:

[Lookleft]

I think you will find Alan is busy enough in retirement consulting on safety investigation to be at all interested in going back to the ATSB. BTW Alan was at the ATSB during the Lockhart investigation so what part of that report requires another look? From what I saw of it, it was the last time the ATSB took a cricket bat to CASA's façade of being an effective regulator. It was the coronial into that accident that led to the MOU because the coroner thought that the ATSB and CASA should be able to work together. We all know where that ended up.

[blackhand]

The ATSB commisions a reveiw IAW what the senate required, yet the usual suspects on Pprune still aren't happy.

Who would have thunk it.

[Sarcs]

Lefty suggest you take a look at the following link in regards to LHR:

ef-121779 pdf (http://www.casa.gov.au/wcmswr/_assets/main/lib100096/ef-121779.pdf)

That rather large FOI released pdf was recently updated because someone noticed that there were missing pages and consequently made a complaint to the Information Commissioner. This led to FF having to do a further search for said missing docs. Then through a typically convoluted process three missing pages miraculously turned up (wonders will never cease!) and now have been appended to the original ef-121779 pdf. {Note: I might add that this was done without any explanation/apology or with a re-issue of the original document on the FF FOI disclosure log with an amended date...sneaky buggers!:=} {Note 2: You can view when the PDF was appended by going into properties etc}

So what were the missing pages?

Ok go to PDF page 181-183 or FOI numbers (written in the top rh corner) 565-563. You will see that these pages relate to the Flight Ops section (069 Checklist) of the Transair port approval for LHR and was dated 01/10/04.

Now if you scroll back up to PDF page 174 you will see the official FF AOC variation for the addition of LHR as an approved RPT port dated the 05 October 2004. {Note:That would have to be close to a world record for FF to process a port approval variation to an RPT AOC, especially to a topographically challenged, potentially high risk port such as LHR!}

Now you will be asking..."what does that have to do with the ATSB investigation??" Well if you scroll through the many and varied variations/additions and keep at the back of your mind how long these changes etc would normally take to administer and be properly approved by FF you will see that there is a systemic pattern of rubber stamping going on. And in the case of the ATSB surely when they were reviewing the Transair AOC (see appendix H (http://www.atsb.gov.au/media/3148359/aair200501977_appendices.pdf)) they should have seen this in the context of their investigation...I mean even a layman can see what was going on FFS!:ugh:

Q/ Wonder if they even bothered to do a proper proving flight??:rolleyes:

ps I also suggest the DN Brasilia crash report should be added to the TSB bucket list.:E

[Creampuff]

There are some other interesting aspects of that Checklist.

The “Operational Manual Rev” entry says “AMENDED 29/09/04”. Wouldn't Ops Manual changes usually be made a little further in advance than that?

The “Training and Checking Manual Rev” entry has ditto marks under the word “UNCHANGED”. No changes to the T&C manual when a new RPT port is added? Is that usual?

[Lookleft]

Organisational influences – CASA

An Air Operator’s Certificate (AOC) holder had a clearly defined responsibility


under the Civil Aviation Act 1988 to ensure the safety of its operations. The

regulator, CASA, also had defined responsibilities for oversighting the activities of an AOC holder, through the processes of approving AOC variations and other permissions, as well as conducting surveillance of the activities of the operator.

AOC approval and surveillance processes will always have constraints in their

ability to detect problems. There is restricted time available for these activities.

Regulatory surveillance is also a sampling exercise, and cannot examine every

aspect of an operator’s activities, nor identify all the limitations associated with

these activities. In addition, to a large extent AOC approval and surveillance

processes have to focus on regulatory requirements, which provide legal checks

and a minimum standard of safety, rather than safety management processes that

can exceed these minimum standards.

Despite these constraints, CASA still had significant interaction with Transair,

through the conduct of scheduled audits and a series of approval activities, as well

as other activities such as the assessment of a complaint from a company pilot. As

a result of these interactions (most notably its audits), CASA identified areas for

improvement in Transair’s procedures and practices, primarily in the area of

maintenance control. However, it did not detect fundamental problems associated

with the Transair’s management of RPT flight operations, such as the problems

with pilot training, pilot checking, supervision of line flight operations, standard

operating procedures, operations manual format useability, organisational structure,

risk management processes and demonstrated management commitment to safety

outlined in Sections 2.6 and 2.7.

Given the significance of the problems within Transair, and the amount of

interaction CASA had with the operator, it is reasonable to conclude that some of

these problems should have been detected by CASA. In considering the reasons

why these problems with Transair were not detected, the investigation identified

safety factors in the following areas:


• consistency of oversight activities with CASA policies, procedures and



guidelines;


– 225 –


• guidance for evaluating management systems;

• risk assessments for changes in operations;

• regulatory requirements for safety management systems;

• guidance for evaluating the useability of operations manuals; and

• processes for assessing an operator’s risk profile.



In addition, limitations were identified with CASA’s processes for validating

instrument approaches.

The relationship between these factors and other factors identified during the

investigation is shown in Figure 46.


2.8.1 Consistency of oversight activities with CASA policies,

procedures and guidelines


There were instances where CASA’s oversight of Transair did not appear to be

consistent with CASA’s own requirements and guidelines.


• The initial approval for Transair to conduct RPT (cargo) operations in



October 1999 did not appear to be subject to a full evaluation process

consistent with CASA’s AOC Manual. More specifically, proving flights

and port inspections were not completed before the approval of operations.


• Transair’s application to add the Inverell – Brisbane route to its AOC was



recommended for approval by the Brisbane airline office on 7 April 2004.

However, on 8 April, the airworthiness inspector who had assessed the

application recommended that the approval not be processed until Transair

demonstrated that it had adequate maintenance control in place. The AOC

was issued on 8 April by a delegate in Canberra, and no information

addressing the airworthiness inspector’s concerns was recorded on file.

The extent to which the delegate in Canberra had been made aware of the

airworthiness concerns could not be determined.


• The first systems-based audit in December 1999 identified several



significant management problems. Transair provided undertakings to

address these problems, yet there was no explicit monitoring of Transair’s

implementation of the agreed improvements. In addition, there was no

recorded evidence that CASA completed the activities it proposed to do,

such as ensuring that Transair submitted weekly progress reports and

conducting a special audit 90 days after the agreement.


• After Transair recommenced RPT operations in September 2001, CASA



generally conducted scheduled audits about every 6 months, in accordance

with CASA’s specified schedule for airline operations. However, the

August 2002 audit primarily focussed on Transair’s helicopter charter

operations. Therefore, there was a period of 15 months between November

2001 and February 2003 when minimal auditing of the operator’s RPT

passenger operations was conducted.

Sarcs that's just a small sample from the actual report of the CASA deficiencies that the ATSB reported on. If you read the whole report there is no doubt that there is no "Pelair" style disregard for the regulator's role in oversighting the operation. In this instance there was more to it than just the sloppy CASA paperwork. The report is 265 A4 pages long and that's before you get to the Appendices. If you are looking for examples of ATSB reports that are superficial and don't provide a lot of detail then Lockhart River is not one of them.

As for the Brasilia the ATSB had already recommended that such MBS be done in a simulator and CASA had already mandated it. I think that's how the system is supposed to work. Its unfortunate that this flight was conducted at all but what further improvement in safety can be made if the ATSB has already recommended that such flights should be done in a simulator?

[Up-into-the-air]

Lefty Read the report and you can see casa's pawprints all over it and in a similar fashion to PelAir

There are things missed, things improperly researched, sections where icao provisions have been missed and even sections where casa are just incompetent

Remember casa is the real defence against t Lockhart River's of aviation

casa is found wanting

[Greedy]

Lookleft,
One thing that intrigued me concerning the extract of the Lockhart River report was the reference to a CASA interaction with Transair to assess a complaint made by a pilot.
Can anyone enlighten us as to what this was?

Greedy

[Lookleft]

Lefty Read the report and you can see casa's pawprints all over it and in a similar fashion to PelAir

Sorry UITA you and I must be reading different reports. I remember when the LHR report was released that CASA was incensed by its findings insisting that they were not in the cockpit with the PIC and he alone was responsible for the accident. The coroner noted the animosity between the two agencies so that alone suggests that CASA did not have any input into LHR that they had at pelair. As mentioned before Alan Stray was still at the ATSB when LHR occurred and there would be no possible chance that he would be letting CASA anywhere near one of his reports.

Greedy are you referring to the extract Sarcs provided or the extract from the report? I can't see what you are referring to.

[Greedy]

Lookleft,
Your post (no 15) second para in.
Greedy

[Lookleft]

Thanks Greedy I can see what you are referring to but I'm not sure of the specifics. The report is a very big report and it could be mentioned in the body of the report. Interesting to compare the CASA response to a pilot complaint at Barrier Aviation to a complaint at Transair though.

[Sarcs]

Lefty believe it or not I too have read and analysed the LHR report and Coroner's report several times. I totally agree with you about the LHR ATSB report being full and comprehensive, as it should have been considering the over 20 million dollars of taxpayers money it took to complete. I also agree the report does not hold back in it's criticism of CAsA's oversight of Transair, however the passages you quote also highlight what was the primary focus of the investigative team in regards to reviewing the Transair/CAsA relationship/management of the AOC i.e. the audit process and surveillance.

There is, as you point out Lefty, one example of the ATsB questioning an AOC variation approval process, where an AWI refused to approve the Brisbane to Inverell route approval on the grounds of inadequate (in his opinion) Company Maintenance Control (PDF page 154-156 of ef-121779 pdf (http://www.casa.gov.au/wcmswr/_assets/main/lib100096/ef-121779.pdf)). {Note: IMO this example was probably highlighted because it is the only instance (that I can see) in all the variations where an AWI or FOI has voiced a concern about the applied for variation/addition to the AOC}

But the one really crucial AOC variation, in light of the accident, that should have been heavily scrutinised was the port approval for LHR...so why wasn't it?:ugh:

Was it maybe because the LHR port approval wasn't redflagged by a AWI or FOI (like the example above) and so didn't draw the attention of the ATSB investigators?:confused:

Or was it because the ATSB primary focus was on the CAsA audit/surveillance processes of Transair and not so much the AOC variations/additions?:confused:

Anyway enough of the thread drift here is a TSB you tube video that perhaps highlights their priorities in regards to OBRs (be it for trains):[YOUTUBE]http://www.youtube.com/watch?v=GH5Iu_BGysY

And in regards to accident/incident investigation methodology and subsequent safety actions/recommendations, perhaps the recently released report into a Beaver amphib crash (with additional links) highlights how the Canucks go about it :ok::

AVIATION INVESTIGATION REPORT (http://bst-tsb.gc.ca/eng/rapports-reports/aviation/2012/A12P0070/A12P0070.pdf)
A12P0070 (http://bst-tsb.gc.ca/eng/rapports-reports/aviation/2012/A12P0070/A12P0070.pdf)CONTROLLED (http://bst-tsb.gc.ca/eng/rapports-reports/aviation/2012/A12P0070/A12P0070.pdf)


Watchlist issue identified in May 2012 floatplane accident near Peachland, British Columbia (http://bst-tsb.gc.ca/eng/medias-media/communiques/aviation/2013/A12P0070-20130809.asp)

Aviation Recommendation A12-01 (http://bst-tsb.gc.ca/eng/recommandations-recommendations/aviation/2012/rec_a1201.asp)

Aviation Recommendation A12-02 (http://bst-tsb.gc.ca/eng/recommandations-recommendations/aviation/2012/rec_a1202.asp)

As I said earlier there is a lot we could learn from the TSB Canada!:ok:

[Lookleft]

If you have ever watched Ice Pilots Sarcs there is a lot we could learn from the Canucks about aviation in general! I think we are in furious agreement about LHR and if the opportunity ever presents itself and you buy the first round I'll tell you about the back story to the report. Cheers

[Sarcs]

Noticed that the ATsB have been busy promoting pooh tube vids..hmm wonder if it has something to do with the TSB pending visit?? The Canucks have been big on using pooh tube vids to highlight top transport safety risks for a number of years:TSBC Utube (http://www.youtube.com/tsbcanada)

I also notice that Beaker has gone all quiet on his personal blog (http://www.atsb.gov.au/infocus.aspx):E. The Canucks also have a blog but the big difference is that it is open to all employees to contribute to:ok:. As a consequence you get a lot more responses/comments and some really noteworthy blog pieces that everyone can learn from. Here's their latest article which is particularly relevant to the PelAir debacle:D:D : Human Factors and Accident Investigation (http://www.bloguebst-tsbblog.com/2013/09/06/human-factors-and-accident-investigation/)

Kind of refreshing hey!:O Ok...back to waiting..waiting:zzz::bored:

[Old Akro]

But the have released effectively no reports in over 2 months. Only a couple of minor ones.

There are 105 pending reports. The oldest dates back to June 2011. 5 are over 2 years old. 21 are over 1 year old.

[Kharon]

When there is so much CASA spin on the ball and the opposition batsmen have nutted out how to hit 'em for six, the options are limited. I doubt anyone, in the world will ever read an ATSB report and accept it as gospel. It's a sad, disgusting, embarrassing indictment, from which, without some serious house cleaning the existing organisation will not recover.

Dolan should resign, I can't see how he bear to be seen in public. Shamed, even before Canley Vale even gets aired and torn apart. Will he dare to sit, squirm and mumble through another Senate inquiry, holding hands under the table with his off sider and believing that you can fool all of the people, all of the time....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/censored.gif

Finishes here, with some carefully selected, robust Anglo Saxon idioms. For example, did you know the word "****" come from the days when manure was bagged and transported to market gardens – and strangely, the boats kept exploding. Well, the ATSB of the day investigated and declared that bilge water (salty) mixed with the manure created methane gas and any old spark would trigger the resultant bang. So, in their wisdom, they insisted the bags be Shipped High In Transit and stencilled accordingly [sic] ****. Well, that's what I was told...http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif

The good old days when not only did they resolve problems, you got a nice new expression to boot....Pete for PM - OK....:D

[Sarcs]

Kharon: Dolan should resign, I can't see how he bear to be seen in public. Shamed, even before Canley Vale even gets aired and torn apart. Will he dare to sit, squirm and mumble through another Senate inquiry, holding hands under the table with his off sider and believing that you can fool all of the people, all of the time....http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/censored.gif
Maybe not Senate inquiry but it would appear that we will be privy, God help us :ugh:, to another Senate appearance (Senate Supp Estimates 18-22 November) by the mi..mi..mi..bean counting Beaker..(ref:BBARF (http://www.atsb.gov.au/publications/2013/annual-report-2012-13.aspx) report:yuk:).

Perhaps Senator Edwards could resubmit his question and statement made in the inquiry....

Senator EDWARDS: "Chair, since we have started, there has been mea culpa after mea culpa after mea culpa in this thing. Now you are hearing evidence for the first time of what is supposed to be a forensic investigation. I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this. I think that the evidence that Senator Xenophon and Senator Fawcett are drawing out would suggest that. We haven't even got to the black box yet. Are you proud of this report?" {loved it then love it now!:D:D}

Well enough of the drift but Senator Edwards does bring up an interesting point.... "I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this."

So my question is what ever happened to the Canucks??:confused: Did they come and go??? If so when can we expect the preliminary review report?? :rolleyes:

There seem's to be no mention of the TSB review in either the BBARF or annual report (page 106-108 under External scrutiny and participation). Maybe this is because the TSB review falls under the next financial year...but the ATsBeaker recent silence on the issue is deafening!:E

[Paragraph377]

Sarcs, it is expected that the Beaker Files will be released in 2014. Obviously the report has to be massaged by the Canucks political interests before being massaged by the Australian government spin doctors including, as you would say, Mr Kingcrat, Beaker and his fellow commissioners and of course the mighty Truss bridge. Only then will the finely polished diamond be unveiled for all to admire? And I am sure that the Beaker made the Canadians pay for their own expenses while here, including sandwiches, office electricity and printer paper, so that he could keep his precious budget on track. Ever the diligent massager of finances is the Beaker.
ATSB poosroom release:
Media releases: 02 August 2013 - Canadian safety investigators to review and compare ATSB processes (http://www.atsb.gov.au/newsroom/2013/canadian-safety-investigators-to-review-and-compare-atsb-processes.aspx)

An interesting comment by Creampuff on another thread indicates that with the induction of a new government there is a cancellation of previous enquiries that were undertaken in relation to the previous governments activities, for example the senate inquiry into aviation. Can anybody confirm whether this is absolute fact? Not doubting your word Creampuff, just trying to establish with accuracy the current state of play is.
I know that the Senators would be seething beneath the surface at the governments blatant whitewash of a very serious topic, that being the complete demise of our industry, especially somebody like Nick who actually cares about other people including those victim to injustice. And for the sake of the Australians killed in local accidents and their families and loved ones, as well as those who have lost their livelihoods by being bullied and harassed to the point of insolvency I am sure that Nick and Co would be at the very least considering how to re-open the Pandora's box :ok:

[Sarcs]

Paragraph377: An interesting comment by Creampuff on another thread indicates that with the induction of a new government there is a cancellation of previous enquiries that were undertaken in relation to the previous governments activities, for example the senate inquiry into aviation. Can anybody confirm whether this is absolute fact? ATsBeaker shows the way on your query Para 377....:E

From page 106 of ATsBeaker's annual report 2012-13:
Response to Senate Inquiry



On 13 September 2012 the Senate referred the matter of aviation accident investigations to the Senate References Committee on Rural and Regional Affairs and Transport for inquiry and report. The terms of reference addressed:
the findings of the Australian Transport Safety Bureau into the ditching of VH-NGA Westwind II, operated by Pel-Air Aviation Pty Ltd, in the ocean near Norfolk Island airport on 18 November 2009;
the nature of, and protocols involved in, communications between agencies and directly interested parties in an aviation accident investigation and the reporting process;
the mechanisms in place to ensure recommendations from aviation accident investigations are implemented in a timely manner; and
any related matters.
On 23 May 2013, the committee presented its report. The committee’s report contained 26 recommendations, a number of which were directed towards the ATSB. The report included additional comments from Senator Nick Xenophon, including an extra recommendation.

Under Parliamentary convention, governments are expected to respond to committee reports within three months. However, the Caretaker Conventions stipulate that responses to outstanding parliamentary committee reports should be taken up with the incoming government. Hope that helps??:ok:

Refer page 9 sub para 7.1 & page 11 sub para 8.1:Caretaker Government Conventions (http://www.dpmc.gov.au/guidelines/docs/caretaker_conventions.pdf)

[Lookleft]

Caretaker Conventions stipulate that responses to outstanding parliamentary
committee reports should be taken up with the incoming government.


My bolding but taken up by whom? The Senate or IOS? If it is by the IOS by what process?

[Creampuff]

The Government: The Senate? Oh no! Oh, herro. Great to see you again, Senate!

The Senate: Government, you were supposed to have responded to all our Committee Report Recommendations by today, but you haven’t done so.

The Government: Senate, Senate, Senate! We've been frew this a dozen times. The Government doesn't have any weapons of mass destwuction, OK Senate?

The Senate: Then let us look around, so we can ease the public’s collective mind. I'm sorry, but the Senate must be firm with you. Respond to the Recommendations, or else.

The Government: Or else what?

The Senate: Or else we will be very angry with you... and we will write you a letter, telling you how angry we are. :eek:

[Paragraph377]

The Senate: Or else we will be very angry with you... and we will write you a letter, telling you how angry we are.

Will they send it as a 'minute'? Letters are great, lots of letters get written to the oil companies, food giants, big tough letters from motoring groups, even politicians! All for nought.
Creampuff, your mirth and sarcasm would sadly appear totally justifiable. The only way to make the changes we all call for is via a revolution.

[Up-into-the-air]

What will the moves be for Mr. Truss this week??

What will be his response be to the atsb annual report (http://vocasupport.com/wp-content/uploads/2013/11/ATSB_AnnualReport2012-13.pdf)??

Will there be a response to the Senate, not just the specious comments in this report??

[Sarcs]

Continued from:Post #1651 (http://www.pprune.org/australia-new-zealand-pacific/429828-merged-senate-inquiry-83.html#post8176951)

Came across a TSBC blog article that is worth consideration as an IOS supported PelAir inquiry solution/recommendation to address the current embuggerance of our air safety watchdog..:( Aren’t we just part of Transport Canada? (http://www.bloguebst-tsbblog.com/2013/01/25/difference-between-transport-canada-transportation-safety-board/)
January 25th, 2013
Posted by: Ewan Tasker
The difference between Transport Canada and the Transportation Safety Board of Canada

Virtually every time I arrive at an accident site, I hear someone say “Transport Canada is here”. I occasionally spend a few seconds trying to clear up the misconception, but often don’t have the time to explain the differences, and why they are important.

In brief, Transport Canada (http://www.tc.gc.ca/eng/aboutus-menu.htm) (TC) is the department responsible for promoting transportation safety and security, which reports to the Minister of Transport. The TSB (http://www.tsb-bst.gc.ca/eng/qui-about/index.asp), however, is an independent agency—separate from other government agencies and departments—that reports directly to Parliament through the President of the Queen’s Privy Council for Canada.

TC’s mandate is vast and complex. The department is tasked to promote and ensure a safe, secure, efficient and environmentally responsible transportation system, which contributes to Canada’s economic, social, and sustainable development objectives. In contrast, the TSB’s mandate (http://www.tsb.gc.ca/eng/qui-about/mission-mandate.asp) is solely to advance transportation safety. This difference might seem insignificant to some, but the distinctions occasionally leave our organizations in disagreement. Recommendations we make that are intended to advance safety have to be weighed by TC against their other objectives and responsibilities. Staying focused on a single objective, and not letting other factors influence our analysis, is one of the main reasons that we must maintain our independence.

Our singular focus on safety also means that we play no role in ensuring rules are followed, or assigning blame or liability. This misconception is probably the most common and unfortunate one that we, as investigators, face during an investigation.

Often people feel as though we are at the scene to determine what happened and whose fault it was. I assure you, this isn’t the case. Nobody wakes up in the morning with the intention of causing an accident, and likewise no TSB investigator wakes up the day after with the intention of placing blame.

Blaming someone for an accident is not only clearly outside of our authority, it is almost always completely ineffective at advancing safety. When mistakes or omission are made, slapping someone on the wrist does little to determine what caused the accident, and almost nothing to prevent it from happening again. Figuring out what happened and why however is essential.

On a more positive note, more commonly these days, we meet professionals who are involved in an accident and know exactly who we are and why we are there. They are usually just as interested in the outcome of the investigation as we are, as they themselves are unsure of what happened.

Once everyone knows our purpose and the fact that we’re not ‘out to get them’, the synergy and collaboration that can result makes identifying safety deficiencies and underlying issues immeasurably more accurate, and as a result, hopefully makes transportation safer.

And this is one area where the TSB and Transport Canada are exactly the same.

I'm sure Beaker :yuk::yuk: will be spinning the point that the bureau operates in much the same way to the TSBC.:ugh: However Beaker's credibility is shot := and coupled with the damning evidence :=:= presented in the AAI inquiry there is no doubt that the current executive regime within the bureau is only paying lipservice to the documented principles of the TSI Act.

Here is an idea that perhaps Sunny's beloved PMC (rather than the Minister's advisers) could do a feasibility study on...:rolleyes:


Changing the TSI Act so that there is a Board rather than a Commission, using the TSBC as a template.
Changing the TSI Act so that the ATsB purse strings are bound directly to the Parliament and the bureau would also be directly answerable to the Parliament (maybe facilitated through the Senate RRAT Committee).
Food for Sundy thought perhaps...??? :ok:

Note: Love the way the Canucks are more than happy to allow team members to contribute to their blog...stark comparison to Beaker's blog hey!:{

[Sarcs]

While we're waiting for the New Year, a certain Government response and the suspect outcome of the TASRR maybe it is worth a pre-New Year cogitation or two...:cool:

From the last Senate Estimates hearing (18/11/13) NX has added some additional written QONs that I'm sure plenty on here would all appreciate the answers for..:E:
144
ATSB 04
XENOPHON
Pel-Air
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
Suspicious bugger our Senator X...;)

However if we give Beaker the benefit of the doubt and remain on the assumption that his intentions are honourable for calling on the Canuck's, then in true IOS tradition let's continue to aid the TSBC with their unbiased, fully independent review..:oh:

Okay a couple of recent bureau research investigations and reports could certainly be helpful to the TSBC review.

First cab off the rank, with much chest beating from Beaker in the media (Media release (http://www.atsb.gov.au/newsroom/2013/night-flight-warning-to-pilots.aspx)) and on his personal blog (Night-flight warning (http://www.atsb.gov.au/infocus/posts/2013/night-flight-warning.aspx)), is the bureau research report Visual flight at night accidents: What you can’t see can still hurt you (http://www.atsb.gov.au/media/4475634/ar-2012-122.pdf)

It never hurts to remind aviators of the inherent risks of flying at night but is the report actually telling us anything new (i.e. that we didn't already know) and has the bureau planned further proactive initiatives to address this significant safety issue or are they merely going through the motions??:rolleyes:

The TSBC comparison: I had to go back a fair bit (1990) to find a partly similar research report to compare but here it is: REPORT OF A SAFETY STUDY ON VFR FLIGHT INTO ADVERSE WEATHER (http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/etudes-studies/90sp002/90sp002.asp#a3)

Now I know the reports are not directly comparable but the TSBC report does have this to say about the risks of NVFR which reads similar to the ATsBeaker report (remember TSBC/CASB report was 1990):3.0 NIGHT VISUAL FLIGHT
Accidents occurring in other than daylight conditions comprised a disproportionately large number of VFR-into-IMC accidents. Approximately 10% of all Canadian accidents occur during the hours of darkness, which parallels estimates of the general level of night flying activity (also 10%). However, VFR-into-IMC accidents occurring during the hours of darkness accounted for almost 30% of the total study accidents. Analysis pointed to three issues: night VFR weather minima; the conditions for obtaining and maintaining a night endorsement; and weather briefings.

3.1 VFR Weather Minima
The consequences of flying in reduced visibilities are exacerbated when operating at night, in light conditions which do not permit sufficient warning for the pilot to see and avoid worsening weather conditions. Inadvertent entry into IMC when the actual conditions can not be seen can be minimized by reducing the possibility of occurrence.
Other countries employ weather minima to reduce the probability of aircraft encountering adverse weather, even during daylight conditions. For instance, in the United States VFR weather minima were recently introduced which prohibit daytime recreational pilots from flight in visibility of less than three statute miles. This measure reduces the risk of bad- weather encounters, and is even more effective for flights at night when bad weather is not so easily detected.
The high proportion of fatal night accidents attributable to adverse weather is in part the consequence of pilots initiating flight in weather conditions which are legally acceptable, but which deteriorate. The first indication to the night-flying pilot can be the inadvertent entry into IMC. The Board believes that, to reduce this risk, VFR flight at night should be restricted to more favourable weather conditions. Accordingly, the Board recommends that:
The Department of Transport increase VFR weather minima for night flight so as to reduce the risk of inadvertent flight into poor enroute weather conditions.
TSB-A90-71

3.2 Night Endorsement
The night endorsement qualifies the private pilot to fly during the hours of official darkness. To obtain this endorsement, the pilot undergoes a minimum of ten hours training in basic instrument flight manoeuvres. The intent is to prepare the pilot for inadvertent entry into IMC and to familiarize the pilot with aircraft control in conditions in which there is no apparent horizon. Five of the instrument training hours can be acquired in a simulator. No evaluation of competency is required prior to endorsement, nor are there re-certification requirements for the continued exercise of privileges of the endorsement.
Twenty-four studied accidents which occurred at night resulted from a loss of aircraft control, often after the apparent onset of vertigo. To understand the circumstances of such occurrences, the training, experience and skills of the accident pilots were examined. The accident pilots had seldom obtained additional instrument training after acquiring the minimum experience for night endorsement. Since instrument flying skills are perishable and require regular practice to maintain even a modicum of proficiency, the criteria for obtaining and maintaining a night endorsement apparently do not adequately reflect the skills required to cope with inadvertent entry into adverse weather. There is a higher probability of these circumstances occurring at night.
At present there is no method of ensuring that a minimum level of skill in flying on instruments has been achieved prior to receiving a night endorsement; an evaluation of a pilot's skills under the type of vertigo-inducing conditions encountered in adverse weather at night appears to be warranted. Furthermore, at present there is no method of ensuring that a minimum level of proficiency has been retained after the issue of a night endorsement; therefore, some form of recurrency training and/or testing also appears to be warranted. Such training and testing should focus on the instrument flying skills required for the safe conduct of night visual flight, skills which are considerably less complex than those required, for instance, to conduct a complete instrument approach.
In view of the disproportionate frequency of VFR-into-IMC accidents which occurred at night, the Board recommends that:



The Department of Transport revise conditions for the issue and maintenance of a night endorsement by:
including a practical evaluation of the pilot's skill prior to issue of the endorsement; and
verifying continued proficiency on a recurrent basis.TSB-A90-72
3.3 Night Weather Briefing In light conditions in which hazardous weather conditions can not be detected until they have been encountered, it is essential that pilots have appropriate information before initiating flight. Seventeen accidents that occurred in other-than-daylight conditions involved pilots who did not use available weather briefing facilities.
Weather information can be obtained by phone, by remotely-located computer terminals, or in-person at a weather office. There are no regulations specifically requiring a weather briefing before VFR flight; yet the probability of inadvertent entry into IMC at night could be reduced if pilots had appropriate information upon which to base their decision to initiate or defer a flight. This applies to all night flights, both private and commercial, but the Board is particularly concerned about the safety of the air transportation system used by fare-paying travellers. The Board believes that the Department of Transport should encourage private pilots to obtain a weather briefing prior to conducting a flight at night, but that the requirement for operations conducted by commercial pilots should be more stringent. Therefore, the Board recommends that:
The Department of Transport require that, prior to initiating night flight under VFR from locations for which weather briefing facilities exist, pilots engaged in commercial passenger-carrying operations obtain a weather briefing.
TSB-A90-73

Point of difference: This TSBC report from 1990 led to a significant educational Safety Promotion initiative from Transport Canada and the promulgation by TSBC of no less than 27 Safety Recommendations. The ATsBeaker report has yet to see any initiative from CAsA but did lead to two wet lettuce SRs being issued that ironically strongly reflect previous (yet to be addressed) SRs from 2003-4.:ugh:

Okay next ATsBeaker vs TSBC research report comparison: Back in October the bureau released their report into LOSA:Loss of separation between aircraft in Australian airspace, January 2008 to June 2012 (http://www.atsb.gov.au/publications/2012/ar-2012-034.aspx)

A TSBC research report (again back in 1990): REPORT ON A SPECIAL INVESTIGATION INTO AIR TRAFFIC CONTROLSERVICES IN CANADA (http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/etudes-studies/90sp001/90sp001.asp) Quote from the executive summary:
..."Following a series of losses of separation between aircraft at Lester B. Pearson International Airport in Toronto in late 1988, the Canadian Aviation Safety Board decided to conduct a special investigation of the safety aspects of the current air traffic control situation in Canada..."

Point of difference(like chalk and cheese these two): The TSBC report led to the promulgation of 48 SRs which, according to the documented evidence, have all been proactively adopted and acted on by Transport Canada since. The ATsBeaker report led to 3 SRs, which again can only best be described as wet lettuce attempts to address some fundamental safety risk issues within the ATC system.

Well there you have it, a couple of comparable research reports with similar subject matters. Those of you with the interest and the time to read can be the judge of who has the better more proactive methodology/approach in compiling research reports....hmm perhaps pass on your thoughts to the TSBC..:ok:

[Sarcs]

Recently released AQONs for November '13 RRAT Supp Estimates yielded this ATsB answer to Senator Xenophon's QON 144: Senator Xenophon asked:

I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?

Answer:
a. The ATSB Commission agreed to enter into an MOU with the TSB of Canada to facilitate the review, on 24 July 2013. The MOU was executed by the ATSB Chief Commissioner and the Chair of the TSB on 29 July 2013.
b. The TSB was identified by the Chief Commissioner as well placed to conduct the review because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.
c. The review will involve the TSB conducting a comparative analysis of ATSB and TSB investigation methodologies, including a comparison against ICAO Annex 13. As part of the review, the TSB will analyse a selection of ATSB investigations, including the Pel-Air investigation, to assess how the investigation methodology was applied. The review will also assess the ATSB’s approach to the management and governance of the investigation process, the investigation reporting process and external communications.

The TSB expects to publish its report by May 2014. b. above is worth reviewing...
"...because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety..."

I would suggest that other than the legislative framework there is very little tangible similarities in the two agencies...:{ But perhaps the biggest point of difference is the culture within, examples are many. However the following blog piece (with vid) by the TSB Chair Wendy Tadros IMO amply demonstrates the cultural difference:Looking back on a year of successes

February 4th, 2014

Posted by: Wendy A. Tadros


The start of a new year is filled with potential, and turning that calendar page provides a great opportunityto look forward to new challenges ahead. But it’s also a perfect time for taking stock, to look back and reflect on what has been accomplished over the previous 12 months. A little over one year ago, the Transportation Safety Board (TSB) launched this blog. We were excited, and as our social media program was still in its initial stages, we wanted to supplement our Twitter and Flickr pages with a more personal view of the TSB, one that showed what goes on behind the scenes, and offered a glimpse into the lives of the men and women whose dedication and expertise help make Canada safer. Yes, we continued to produce our investigation reports on accidents from coast to coast to coast, but we wanted this blog to take a wider view, placing the emphasis on the human interest stories—especially the ones that don’t always get told.

In other words, we wanted to give Canadians a fuller picture of who we are and what we do, to answer some of their questions, and then invite them to join the conversation.

And that‘s exactly what we’ve done. We’ve blogged about topics such as getting to accidents sites in really remote areas, a young Marine cadet’s first encounter with tragedy at sea, and even a TSB employee whose hobby is being an aviation consultant for Hollywood blockbuster movies!

But we’ve also used the blog as an opportunity to shine a spotlight on key issues and investigations—and to that end we’ve written about the recurring problem of floatplane safety, as well as what it’s like to be on site in the days following a devastating train accident.Looking ahead, 2014 is already shaping up to be a busy year. The coming months will see the release of several long-awaited TSB investigations, including into the deadly 2011 crash of a Boeing 737 in Resolute Bay, Nunavut; and the tragic 2013 derailment and fire in Lac-Mégantic, Quebec. As always, though, we won’t wait until the final release of a report to communicate safety information; if we discover risks that need to be communicated sooner, we’ll do that.

In the meantime, watch this space. We have lots of stories to tell, and plenty of TSB people who want to tell them. Because whether they’re putting together the pieces of a shattered airliner, interviewing crew members from a capsized fishing vessel, or computer modeling the deadly results of a train derailment or pipeline explosion, our people have a passion for their work—a passion they’re happy to share.

And one we think you’ll enjoy reading about.
[YOUTUBE]Introducing our blog: the TSB Recorder - YouTube (http://www.youtube.com/watch?v=BanhpN59e6Y#t=49)


Versus Beaker's blog that no one within the ATsB can contribute to and hardly anyone comments on: Beaker's blog (http://atsb.gov.au/infocus.aspx)

Full, frank & open vs mi..mi..mi..Beaker obfuscation & spin..:ugh:

Another big point of difference is the TSB/ATsB claims of being totally independent...one is legitimate: Aren’t we just part of Transport Canada? (http://www.bloguebst-tsbblog.com/2013/01/25/difference-between-transport-canada-transportation-safety-board/#.UvWD2EjNvIU)...and one is no more than a charade (perfectly highlighted by the PelAir debacle)..:=

Finally there is the 'no blame' game contention..

TSBC: Human factors and accident investigation: avoiding the blame game

Like many other investigators at the TSB, I often encounter those who assume “human error” is to blame for an accident. And while I understand this reaction— it’s easy, especially with hindsight, to judge a person or an organization for failing to do something— blame is a knee jerk response that does little to promote safety for the future.

Instead, the goal of a human factors specialist is to understand the actions of the people involved, thereby making informed assessments as to whether conditions will repeat themselves or an accident will reoccur.

A simple assumption

I start with a simple assumption: that the people involved didn’t wake up that morning and plan to have an accident. Thus the question shifts from “what did these people do wrong?” to “why did their actions make sense to them at that time?” Other questions soon follow, including:

1) Are other people or organizations likely to find themselves in the same situation and make the same decisions?
2) What factors in the work environment led to these actions?
3) What can be put in place to change those factors for the better?


Typically, accidents happen when actions and circumstances come together at just the right time. Many of the variables or changes can seem insignificant at the time, with people often reporting that they did little different from any other day. To get to the bottom of things, I focus on how work is supposed to be carried out (standard operating procedures, training manuals, etc). Then I compare it to how work really gets done, and again to what happened on the specific day in question.


Understanding the adaptations


Understanding these differences, or adaptations, is critical—it helps me understand the drivers for the choices people make. For instance, as adaptations are identified, we assess the extent to which they have become the “unofficial” workplace standard, and how these new (and possibly undocumented) adaptations impact the workplace. For example: are other employees aware of the changes? Is management?


The boundaries of human capacity


In any workplace, people are always juggling a variety of tasks—and with differing levels of success. Human factors investigators assess all relevant aspects of human performance: perception, attention, memory, and planning—all to determine whether the demands of the job exceed a person’s ability to perform a task reliably. We use the results from established research studies to define the boundaries of human capacity and then develop a compelling argument to explain why the event happened.


Hopefully, by identifying the factors that led to an accident (or which might increase the risk of another accident taking place), we can better understand how our complex transportation system really works. And while there is never an “ah-ha moment” in which a single cause is identified as solely responsible, our work helps shine a spotlight on the management and operational characteristics that place excessive demand on people. - See more at: Human Factors and accident investigation ? Avoiding the blame game - The TSB Recorder (http://www.bloguebst-tsbblog.com/2013/09/06/human-factors-and-accident-investigation/#.UvWEzkjNvIU) Versus...well let's just say the word PelAir shall we??...:ugh: :yuk::yuk:

Yep Beaker has done us all a favour by bringing in the Canucks...:ok:

[ozbiggles]

So Sarcs
One of your points here I think is you believe the ATSB would be better if they all blogged about what they were doing instead of just doing it?
I think I would prefer them to just produce timely well informed reports than fill their time with updating personal internet waffle giving even more ammo to those amongst us on vendettas.
I think the NTSB investigation into the 777 is a good example of what happens when the bosses are more interested in their own careers and profiles than getting on with the job.

[Sarcs]

Lessons to be learnt: Although probably too late for TSB review purposes, it is worth doing a comparison with a recently completed TSB investigation vs a bureau ongoing investigation, which appear to have some very similar causational elements...unstablised approach, SOPs, IFR to VFR visual segments etc...:cool:

This is the summary for ATsB investigation AO-2013-085 (http://atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-085.aspx)On 15 May 2013, an ATR-GIE Avions de Transport Régional, ATR72‑212A aircraft, registered VH-FVR and operated by Virgin Australia Regional Airlines, was conducting a scheduled passenger service from Brisbane to Moranbah, Queensland.

At about 0715 Eastern Standard Time1 the flight crew commenced a descent from flight level (FL)2 180 and conducted a visual approach3 to runway 16 at Moranbah Airport (Figure 1).

During the approach to the downwind position of the circuit, the crew observed a band of low scattered cloud4 and fog along the flight path. The crew reported that the cloud base appeared to be about 1,500 ft above ground level (AGL), which was their planned downwind altitude for the circuit.

As the aircraft approached 1,500 ft AGL the captain, who was the pilot flying, elected to continue descending the aircraft to remain clear of the cloud. The captain reported that, as the cloud appeared to be ‘sloped’ and he had visual reference with the ground, the aircraft could be flown visually under the cloud on the downwind leg.

It became apparent during the descent that the cloud was more extensive than expected and, in order to remain visual, the captain increased the aircraft’s rate of descent to about 1,900 ft/min until levelling below the cloud at a recorded altitude of about 450 ft AGL.

Recorded data identified that, during the descent, the aircraft’s terrain alert warning system (TAWS) activated a number of terrain proximity and aircraft configuration alerts to the crew (Figure 1). The crew reported that, as they were visual, the alerts were acknowledged and flight continued below the cloud base. They also reported that the height of the cloud base was difficult to judge due to the combination of the scattered cloud and the underlying fog.

Once past the low band of cloud, the aircraft was climbed to about 950 ft AGL before the captain turned the aircraft onto the base leg of the circuit. While on base, two TAWS 'Don’t Sink' alerts, which were based on a number of parameters including the degree of altitude loss and radio altitude, were annunciated to the crew. These alerts were acknowledged by the crew and, as the aircraft’s performance appeared normal, the approach was continued and the aircraft landed on runway 16.

The investigation is continuing and will include a review of the:
•operator’s standard operating procedures and pilot training relating to the conduct of approaches
•operation and performance of the TAWS
•operator’s management of TAWS alerts.

It is anticipated that the investigation report will be released to the public no later than April 2014.
{Note:This incident was also covered by Planetalking What were they thinking on this Virgin flight? (http://blogs.crikey.com.au/planetalking/2014/01/09/what-were-they-thinking-on-this-virgin-flight/) }

And this is the Findings & Safety Action statements for TSB Final report for AIR A12P0034 (http://tsb.gc.ca/eng/rapports-reports/aviation/2012/a12p0034/a12p0034.asp)Findings

Findings as to causes and contributing factors

1.Although the hazardous runway condition had been identified by the company's safety management system, the delay in action to mark the runway allowed this condition to persist.
2.Up-to-date weather and runway condition information was not provided to the crew, nor was it requested by the crew.
3.The pilot continued the approach below the visibility limits specified in the company's standard operating procedures.
4.Deteriorating weather, as well as the lack of approach aids and runway markings, hampered the pilot's ability to establish the aircraft onto a stable final approach prior to crossing the threshold.
5.The company's standard operating procedures for stabilized approaches were not followed, and an unstabilized approach was allowed to continue.
6.The pilot was unable to position the aircraft over the centre of the runway as it settled to land, and the left main landing gear entered the deeper snow at the runway edge, causing the aircraft to veer into the snow bank.

Findings as to risk

1.If a company's risk mitigation strategy is not implemented in a timely manner, hazards are allowed to persist, increasing the risk of an accident.
2.If company standard operating procedures do not include criteria and procedures for stabilized approaches, or they are not followed, there is an increased risk of landing accidents.
3.Operating on a snow-covered runway that does not have markings or devices to allow a pilot to easily identify the runway surface increases the risk of runway excursions.
4.If the identified risks and mitigation strategies are not communicated to the people exposed to the risks, it is possible they will deem the risk as acceptable to management and continue operations.

Safety action

Safety action taken

Transport Canada

Transport Canada indicated that further prescriptive regulations may not be the appropriate way forward, but rather that the issue of rejected approaches may be better addressed through guidance material on pilot decision making and crew resource management.

This issue will be addressed in the development of the contemporary crew resource management (CRM) and pilot decision making (PDM) training standards for 702, 703, 704, and 705 operations. These standards will include the threat and error management (TEM) model.

The regulatory development of CRM and PDM is part of the 2013/2014 priorities.

This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 18 December 2013. It was officially released on 07 Februrary 2014.
It will be interesting to see if we get the same standard of informative, clear & concise reporting with similar (but somewhat repetitive) safety messages when the bureau report comes out...:rolleyes: