ATSB reports
Perhaps a more robust PFI of Santa's sleigh this year...??
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...
Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..
:
The fire fighting Dromader tragedy has also apparently led to the bureau generating a Safety Advisory Notice, see here: AO-2013-187-SAN-005
Also released within the last few days was..
VFR flight into IMC involving de Havilland DH-84 Dragon VH-UXG
{Note: Interesting point that from accident to Final Report only took 445 days
}
This accident has also generated an addition to the ATSB Aviation safety issues and actions database: AO-2012-130-SI-01
But in keeping with the Beaker BASR methodology..
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):
Ho..ho..ho..Merry XMAS!
ps err..what vintage is Santa's sleigh maybe his gingerbeer elf and loadmaster elf better beef up their preflight procedures prior to departure??
Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..
:
AO-2013-226
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
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
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
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
Also released within the last few days was..
VFR flight into IMC involving de Havilland DH-84 Dragon VH-UXG
{Note: Interesting point that from accident to Final Report only took 445 days
}This accident has also generated an addition to the ATSB Aviation safety issues and actions database: AO-2012-130-SI-01
But in keeping with the Beaker BASR methodology..
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.
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.
ps err..what vintage is Santa's sleigh maybe his gingerbeer elf and loadmaster elf better beef up their preflight procedures prior to departure??
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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?
I wonder who will write this one up?
TSBC in-flight breakup report a benchmark for ATsB??
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) 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...
In reference to my previous post:
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....
Aviation Investigation Report A11W0048
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:
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?? 
Most of us have been dubious (including Senator X #34) 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...
In reference to my previous post:
Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..
:
Quote:
AO-2013-226
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
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
: Quote:
AO-2013-226
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
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
Aviation Investigation Report A11W0048
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
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
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 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
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
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
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
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 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
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
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sarcs, maybe I am a pessimist, but your:
Most of us have been dubious (including Senator X #34) 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.
Most of us have been dubious (including Senator X #34) 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.
Thread Starter
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...-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?
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...-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?
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atsb gets it wrong again!!
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?
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?
Man Bilong Balus long PNG
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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?
Oh, and bring back the Safety Digest whilst he's at it!
Well.....I can dream....can't I?
Oh, and bring back the Safety Digest whilst he's at it!
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?
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Like to help with the list?
TICK TOCK
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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
Besides, I was in Montreal at the time.TICK TOCK
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.
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atsb - Reports
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
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
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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
Cheers
TICK TOCK
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
Cheers
TICK TOCK
UITA out of line on BASI Monarch report.
Warning: Longish post following
UITA:
Hmm...took your advice UITA and reviewed the BASI report 9301743, & subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one...
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...??
Ok let's go through the motions and cut to the chase of AAIR199301743 i.e. the Safety Actions section:
Note: For those interested in the NTSB 1994 study report mentioned above here is a link: NTSB Commuter Airline Study
It is also worth noting that the Monarch Airlines crash at Young was extensively referred to in the very comprehensive Regional Airline Safety Study 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...
So UITA please explain to me how the Monarch BASI report is as defective/useless as per the ATsBeaker version of reporting these days...
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.
Then form a real opinion as the whether atsb was correct, or Monarch just joins my list.
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...??
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.
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.
It is also worth noting that the Monarch Airlines crash at Young was extensively referred to in the very comprehensive Regional Airline Safety Study 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...So UITA please explain to me how the Monarch BASI report is as defective/useless as per the ATsBeaker version of reporting these days...
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Sarcs # 118 –" [&] subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one.
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.
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.
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.
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.
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.
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.
Last edited by Kharon; 26th Jan 2014 at 18:20.
While you are reading the Monarch report again UITA you might also like to get a hold of James Reasons book where he goes into a fair bit of detail on why the Monarch investigation was an excellent example of an organizational accident.
As I suspected you still haven,t explained why Monarch is on your list other than for reasons of hysteria and bias. The other issue is the discussion about how good accident investigation was in this country when Rob Lee and Alan Stray were at the helm. Monarch occurred under their watch so you can,t have it both ways. The investigation was either conducted by two very competent investigators or you are full of hot air?
As I suspected you still haven,t explained why Monarch is on your list other than for reasons of hysteria and bias. The other issue is the discussion about how good accident investigation was in this country when Rob Lee and Alan Stray were at the helm. Monarch occurred under their watch so you can,t have it both ways. The investigation was either conducted by two very competent investigators or you are full of hot air?
