PPRuNe Forums - View Single Post - ATSB report just published on A320 throttle asymmetry incident
Old 27th Jan 2013, 02:48
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Sarcs
 
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Been monitoring this thread with particular interest, it is good to see posters with very real experience in High Capacity Jet ops getting involved in the debate. This thread highlights the importance of the ATSB in publishing good factual reports that disseminates vital safety issues that we all can learn from.

However as several posters are now starting to realise the ATSB report is somewhat short in detail in the technical and operational aspects.

Kharon’s 2006 comparison is a particularly good one as it displays what appears to be a totally different methodology of investigation by the ATSB (that was then this is now!) and the nuances are obvious in the final report.




Examples:
  • In the ‘Additional information’ section of the 2006 report the ATSB highlights research into ‘Previous events’, this is described as finding a ‘causal chain’ (Reason model). The 2012 report is totally devoid of any such information suggesting that this was a isolated (one in a million incident) but judging by some of the posts that is probably not entirely true.

d_concord said: What happened here is not unusual. I have seen other do it and have done it myself. And as you say, in all the cases I have seen or done myself you just put the lever instantly back into to the detent and presto now you have the power you programmed. I have never heard of anyone to just sit there with the problem until now.
  • It has also been pointed out that the 2012 report seems to be lacking in the organisational and management information:
scrubba said: FWIW, I am particularly glad that it was reported, investigated and published.I thought that a lot more could have been drawn from the event and the lead up to it, as well as the company SOPs, preparation of training captains, etc and what reviews took place post-event.

d_concord said: It is interesting that the findings did not see the need to look at or make any comment on any deficiency in understanding or the need to improve the initial conversion training onto the aircraft. Seems as though they did not even look at the ground course or training syllabus of the organisation that did the training. Given the PF had only 120 hours on type this incident started there.
Whereas the 2006 report has a whole section devoted to “Organisational and management information” which includes quoting from the Operations Manual the relevant section dealing with; “The A330 operating techniques, instructions, standard operating procedures (SOP) and limitations in the operations manual that affected the conduct of an RTO” (pg 6 of the report).



  • The ‘Safety Actions’ sections of both reports are also like chalk and cheese..
2012 Safety Actions (operator):
Jetstar

Simulator training

The operator advised that, in response to this occurrence, they have incorporated a ‘thrust mishandling/abnormal event prior to V1’ into their ‘Captain Simulator’ qualification. They have also incorporated a module into their simulator cyclic training regarding incorrect thrust setting on takeoff.

Communications

The operator advised that, in response to this occurrence, they have issued a communication to flight crew regarding ‘Command of Flight’ requirements for the pilot in command in circumstances where an operational event occurs during a flight.
2006 Safety Actions (operator):
Aircraft operator

On 5 February 2006, prior to this incident, following a third airspeed–related occurrence involving an A330 where wasp activity was suspected, the operator’s engineering department initiated the following actions:

• A property fault report was raised requesting urgent action be taken to remove mud wasp infestations on the operator’s ground support equipment (GSE) that was located at the Brisbane Airport international apron. In response to that fault report, a contractor was employed to inspect and spray the operator’s portable equipment. During the process, a wasp nest was found and removed from one set of portable stairs.

• An arrangement was put in place for the quarterly inspection and spraying of all ground equipment.

• An email was distributed to all line maintenance staff at Brisbane that included an overview of the wasp-related problems, and an instruction to fit pitot probe covers as soon as possible after an aircraft’s arrival, with their subsequent removal as close as possible to the aircraft’s departure.

• As a precautionary measure, the operator inspected all pitot lines throughout its A330 fleet. No foreign matter was found in those aircraft’s lines.14

In May 2006, the operator assumed responsibility for the ongoing wasp inspection/eradication program in their GSE area. The following schedule was established:

• weekly inspections/eradication took place until the end of June 2006

• monthly inspections/eradications were invoked from July to September 2006 (the period of least expected wasp activity)

• a weekly program was to be reinstated from 1 October 2006 (the perceived time of greatest wasp activity).

In addition, the operator promulgated information to flight crews in order to alert them of the potential hazards of wasp activity at Brisbane Airport.

In October 2006, the operator implemented a formal Local Area Procedure at Brisbane, which provided more detailed guidance than the maintenance instruction manual for the fitment of pitot probe covers to A330 aircraft as follows:

• when aircraft ground time exceeded 2 hours, pitot covers were to be fitted and a Technical Log item raised to reflect their fitment

• when the aircraft were on the ground for less than 2 hours, and at the discretion of the certifying Licensed Aircraft Maintenance Engineer (LAME), pitot probe covers were to be fitted and a Technical Log item raised as necessary to reflect their fitment

• if wasp activity increased during the summer months, the less than 2 hour option should be adopted.

Finally, the operator also planned to introduce low-to-intermediate speed range rejected takeoffs (RTOs) to the company’s recurrent simulator training program.
I also find the following comments interesting… “The ATSB show again that they can’t do any sort of analysis or have any expertise. This is just a regurgitation of an internal Jetstar report it would seem.”…As Rudder indicated you really have to wonder about the ATSB and the level of experience, skill and analysis”.

Not that we are expecting the bureau to necessarily have a type rated expert in the investigation team, however it is perhaps poignant to make a comparison to the NTSB system of investigation and how they get around the ‘expertise’ issue.

Within the NTSB investigative process they have what they call a ‘Party System’, see here:
The Party System


The Board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents in the other modes of transportation - rail, highway, marine and pipeline. With about 400 employees, the Board accomplishes this task by leveraging its resources. One way the Board does this is by designating other organizations or companies as parties to its investigations.
The NTSB designates other organizations or corporations as parties to the investigation. Other than the FAA, which by law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as parties to the investigation. Only those organizations or corporations that can provide expertise to the investigation are granted party status and only those persons who can provide the Board with needed technical or specialized expertise are permitted to serve on the investigation; persons in legal or litigation positions are not allowed to be assigned to the investigation. All party members report to the NTSB.
Eventually, each investigative group chairman prepares a factual report and each of the parties in the group is asked to verify the accuracy of the report. The factual reports are placed in the public docket.
This system makes a lot of sense as it means that various parties with a particular interest and expertise can provide a ‘team’ effort to proactively analyse, research and contribute to getting the best possible safety outcome from the NTSB Final Report.

With the 2006 report there does appear to be more of a ‘team effort’ and level of cooperation between the ATSB and the operator, however the 2012 report hints at a distinct lack of cooperation and there is almost a level of ‘political correctness’ displayed i.e. ‘we don’t want to upset them best let them address the safety issues.’

Anyway back to the thread and keep up the good work filling in the gaps that the ATSB is apparently happy to leave out these days!
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