Senator Fawcett on page 5 of the Hansard
:
Senator FAWCETT: Do you happen to have looked at the Indonesian report from 6 November 2008 into a Dornier aircraft that had its undercarriage collapse after a heavy landing?
Mr Dolan: No, that is not one that I can recall having looked at.
Senator FAWCETT: I merely raise that to highlight the point that my understanding is that the ATSB actually spent some time instructing, supporting and helping the Indonesian government in terms of their ability to conduct aviation accident investigations?
Mr Dolan: That is correct.
Senator FAWCETT: As I look at the scope of the report, whilst it was fairly clear from their examination that in this case it was pilot error—a fast approach, inappropriate crew interaction and other things—they were very brief but quite good in highlighting that things like the runway and safety area airport facilities oversight and the level of compliance were not up to speed. They were quite blunt about making those observations around other government agencies and around the recommendations that then flowed in the report to those other agencies and the operator, which can then clearly be tracked.
Noting the Air France report looking at the A330 that had the icing problem, and EMS accidents in the USA, all of them appear to take the same basic analysis model you have started with but put quite clear emphasis on organisational factors that you are saying, even having looked at the Chambers report, are not applicable. Does it concern you at all that we seem to be out of step with our near neighbours as well as probably the world leaders in aviation?
Mr Dolan: Important though it is, the Norfolk Island investigation report is only one of a considerable number of reports we produce on an annual basis. Each investigation results in those reports. We have an assessment as to scope, taking account of a range of factors, and in a number of cases, because we think it is necessary for the purposes of the investigation to go all the way to organisational factors both at the operator level and the regulator level, we will quite often go there and make quite clear statements and findings in relation to it.
Perhaps we can help Beaker in finding that Indonesian report...hmm here it is:
http://www.dephub.go.id/knkt/ntsc_av...t%20PK-TXL.pdf
And here’s an excerpt to show what the Senator is actually referring to…
1.17 Organizational and Management Information
1.17.1 Operator
Aircraft Operator : Express Air
Operator Certificate : AOC 121-038
1.17.2 CFIT and ALAR training5
The DGCA introduced the CFIT ALAR training program using the United States Flight Safety Foundation’ CFIT and ALAR material (Appendices G and H), to all Indonesian operators between 18 and 21 July 2005. The training for operators’ training instructors and some line pilots was jointly conducted by the DGCA and International Civil Aviation Organization.
The FO(1), handling pilot involved in this occurrence had successfully completed the DGCA/PT. Aurora Perdana Mandiri CFIT and ALAR Implementation Flight Safety Training course number 28, conducted between 13 and 15 August 2008.
Despite a number of requests, no evidence was provided to demonstrate that the FO(2), and the PIC (Monitoring/instructor pilot) had completed CFIT and ALAR training.
1.17.3 Express Air safety programs and training
At the time of the accident Express Air had not implemented Flight Operations’ Quality Assurance (FOQA) or Line Operations Safety Audit (LOSA) programs.
5 Copies of the ALAR education and training programs, including video programs, are available in CD-ROM format and can be obtained directly from the FSF (www.flightsafety.org).
This subject was extensively covered in the report
published 22 October 2007 by the National Transportation Safety Committee into the Boeing 737 accident on 7 March 2007 at Yogyakarta. Recommendations were made in that report to the Directorate General of Civil Aviation and Indonesian airlines. www.dephub.go.id/knkt
The Crew Resource Management (CRM) training was not adequately and
effectively implemented during post-ground school training. The operator did not have a robust CRM program. No evidence was provided to demonstrate that the pilots involved in this accident had received CRM training.
1.17.4 Airport Emergency Planning
Based on the lack of emergency personnel and equipment at Torea Airport, Fak Fak, Papua, to respond to an aircraft accident, it was clear that emergency planning and exercising did not meet the ICAO Annex 14 Standards.
ICAO Annex 14 contains Standards and Recommended Practices with
respect to Airport Emergency Planning.
Paragraph 9.1.12;
The plan shall contain procedures for periodic testing of the adequacy of
the plan and for reviewing the results in order to improve its effectiveness.
Note.— The plan includes all participating agencies and associated
equipment.
Paragraph 9.1.13
The plan shall be tested by conducting:
a) a full-scale aerodrome emergency exercise at intervals not
exceeding two years; and
b) partial emergency exercises in the intervening year to ensure that
any deficiencies found during the full-scale aerodrome emergency
exercise have been corrected; and reviewed thereafter, or after an
actual emergency, so as to correct any deficiency found during such
exercises or actual emergency.
ICAO Annex 14, paragraph 9.1.14 states that:
The airport rescue and fire fighting services shall have a plan that
shall include ready availability of coordination with appropriate
specialist rescue services to be able to respond to emergencies where
an aerodrome is located close to water/or swampy areas and where a
significant portion of approach or departure operations takes place
over these areas.
Paragraph 9.2.2 states that:
Where an aerodrome is located close to water/or swampy areas and
where a significant portion of approach or departure operations takes
place over these areas, specialist rescue services and fire fighting
equipment appropriate to the hazards and risks shall be available.
The requirement for Airport emergency planning and exercising at Indonesian airports was extensively covered in the report published 22 October 2007 by the National Transportation Safety Committee into the Boeing 737 accident on 7 March 2007 at Yogyakarta. Recommendations were made in that report to the
Directorate General of Civil Aviation and Indonesian airport operators.
www.dephub.go.id/knkt
It would also be worth Beaker having a look at another of our regional neighbour’s efforts, again with the support of the ATSB. In this case PNG’s AIC report into the C550 runway overrun at Misima
:
http://www.aic.gov.pg/pdf/P2-TAA%20F...812.221112.pdf
How’s that for giving a friendly, helpful hand?? Certainly beats getting a 16:55 Friday Arvo fax from Fort Fumble!
