Glad to see the mods have merged these two threads it kind of sets a background to the demise and hit to the reputation of the once proud aviation safety watchdog, the ATSB/BASI.
The bureau, much like Fort Fumble, has always had its detractors but even the critics would (once upon a time) grudgingly admit that on the whole the ATSB generally get it right and make a worthwhile contribution for the betterment of aviation safety. However IMO in the last 5 years they have seriously lost their way. The evidence of this was very much on display throughout the Senate Inquiry (hence *Recommendation 8). Also, as posters on here are noticing, through the quality of the reports being produced. The mantra now appears to be…
politically correct and
on budget.
*R8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.
Note: Beaker attempted to placate the Senators by bringing in the Canucks but Senator Fawcett rather scathingly struck back with this comment in a press release…
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation processes as identified in the Senate report including the Canley Vale accident.”
Some would say this decline of the bureau can be tracked back to the Lockhart River investigation with the subsequent Coroner’s findings through to the Miller review. However IMO, despite all those troubling times, the bureau on the whole could still hold their heads up high till at least the middle part of 2008.
Perhaps to highlight this there were two important report publications put out by the ATSB in 2008-09, one was the decade review
; Australian Aviation Safety in Review: 1998 to 2007 and the other (internationally recognised) wasthe
worldwide review of commercial jet aircraft runway excursions.
In the foreword of the Aviation Safety Review the former and last Executive Director Kym Bills (rather proudly) had this to say:
It has been an exciting and progressive year for air safety in Australia. The December 2008 release of the National Aviation Policy Green Paper established the future direction of the aviation industry, asserting the Government’s position on air safety in Australia as the number one priority. This includes the establishment of the Australian Transport Safety Bureau (ATSB) as a statutory agency with a Commission structure to enhance its independence. Legislative amendments to the Transport Safety Investigation Act 2003 to give effect to the governance changes have been passed by Parliament and the new Commission will come into place on 1 July 2009.
I am delighted to release the third edition of the ATSB’s Australian Aviation Safety in Review. The format of this edition departs from that of the first two editions to provide a range of new information not previously presented. The report provides an overview of the aviation industry with a focus on safety data derived from aviation occurrences reported to the ATSB. It covers a
10-year period (1998 to 2007) and describes trends and analysis of both aviation incidents and accidents.
The first chapter deals with the structure and size of Australia’s aviation sector, including the number of aircraft registered and numbers of pilots and engineers licensed, and the amount aviation activity in different sectors. The next two chapters delve into measures of aviation safety. Chapter 2 examines the trends across 10 years for the number of fatal accidents, accidents and incidents, and their rate expressed as a proportion of annual flying hours. Chapter 3 takes a closer look at the nature of aviation occurrences (incidents and accidents) in Australia through an analysis of what occurred. Chapter 4 looks at why they occurred. That is, what human actions and technical failures contributed to the occurrences. Aviation occurrence reporting requirements and procedures are described in Chapter 5, and in Chapter 6, the special topic covered is the issue of birdstrikes in airline operations.
The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety.
I commend the report to you.
Kym Bills
Executive Director
Australian Transport Safety Bureau
Note: I wonder on reflection whether KB would have made the same statement today?? And does he feel somewhat betrayed by the turn of events that was to occur since the end of his tenure at the ATSB??
The other report/review is still highly regarded internationally as a reference for jet runway excursions and is incorporated into an ICAO/FSF report on Reducing the Risk Runway Excursions.
As an example of the worth of this excellent proactive report and the knock on safety benefits, lessons learnt etc..etc our fellow Canuck comrades, the TSB Canada, have just released a final report into a Quebec runway excursion by an American Airlines 737:
Aviation Investigation Report A10Q0213.
Note: This excellent and very informative report is worth taking the time to read and you will find that in the web portal format is extremely easy to navigate around. You will also observe that the ICAO/FSF is listed as a reference and that the ATSB database on similar B737 incidents is referred to in appendix G.
Extract from Safety Action section of this report:
Safety action taken
American Airlines
In April 2011, as part of its pilots’ recurrent training, human-factors class, American Airlines introduced a simulation and discussion of this Boeing 737 runway excursion. This training is given to company pilots to educate them on the possibility of a runway excursion due to a nosewheel steering problem on landing roll-out after a normal approach and landing.
Safety concern
Despite efforts in analyzing past nose-gear steering, low-slew rate-jam events and carrying out post-event valve examinations, the cause of these uncommanded steering events remains uncertain. The safety review process completed by the manufacturer and based on a quantitative, cycle-based occurrence rate of 1 X 10-7, classified this event as an extremely remote probability, and gave it an acceptable risk level, combined with a major severity level. An occurrence rate of 1 X 10-7 meets the Federal Aviation Regulations (FARs) certification requirements. Additionally, an acceptable level of risk does not require further tracking of the hazard in the Federal Aviation Administration (FAA) Hazard Tracking System. Consequently, other than flight data analysis and valve examination, the manufacturer has not taken further action following the 11 known nose-gear steering rate-jam events that have occurred over the past 21 years.
Rate of occurrence determines whether a manufacturer needs to take safety action. In order to determine the rate of occurrence, there is a need to capture as many events as possible. This capture allows identification of possible safety deficiencies, and aids in the application of risk-mitigation strategies. Since no defences have been put in place to mitigate the risk of a runway excursion following a rate jam, damage to aircraft and injury to aircraft occupants remains a possibility.
The present known low rate of nose-gear steering rate jams may be explained by the fact that, directional control difficulties on take-off or landing would not often result in an excursion and/or damage or injury, and therefore would not be reported. The lack of reporting may also be due, in part, to the fact that operators, flight crew and maintenance personnel have not been made aware of the possibility of rate-jam events, nor have they been provided information on how to recognize, react or troubleshoot. The rate of occurrence would have to show a significant increase to validate corrective action, as safety action is based on FARs certification and in-service fleet following requirements.
Despite technological advancements in recording devices, many Boeing aircraft do not record nosewheel steering system parameters. Boeing models affected include 707/720, 727, 737, 747 (some models), 757, 767, and 777.
The cause of these low-slew, nose-gear steering rate jams over the past 21 years remains uncertain. A lack of recognition and reporting prevents adequate data collection, analysis, and implementation of risk-mitigation strategies if necessary.
The Board is concerned that, in the absence of information as to the cause of uncommanded steering events due to nose-gear steering rate jams, there remains a risk for runway excursions to occur.
The safety action section shows the benefits or flow on affect of compiling worldwide information, including the ATSB review and draws attention to a possible safety issue on B737 aircraft that will now be noted (at least) on the TSB database. It also reinforces the ICAO/FSF initiative to create a
Runway Excursion Database.
So the question is can our bureau recover from the
Beaker years and return to some of its former glory as a proactive AAI organisation at the forefront of contributing to aviation safety worldwide, or are we to continue with these politically correct, fiscally accountable, dribble of reports that have no substance or relevant safety recommendations attached?? If it is the latter then industry and taxpayers deserve a refund and our once proud safety watchdog should be disbanded! Minister it is your call but please take account of the disturbing findings in the PelAir inquiry and action a government response to the partisan Senators recommendations ASAP…
