Merged: Senate Inquiry

[Sarcs]

Dichotomy: Bureau’s air safety investigations & lessons (not) learnt??

Dromader drift but there is a point…

Perhaps one of the most insightful statements ever made on the ANZ & P thread boards…

framer –"That's life, now we need to look at why we haven't learnt from it."

…was eerily echoed in the title and content of a blog from the Malaysian PM: This time, we have to act on lessons learned from an air tragedy

“…The global aviation industry must not only learn the lessons of MH370 but implement them. The world learned from Air France but didn’t act. The same mistake must not be made again…”

Some of the key Safety Recommendations from AF 447 relevant to MH370 and what PM Najib is referring to:

On the basis of this work, the BEA recommends that EASA and ICAO:
· extend as rapidly as possible to 90 days the regulatory transmission time for ULB’s installed on flight recorders on aeroplanes performing public transport flights over maritime areas;
· make it mandatory, as rapidly as possible, for aeroplanes performing public transport flights over maritime areas to be equipped with an additional ULB capable of transmitting on a frequency (for example between 8.5 kHz and 9.5 kHz) and for a duration adapted to the prelocalisation of wreckage;
· study the possibility of making it mandatory for aeroplanes performing public transport flights to regularly transmit basic flight parameters (for example position, altitude, speed, heading).

In addition, the BEA recommends that ICAO:
· ask the FLIRECP group to establish proposals on the conditions for implementing deployable recorders of the Eurocae ED-112 type for aeroplanes performing public transport flights.

On the basis of this work, the BEA recommends:
· that EASA and ICAO make mandatory as quickly as possible, for aeroplanes making public transport flights with passengers over maritime or remote areas, triggering of data transmission to facilitate localisation as soon as an emergency situation is detected on board;
and
· that EASA and ICAO study the possibility of making mandatory, for aeroplanes making public transport flights with passengers over maritime or remote areas, the activation of the emergency locator transmitter (ELT), as soon as an emergency situation is detected on board.

4.3 New Recommendations
4.3.1 SAR coordination plans over maritime and remote areas
Those responsible for Brazilian SAR stated that they did not know what means were available in the neighbouring SAR areas and had not tried to obtain information on the subject. Contrary to ICAO standards and recommended practices, there is no SAR coordination plan between Brazil and Senegal. This lack of a plan caused a considerable delay in the start of SAR operations.
Consequently, the BEA recommends that:
· ICAO ensure the implementation of SAR coordination plans or regional protocols covering all of the maritime or remote areas for which international coordination would be required in the application of SAR procedures, including in the South Atlantic area. [Recommendation FRAN-2012-032]

Drifting back to Dromaders and ‘other safety related (ATsBeaker) matters’…

yr right: “ I cant say loudly enough how long ago they where told of this problem. The sad thing is they turned there heads away and closed there ears”

And from Kharon’s post titled…2008 M18 – ATSB report…that when it came to the Dromader mod there were indeed lessons learnt and safety issues diligently recorded, yet fast forward to 2013 and these lessons/warnings appear to have been unheeded.

More disturbing is that the 2008 Dromader fatality is not isolated, for inaction by relevant authorities, and has ultimately led to there being similar causal factors in recent accidents/incidents.

Example: Cape Hillsborough EMS Chopper accident 2003 v ABC Chopper accident Lake Eyre 2011
The Hillsborough accident also highlighted that there were outstanding Safety Recommendations that were (and still are) to be adequately addressed.

This apparent ineffective actioning (obfuscation) of SRs was further highlighted in the PelAir inquiry in a 2000 SR (see here) addressed to the BOM. To be fair this SR was somewhat proactively addressed by the BOM and ultimately led to changes in the regs for provision of alternates for remote islands for RPT/Charter but not airwork.

On the subject of provision of alternates, reliability/dissemination of BOM Wx reports:

If we fast forward to the PelAir inquiry we saw a 50:50 split in the CAsA Flight Ops inspectorate on whether DJ should have diverted due wx forecast below alt minima. We also saw several aberrations in what wx information was/wasn’t transferred to VH-NGA inflight and several interpretations on how DJ (as PIC) could have/should have disseminated this wx information.
{Comment: It is worth pointing out that the ATSB investigators, up till the issuance of the prelim report (Jan 2010), had deduced that there was a safety issue in all this (confused interpretation) and deemed it significant enough to fwd to FF as ‘critical’ i.e. a CSI.}

Now if we fast fwd to the bureau Mildura fog incident investigation here (I know touchy subject for some), & refer to the ‘Safety Action’ section (besides the proposed ‘love in’) we get this on the future scoping of the investigation (my bold)…

“…The investigation is continuing and will:

• examine the accuracy of aviation meteorological products in Australia
• examine the procedures used to provide information to flight crews from air traffic services and management of changes to those procedures
• examine the provision by the operators of information to the respective flight crews
• examine the relevant recorded data
• review the distribution, dissemination and sharing of operational information to the aviation industry as stipulated by the Civil Aviation Safety Authority, and enacted by Airservices Australia and the Bureau of Meteorology…”

Which is all good stuff in theory (despite the possible thirteen plus year lag in possible lessons learnt), but on recent observations is this just more ‘weasel words’ to appease the IOS masses?

MTF…Sarcs

Addendum

On the subject of ‘weasel words’ and following on from my post #1909 & Kharon’s post #1911 (& the weasel worded notified difference for Annex 13 CH 8 ACCIDENT PREVENTION MEASURES Para 8.2), the bureau recently published a REPCON that is particularly relevant to this post:

Reporter's concern

The reporter expressed a safety concern regarding the procedure used by Airservices Australia to alert flight crews when a Hazard Alert is issued after the flight has departed.

The crew advised that recently they departed on a Melbourne to Sydney commercial high capacity flight at 0653 UTC (due to land at 0756 UTC). During the cruise, the controller advised that their expected landing time was now 0830 UTC.

As this was well outside the NOTAM, which advised a holding time of up to 15 minutes, the crew questioned if a Hazard Alert had been issued. They were advised that one had been issued at 0655 UTC, but no advice had been passed to the crew.

As this is not the first time this has happened, the reporter advised that there appears to be a systemic failure of the system in the flow of information to flight crew of flights which have departed after the Hazard Alert has been issued.

Operator's response (Operator 1)

Airservices Australia (Airservices) appreciates the opportunity to respond to the reported concern regarding the procedure used to inform flight crews of when Hazard Alerts are issued after the flight has departed.

Due to the de-identified nature of the report, Airservices is unable to comment on the specific circumstances of the reported concern and cannot verify the reporter's statement that similar incidents have previously occurred. However in order to address the reporter's concern Airservices has investigated the matter and can provide the following commentary.

Airservices notes that the provision of Hazard Alerts and flight information service (FIS) dissemination is not based on whether an aircraft has departed, but rather on whether the aircraft is within one hour flight time of the condition (see Aeronautical Information Publication (AIP) Australia GEN 3.3 sections 2.1.1 and 2.5.4).

With specific reference to AIP GEN 3.3 section 2.1.1, aircraft within one hour flight time of the condition are required to be notified by air traffic control (ATC) of the existence of new operational information. Based on the information provided in the report, the aircraft should have been provided with the relevant information. If the information was not already described in a current meteorological (MET) product or Notice to Airmen (NOT AM) then ATC is required to communicate the information using the prefixed "HAZARD ALERT".

In response to the reporter's concern Airservices will remind controllers of their obligations regarding the provision of FIS to pilots.

Operator's response (Operator 2)

The reporter’s concern was also sent to the aircraft operator and the following is their response:

Hazard Alerts are usually issued by the Tower and / or the Enroute controller.

These are not generally communicated to Flight Dispatch or other operational entities within the operator.

ATC relays these alerts directly to the aircraft when no formal NOTAM is released.

If a NOTAM reflecting changes is released (pertaining to standard traffic holding or any other operational issues) it appears in our dispatch systems and is appropriately disseminated by our Flight Following unit. With regard to aircraft in flight, this is affected by means of ACARS and / or HF, and for aircraft on the ground by contacting the crew.

This process is incorporated into our Operations Manual and is strictly adhered to.

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and notes Airservices response. CASA agrees that there appears to have been a lapse on the part of Air Traffic Control to provide a Hazard Alert. As the operator only has an obligation for flight following for Extended Diversion Time Operations and therefore, in this case were not required to monitor changes after a flight departs.

CASA also notes that the nature of confidential reporting makes it difficult for the air navigation service provider and the regulator to take specific action as there is insufficient detail provided to do so.

CASA will include this information as part of its risk assessment of the certificate holder.

ATSB comment

The following further response was received from Airservices Australia:

Consistent with our response dated 28 March 2014, Airservices has published a National Information Circular (NIC 15/2014) to all controllers reminding them of their obligations regarding the provision of FIS to pilots including the provision of Hazard Alerts.

So 'weasel words' or good proactive response, you be the judge..

MTF on the history of REPCON (WOFTAM) the bureau's obfuscation of ICAO Annex 13 plus the legalities of the bureau/FF 2010 MOU...