ATSB Gobbledygook

[A37575]

From a recent ATSB incident report.

The identification and mitigation of threats were
not an active component of the operator’s
approach brief model. Therefore, the forecast
turbulence and captain’s tiredness were not
identified as a potential threat.

It is about time ATSB writers used plain English instead of goobledygook. (def. nonsense, pretentious jargon):=

[Baileys]

I'll pay a carton for the best translation....

[Wally Mk2]

It's understandable....it's called ALAR:-)


Wmk2

[XRlent320]

During our approach brief before arrival at an airport we brief the obvious points, ie
Instrument App
Aircraft Configuration for landing
Airfield Length/width/obstacles
Fuel considerations
etc etc

Additional to this we talk about the "threats" for arrival. This may include any unusual weather, other traffic, Notams and crew capabilities.
During the brief on threats we would also talk about how we the crew are feeling, has it been a long day or is it late at night etc and if there was any forecast turbulence or the possibilty of unforecast turbulence.

Obviously this operator does not include these items in their approach brief and therefore the Captains tiredness and the turbulence were not raised. They were not discussed between the crew to consider other options. If it was raised they could mitigate the issues (threats) by possibly handing over to let the not as tired FO fly, or the FO could be a bit more observant knowing the Capt is tired. They could consider a different configuration to make allowance for the turbulance or ask for a different approach etc etc.

Hope that helps

[thorn bird]

Yeah but thats logical...sometimes the ATSB aint.

[Howard Hughes]

I'll pay a carton for the best translation....
ATSB investigators get paid by the word?:E

[Arm out the window]

The only really crap bit is:

The identification and mitigation of threats were not an active component of the operator’s approach brief model.

I suppose a plainer way to say it would be something like 'the operator's standard approach brief didn't include identification and mitigation of threats.'

The rest of it's fair enough. Much worse than that out there.

[sheppey]

Additional to this we talk about the "threats" for arrival. This may include any unusual weather, other traffic, Notams and crew capabilities.
During the brief on threats we would also talk about how we the crew are feeling, has it been a long day or is it late at night etc and if there was any forecast turbulence or the possibilty of unforecast turbulence.
Let me see. Have I got this right? "Threats". A threat is someone poking a gun in my face. Or holding a knife to my throat. Them's "threats" in most average person's minds.

To have a group hug top of descent on the flight deck and discuss how tired you feel because of a night out on the tiles then say "that's a threat" so I better do the landing because as a monitoring pilot I need to be wide awake to counter the next "threat".

Discuss the `crew capabilities` - what the hell is that supposed to mean? My instrument rating has six months to go and your instrument rating is due for renewal next week. Jeez, Dude - that's a real threat because you are nearly out of currency so I'd better do the STAR but you can do the landing.

Now about this possibility of unforecast turbulence. We have to manage that threat carefully so this is how we mitigate it. Grab the synoptic chart before top of descent and check those isobars and iotachs and the station model plots for Benalla, the Dandenongs and Baccus. That should give us a clue on un-forecast turbulence for landing 34 at Melbourne. Now in case we hit this threat of unforecast turbulence make sure you follow me on the controls up until touch down. The other threat is the automatic speed brakes on touch down. It is possible to have an unknown defect in the automatic wiffle valve that operates the speed brake electronics. Saw one years ago. You will mitigate that threat by operating the speed brakes manually if the buggers don't come up.

Listen here because the next threat is the PAPI on 34. Standby for a go-around on short final in case the PAPI fails and we have to divert to a PAPI airport. We will mitigate that threat by checking on the weather at the alternates and the current situation on standby power for the PAPI at those alternates. You never know with PAPI's - they work by electricity and you know how reliable electricity is when the ground is wet. So let's brief on the threat of a crook PAPI. Now the next "threat" is ATC the bastards. They'll dob you for a wrong read back so I read on Pprune the other day. Make sure you get the right read back Dude and I'll get my mini recorder going to back you up. Any questions?

Yes Skipper - you forgot the "threat" of Pprune where you read so much silly crap about TEM every night you fall asleep at the computer. And that's why you get so tired while flying and make all the mistakes you have to mitigate for..:ok:

[blackhand]

One mitigates the known threats and prepares for the unknown.
The word threat means a threat against the safe management of the aircraft.
Your CRM training should cover it.

[Wally Mk2]

'Shep' although I can understand to some degree yr angst about this subject as I'm from the old school where CRM & ALAR etc where words that where being dreamed up by some uni boffins but Threat & Error management have a very real place in today's work place not just aviation.
A slippery floor at a supermarket is a threat, you don't need to have a gun held to yr head to be threatened.
High terrain around an aerodrome is a threat as well as fatigue despite both pilots knowing the area well & feel they had adequate rest the previous night.
That terrain will always be there, you can't change it you may think you know it well enough not to even consider it anymore but it only takes a slight distraction & bingo that terrain is now a huge threat hence bringing it to ones mind just as a top-up prior to decent could very well mitigate a threat not even thought of.

There's been plenty of cases where the pilots who where well versed with the AD & it's surroundings flew a perfectly serviceable plane into terrain.
Everything we do in our lives could be considered a threat,a risk so to speak and like in aviation where the risks are calculated, learned & assessed the same goes for you simply getting in yr car to drive to work although the latter we take for granted & see the results nightly on the news!.

CRM which is all part of ALAR/threats etc to me means I am not alone up there whilst flying & there are many things to consider where once upon a time I would never have considered half the stuff I do these days of any consequence.
It's about being educated, right or wrong we live & work in a very different world these days where work pressures,time scheds & family life is fast & forever changing:-).

Stay safe out there guys/gals, the bogey man is ever present!:)


Wmk2

[XRlent320]

Sheppey, I think you've missed the point. I'm not saying we talk about every possible threat. As you have shown you could get out of control and brief for every possible scenario if you wanted too. When I referred to tiredness and turbulence it was in relation to this report. Obviously, fatigue and turbulence were a factor in this incident so perhaps the crew could of identified these threats in their brief and taken actions to lesson the risk.

If you approach an aerodrome with thunderstorms in the area do you brief on the possibility of microbursts and what actions you'd take if windshear is experienced? I would. But I wouldn't if their were no thunderstorms.

When I talk about Crew Capabilities I refer to things like experience and recency. But only if they are significant issues. More often than not they aren't spoken about. Say your flying with a brand new FO who hasn't been into that Airport at that time of year with those conditions, I would confirm they're happy to do the approach etc etc

It really comes down to professionalism and airmanship. Talk about the pertinent points and take actions to lesson the chance of ending up the subject of a PPrune topic.

[Keg]

An interesting point. If a Captain is tired then I'd suggest the 'error' has already occurred. :E Of course, we still need to manage the error and it's ongoing effects but it's not a threat.

To be technical too, if I'm tired on descent, the appropriate way to manage that threat is to 'rest'. I can't actually mitigate my tiredness by rest on descent can I.

Of course, we all know that when tired, what actually occurs is that our error rate will increase and our ability to trap errors will also decrease. Is that a threat? The error may be flying into a turbulent area with pax and carts still out. The error was lack of vigilance when ATC reported turbulence on descent because someone was so busy talking about all the stupid threats that people dream up to fill the briefing time. :ok:

[MakeItHappenCaptain]

The captain was too tired to identify he was tired?:confused:

[Servo]

Shep,

I have flown with some guys that actually brief like that, with that much "detail" and waffle, that I end up falling asleep :yuk:

Very interesting operators (pilot).

[clark y]

Hey Keg, you can mitigate tiredness on descent.......... just ask to hold and have some controlled rest.

[Captain Dart]

CRM had a noble start which was focused on ex-WW 2 fighter and bomber pilots who became airline pilots; some of these characters, while colourful, had to be 're-jigged' in their attitudes to the crew environment in complex, multi-crewed jet transports.

Now, CRM has become an 'industry', hi-jacked by empire builders, lawyers and insurance companies; a nice little earner. The annual 'CRM Refreshers' I used to look forward to are now just psychobabble sessions and, in my outfit, excruciating 'parlor games' with the cabin crew that achieve nothing.

On a beautiful CAVOK day, a short sector and no MEL items, most of the F/O's still manage to make up a 'threat' or two. And the bloody briefings are becoming so long-winded, they are becoming a 'threat' in themselves.

[ozbiggles]

I ain't that smart...but that seemed pretty straight forward to me.

[Jack Ranga]

Maybe you are smarter than you think? :=

[Stationair8]

Perhaps ATSB would like to include in the SOP's a check of the horoscope for each pilot, reading a passage from the bible followed by a group hug?

[Arm out the window]

Now you're talkin'!

[Horatio Leafblower]

Perhaps ATSB would like to include in the SOP's a check of the horoscope for each pilot, reading a passage from the bible followed by a group hug?

Have submissions closed for the next Austrealian Aviation Psych Assoc conference? I have my abstract right here! :8

[gobbledock]

Fruity intelectual language and absolute wankery - perhaps the ATSB have been receiving lessons from the CAA Voodoo Witch Doctor?

[Kharon]

Ben does have a point.
Jetstar report is reason to inquire into CASA and carrier | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/04/20/jetstar-report-is-reason-to-inquire-into-casa-and-carrier/)

When you do the research -

Jetstar events:-
Operational event - Airbus A320, VH-JQX, Sydney Airport, 6 February 2012.
http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-022.aspx (http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-022.aspx)
Incorrect aircraft configuration - Airbus A320-232, VH-VQA, Melbourne Airport, 28 July 2011.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-089.aspx (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-089.aspx)
Windshear event - Airbus, A320-232, VH-VQT, Darwin Airport, 31 October 2010.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-039.aspx (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-039.aspx)
Operational event - VH-*VQZ, Gold Coast aerodrome, 30 May 2010.
http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-037.aspx (http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-037.aspx)

Tiger events:-

Operational non-compliance - Airbus A320, VH-VNG, 17 km ENE Melbourne Airport, Victoria, 7 June 2011.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-070.aspx (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-070.aspx)
Operational non-compliance - Airbus A320-232, VH-VNC, 15 km south of Avalon Airport, Vic, 30 June 2011.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-076.aspx (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-076.aspx)
Pre-flight planning event - Airbus A320-232, VH-VNB, Melbourne aerodrome, 11 February 2011.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-021.aspx (http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-021.aspx)
Flight control system event - 520km NW of Gold Coast Aerodrome, Qld, 18 May 2009, VH-VNC, Airbus A320-232.
http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-021.aspx (http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-021.aspx)

Did "He who must not be named" steer Tiger into a well spun tail spin, then brag about the monstrosity to the Senate ?.

Well, William Blake had somewhat to say about Tigers;

"When the stars threw down their spears,
And water'd heaven with their tears,
Did He smile His work to see?
Did He who made the lamb make thee?".

[Mach E Avelli]

Sheppey, love ya work! I must incorporate all this into my new-age touchy-feely 20 minute approach briefing in future so that my F/O will go to sleep with the boredom of it all. That way he won't notice my sloppy flying, brought on by old eyesight and slowed reflexes. Maybe a warning of the threat presented by those infirmities could be added to pad it out a bit longer.
Jesus, whatever happened to "time-out; my radios while you read the approach plate, memorise the minima and missed approach, tune the navaids for me; then I will quiz you on the pertinent details to make sure we are on the same page"? It's served me well.
Any in-cockpit briefing should be short and sweet. A briefing does not need to regurgitate SOP - we have operations manuals and regular checkrides to reinforce all that good oil. My attention-span runs about 30 seconds, so I try to keep all briefings within this time limit in case the other guy also suffers from similar attention deficit disorder.