How unsafe is the ATSB?

[ozbiggles]

3 years to release a report on a loss of separation at Melbourne airport....3 years?

This is an ongoing issue with the ATSB who seem unable to release timely final reports into incidents that have all the information readily available and need urgent rectification.

The resolution to this event occurred within days of the event. Anything in this report is now 3 years old. How are we meant in the professional aviation space to rely on anything the ATSB produce when it happened so many years ago we have all moved on. It’s like a news report telling us who was PM 3 years ago.

AO-2015-084, released 06 Aug 2018

[patty50]

Horrifying ATC.

A trainee with 11 years experience overseas asking a 737 at 1,100ft to slow to minimum speed, who also mixes up call signs.

Then an instructor telling pilots if they go missed to expedite said missed approach. Whatever an expedited missed approach is I don’t know, I do know mismanagement of energy during go arounds can be catastrophic (FlyDubai anyone). Coordinator then intervened and told trainee that the second 737 should go around.

Authors seem confused about what a 90 degree turn is with a soft apportionment of blame to the EK pilots for following the taxiway lights. They mentioned a call to HQ and a please explain for why 777 pilots are following lights instead of cutting corners so ATC doesn’t look bad.

The entire report reads like a coverup for AirServices. I can certainly see why they sat on this for a while. No pilots to blame.

[Ex FSO GRIFFO]

Crikey....Who was 'PM' 3 years ago.....??

I can't remember...….
No Cheerss...

[QuarterInchSocket]

In my opinion, extremely unsafe.

i seem to recall that the prelim report for the mismanaged Emirates 777 go-around in UAE was released within 30days of the event and was of decent quality. If one expects level of quality from ATSB we’re dreaming.

I was waiting for a ground staff lightning strike report to develop some policy and procedures whilst operating on the ramp area during thunderstorms, some time back. Took 3 years to get to a final report after about 3 different delays (the prelim was just a statement of facts and took a year to come out)!! WTF! In the meantime, everyone is left vulnerable and exposed.

Much in the same way as you’ve said (if I’ve understood you properly), the final report said nothing of worth. No accountability! Nothing.

Useless bureaucrats!

[cattletruck]

In relatively recent times the Australian Public service has been besot with organisational paralysis. There is too much introspective focus by them on things that don't matter to us customers like HR, OH&S, LGBT+A-Z equality, etc, etc, which is allowing the boat anchors to thrive at being boat anchors while stifling the abilities of the doers.

[sumtingwong]

ATR pitch disconnect that put cabin crew in the hospital and very close to an airframe in the ground. The final report has been pushed back many times. The last promise of the final report? August 2018. So much for that. This event occured in Feb 2014. Over 4.5 years...yes years ago.
Something stinks here.

[ZeroOneTwo]

There are plenty of mechanisms in the ICAO Annex 13 to get information into the public domain without delay.

This looks like a paper shuffling exercise gone wrong, but three years? There should be public accountability somewhere in the process...surely?

[73qanda]

With the examples given of delayed reports it certainly looks to be a safety issue. Lessons learned need to be gained before the incident is 4-5 years old that is for sure!
In the ymml loss of separation report we can see that both CASA and Airservices knew about the safety issue since 2011, words were said, hands were wrung but nobody wanted to actually make a decision that might be inconvenient.

[4 Holer]

What do you expect ? Australia, Africa same thing these days. Lucky to get a report at all. BTW Another Prime Minister around March NICE.

[runway16]

It is not only the speed of delivery of accident reports but the accuracy of the actual reports themselves. In a number of ATSB GA accident reports that I have reviewed lately I can see errors of fact. To me they stick out like the proverbial. I have emailed ATSB re these items but no reply was the reply. The errors continue unchecked.

Some would say that they do not have the funding for more staff to clear the back log and to proof read the reports. Fine then perhaps ATSB should get less involved in the likes of a South African Convair accident or that of MH370. Both involved manpower and funds.

R16

[73qanda]

Some would say that they do not have the funding for more staff to clear the back log and to proof read the reports. Fine then perhaps ATSB should get less involved in the likes of a South African Convair accident or that of MH370
True. Probably shouldn’t assist overseas if we can’t deliver the basics at home.

[wheels_down]

Staff funding isn’t necessary the issue here. It’s the timeframe to get the new investigators trained up to the required standard which is multiple years. They are going through this currently.

What concerns me is it’s taking multiple years for key safety alerts/fixes coming out of more serious incidents, by the time they have got to this point either it’s happened again (think AirAsia incident and incident) or loss of life.

[Falling Leaf]

I think you will find that the investigators complete the report in 3 to 6 months. Then the upper management of ATSB, Airservices, CASA, the airline involved kick the report back and forth for the next 2-3 years with different legal threats until the final neutered report, which says nothing and blames no-one, is finally released.

[73qanda]

None left by the time the Norfolk ditching report came out?

[Lead Balloon]

But you can be sure that at Senate Estimates it will be all under control - short term issues that are being managed. Some huffing and puffing for show, from the usual duopoly Senators, and some genuine attempts to get to the truth from the non-major party Senators.

The machine is broken. Once the machine is broken, it no longer has the corporate integrity to admit it, even if it knew it was broken.

[SIUYA]

Petropavlovsk (https://www.pprune.org/members/162906-petropavlovsk) …No-one is defending the ATSB Whyalla investigation report – it was less than competent.

But you draw a really long-bow in saying that everything after the Whyalla report was a fiasco.

Did you ever read the ATSB report into the 2003 IL-76 CFIT accident in East Timor?

That one was an absolutely top-class investigation report, and it was acknowledged in the ICAO Journal – see:

https://www.atsb.gov.au/publications/investigation_reports/2003/aair/aair200300263/ (https://www.atsb.gov.au/publications/investigation_reports/2003/aair/aair200300263/)

https://www.asasi.org/papers/2004/Barter%20et%20al_IL76_%20ISASI04.pdf (https://www.asasi.org/papers/2004/Barter%20et%20al_IL76_%20ISASI04.pdf)

http://www.aaiu.ie/sites/default/files/ATSB%20Australia%20Controlled%20Flight%20into%20Terrain%20Il yushin%20IL-76%20RDPL-34141%20Bacau%20Timor%20Leste%202003-01-31.pdf (http://www.aaiu.ie/sites/default/files/ATSB%20Australia%20Controlled%20Flight%20into%20Terrain%20Il yushin%20IL-76%20RDPL-34141%20Bacau%20Timor%20Leste%202003-01-31.pdf)

https://www.flightglobal.com/news/articles/crew-errors-contributed-to-il-76-crash-183768/ (https://www.flightglobal.com/news/articles/crew-errors-contributed-to-il-76-crash-183768/)

The web has got MANY complimentary articles about that investigation. It set the scene for a lot of benchmarks on HOW a complex investigation COULD be managed in a remote location with LIMITED resources EFFECTIVELY to provide a top-class result.And, the report was issued in less than a year of the accident. So, with the right folks, ‘yes’, the ATSB was good at what it did.

Now? Not so sure.

But maybe you need to consider AND acknowledge that the ATSB DID have some very competent investigators at the time of the Whyalla report, who really DID know what they were doing, and ask WHY that’s no longer the case, instead of throwing **** at the good guys who left and then addressing WHY they left? I know a few of them and they are VERY bloody good operators...….and they still work in PNG!

You refer to the PNG AIC…..seen the good work that outfit is doing lately Petropavlosk? Somehow I don’t think so.

[Lead Balloon]

Yep - the ATSB used to have a critical mass of competent personnel, competently led (although, in the case of the original Whyalla report, no one with sufficient competence in piston engine physics and chemistry).

ASTB no longer has that critical mass. Just like CASA.

Although it’s true and nice to say that there are some ‘really good people’ working in these organisations - some of whom I count as friends - the fact remains that the organisations are busted. The machines are busted. They are less than the sum of their parts and - what’s worse - governments no longer know how to fix them.

[Chris2303]

You want late reports?

Take a look at the NZ TAIC website!

https://taic.org.nz/