CASA response to the ATSB report on Lockhart River
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Drag Chute,
What legislation CURRENTLY requires an operator to have a safety system in place?
Agree with your comments, though.
Also, not one of the reportable issues contributed to the crash. This was a CFIT, nothing more and nothing less.
What legislation CURRENTLY requires an operator to have a safety system in place?
Agree with your comments, though.
Also, not one of the reportable issues contributed to the crash. This was a CFIT, nothing more and nothing less.
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This is the statement from the CAR 215 operations manual in question;
"Quality/Safety Cell
The Quality/Safety cell shall consist of a Quality Manager and an Aviation Safety Manager.
The Aviation Safety Manager shall be responsible to the Managing Director for:
The development, management and maintenance of the Aviation Safety Program (ASP) in accordance with the ASP Manual"
Perhaps I must be confusing the CASA approved document status - this statement was prepared by the company therefore they should have compiled - or amended the manual to remove the reference. This is the puzzling part. Why did CASA not enforce strict compliance with the company's own documented procedures relating to 'self auditing and safety regulation'.
As for a legistalive reference I am presuming the approval status of the company manual is sufficient. However, I rememer the managing director of the accident airline saying that "the human factor's training reference was similar to having the pilots wear shiny shoes or similar..."
Casper,
Not one contributed? Yes they did. The final stuffup was the CFIT. But had any one of the other issues been corrected beforehand, the accident probaby wouldn't have happened.
So what would you do now? Just forget about it and move on?
not one of the reportable issues contributed to the crash. This was a CFIT, nothing more and nothing less.
So what would you do now? Just forget about it and move on?
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I would endorse the previous post. CFIT is a result of a combination of contributory causes. Poor safety culture, little or no incident reporting (mandatory) are latent failures that undoubtedly contributed to this accident.
There were, of course, many other contributory causes in this case as there are in all CFIT accidents
There were, of course, many other contributory causes in this case as there are in all CFIT accidents
Last edited by 4Greens; 20th Apr 2007 at 07:45.
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Perhaps the management of Transair are not afforded the "statute of Limitations" provisions in regards to some of the issues after all.
Recent media release.
"The ATSB is reviewing scope for possible action against Transair but re-emphasises that this is unrelated to the Transair accident on 7 May 2005 when all 15 on board lost their lives.
The Deputy Prime Minister as Minister for Transport and Regional Services has today been informed that earlier advice from the ATSB suggesting that it was unable to pursue any prosecution with respect to some more serious incidents that Transair failed to report before the accident was incorrect. The ATSB has apologised to the Minister.
The ATSB wishes to highlight that it is an independent safety investigator and not a body that prepares charges after an accident. Its only charge-related role is in relation to breaches of the Transport Safety Investigation Act 2003 (TSI Act), such as through the non-reporting of incidents, and not any charges in relation to the accident itself.
Any prosecution action against Transair and its officers in relation to the fatal accident itself is a separate matter.
As stated in the ATSB’s media release of 1 December 2006 and in evidence to the Senate on 15 February 2007 the ATSB uncovered that Transair failed to report 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident, as well as more routine matters. They include a gear failure on departure from Bamaga, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and flight issues from Gunnedah to Sydney. But none of these incidents was linked to the 7 May 2005 fatal accident.
Under the TSI Act such IRMs must be reported immediately by responsible persons (eg Transair) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (TSI Act Section 18). The Director of Public Prosecutions (DPP) advised the ATSB that under the Crimes Act 1914 a 12-month statute of limitation applied to Section 18 and also with respect to individuals’ written reports under Section 19.
However, the DPP also advised that under Section 19 of the TSI Act failure to make a written report of IRMs by a company (ie Lessbrook Pty Ltd trading as Transair) within 72 hours (which carries a maximum penalty of up to 300 penalty units or $33,000) is not time-barred.
The ATSB mistakenly drew the conclusion that all TSI Act prosecution action in relation to IRM incident reports was time barred and will now work with the DPP as a matter of priority to see if a viable prosecution case can be prepared in relation to Section 19.
Separately, the time limits for a prosecution under the TSI Act are being reviewed"
Recent media release.
"The ATSB is reviewing scope for possible action against Transair but re-emphasises that this is unrelated to the Transair accident on 7 May 2005 when all 15 on board lost their lives.
The Deputy Prime Minister as Minister for Transport and Regional Services has today been informed that earlier advice from the ATSB suggesting that it was unable to pursue any prosecution with respect to some more serious incidents that Transair failed to report before the accident was incorrect. The ATSB has apologised to the Minister.
The ATSB wishes to highlight that it is an independent safety investigator and not a body that prepares charges after an accident. Its only charge-related role is in relation to breaches of the Transport Safety Investigation Act 2003 (TSI Act), such as through the non-reporting of incidents, and not any charges in relation to the accident itself.
Any prosecution action against Transair and its officers in relation to the fatal accident itself is a separate matter.
As stated in the ATSB’s media release of 1 December 2006 and in evidence to the Senate on 15 February 2007 the ATSB uncovered that Transair failed to report 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident, as well as more routine matters. They include a gear failure on departure from Bamaga, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and flight issues from Gunnedah to Sydney. But none of these incidents was linked to the 7 May 2005 fatal accident.
Under the TSI Act such IRMs must be reported immediately by responsible persons (eg Transair) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (TSI Act Section 18). The Director of Public Prosecutions (DPP) advised the ATSB that under the Crimes Act 1914 a 12-month statute of limitation applied to Section 18 and also with respect to individuals’ written reports under Section 19.
However, the DPP also advised that under Section 19 of the TSI Act failure to make a written report of IRMs by a company (ie Lessbrook Pty Ltd trading as Transair) within 72 hours (which carries a maximum penalty of up to 300 penalty units or $33,000) is not time-barred.
The ATSB mistakenly drew the conclusion that all TSI Act prosecution action in relation to IRM incident reports was time barred and will now work with the DPP as a matter of priority to see if a viable prosecution case can be prepared in relation to Section 19.
Separately, the time limits for a prosecution under the TSI Act are being reviewed"
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Glad to see the 'rule makers' are also having a problem with Aviation Legislation - perhaps there must be a common thread between the ATSB lawyers and CASA's OLC.
Pity the media releases were made prior to getting the facts straight - as usual.
Pity the media releases were made prior to getting the facts straight - as usual.
Moderator
Addendum to this media article:
The Australian Federal Police is gathering a brief of evidence for legal proceedings against the airline involved in one of Australia's worst aviation disasters.
A Transair plane crashed into a hillside near Lockhart River in Queensland on May 7, 2005, killing all 13 passengers and two pilots on board.
"The seven immediately reportable matters, we believe, should be looked at in terms of possible action against the company for not reporting them," ATSB executive director Kym Bills told a parliamentary committee yesterday.
A Transair plane crashed into a hillside near Lockhart River in Queensland on May 7, 2005, killing all 13 passengers and two pilots on board.
"The seven immediately reportable matters, we believe, should be looked at in terms of possible action against the company for not reporting them," ATSB executive director Kym Bills told a parliamentary committee yesterday.
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ABC Web Site today
Pilot flying too low, fast, Lockhart River inquest told
A coronial inquest into the events surrounding one of Australia's worst air disasters has heard the pilot in question was flying lower and faster than he should have been.
State coroner Michael Barnes is examining the deaths of 15 people in a plane crash at Lockhart River in far north Queensland two years ago.
In his opening address the counsel assisting the coroner, Ian Harvey, said a crucial question was why the pilot of the Transair Metroliner was flying lower and faster than he should have been before the plane slammed into a ridge.
The Australian Transport Safety Bureau (ATSB) report into the crash will be a crucial piece of evidence.
Mr Harvey said the ATSB had found pilot Brett Hotchins was flying below the minimum safe altitude and 100 kilometres an hour faster than he should have been as he approached the runway at Lockhart River.
He said Mr Hotchins was an experienced pilot but the ATSB had found he had a history of conducting similar landings at higher than accepted speeds.
A coronial inquest into the events surrounding one of Australia's worst air disasters has heard the pilot in question was flying lower and faster than he should have been.
State coroner Michael Barnes is examining the deaths of 15 people in a plane crash at Lockhart River in far north Queensland two years ago.
In his opening address the counsel assisting the coroner, Ian Harvey, said a crucial question was why the pilot of the Transair Metroliner was flying lower and faster than he should have been before the plane slammed into a ridge.
The Australian Transport Safety Bureau (ATSB) report into the crash will be a crucial piece of evidence.
Mr Harvey said the ATSB had found pilot Brett Hotchins was flying below the minimum safe altitude and 100 kilometres an hour faster than he should have been as he approached the runway at Lockhart River.
He said Mr Hotchins was an experienced pilot but the ATSB had found he had a history of conducting similar landings at higher than accepted speeds.
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Found this today on website -
Plane crash 'could have been avoided'
Monday Jun 4 14:51 AEST
A plane crash that claimed 15 lives in far north Queensland two years ago would have been averted if the doomed aircraft had been fitted with a vital warning system, an inquest has heard.
The coronial inquest has begun into the circumstances surrounding the crash, one of Australia's worst ever, near the Lockhart River Aboriginal community on Cape York on May 7, 2005.
The inquest was told the crash would probably not have happened if the aircraft had been fitted with a terrain alerting warning system (TAWS), which was due to become mandatory equipment less than two months later.
Family members of the victims, legal representatives, journalists and others on Monday packed the courthouse and spilled out into the foyer on Thursday Island in the Torres Strait, where hearings are expected to last four days.
All 13 passengers and two pilots on board perished when the Fairchild Metroliner III ploughed into a 500-metre high, tree-covered hill and exploded in flames while approaching Lockhart River airstrip on a flight from Bamaga on the tip of north Queensland.
Counsel assisting the inquest, Ian Harvey, told the hearing the Australian Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA) both believed the tragedy would have been averted if the plane had been fitted with the enhanced terrain warning system.
The safety bureau's investigations showed the flight crew did not react to the mountain rising up before them.
But Mr Harvey said the warning system would have "pictorially" displayed terrain rising in front of the aircraft, providing the flight crew with the "cues or the clues to take appropriate action" well before impact.
"ATSB and CASA assert that had (the plane) been fitted with a fully-functioning TAWS (terrain alerting warning system), this aircraft accident would not have occurred," Mr Harvey said.
In a tragic twist, CASA had set a June 30, 2005 deadline for the mandatory fitting of the technology across the aviation industry.
But Mr Harvey said while CASA had earlier flagged the need to introduce TAWS, its enforcement had been delayed.
"Effectively, there was a moratorium of not doing anything to introduce the new technology of TAWS for some four years - this is of poignant significance in the context of the present inquiry," he told the inquiry.
"It's, to say the least, puzzling ... why the mandatory fitting of such a significant and vital piece of technology was deferred for so long."
The aircraft featured an outdated ground proximity warning system that only measured terrain directly below it.
It did not have any pictorial display and only provided oral warnings.
The hearing continues.
©AAP 2007
Apoligies if this has already beed posted - only found it today.
Plane crash 'could have been avoided'
Monday Jun 4 14:51 AEST
A plane crash that claimed 15 lives in far north Queensland two years ago would have been averted if the doomed aircraft had been fitted with a vital warning system, an inquest has heard.
The coronial inquest has begun into the circumstances surrounding the crash, one of Australia's worst ever, near the Lockhart River Aboriginal community on Cape York on May 7, 2005.
The inquest was told the crash would probably not have happened if the aircraft had been fitted with a terrain alerting warning system (TAWS), which was due to become mandatory equipment less than two months later.
Family members of the victims, legal representatives, journalists and others on Monday packed the courthouse and spilled out into the foyer on Thursday Island in the Torres Strait, where hearings are expected to last four days.
All 13 passengers and two pilots on board perished when the Fairchild Metroliner III ploughed into a 500-metre high, tree-covered hill and exploded in flames while approaching Lockhart River airstrip on a flight from Bamaga on the tip of north Queensland.
Counsel assisting the inquest, Ian Harvey, told the hearing the Australian Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA) both believed the tragedy would have been averted if the plane had been fitted with the enhanced terrain warning system.
The safety bureau's investigations showed the flight crew did not react to the mountain rising up before them.
But Mr Harvey said the warning system would have "pictorially" displayed terrain rising in front of the aircraft, providing the flight crew with the "cues or the clues to take appropriate action" well before impact.
"ATSB and CASA assert that had (the plane) been fitted with a fully-functioning TAWS (terrain alerting warning system), this aircraft accident would not have occurred," Mr Harvey said.
In a tragic twist, CASA had set a June 30, 2005 deadline for the mandatory fitting of the technology across the aviation industry.
But Mr Harvey said while CASA had earlier flagged the need to introduce TAWS, its enforcement had been delayed.
"Effectively, there was a moratorium of not doing anything to introduce the new technology of TAWS for some four years - this is of poignant significance in the context of the present inquiry," he told the inquiry.
"It's, to say the least, puzzling ... why the mandatory fitting of such a significant and vital piece of technology was deferred for so long."
The aircraft featured an outdated ground proximity warning system that only measured terrain directly below it.
It did not have any pictorial display and only provided oral warnings.
The hearing continues.
©AAP 2007
Apoligies if this has already beed posted - only found it today.
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Plane crash 'could have been avoided'
http://www.theage.com.au/news/Nation...809390029.html
Plane crash 'could have been avoided'
A plane crash that claimed 15 lives in far north Queensland two years ago would have been averted if the doomed aircraft had been fitted with a vital warning system, an inquest has heard.
The inquest was told the crash would probably not have happened if the aircraft had been fitted with a terrain alerting warning system (TAWS), which was due to become mandatory equipment less than two months later.
Counsel assisting the inquest, Ian Harvey, told the hearing the Australian Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA) both believed the tragedy would have been averted if the plane had been fitted with the enhanced terrain warning system.
"ATSB and CASA assert that had (the plane) been fitted with a fully-functioning TAWS (terrain alerting warning system), this aircraft accident would not have occurred," Mr Harvey said.
Hmmmm... Is it just me - or is all this reference to "it could have been avoided with TAWS" an attempted diversion?
This list of things which would have avoided this tragedy is a long one - and high on this list is CASA's performance.
Di
Plane crash 'could have been avoided'
A plane crash that claimed 15 lives in far north Queensland two years ago would have been averted if the doomed aircraft had been fitted with a vital warning system, an inquest has heard.
The inquest was told the crash would probably not have happened if the aircraft had been fitted with a terrain alerting warning system (TAWS), which was due to become mandatory equipment less than two months later.
Counsel assisting the inquest, Ian Harvey, told the hearing the Australian Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA) both believed the tragedy would have been averted if the plane had been fitted with the enhanced terrain warning system.
"ATSB and CASA assert that had (the plane) been fitted with a fully-functioning TAWS (terrain alerting warning system), this aircraft accident would not have occurred," Mr Harvey said.
Hmmmm... Is it just me - or is all this reference to "it could have been avoided with TAWS" an attempted diversion?
This list of things which would have avoided this tragedy is a long one - and high on this list is CASA's performance.
Di
Thanks Diatryma. Interesting innit?
TAWS is a diversion - other non TAWS equipped aircraft don't run into that hill. If TAWS was not mandated at that time, it is not a relevant issue.
Lets get to the nitty gritties - C&T, operational control and CASA's surveillance of both operators involved.
TAWS is a diversion - other non TAWS equipped aircraft don't run into that hill. If TAWS was not mandated at that time, it is not a relevant issue.
Lets get to the nitty gritties - C&T, operational control and CASA's surveillance of both operators involved.
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He said Mr Hotchins was an experienced pilot but the ATSB had found he had a history of conducting similar landings at higher than accepted speeds.
------------------------------------------------------------------------
How did the ATSB identify this history?
Was it obtained from readings of the FDR after the accident?
Was it obtained from pilot reports AFTER the accident? If this is the case, then WHY did these pilots not report it earlier - BEFORE the accident? Reporting such incidents to CASA might not have achieved much BUT reporting them to the employer might, just might, have alerted someone.
Re TAWS: Why did CASA extend the deadline to have TAWS fitted? Who in CASA approved such extension?
It is obvious that the aircraft flew into terrain. Just why is the question? Will the design of GPS approaches be questioned?
------------------------------------------------------------------------
How did the ATSB identify this history?
Was it obtained from readings of the FDR after the accident?
Was it obtained from pilot reports AFTER the accident? If this is the case, then WHY did these pilots not report it earlier - BEFORE the accident? Reporting such incidents to CASA might not have achieved much BUT reporting them to the employer might, just might, have alerted someone.
Re TAWS: Why did CASA extend the deadline to have TAWS fitted? Who in CASA approved such extension?
It is obvious that the aircraft flew into terrain. Just why is the question? Will the design of GPS approaches be questioned?
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Crash pilot said he was dangerous
From the Courier Mail:
http://www.news.com.au/couriermail/s...7-3102,00.html
Counsel assisting a Queensland coronial inquest into the crash, Ian Harvey, today shed light on a transcript from an inquest into the death of pilot Zachary Short, whose plane crashed into the sea during an ill-fated flight from Badu Island to Horn Island in the Torres Strait in January 2002.
The transcript revealed Mr Hotchin testified to the inquest in June 2004 - 11 months before his death - that he personally engaged in deadly flying practices.
Following a two-year-long investigation into the Lockhart River plane crash, the Australian Transport Safety Bureau found, among other contributing factors, that Mr Hotchin had a history of flying too fast and was flying the doomed plane at about 100km/h over the limit shortly before impact.
Giving evidence to the 2004 inquest, Mr Hotchin testified that he had, only the week before, aimed his plane through a cloud gap, known as "shooting for the hole", on approach to landing in Port Moresby in Papua New Guinea.
However, amid the thunderstorm the cloud gap disappeared, and Mr Hotchin was then left flying blind.
"You look for a break in between the clouds, so you can see a very white light coming through the darkness of the clouds," Mr Hotchin said, according to the transcript.
"So you aim for the point ... and then all of a sudden you notice that you're enclosed by two cells on either side.
"But the only thing you can do, once you've made that decision, is keep going straight ahead because you know that at some stage beforehand you saw the light there."
So the obvious question is..................why was he still flying?
Di
http://www.news.com.au/couriermail/s...7-3102,00.html
Counsel assisting a Queensland coronial inquest into the crash, Ian Harvey, today shed light on a transcript from an inquest into the death of pilot Zachary Short, whose plane crashed into the sea during an ill-fated flight from Badu Island to Horn Island in the Torres Strait in January 2002.
The transcript revealed Mr Hotchin testified to the inquest in June 2004 - 11 months before his death - that he personally engaged in deadly flying practices.
Following a two-year-long investigation into the Lockhart River plane crash, the Australian Transport Safety Bureau found, among other contributing factors, that Mr Hotchin had a history of flying too fast and was flying the doomed plane at about 100km/h over the limit shortly before impact.
Giving evidence to the 2004 inquest, Mr Hotchin testified that he had, only the week before, aimed his plane through a cloud gap, known as "shooting for the hole", on approach to landing in Port Moresby in Papua New Guinea.
However, amid the thunderstorm the cloud gap disappeared, and Mr Hotchin was then left flying blind.
"You look for a break in between the clouds, so you can see a very white light coming through the darkness of the clouds," Mr Hotchin said, according to the transcript.
"So you aim for the point ... and then all of a sudden you notice that you're enclosed by two cells on either side.
"But the only thing you can do, once you've made that decision, is keep going straight ahead because you know that at some stage beforehand you saw the light there."
So the obvious question is..................why was he still flying?
Di
