CASA response to the ATSB report on Lockhart River
Don Quixote Impersonator
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CASA response to the ATSB report on Lockhart River
http://www.casa.gov.au/media/2007/07-04-03.htm
Well I guess this is where you get to earn your keep and learn all about poisoned chalices.
Good luck Bruce and I hope you can keep the media on message.
They have moved on a fair bit from those days twould be a pity if the progress was derailed by the ghosts of the past.
I imagine we will hear from the usual media tart
suspects.
Well I guess this is where you get to earn your keep and learn all about poisoned chalices.
Good luck Bruce and I hope you can keep the media on message.
They have moved on a fair bit from those days twould be a pity if the progress was derailed by the ghosts of the past.
I imagine we will hear from the usual media tart
suspects.
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"I have directed my approach designers to come up with a new GPS NPA standard that does not have a waypoint at the Final Approach Fix".
where did this quote come from, and to whom is it attributed?
Interesting, CASA has NO approach designers, would go against international standards and would imply that CASA has the ability to force Garmin, Honeywell etc to locally change their systems programming.
Last edited by hot_buoy; 4th Apr 2007 at 00:13. Reason: contextual change
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hot_buoy
Settle down my man here's the ATSB Media release on it, the report will take a bit of digesting, and hey we are supposed to be learning from these things
MEDIA RELEASE
Final ATSB investigation report on Lockhart River 15-fatality aviation accident
04 April 2007
The ATSB has released a 500-page final report into Australia’s worst civil aviation accident since 1968. The report spells out contributing safety factors involving the pilots, the operator and the regulator as well as other safety factors, and has made further recommendations to improve future safety.
An Australian Transport Safety Bureau team of a dozen investigators has taken nearly two years of painstaking investigation to complete the final report since the tragic accident on 7 May 2005 which killed both pilots and all 13 passengers. Three ATSB factual reports, a research report and ten safety recommendations were released in the interim. The investigation was complicated by an inoperative cockpit voice recorder, no witnesses, and the extent of destruction of the aircraft.
The ATSB found that a mechanically serviceable Metro 23 aircraft operated by Transair was unintentionally flown into South Pap ridge in poor weather during a satellite-based instrument approach, probably because the crew lost situational awareness in low cloud.
The experienced 40-year old pilot in command was very likely flying the aircraft but was reliant on the 21-year old copilot to assist with the high cockpit workload. He knew the copilot was not trained for this type of complex instrument approach. Despite the weather and copilot inexperience, the pilot in command also used approach and descent speeds and a rate of descent greater than specified in the Transair Operations Manual, and exceeded the recommended criteria for a stabilised approach. The pilot in command had a history of such flying.
The investigation found significant limitations with Transair’s pilot training and checking, including superficial training before pilot endorsements and no ‘crew resource management’. Deficiencies also existed in the supervision of flight operations and standard operating procedures for pilots. There were also significant limitations in the way Transair managed safety, Transair’s management processes and because the chief pilot was over-committed with additional roles as CEO, the primary check and training pilot, and working regularly in Papua New Guinea.
The regulatory oversight was also not as good as it could have been, especially when Transair moved from a charter to a regular passenger transport operator and was growing rapidly in Australia. In addition to the serious pilot and company contributory factors, if CASA’s guidance to inspectors on management systems and its risk assessment processes had been more thorough, the accident may not have occurred.
The ATSB investigation also identified a range of other safety issues which could not be as clearly linked to the accident because of limited evidence. These included shortcomings in the design of the navigation chart used and the possibility of poor crew communication in the cockpit.
The ATSB hopes that this final report will assist the families and friends of those who perished in this tragedy to move towards closure, and will lead to further improvements in aviation safety to ensure that such an accident never happens again.
Media Contact: George Nadal business hours & after hours duty officer 1800 020 616
Full report here:
http://www.atsb.gov.au/publications/...200501977.aspx
Settle down my man here's the ATSB Media release on it, the report will take a bit of digesting, and hey we are supposed to be learning from these things
MEDIA RELEASE
Final ATSB investigation report on Lockhart River 15-fatality aviation accident
04 April 2007
The ATSB has released a 500-page final report into Australia’s worst civil aviation accident since 1968. The report spells out contributing safety factors involving the pilots, the operator and the regulator as well as other safety factors, and has made further recommendations to improve future safety.
An Australian Transport Safety Bureau team of a dozen investigators has taken nearly two years of painstaking investigation to complete the final report since the tragic accident on 7 May 2005 which killed both pilots and all 13 passengers. Three ATSB factual reports, a research report and ten safety recommendations were released in the interim. The investigation was complicated by an inoperative cockpit voice recorder, no witnesses, and the extent of destruction of the aircraft.
The ATSB found that a mechanically serviceable Metro 23 aircraft operated by Transair was unintentionally flown into South Pap ridge in poor weather during a satellite-based instrument approach, probably because the crew lost situational awareness in low cloud.
The experienced 40-year old pilot in command was very likely flying the aircraft but was reliant on the 21-year old copilot to assist with the high cockpit workload. He knew the copilot was not trained for this type of complex instrument approach. Despite the weather and copilot inexperience, the pilot in command also used approach and descent speeds and a rate of descent greater than specified in the Transair Operations Manual, and exceeded the recommended criteria for a stabilised approach. The pilot in command had a history of such flying.
The investigation found significant limitations with Transair’s pilot training and checking, including superficial training before pilot endorsements and no ‘crew resource management’. Deficiencies also existed in the supervision of flight operations and standard operating procedures for pilots. There were also significant limitations in the way Transair managed safety, Transair’s management processes and because the chief pilot was over-committed with additional roles as CEO, the primary check and training pilot, and working regularly in Papua New Guinea.
The regulatory oversight was also not as good as it could have been, especially when Transair moved from a charter to a regular passenger transport operator and was growing rapidly in Australia. In addition to the serious pilot and company contributory factors, if CASA’s guidance to inspectors on management systems and its risk assessment processes had been more thorough, the accident may not have occurred.
The ATSB investigation also identified a range of other safety issues which could not be as clearly linked to the accident because of limited evidence. These included shortcomings in the design of the navigation chart used and the possibility of poor crew communication in the cockpit.
The ATSB hopes that this final report will assist the families and friends of those who perished in this tragedy to move towards closure, and will lead to further improvements in aviation safety to ensure that such an accident never happens again.
Media Contact: George Nadal business hours & after hours duty officer 1800 020 616
Full report here:
http://www.atsb.gov.au/publications/...200501977.aspx
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From Sydney Morning Herald;
Australia's aviation safety regulator has lessons to learn after the release of a report on a fatal plane crash, federal Transport Minister Mark Vaile says.
Fifteen people died when the TransAir-operated Fairchild Metroliner plane crashed into a mountain near Lockhart River in far north Queensland in May 2005.
Pilot error and poor maintenance were at the core of the crash, one of Australia's worst aviation accidents, the Australian Transport Safety Bureau (ATSB) said in the report.
Mr Vaile said he had written to the Civil Aviation Safety Authority (CASA) chief executive Bruce Byron asking that he make a detailed assessment of the implications of the report for future safety regulation, and reply with what action the organisation would take on the findings.
He said from his reading of the report, it was recommending that CASA pay more attention to regional airline operators and give greater emphasis to surveillance of them.
"Somebody buying a ticket to fly on a commercial airline in Australia is entitled to the expectation that the airline is safe to travel with and has the certification of the safety regulator," Mr Vaile told reporters.
"As far as I'm concerned, CASA needs to do whatever is necessary to fulfil that obligation."
Mr Vaile said the recommendations in the report focused particularly on surveillance of the training and standards of pilots.
He said the laying of any criminal charges would be a matter for a coronial inquiry to be held in Queensland, while any disciplinary action at CASA was an internal matter for that organisation.
"I do expect that CASA responds appropriately to those recommendations with any changes that are necessary," Mr Vaile said.
"We as a government are going to make sure that there is no limitation in terms of resourcing that may be needed to provide the appropriate levels of surveillance, if there is resourcing needed it will be provided."
He said while it had been almost two years since the crash, there had not been a delay in the report, saying it required extensive investigation and research.
Mr Vaile also announced that an industry taskforce had been established to assist him and Mr Byron in undertaking aviation regulatory reform.
The taskforce will be chaired by Dr Allan Hawke, a former secretary of the Department of Transport and Regional Services, and will include former CASA chairman Dick Smith, Brindabella Airline's Jeff Boyd and aviation industry consultant Rob Graham.
"We need to expedite the regulatory reform program to ensure we have up-to-date, effective safety regulatory and management systems in place," Mr Vaile said.
The taskforce would work with the aviation industry and provide advice on the best model for safety regulation in Australia.
Di
Australia's aviation safety regulator has lessons to learn after the release of a report on a fatal plane crash, federal Transport Minister Mark Vaile says.
Fifteen people died when the TransAir-operated Fairchild Metroliner plane crashed into a mountain near Lockhart River in far north Queensland in May 2005.
Pilot error and poor maintenance were at the core of the crash, one of Australia's worst aviation accidents, the Australian Transport Safety Bureau (ATSB) said in the report.
Mr Vaile said he had written to the Civil Aviation Safety Authority (CASA) chief executive Bruce Byron asking that he make a detailed assessment of the implications of the report for future safety regulation, and reply with what action the organisation would take on the findings.
He said from his reading of the report, it was recommending that CASA pay more attention to regional airline operators and give greater emphasis to surveillance of them.
"Somebody buying a ticket to fly on a commercial airline in Australia is entitled to the expectation that the airline is safe to travel with and has the certification of the safety regulator," Mr Vaile told reporters.
"As far as I'm concerned, CASA needs to do whatever is necessary to fulfil that obligation."
Mr Vaile said the recommendations in the report focused particularly on surveillance of the training and standards of pilots.
He said the laying of any criminal charges would be a matter for a coronial inquiry to be held in Queensland, while any disciplinary action at CASA was an internal matter for that organisation.
"I do expect that CASA responds appropriately to those recommendations with any changes that are necessary," Mr Vaile said.
"We as a government are going to make sure that there is no limitation in terms of resourcing that may be needed to provide the appropriate levels of surveillance, if there is resourcing needed it will be provided."
He said while it had been almost two years since the crash, there had not been a delay in the report, saying it required extensive investigation and research.
Mr Vaile also announced that an industry taskforce had been established to assist him and Mr Byron in undertaking aviation regulatory reform.
The taskforce will be chaired by Dr Allan Hawke, a former secretary of the Department of Transport and Regional Services, and will include former CASA chairman Dick Smith, Brindabella Airline's Jeff Boyd and aviation industry consultant Rob Graham.
"We need to expedite the regulatory reform program to ensure we have up-to-date, effective safety regulatory and management systems in place," Mr Vaile said.
The taskforce would work with the aviation industry and provide advice on the best model for safety regulation in Australia.
Di
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ATSB : Distance references on charts inadequate:
Airservices response:
" All Australian DAP RNAV (GNSS) instrument approach charts produced by Airservices Australia have distance to the MAPt reference from the Initial Approach Fix (IAF) to the MAPt below the profile view of the procedure."
Who cares what you scribble on the bottom of the chart? The most important thing missing in these approaches is a distance-to-run, an altitude you should be at (at that distance) and a display of that in front of the flying pilot.
Another issue I noticed the other day...certain scales allow the last letter of the waypoints to get "chopped off". I got an approach with a whole bunch of " BLTW.. BLTW.. BLTW..BLTW.."
Where are we now? errr
Airservices response:
" All Australian DAP RNAV (GNSS) instrument approach charts produced by Airservices Australia have distance to the MAPt reference from the Initial Approach Fix (IAF) to the MAPt below the profile view of the procedure."
Who cares what you scribble on the bottom of the chart? The most important thing missing in these approaches is a distance-to-run, an altitude you should be at (at that distance) and a display of that in front of the flying pilot.
Another issue I noticed the other day...certain scales allow the last letter of the waypoints to get "chopped off". I got an approach with a whole bunch of " BLTW.. BLTW.. BLTW..BLTW.."
Where are we now? errr
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GORN ROUND
I suggest you take your nic as a first step and go to the holding pattern for bit of a think.
I can assure you Capt Bloggs knows precisely of which he speaks.
Furthermore, it IS particularly now, in CASAs purview to have regard for approach design where it impacts on safety.
Now play nice, this is much too an important issue on which to polish your ego.
I suggest you take your nic as a first step and go to the holding pattern for bit of a think.
I can assure you Capt Bloggs knows precisely of which he speaks.
Furthermore, it IS particularly now, in CASAs purview to have regard for approach design where it impacts on safety.
Now play nice, this is much too an important issue on which to polish your ego.
Do you understand why Instrument Approaches have Final Approach Fixes?
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It is my belief and opinion, the aircraft had a different name and web address to the airline quoted, the tickets were in a different name, the route was flown by a different AOC holder, the Qld Coroner and Government may still ask questions as to who did what and where, that may be in opposition to established dogma and political "spin".
Someone should ask those involved for a pre-empive comment before it becomes opportunistic for the other side of politics, (well briefed), to dredge it out for the exposure it urgently needs.
Given a pending Fed election, this could be soon.
I have said about as much as I dare under my own name.
Someone should ask those involved for a pre-empive comment before it becomes opportunistic for the other side of politics, (well briefed), to dredge it out for the exposure it urgently needs.
Given a pending Fed election, this could be soon.
I have said about as much as I dare under my own name.
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Diatryma
I do not know the answers to the particular questions raised by Mr Murphie, but if what he says is correct they are indeed very pertinent.
The passenger has a right to know with whom exactly he is trusting his backside and immortal soul.
A Government by proxy determines the safeness or not of the individual operator, it is still the passengers right, and it is exercised every second of every day to decide whether he/she agrees with it.
I do not know the answers to the particular questions raised by Mr Murphie, but if what he says is correct they are indeed very pertinent.
The passenger has a right to know with whom exactly he is trusting his backside and immortal soul.
A Government by proxy determines the safeness or not of the individual operator, it is still the passengers right, and it is exercised every second of every day to decide whether he/she agrees with it.
"We as a government are going to make sure that there is no limitation in terms of resourcing that may be needed to provide the appropriate levels of surveillance, if there is resourcing needed it will be provided."
Example: I have been flying for twenty three years in commercial operations all around Aus with 11,000 hours, how many ramp checks do you think I have had? How many would be reasonable...TRY ZERO!
Mr Vaile put your money where your mouth is and RESOURCE the HELL OUT OF IT!