Australia, New Zealand & the Pacific Airline and RPT Rumours & News in Australia, enZed and the Pacific

Merged: Senate Inquiry

Old 11th May 2014, 22:58
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Ozfucation of Annex 13 & 'saving for a rainy day'??

Stick it....said:
According to the ATSB Annual Plan for 2013-2014, the 'weasel words' are still being used to evade the obligations under paragraph 5.1 of Annex 13 to investigate ....... accidents.
Maybe the Ozfucation of Annex 13 is all about recouping the taxpayer funds spent (some would say wasted) on previous big bureau investigations, like Whyalla (over $15 million) & Lockhart ( over $20 million). To follow on...maybe the hiring of bean counter Beaker was put in place to save for the next big 'event horizon'??

But back to the Annex 13 and the bureau notified differences, from 2008 ICAO audit report...

"...Australia meets its Article 26 obligations. However, Australia has also lodged a difference with ICAO in relation to standard 5.1 and recommended practice 5.1.1 of Annex 13 as Australia considers it impractical to investigate all accidents and serious incidents within resources available..."

Which led to this, in our massively expanded version of AIP GEN 1.7, para 5.1 ND (NB: copied from SUP H18/14 , same as for H12/11):

However, most disturbingly, the Annex 13 differences did not stop at para 5.1 and it would appear that the 'weasel words' have continued unabated in the latest version of GEN 1.7 (SUP H18/14)...

Quick compare for IOS consumption...

Chapter 5 (2014) addition:

Chapter 6 (2011) deletion:

Chapter 7 & 8 comparison...

SUP H12/11:

SUP H18/14:

So it can be seen that Beaker (& his minions) have got the hang of this ICAO ozfucation thingy....and all in the name of saving us millions???

While on the subject of NDs to Annex 13 and in light of this comment from the bureau in reply to CE-3/02 of the 2004 audit....

"...However, the ATSB is not aware of many, if any, ICAO states that do not face a budget constraint that impacts the number and extent of accident and serious incident investigations..."

...I thought it might be prudent to do a quick compare with some other ICAO states, starting with the current benchmark in our region i.e. Singapore which, surprisingly, also has a ND for para 5.1:

ANNEX 13 Aircraft Accident and Incident Investigation, 10th edition
Chapter 5 (Amendment 13)

5.1.2 ICAO requires States to investigate serious incident involving aircraft of a maximum certificated take-off (MCT) mass of over 2250kg. With effect from 2 August 2010, Singapore requires all serious incidents to be investigated, regardless of the aircraft’s MCT mass.
Gotta love the Singas...

And here's a couple more for comparison with a link to NZed:

Hong Kong
13. ANNEX 13 - AIRCRAFT ACCIDENT INVESTIGATION (9th edition, Amendment 13)
Annex 13, Aircraft Accident and Incident Investigation
NZ Annex 13 differences

Yep SIUYA weasel words indeed...MTF Sarcs...
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Old 11th May 2014, 23:32
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"...However, the ATSB is not aware of many, if any, ICAO states that do not face a budget constraint that impacts the number and extent of accident and serious incident investigations..."

Chicago Convention - Article 38 Departures from international standards and procedures

Any State which finds it impracticable to comply in all respects with any such international standard or procedure, or to bring its own regulations or practices into full accord with any international standard or procedure after amendment of the latter, or which deems it necessary to adopt regulations or practices differing in any particular respect from those established by an international standard, shall give immediate notification to the International Civil Aviation Organization of the differences between its own practice and that established by the international standard.

The Ninth Edition of the Supplement to ICAO Annex 13 that was published in 2003 contained a list of Contracting States which had notified ICAO that no differences exist with regard to their compliance with the standards and recommended practices of ICAO Annex 13, as follows:

China (Hong Kong SAR)
Costa Rica
Czech Republic
Democratic People’s Republic of Korea
El Salvador
Iran (Islamic Republic of)
Republic of Moldova
Saudi Arabia
South Africa
Sri Lanka
The former Yugoslav Republic of Macedonia
United Arab Emirates
United Republic of Tanzania
Viet Nam

Seems like the person who made the comment in 2004 about the ATSB not being aware of ...many, if any... ICAO states that do not face a budget constraint that impacts the number and extent of accident and serious incident investigations didn't read the Supplement before shooting from the lip, doesn't it, because it that was a case then the States in question would have needed to file a difference.

Last edited by SIUYA; 11th May 2014 at 23:53.
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Old 12th May 2014, 03:23
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The safety slippery dip.

Ever watched the kids on a slippery dip? – some who try desperately to stop; others who manage to stop and then try to run back up to the top; all ends in tears. All you can do is pray they don't get too hurt or hurt others while the hard lessons of life are learned.

That's how our impoverished ATSB seem to be to me, stuck halfway on the slippery path to perdition, led to this sorry impasse by bureaucrats, politicians and bean counters; seduced by association with some of the darkest forces ever to hold sway over matters aeronautical, ably assisted by an incompetent, parsimonious management squadron of trained buffoons and spin kings. Have a look at the calm, professional bunch running the AMSA, then decide.

Some cultures do not place very much value on a human life, never have and are not likely to change. This is not the Australian way; men and women from the armed forces, police, ambulance services, fire-fighters and many, many more daily demonstrate the value we as a nation place on life. Where someone dies or is hurt there is an inquiry of some description – even a humble coroners court will attempt to define the cause and create some form of preventative measure, where practical and possible. We have an extensive, expensive system of rule, regulation, law, protocol, practice and common sense that attempts, barring stupidity, to prevent the unnecessary wasting of life.

Cause; now there's a word to consider: in the Beaker lexicon, a life is only as valuable as his parsimonious edicts say it is. You die in an aircraft tomorrow, the ATSB may, or may not deem your incident worthy of investigation, just a GA prang, move along. It may well be that there is some 'value' to the investigation: but only so far as to shift the blame; or, to be in concert with what the 'big dogs' want. No, not bollocks; look about you, see what you are spoon fed for reports, see what is passed off as 'cause', see what is milked as blame, see what is done to prevent, see, if you dare, what impact the 'investigation' has on the 'authority' responsible. You don't need to look very far or very deep, just ask any Pel Air committee Senator.

You can read it in the H14/18 words, these are 'differences'; scripted by lawyers who know how to appear ICAO compliant, while arrogantly flipping the bird at the ICAO spirit, intent and the rest of the world. Australia's Annexe 13 is a calculated, cynical exercise designed to confound the unwashed masses and makes a cuckold of the ICAO. No other country makes a such an open mockery of accident investigation, is selective in what it will investigate and blatantly blames this on lack of 'resources'. The budget may be constrained but there's no reason not to spend it – all of it and ask for more if needed. Hells bells that 'Direct action' outfit cleans up $2.55 Billion in handouts, surely we could use some of that so as not be an international, smart arse pariah, crying poor at every (given, taken or engineered) opportunity. Shame on you.

No other country takes the Mickey out of 'confidential' reporting; read what we say in H18/14:- Chapter 8 paragraph 8.2 – read it and weep. The only thing not provided to CASA is the pilot name; same - same for Repcon – colour of socks to date time place of the alleged incident; even if you reported yourself. Signed confession; and, ATSB dare claim to be 'puzzled' by a sharp decline in the numbers of 'reports'. FFS why hide it – we tell CASA all as per the MOU, which we will call 'differences'.

Have a look at the SIUYA list of other NAA, then have a look at any of the ICAO annexe 13 protocols; almost every country bar Australia is in tune, investigates accidents 'properly', generates reports and safety recommendations. The dinosaurs departed the fix many, many moons ago. It's time now for our cynical, parsimonious, deviate system to head in that direction.

Just stop it before Australia gets hurt – or ICAO spot the deliberate, systematic rapine of what should be a world class safety outfit, reporting honestly, openly and regularly to the industry it is paid to serve.

Arrrggggh – steam off.

Last edited by Kharon; 12th May 2014 at 04:55. Reason: I knew, the moment I started reading it; I'd made a bad blue
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Old 12th May 2014, 05:04
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The facts are in and documented but still if the go the white wash going cost him $$$$$$$$$$$$$ to prove him self innocent while they get away with it. Watch this space
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Old 12th May 2014, 05:30
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Can you run that by us again please yr right?

Not too sure I'm with you there unfortunately.
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Old 12th May 2014, 09:12
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was in reply to this statement, they have the facts and statements but they in to deep now and cya themselves and looking to knock someone up for there own failings it seams as though they found that person sadly.

Get facts

YR right,
Get the facts on these guys and go to the Senate with solid evidence. They will back you. Vale David . RIP

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Old 12th May 2014, 19:45
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Cross words and puzzles.

SIUYA -Can you run that by us again please yr right?
Yr right – "was in reply to this statement, they have the facts and statements but they in to deep now and cya themselves and looking to knock someone up for there own failings it seams as though they found that person sadly
Without meaning to offend – I have been reading the Yr-right posts in an attempt to join the dots and get a picture. To do this some assumptions were needed, no doubt YR will correct any errors or omissions.

a) "Dave" – was the pilot of the Drom involved in the fatal fire bombing accident, the one where the wing came off and was known to YR.

b) There has been a wrangle going on for many years related to concerns over the CASA ruling which allowed gross overloads; for special tasks.

c) YR is probably an 'engineering type' with much inside knowledge of the arguments, for and against, the modified weight, airframe modifications, maintenance and operations.

If that is ball park accurate, then we can join up another dot in the YR 'puzzle'. The investigation is complete and CASA are somehow implicated, by association, with the accident as the responsible authority which allowed the 'over-weight' operations. Which, from the last YR post, leads me (blindly) to the conclusion that 'someone else', probably an engineer is on the blame game chopping block for the accident. IF this is the case, then the anger and frustration in the post is understandable.

Yr right – "The facts are in and documented but still if the go the white wash going cost him $$$$$$$$$$$$$ to prove him self innocent while they get away with it.
Just saying – but I often stumble over the YR posts and the daemon curiosity whispers in my ear. No offence YR, but if this is the case.....always room for one more on the ferry.

Toot toot.
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Old 12th May 2014, 23:07
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Look I am sorry but am limited to what I can and cant say as it has gone before the senate and is still under investigation by CASA the inquest and then possibly a trail for the person involved. But you are right on the mark 4 deaths in Australia alone. Aircraft now parked up all over the place just a sorry mess at the end of the day.
The extended hopper was for bulk not liquid and hence we have wing fitting failures this was told to CASA approx. 10 years ago, what we can hope for if the inquest can reopen the other accidents and relook at what happened and maybe place blame where it rightly should be. And yes I am a LAME. What upsets me is they going to try and lay blame at a person that in the course of there duties didn't find anything wrong with the aircraft. The day was not fit for flying a kite let alone fight a fire in thoose conditions and an RFS officer believed to have said oh the real pilots are flying . Then we loose a life.

Its sad frustrating that it had to come to this.

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Old 12th May 2014, 23:40
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yr right ...

You're right!

I initially didn't 'join the dots' from your post, but it's all coming back to me now.

From what I can recall, there was nearly a 50% increase in MTOM under the STC for the modification to that aircraft.

The NZ CAA addressed increases to MTOM with modifications in Civil Aeronautics Manual (CAM 8), as follows:

7 – Weight and Balance

7.0 General This section stressed the importance of weight to the structure, of weight control and balance, and that if approved limits are exceeded then flight tests should be made.

7.1 General Effects of Gross Weight Changes This section begins a discussion on the relationship between the design load factor and gross weight. It made the point that gross weights chosen should permit safe operation under all normal and emergency conditions. The chart that is currently reproduced in CAR Part 137 Appendix B is mentioned as a guide to determining gross weight provided the aircraft is flown in a restricted manner.

7.10 Effects of Gross Weight Changes on Aircraft Structure This section noted that the aircraft landing gear and supporting structure are particularly critical if the aircraft is landed overweight; and taxiing is very likely to be unfavourably affected by increased gross weights.

With the increase in gross weight there must be a proportionate decrease in the load factor that can be reached in flight. It again notes that caution should be exercised in all flights at overload weights whether or not they are below the possible maximum. There was some discussion on the distribution of load with respect to the structural strain on the fuselage

7.11 Effects of Gross Weight Changes on Maneuvers This section notes that to prevent excessive loading the aircraft must be maneuvered cautiously, and that the stalling speeds are increased and stalls in turns are more easily encountered. A lower allowable load factor means restricting bank angle. Another factor is gust loads; the level flight and never exceed speeds should be reduced by the ratio of specification weight to overload weight but not below maneuvering speed. Again it advised caution in all flight conditions. There was discussion about pull-up speeds and the use of full deflection of control surfaces.
Source: Agricultural Aircraft Safety Review - Agricultural Aircraft Safety Review

Seems to me that under the circumstances, the factors considered by the NZ CAA may have been applicable?
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Old 13th May 2014, 00:46
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Good pick up SIUYA... Once again a disturbing tale of CYA (cover your ass) at all costs, seems to be filtering out in the aftermath of the RFS fire bombing tragedy. Going by yr right's last post, it would seem the standard BTP i.e. blame the pilot modus operandi (bit hard in this case) of FF has shifted to BTE (blame the engineer)...

As YR mentions this matter has been queried in the Senate by none other than the Heff himself, who will all know by now is a Terrier and will not let the matter slide


Which illicited this 'weasel worded'....response from (& referred to by YR) FF to the Heff QON:
Rural & Regional Affairs and Transport Legislation Committee ANSWERS TO QUESTIONS ON NOTICE Supplementary Budget Estimates November 2013 Infrastructure and Regional Development
Question no.: 131
Program: n/a
Division/Agency: (CASA) Civil Aviation Safety Authority
Topic: Relationship between CASA and the Rural Fire Service
Proof Hansard Page/s: 52 (18/11/2013)

Senator Heffernan asked:

Mr McCormick: I can give you a notice, if you like, about the relationship between us and the Rural Fire Service.

CHAIR: I think it is not between the pilot and the Rural Fire Service; it has to be between you and the Rural Fire Service. There needs to be some steadying influence in the cowboy attitude at times. I am not alleging anything, broadly, but it is an uncomfortable feeling that a lot of very learned, experienced pilots have. This guy was disgusted that a remark would be made: 'Are you a man or aren't you? Get up there!' I can give you the details.

Mr McCormick: We will look into that.

Answer: CASA provides oversight of Air Operator Certificate holders, including those who conduct aerial firefighting operations under a commercial relationship with the Rural Fire Service. CASA does not oversight Rural Fire Service organisations directly.

CASA has been advised by the NSW Rural Fire Service that it is undertaking an investigation into the matter raised by Senator Heffernan. CASA has requested a copy of that report when completed, and will consider its content in respect of any aviation safety concerns.
From that it would appear it is all in the lap of the gods but the signs are ominous that another CYA SOP action is being crafted behind closed doors...
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Old 13th May 2014, 21:50
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Man up – expletive deleted.

Seems like Heff is onto this fire bomber farce (good on 'im); it's yet another page in his ever expanding notebook of aviation atrocities. Said it before; this Senate committee is bloody furious and the arrogant handlers of the likes of McComic have over estimated the strength of the cards they hold; at the end of the day a Senate royal flush will trump a public servant bluff. Just watch NSW ICAC, one squeals, down they all go.

The 'official' attitude is summed up in the "real pilots are flying" speech. Think on that for a moment,- some ground dwelling office wallah wants to tell an Ag pilot who is fire fighting to "Man up"; Un-Furkin-Believable. The only reason that fool still has teeth in his head is that he didn't say it to me. Seriously; there are limits to contractual politeness. I can only hope Heff tracks this idiot down and sends him my way: for quiet 'chat' over tea and biccy's....behind the shed.

In the video McComic tried to huff, puff and bluff his way out, once again CASA fail the industry it is paid to serve. The Ag boys will go flying, too much money to ignore; they will carry as much as (legally approved) possible; that's the nature of the beast. The RFS want them out there carrying whatever. So somewhere there must be a balance – to even dare to challenge a pilot in that fashion should have brought McComic screaming out of his kennel. But no; (anti-climax) McComic is quite happy to apply the law, just as long as he can rely on the 'expertise' of the operators (to act as CASA approved); nice little get out of jail card that one. Then there's always the trusty pilot, engineer or operator 'error' blame card to robustly apply at a later date, with 20/20 hindsight. Now – Oh, they are 'grounded'. – Excellent choice, stellar management. Crazy stuff.

Last edited by Kharon; 13th May 2014 at 22:07. Reason: But, is Tmesis an art form???
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Old 13th May 2014, 22:38
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always the trusty pilot, engineer or operator 'error' blame card to robustly apply at a later date, with 20/20 hindsight

That's if its given after the fact. They where and still being told for the last 10 years that's not 20/20 hindsight sorry. 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.

Now don't forget the AAAA are in this as well and they wont to self regulate how the hell can any possibly think that a great idea only one person who wants to make a name for him self and as he told me he has NO aviation knowledge.

Its such a mess where been all put into. Now somehow we got to get out of it. I don't believe aviation has been in a more dangerous place than what we find ourselves into now.

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Old 14th May 2014, 09:21
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Yr deserves a choccy frog

I enjoy Yr's posts - Somewhat elusive, often cryptic, occasionally bizzare often downright odd, but yet in his own way very informative! Reminds me of the night that myself, Herr Kharon and Gobbledock played Word Yahtzee after two bottles of Jack Daniels while sitting beneath a crimson sunset on the deck of the Styx River boat as we sailed up to a government department to pick up a large contingent of passengers.

But Yr makes a valid point. The regulators 'feelings' towards 'Dave' are despicable. Blame the pilot, blame the engineer, blame the one armed man with one testicle and gingivitis, blame everyone for having a hand in any accident except of course the two-bit hack outfit Regulator.
Go for it Heff, take it to these morons.

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Old 14th May 2014, 18:02
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I enjoy Yr's posts - Somewhat elusive, often cryptic, occasionally bizzare
I must say I have revised my opinion of yr considerably. he's a good cookie.

what you are haphazardly documenting here is what I see as the core enduring incompetence that is CAsA.
they have little or no serious aeronautical engineering competence and yet as the countries' NAA (national airworthiness authority) they are making variations to aircraft permissions that have no basis in competent engineering.

They have systematically worked to kill off manufacturing in this country to avoid having to be competent.

CAsA are a disaster. They should not be allowed to change the aviation environment to make their inadequacies in this regard in any way acceptable.

Lawyers simply cannot do what aeronautical engineers should be doing.
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Old 14th May 2014, 21:17
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W8 Lawyers simply cannot do what aeronautical engineers should be doing.
The technical people LAMEs, pilots, engineers etc seem marginalized by lawyers, HR, IR and a general public sector way.

CASA never have understood certification, engineering and manufacturing adequately for an NAA. Some treat the same as maintenance. Where is the approved data ? Err, that is what certification program will achieve.

There is manufacturing in Australia. But as tier 1 suppliers working under supplier approval to OEM's without any casa involvement.

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Old 14th May 2014, 22:35
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2008 M18 – ATSB report.

It's not often, these days anyway, to do anything else when CASA of ATSB are mentioned other than doubt the probity or value of anything said or written; but back in 2008, when an M18 had a wing failure, both agencies did a first rate job. It's very satisfying to be able to say that. The curiosity bump was driving me spare, so a drop or two of midnight oil was burned in an attempt to assuage the itch. Started – HERE – (of course) and found this:-

DFE flieger # 35 – "I think this is probably the link you are after wheatbix:

It makes reference (Pages 43 to 46 or thereabouts) to the original MTOW of the M18 being 4200kg, and by supplemental amendments and exemptions, increases in MTOW to 4700, then 5300kg, then finally to 6600kg for fire-fighting work. These changes involved reductions in allowable load factors, Vne, Vno and factoring of hours of service, such that 1 hour of flight time would count for more than 1 hour of service life, depending on actual takeoff weights. The report also discusses problems with recordkeeping and tracking of actual takeoff weights, among other issues that could potentially lead to structural problems, and how CASA would act to prevent the problem that occurred in the linked report from recurring."
There are almost 100 pages comprising the excellent, most refreshing ATSB report. Lately I seem to end up 'hunting' for facts and pertinent information; but not this time. The report is well worth reading; of particular interest are the following pages:-

Aircraft modifications - ATSB page 8 (p 18 pdf).
Tests and research – ATSB page 37 (p 47 pdf).
Overweight operations – ATSB page 40 (p 50 pdf).
Aircraft manufacturer-approved overweight operation. ATSB page 41 (p 51 pdf).
CASA general weight exemptions - ATSB page 44 (p 55 pdf).

The following are cherry picked paragraphs from the report:-

During the course of the investigation, it was determined that a number of operators of the aircraft type were not applying the appropriate service life factors to determine the effective hours flown when their aircraft were operated at take-off weights above 4,700 kg. The effect was to overestimate the remaining service life of those aircraft.
It was also found that operators had an interpretation of the Civil Aviation Safety Authority (CASA) exemptions that, by their understanding, permitted operation at weights in excess of the maximum take-off weight and allowed them to operate at higher take-off weights without the need to account for the additional limitation imposed by the manufacturer for operation at those weights.
As a result of the accident, the following safety action has been taken or proposed:
• The operator undertook a retrospective process of applying the service life factors to its aircraft fleet during operations that had involved take-off weights above 4,700 kg and will apply them to all relevant future flights.
• CASA advised that they had contacted Certificate of Registration holders of M18 Dromader aircraft to verify that they had a procedure for recording and factoring aircraft hours that included overweight operations. Further verification would also occur as part of CASA’s routine surveillance program. CASA also advised that they will provide education to operators on the intention of the exemptions and will be revising the exemptions to ensure that the intended interpretation is clear.
The original type-certified aircraft had a 9-cylinder, supercharged, radial engine, developing 967 shaft horsepower. In more recent years, modifications have incorporated more powerful turboprop engines. One such modification, which was approved under United States (US) Federal Aviation Administration (FAA) Supplemental Type Certificate (STC) number SA09039SC, used a Garrett model TPE331 turboprop engine. As a result of the engine change, the modification increased the length of the aircraft’s forward fuselage. After the incorporation of that modification, the aircraft was designated an M18A Dromader (TPE331).
Other modifications to the aircraft included increasing the capacity of the hopper from 2,650 L to 3,028 L, the installation of servo tabs14 to the flight controls, and installation of vortex generators on the wings. The vortex generator manufacturer claimed that the installation resulted in a 7% reduction in the aircraft’s aerodynamic stall speed.
All of the modifications were carried out in accordance with FAA STCs and/or Australian Civil Aviation Regulation (CAR) 35-approved engineering orders.
The upshot seems to be that the modifications made were not some 'back yard bodge up'; not by a long shot. The CASA approach appears to be 'sound' and if it is in error, then it has been on the side of 'reasoned' caution; the CASA operational approval is well supported and (IMO) justified. There was little else, of a practical nature that they could have realistically done. Good job by someone. Once again, most refreshing.

Which only leaves a couple of loose ends, questions if you like. Why is there no engineering data available to support claim of a 'highly dangerous' modification?; the ATSB went to some pains to troll the world looking for similar and came up dry. The AAAA and type operators seem to be a level headed bunch, safety conscious and have a vested interest in preserving life and promoting their services; so I wonder why there are no howls of protest or internal limitations imposed?; if anyone knows and can sensibly evaluate the risks, they can. No; IMO we must look elsewhere for answers this time. Old Akro # 40 makes some sense of the problem.

I just hope the 2014 ATSB report is as good. I think we may have to cut the ATSB and CASA some slack (benefit of doubt) this time, if the 2008 effort is anything to judge by. We'll just have to wait and see; but one would hope the RFS get a sternly worded letter spelling out the authority of the PIC - if the case is proved.

Itch scratched – Endit.

Last edited by Kharon; 14th May 2014 at 23:27. Reason: Beens and peas are good for your heart - the more you eat.
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Old 15th May 2014, 00:35
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Ventus,it cracked from the edge of the hole, probably started at a tiny nick in the edge or a tiny manufacturing defect.

The problem with all this life factoring is that the fatigue life is determined not just by the load the joint has carried, but by the duration of the load - in effect the "stress strain history" of the joint for its entire life. Today digital recorders give us the possibility of actually recording something like that history but mostly we have to make approximations of what the loading history would look like and then test to destruction.
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Old 15th May 2014, 10:36
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Hey Sunfish...I am unfamiliar with the digital recorders you are talking about that will record the "stress strain history" of a joint such as a wing attach point. Can you shed more light?....Cheers
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Old 15th May 2014, 11:56
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Gas bag

Most common is a strain gauge. If you can imagine a little stamp self adhesive that has like a "S" in the centre of it with wires to each end. As the material stretches under load the "S" also stretches and they can measure the resistance across the "S" this is recorded and then they can work out the load on the part. They put 100s on when testing.
With computers they can also do modelling with program's. But still sometimes you only have to use your own eyes to know what's going to work and what's not.
White man magic

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Old 15th May 2014, 12:12
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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;
· 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?



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...

Last edited by Sarcs; 15th May 2014 at 12:45.
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