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ATSB report just published on A320 throttle asymmetry incident

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ATSB report just published on A320 throttle asymmetry incident

Old 27th Jan 2013, 03:48
  #41 (permalink)  
 
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Been monitoring this thread with particular interest, it is good to see posters with very real experience in High Capacity Jet ops getting involved in the debate. This thread highlights the importance of the ATSB in publishing good factual reports that disseminates vital safety issues that we all can learn from.

However as several posters are now starting to realise the ATSB report is somewhat short in detail in the technical and operational aspects.

Kharon’s 2006 comparison is a particularly good one as it displays what appears to be a totally different methodology of investigation by the ATSB (that was then this is now!) and the nuances are obvious in the final report.




Examples:
  • In the ‘Additional information’ section of the 2006 report the ATSB highlights research into ‘Previous events’, this is described as finding a ‘causal chain’ (Reason model). The 2012 report is totally devoid of any such information suggesting that this was a isolated (one in a million incident) but judging by some of the posts that is probably not entirely true.

d_concord said: What happened here is not unusual. I have seen other do it and have done it myself. And as you say, in all the cases I have seen or done myself you just put the lever instantly back into to the detent and presto now you have the power you programmed. I have never heard of anyone to just sit there with the problem until now.
  • It has also been pointed out that the 2012 report seems to be lacking in the organisational and management information:
scrubba said: FWIW, I am particularly glad that it was reported, investigated and published.I thought that a lot more could have been drawn from the event and the lead up to it, as well as the company SOPs, preparation of training captains, etc and what reviews took place post-event.

d_concord said: It is interesting that the findings did not see the need to look at or make any comment on any deficiency in understanding or the need to improve the initial conversion training onto the aircraft. Seems as though they did not even look at the ground course or training syllabus of the organisation that did the training. Given the PF had only 120 hours on type this incident started there.
Whereas the 2006 report has a whole section devoted to “Organisational and management information” which includes quoting from the Operations Manual the relevant section dealing with; “The A330 operating techniques, instructions, standard operating procedures (SOP) and limitations in the operations manual that affected the conduct of an RTO” (pg 6 of the report).



  • The ‘Safety Actions’ sections of both reports are also like chalk and cheese..
2012 Safety Actions (operator):
Jetstar

Simulator training

The operator advised that, in response to this occurrence, they have incorporated a ‘thrust mishandling/abnormal event prior to V1’ into their ‘Captain Simulator’ qualification. They have also incorporated a module into their simulator cyclic training regarding incorrect thrust setting on takeoff.

Communications

The operator advised that, in response to this occurrence, they have issued a communication to flight crew regarding ‘Command of Flight’ requirements for the pilot in command in circumstances where an operational event occurs during a flight.
2006 Safety Actions (operator):
Aircraft operator

On 5 February 2006, prior to this incident, following a third airspeed–related occurrence involving an A330 where wasp activity was suspected, the operator’s engineering department initiated the following actions:

• A property fault report was raised requesting urgent action be taken to remove mud wasp infestations on the operator’s ground support equipment (GSE) that was located at the Brisbane Airport international apron. In response to that fault report, a contractor was employed to inspect and spray the operator’s portable equipment. During the process, a wasp nest was found and removed from one set of portable stairs.

• An arrangement was put in place for the quarterly inspection and spraying of all ground equipment.

• An email was distributed to all line maintenance staff at Brisbane that included an overview of the wasp-related problems, and an instruction to fit pitot probe covers as soon as possible after an aircraft’s arrival, with their subsequent removal as close as possible to the aircraft’s departure.

• As a precautionary measure, the operator inspected all pitot lines throughout its A330 fleet. No foreign matter was found in those aircraft’s lines.14

In May 2006, the operator assumed responsibility for the ongoing wasp inspection/eradication program in their GSE area. The following schedule was established:

• weekly inspections/eradication took place until the end of June 2006

• monthly inspections/eradications were invoked from July to September 2006 (the period of least expected wasp activity)

• a weekly program was to be reinstated from 1 October 2006 (the perceived time of greatest wasp activity).

In addition, the operator promulgated information to flight crews in order to alert them of the potential hazards of wasp activity at Brisbane Airport.

In October 2006, the operator implemented a formal Local Area Procedure at Brisbane, which provided more detailed guidance than the maintenance instruction manual for the fitment of pitot probe covers to A330 aircraft as follows:

• when aircraft ground time exceeded 2 hours, pitot covers were to be fitted and a Technical Log item raised to reflect their fitment

• when the aircraft were on the ground for less than 2 hours, and at the discretion of the certifying Licensed Aircraft Maintenance Engineer (LAME), pitot probe covers were to be fitted and a Technical Log item raised as necessary to reflect their fitment

• if wasp activity increased during the summer months, the less than 2 hour option should be adopted.

Finally, the operator also planned to introduce low-to-intermediate speed range rejected takeoffs (RTOs) to the company’s recurrent simulator training program.
I also find the following comments interesting… “The ATSB show again that they can’t do any sort of analysis or have any expertise. This is just a regurgitation of an internal Jetstar report it would seem.”…As Rudder indicated you really have to wonder about the ATSB and the level of experience, skill and analysis”.

Not that we are expecting the bureau to necessarily have a type rated expert in the investigation team, however it is perhaps poignant to make a comparison to the NTSB system of investigation and how they get around the ‘expertise’ issue.

Within the NTSB investigative process they have what they call a ‘Party System’, see here:
The Party System


The Board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents in the other modes of transportation - rail, highway, marine and pipeline. With about 400 employees, the Board accomplishes this task by leveraging its resources. One way the Board does this is by designating other organizations or companies as parties to its investigations.
The NTSB designates other organizations or corporations as parties to the investigation. Other than the FAA, which by law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as parties to the investigation. Only those organizations or corporations that can provide expertise to the investigation are granted party status and only those persons who can provide the Board with needed technical or specialized expertise are permitted to serve on the investigation; persons in legal or litigation positions are not allowed to be assigned to the investigation. All party members report to the NTSB.
Eventually, each investigative group chairman prepares a factual report and each of the parties in the group is asked to verify the accuracy of the report. The factual reports are placed in the public docket.
This system makes a lot of sense as it means that various parties with a particular interest and expertise can provide a ‘team’ effort to proactively analyse, research and contribute to getting the best possible safety outcome from the NTSB Final Report.

With the 2006 report there does appear to be more of a ‘team effort’ and level of cooperation between the ATSB and the operator, however the 2012 report hints at a distinct lack of cooperation and there is almost a level of ‘political correctness’ displayed i.e. ‘we don’t want to upset them best let them address the safety issues.’

Anyway back to the thread and keep up the good work filling in the gaps that the ATSB is apparently happy to leave out these days!
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Old 29th Jan 2013, 12:37
  #42 (permalink)  
 
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Asymmetry, assclownery and an assimilated bureau

Excellent post sarcs, excellent.

If my memory is correct, the ATSBeaker indeed did on occasion call on the assistance of third party's to assist with investigations. One such example was QF71 into Learmonth, in 2008 I am fairly sure. They seconded a CASA FOI who had A330 experience to assist. The ATSBeaker didn't have the internal specialist so they went external, a good call. Smart, mature and genuine approach to a thorough investigation.
However that was in the days before Beaker came onboard and applied his 27 years of Government bureaucratic crap to the well respected investigative bureau and turned it onto the embarrassing mess it is now. Now he won't even sign off on recovering the key known pieces of evidence required so that an accident investigation can be fully concluded (Norfolk).

No, the only external party's Beaker involves in anything are the ones that provide high tea served on fine porcelain along with silver cutlery, at events where he and his cohorts can hypothesise,philosophise and muse over universal complexities and mysteries.

And Kharon, if what you say is true, and I have heard the same rumour, then this industry really has gone loco, raving
mad, insane when a pilot is threatened for following an S.O.P written in the aircraft manual by the manufacturer? Are we to believe the pilot is expected to violate S.O.P's? Is that part of a just culture? Would that not constitute a 'workaround'? Sounds like somebody's SMS isn't working??

No wonder the Senators are all over this mess, at least somebody in higher power is concerned.
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Old 29th Jan 2013, 20:09
  #43 (permalink)  
 
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So to summarise from the comments here in laymans langauge, and please correct me if I am wrong:

1. A Jetstar pilot mishandled the throttles of the aircraft which could have resulted in not enough thrust being available for a successful takeoff.

2. The training pilot and pilot flying miscoordinated the takeoff rotation action and the pilot flying did not check the airspeed - which could also have resulted in takeoff failure.

3. The ATSB decided their was a single cause for the incident and did not subscribe to the James Reason / chain of circumstance model of incident eventuation and did not examine the causes of the incident in more detail as they relate to management and training. They employed the far cheaper and quicker "one off" incident model.

3, The safety action taken by Jetstar was to tell the pilots not to do it again.

4. The ATSB was entirely satisified with this outcome.

So am I right if I draw the conclusion from this that the ATSB/Jetstar safety action does not, in the opinion of airline pilots, comprehensively preclude a similar incident happening again?

.........Especially since Airbus side sticks don't provide any direct haptic feedback to the non flying pilot about what the pilot flying is trying to get the aircraft to do. (translation: the other pilot can't feel what the other guy is trying to do because the side sticks aren't mechanically connected)

to put that yet another way, is there a tail dragging incident or worse in Jetstars future?

Last edited by Sunfish; 29th Jan 2013 at 20:14.
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Old 29th Jan 2013, 20:41
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Definitely appear to be non believers in Jame Reason's theories. This guy has been involved in some pretty serious accident investigations, Piper Apha and Kings Cross London Underground fire as a starter.

As Sunfish points out this report on Jetstar is pretty average at best. However, when you look at Pel Air. Pilot error! Then compare with what contributing factors the senate inquiry has been presented with. Now, if the ATSB had looked at these and then concluded pilot error that would be a different matter. But they were not even considered and to leave the CVR and FDR on the ocean floor too! I think it was around 44m from previous info?

CASA even had a SMS presentation with a DVD containing a James Reason and Patrick Hudson lecture on it that they were distributing a few years back.
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Old 29th Jan 2013, 21:47
  #45 (permalink)  
 
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Horse and cart.

Sunny – there are several issues which, I imagine will be hammered out at Check &Training meetings. As has been pointed out the incident of it's self was essentially a something nothing at face value. The guys here are pointing out and highlighting very well some of the subtle, deeper issues relating to modern operations.

For example - Flight engineers were replaced by automation – so when an 'old' school' skipper called for power there was a pair of practised hands to make sure all the donkeys were pulling in harness and not behaving badly. The flight crew probably had at least one eye on the engine clocks, 'tuther on the ASI and various other things. Now the 'automatic' flight engineer is still monitoring but, with the new gear, there is a risk that a casual glance, rather than 'intense' monitoring of the engine clocks and reliance on a 'warning' can become a normalised deficiency, where small aberrations, such as we have here can pass undetected. This crew spotted the deliberate error; the 'procedure for correcting' seems to have got tangled up. Good on the crew for reporting it.

ATSB have identified this as a single issue "in house", but as many others have pointed out, that is not the end of the story. There are training issues, CRM issues and some deeply entrenched, subjective issues which deserve consideration and discussion. I dare say some C&T brainstorming will develop into revised protocol and practice. This will be limited to what the manufacturer SOP allows, but in the sim, perhaps now there will be additional notice taken of what the engines are doing early in the piece, that correction is made a long time before the business end of a take off and that communication is absolutely clear.

This is one those sneaky, non events which can and do create havoc even on the best run flight deck. The Airbus and Boeing crews have the best of both worlds, the manufacturer pays a lot of attention to incidents, company C&T and SMS similar and usually; if there is a serious issue, it gets sorted, in house.

Simply telling the crew not to do it again or changing a rule or three will not solve the problem, particularly if the problem is deeply entrenched, or not recognised. It will be industry, probably an in house C&T team which identifies and fixes many of the issues not raised; not the ATSB and certainly not the 'expert' opinion of CASA.

There are 'other' elements of the report which bother me, but they will keep for another day. Tricky business this C&T stuff.

Last edited by Kharon; 31st Jan 2013 at 09:09. Reason: as - drives me nuts.
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Old 30th Jan 2013, 00:52
  #46 (permalink)  
 
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Sarcs post says it all

I used to think the ATSB was a good counterbalance to CASA, political correctness from sheltered public servants is now a real threat to flight safety. It's obvious they have thrown out their text books that have any of James Reason's work in it. If they hadn't they would have to name themselves as a huge threat, as one of the biggest holes in the piece of cheese
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Old 30th Jan 2013, 05:50
  #47 (permalink)  
 
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To many contenders for the 'chocolate frog award'.

Jack, you are correct. They WERE a good non political outfit. They would act and report independently, and they sure as hell had the respect of those of us on the industry.
But under Albanese we have seen Beaker appointed as Comissioner at ATSB, the Skull at CASA (along with the rise of Aleck), and Russell at ASA (and now Staib). If you want Swiss cheese then look no further. These 3 aviation bodies have imploded and melted like Danish butter ever since bureaucracy got in the way of safety. The appointment of these type of individuals into executive roles has seen a rapid deterioration in the safety and core functions of these individual silo's.
Not a week goes by when we at the coalface don't see a further erosion of safety and standards at the hands of a disconnected spreadsheet monitoring, budget focused, spin doctoring group of magicians.

Well the act is up, the mystery, the mystique, the masquarades, the pony tricks, the disappearing act, the sock puppets and smoke and mirrors has been exposed for all to see. It's up to the Senators whether the magic game will continue or whether a giant carving knife will be taken to the top layers of the rotten cake and the rancid rot will be thrown away.

Last edited by my oleo is extended; 30th Jan 2013 at 06:11.
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Old 30th Jan 2013, 06:52
  #48 (permalink)  
 
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Sometimes, I just sits and thinks – sometimes I just sit.


ATSB - Ben Sandilands – Plane Talking.
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Old 30th Jan 2013, 12:29
  #49 (permalink)  
 
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Kharon, thanks for the link.

Mr Sandilands, once again a brief but succinct article.
Indeed, more hypocrisy, more empty words, more glossy statements and more scarily - MORE STUPIDITY!

The ridiculous babble, contradictions, backflips and bureaucratic baloney is nauseating. And Ben is right, how stupid do these Executives think we all are? The fact that they continue to spin all this folly out to all and sundry expecting that we will all swallow it proves how arrogant, ignorant, conceted and disconnected from reality they are.

Apart from a small smattering of loyal followers including mid tier management, everybody else knows they are full of crap. I just hope for aviations sake this dross gets what it deserves, which in itself is long overdue.

There is a saying that 'a team is only as strong as its leader', and if the outputs and direction of CASA, ATSBeaker and ASA is anything to measure success against then I rest my case.

Senators, it is time to go for the jugular. Hold these buffoons to account. Ask the hard questions and demand logical answers. Do not stand for any delayed responses, limp wristed explanations or answers spun with brown matter. With all due respect please do what your constituents have voted for and trusted in you to do, and that is act on our behalf and fix out declining aviation problems. The last 14 months has clearly exposed to you what the real issues are. The evidence is there, now you have to act upon it. You must force change, introduce real accountability. We can no longer tolerate nor accept the squandering of taxpayer money over grudges and payback. We can no longer accept inept investigations such as Norfolk. We can no longer accept the lack of frontline resources in air traffic controllers, we can no longer accept bullying and intimidation such as with Quadrio as being the 'norm' and 'accepted practise'.

What do we actually want? Simply and truthfully and without the irony, 'safe skies for all'.

Last edited by my oleo is extended; 30th Jan 2013 at 12:37.
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Old 31st Jan 2013, 06:20
  #50 (permalink)  
 
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In regards to checking the ground speed, a little off topic, but as the aircraft is accelerating it is a little difficult to check and compare ever changing gs and tas on the nd.
Important to check at some stage but at vr it is a bit pointless, as someone else mentioned.

My fix is, when 100 kts is called check the nd, this is the point where the number are joined on the nd by a wind direction arrow, if it indicates a hw life is good but if a tw it is time to make some decisions.

I have never heard this being taught it is just something I picked up by chance in this self help airline.

The other one that amazes me is when I ask the FO to monitor the tw on approach nearly everyone just looks at the wind arrow, my advice and this is nothing new for those with some experience, is to compare the gs and tas numbers (they should be fairly steady because the aircraft should be stabilised at Vapp) and if the gs is tas + 10kts please let me know.

The problem with Jetstar is that if you have had a command for 2 weeks you will be accepted into C&T. How are pilots meant to learn if their training captains are inexperienced?
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Old 31st Jan 2013, 07:42
  #51 (permalink)  
 
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The problem with Jetstar is that if you have had a command for 2 weeks you
will be accepted into C&T. How are pilots meant to learn if their training
captains are inexperienced?
Bollocks! Before you get to be a training captain you have to go through a process of applying, interview, ground school, sim then line observation flights and a check before getting near a student. Your sim and route checks scores also have to demonstrate a high standard. All takes a bit more than 2 weeks in the command seat. MOU guys have been getting TC spots but they are hardly inexperienced and most of them have at least 12 months LHS time.
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Old 31st Jan 2013, 12:20
  #52 (permalink)  
 
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Must admit I thought PF's job was centreline alignment and PNF's job was to scan for temps, surges and to call out bugged speeds.
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Old 1st Feb 2013, 11:45
  #53 (permalink)  
 
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PNF's job was to scan for temps, surges and to call out bugged speeds
Hopefully he will also be watching the centre-line tracking like a hawk. Never ever trust captains to be perfect...although some like to think they are
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Old 2nd Feb 2013, 03:03
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I am amazed at how few F/O's do check the EGT and N1's during the takeoff especially in the simulator. I am often well into an RTO while the PNF is still trying to work out whats going on. During the early stages of command training I always ask the question after takeoff "Which engine had the higher EGT?" and they soon realise that they should be scanning a lot more than just the speed tape. As for centreline tracking that should be easy to monitor just with the peripheral vision.
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Old 2nd Feb 2013, 03:47
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... So, just to clear things up for me - on a jet, where should the PF's visual focus be - mainly down the runway, or mainly scanning the panel?

Shouldn't PNF be mainly focused on the temps and pressures checking for potential RTO criteria and calling it before V1?
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Old 2nd Feb 2013, 06:15
  #56 (permalink)  
 
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On a jet the only person calling an RTO is the PIC. If the PIC is also PF then the primary focus is on everything! Realistically as you get closer to V1 then you should be go minded so your emphasis shifts to outside. Most F/O's tend to focus outside when they are P/F as they know they are not responsible for an RTO.
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Old 2nd Feb 2013, 06:52
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Most F/O's tend to focus outside when they are P/F as they know they are not responsible for an RTO.
They are also steering the thing, so focussing outside helps a lot...and they are responsible for bringing to the captain's attention (if he's the PNF) anything they might run into, on the ground or in the air.

Shouldn't PNF be mainly focused on the temps and pressures checking for potential RTO criteria and calling it before V1?
Correct.
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Old 2nd Feb 2013, 08:31
  #58 (permalink)  
 
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and they are responsible for bringing to the captain's attention (if he's the PNF) anything they might run into, on the ground or in the air.
If they are going to run into anything I think the captain will be aware of it. The captain won't have his/her eyes buried in the "temps and pressures" (are we talking piston or jets here ). If the captain is PNF he/she does not rely on the F/O PF to alert them to the possibility of an RTO.
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Old 2nd Feb 2013, 08:41
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No need for an FO then, right Lookleft? In fact perfect user name for you....

Last edited by kellykelpie; 2nd Feb 2013 at 08:42.
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Old 2nd Feb 2013, 09:12
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No need for an FO then, right Lookleft?
Bit sensitive KK? I did say most F/O's, the good ones won't just be focused on the dashed white line. Have a look at the report. The bloke under training rotated 20kts early. Do you think he was more situationally aware than the PIC even though he was training to be one? I have trained people to be in the LHS and initially they are purely focused on the path ahead and are not scanning the EGT and N1. Thats because they never have looked at them before and it is a habit they have to develop.
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