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Another example of ATSB superflous report writing

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Another example of ATSB superflous report writing

Old 19th Sep 2017, 07:21
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Another example of ATSB superflous report writing

TheATSB has released its investigation report into the

Engine failure involvingSAAB 340, VH-RXS, near Dubbo Airport, NSW, on 23 March 2017


On 23 March 2017, at about 0942 Eastern Daylight-saving Time, a RegionalExpress SAAB 340B, registered VH-RXS, departed Dubbo Airport, New South Walesto operate scheduled passenger flight ZL821 to Sydney, New South Wales. Therewere three crew and 23 passengers on board.

At about 0944, as the aircraft climbed through about 4,300 ft, the flight crewheard several bangs from the right engine accompanied by jolts through theaircraft. At the same time, the cockpit master warning illuminated and theright engine instruments displayed multiple warnings. The first officeridentified a failure of the right engine and the flight crew immediatelyenacted the memory items of the engine failure checklist.

After completing the memory items, the flight crew commenced the standardfailure management procedures. The flight crew secured the right engine andestablished that the aircraft was performing satisfactorily. The captainidentified Dubbo as the most suitable airport for landing. The flight crewreviewed the weather conditions for Dubbo and elected to conduct a visualapproach and landing.

At 1004 the aircraft landed on runway 05. No persons were injured and theaircraft suffered minor damage in the incident.

This incident highlights the importance of effective training and emergencyprocedures. Faced with an abnormal situation, the training provided to theflight crew ensured they were able to effectively implement the standardfailure procedures, secure the failed engine and return for a safe landing.

During an emergency, the flight crew prioritise the management of the emergencyto ensure that the safety of the flight is not compromised. Completing theemergency procedures, along with the coordination of emergency services andcommunications with supporting agencies may absorb a significant amount of timebefore the flight crew are able to provide an update to passengers.

Final Report:Enginefailure involving SAAB 340, VH-RXS, near Dubbo Airport, NSW, on 23 March 2017

............................................................ ............................................................ ......


What a lot of superfluous waffle. The facts were the aircraft experienced an engine malfunction during the climb from Dubbo and the crew feathered the propeller. The aircraft returned to Dubbo for landing. All the additional text was simply padding and self congratulations.
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Old 19th Sep 2017, 08:08
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ummm... to be fair there was a bit more in the report than what you quoted and some of the comments you are critical of appear to be addressing concerns expressed by pax about not being notified earlier in the incident about the situation.

Maybe the grammar is a little clunky but I am not getting why the angst about this report? Seemed reasonable. Better and more informative and helpful than what a newspaper would report it as (something like "Passengers kept in the dark by panicked pilots during mid air nightmare... exclusive!")

The crew managed the situation professionally, procedures were followed and choices made, some pax were critical of not being informed earlier, the report discusses why.

The aircraft returned safely, bearings failed in the engine possibly due to lack of lubrication however reason is yet to be determined.

They commend the crew for their actions and sticking to SOPs, I can't see a problem but I guess I may be missing something.
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Old 19th Sep 2017, 08:29
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Before the usual crowd get on and criticize the use of the term their , there and they're, the engine failure was dealt with professionally and IAW procedure. There were times in the past when there have been mishandled engine failures on SAABs that resulted in an incomplete shutdown procedure used. The value of regular simulator training has resulted in this incident really being a non-event. I remember years ago watching a CRM video of an EFATO of an A320 with an immediate return to land. All filmed in the simulator. Cabin crew commented that the crew didn't let the CC know earlier by way of a PA that there was a problem. The fact that the crew were busy with checklists and dealing with the failure did not register with them.
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Old 19th Sep 2017, 12:21
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They commend the crew for their actions and sticking to SOPs, I can't see a problem but I guess I may be missing something.
Interesting to read the old DCA Aviation Safety Digests where political correctness was yet to be invented and the editors had no hesitation in calling a spade a spade by saying the pilot stuffed up. Having said that nowadays ATSB do say: It is not a function of the ATSB to apportion blame or determine liability.
Examples (edited for brevity) from ASD No1 July 1953 and others of that era:

.The failure of the pilot of the DH.84 to complete a circuit of the aerodrome prior to landing is considered to be a poor display of airmanship. In addition it is considered that the pilot of the DC-3 was not completely blameless as he apparently failed to ensure the approaches were clear before entering the runway.
............................................................ ...............................
A DH.82 flown by an instructor carried out violent manoeuvres in the circuit area at Maylands. This was the second breach by the pilot within a short time and he has been reprimanded for his conduct. In addition his recent application for the pilot for upgrading as an instructor has been deferred pending his demonstration of ability to accept the responsibilities ands privileges specified in A.N.O. Part 40.
............................................................ ....................................
An Auster taxied past the Control Tower at Bankstown within 20 feet of the signal square. The wind "T" was pointing NE, but the pilot took off into the SW without the pilot giving any notice of his intentions. During the take-off, the aircraft crossed the landing path of several aircraft causing some of them to go around again, and shortly after becoming airborne made a climbing right-hand turn from 100 feet on to course.

The pilot of the Auster displayed a serious lack of airport discipline resulting in other aircraft being placed in a hazardous position. The pilot has been severely reprimanded for his carelessness in failing to keep a proper look out.
............................................................ .............................................
An Auster crashed into Vanimo Harbour shortly after take-off from Vanimo airstrip New Guinea. The pilot was killed and the two passengers received minor injuries. The probable cause of the accident was incorrect technique on the part of the pilot in effecting recovery from an inadvertent stall. The stall probably resulted from a lack of care on the part of the pilot in the execution of a steep turn at a low altitude without the assistance of an airspeed indicator and tachometer.
Violations. The evidence indicates that the pilot committed breaches of the following Air Navigation Regulations:-

Regulation 239. Banked the aircraft at an altitude below 500 feet above terrain after take-off.

Regulation 225 (A) Operated the aircraft with an unserviceable airspeed indicator and tachometer.

Regulation 227. Took off at an all-up-weight which exceeded the maximum permitted for Auster operations at Vanimo airstrip.

Regulation 38. Operated an aircraft without a current Certificate of Safety.

Regulation 244. Carried a passenger who was not provided with, and consequently did not wear, any form of safety belt during the take-off.
............................................................ .....................................
As Norseman aircraft was levelling out to land on Vanimo Airstrip, the port wheel struck a stump just short of the airstrip and on subsequent touchdown, the aircraft nosed over and came to rest inverted. It was concluded that the cause of the accident was poor technique on the part of the pilot in that he landed short of the airstrip and damaged the port landing wheel in such a manner as to subsequently cause the aircraft to overturn.
............................................................ ....................

This writer has no problem with ATSB commending a pilot for superb flying skill in a serious situation. But not where everyone gets lots of kudos and hand claps like kindergarten kids simply for using SOP's.

Last edited by Centaurus; 19th Sep 2017 at 12:31.
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Old 19th Sep 2017, 18:17
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Agree Centaurus.

There should be two reports.

One for pilots where brevity and frankness prevail. And one for legal officers and window lickers.
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Old 19th Sep 2017, 19:16
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This writer has no problem with ATSB commending a pilot for superb flying skill in a serious situation. But not where everyone gets lots of kudos and hand claps like kindergarten kids simply for using SOP's.
Hear hear.
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Old 20th Sep 2017, 10:20
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What Centaurus said!

The old ASD really had it right. If you stuffed up, you were informed so!
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Old 20th Sep 2017, 23:12
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So with the Norfolk Island crash, was it right for the report to put the blame on the crew? From memory there was much outrage that in this day and age the crew, who were at the end of a long organisational chain of factors, were considered to be the sole reason for the ditching. I really don't see in this report that the crew are getting
lots of kudos and hand claps like kindergarten kids simply for using SOP's.
.

The report is just reinforcing how a well trained crew dealing with a non-normal was able to make a safe landing.
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Old 21st Sep 2017, 00:24
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The first officeridentified a failure of the right engine and the flight crew immediatelyenacted the memory items of the engine failure checklist.
I hope it wasn't only the First Officer who identified the engine failure, especially if the engine failure checklist was 'immediately enacted'.
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Old 21st Sep 2017, 00:47
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Originally Posted by Lookleft View Post
So with the Norfolk Island crash, was it right for the report to put the blame on the crew? From memory there was much outrage that in this day and age the crew, who were at the end of a long organisational chain of factors, were considered to be the sole reason for the ditching. I really don't see in this report that the crew are getting .

The report is just reinforcing how a well trained crew dealing with a non-normal was able to make a safe landing.
You're conflating a finding to the effect that mistakes were made by an individual with a finding that the individual was entirely to blame for an accident. They are different things.

The PIC of NGA has never denied that he made mistakes. But lots of the other holes in the Swiss cheese were drilled by systemic failures and mistakes made by other people, which circumstances increased substantially the scope for the PIC to make mistakes.
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Old 21st Sep 2017, 02:34
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Look at the post in context LB. Centaurus et al are saying that reports should blame the pilot for accidents where the pilot is obviously to blame. By citing NGA I am merely pointing out that is not an appropriate conclusion for any report as there are usually other factors involved.
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Old 21st Sep 2017, 17:04
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Coincidentally I am currently on a course with a (foreign) pilot turned investigator who has worked on several high profile accidents that are well known to just about any pilot on the planet.

In discussion it would seem that the good and the bad human factors are to be integral to any report. Rereading this report tonight, it isn't the inclusion of the acknowledgement of the following of SOPs that now is of concern to me. It's the fact that the report has been released without any factual investigative information of the root cause of the event.
however the examination was not completed in time for the release of this report.
At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.
The crew's following of SOPs would normally have been drowned out in the investigation of the engine and other factors that actually caused the event. i.e. These detailed technical factors caused a situation which (incidentally) was well handled. The primary safety message would be in the reasons for the engine failure.

Last edited by compressor stall; 21st Sep 2017 at 20:45. Reason: Errant apostrophe.
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Old 21st Sep 2017, 22:12
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Spot on Mr Stall. What we have is in effect an 'interim' report not a 'final' report. Does this mean we are never going to find out what actually caused the incident..?? (And thereby be deprived of the opportunity to prevent it happening again)??


Why was the report released as final, before receiving the engineering report from the engine manufacturer..? Who put a time constraint on it..? Some reports take years to finalise, why was this one 'rushed through'..?

Last edited by IFEZ; 21st Sep 2017 at 22:19. Reason: Added text
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Old 22nd Sep 2017, 00:24
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Job well done by the crew. No matter how much training you have, the event is still thankfully rare. As such, minor imperfections in procedure and execution are always possible. Not suggesting this was the case here.

What the report does not identify (yet) is exactly why this professional crew and their paying passengers were put into this situation in the first place? That might be interesting reading.
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Old 9th Oct 2017, 22:27
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Hear that...

Crickets chirping at the ATSB.
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Old 9th Oct 2017, 22:58
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Originally Posted by KRUSTY 34 View Post
Hear that...

Crickets chirping at the ATSB.

An initial engineering examination found that the number four bearing failed. The bearing failure allowed the high pressure compressor to move off-centreline within the engine. This caused further damage and led to complete failure of the engine.
The damage to the failed bearing was consistent with overheating due to a lack of lubrication. At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.


What more would you need to know mate, that would help you in a similar incident?
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Old 10th Oct 2017, 03:32
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WAG: Finding out the cause of the bearing failure might lead to changes to the pre-flight inspection items, with a view to spotting signs of a potential failure before taking to the skies.

But of course, we don’t know that, do we. Which is kinda the point...
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Old 10th Oct 2017, 03:56
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What a load of cobblers. RPT turboprops have an engineering department that monitor engine trends and oil consumption etc. The pilot does an external inspection and looks for something obviously wrong like a great big puddle of oil underneath the wing or covering the cowl. There is no way a pilot is going to be able to detect anything amiss within the internals of a gas turbine engine.
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Old 10th Oct 2017, 04:45
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Your level of certainty is unusual for someone of your experience and maturity.

I used the word “might”.

You may well be correct, but it seems to me that it would be useful to have that confirmed. However, I now realise that there is no benefit in the ATSB investigating the cause of the failure of an engine on an RPT aircraft unless the outcome would be the discovery of information that would assist pilots dealing with the same failure in flight.
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