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.

"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".

Thank God for that.

Where do you get this rubbish from Bloggs?

CASA do not employ any approach designers.

you don't have any designers, do you CapnBloggs?
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.

the interim factual report doesn't mention the FAF as an issue.
have you read the final report already, and if so, tell all?

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

Windup chaps.

My point about Foxtrot stands. Thanks Gaunty.

Bloggs,

Do you understand why Instrument Approaches have Final Approach Fixes?

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 :suspect:

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
:*

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.:=

Oh for the days when the regulator employed Airways Surveyors and actually validated approaches in DCA aircraft.

I thought the passengers and flight were of a different airline, how could ATSB get this so wrong?

Yes I do. I am not suggesting that the FAF be removed, I am suggesting that the waypoint depicting it be removed.

"I thought the passengers and flight were of a different airline, how could ATSB get this so wrong?"

What are you on about Bob?

Di :uhoh:

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.

WOW - are you in politics? I still don't know what you're on about.

Oh well - perhaps in the fullness of time!

Di. :cool:

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 can only beat the drum lightly. Need help if this is to be exposed. You are on the right track gaunty.

Okey dokey then... first off all. How about unburdening the FOIs around the country from their paperwork load and get them OUT OF THE OFFICE and on the ramp, in the cockpit, in the crewroom etc. In a similar way to the police moving administration duties to unsworn staff to get front sworn officers back at the front line. Mr Vaile do you not understand that YOUR GOVERNMENT has been reducing staff numbers in all the wrong areas and loading the operational staff up with admin duties that could be done by a clerk.
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!

Whilst not directly related to the RPT issues here, in the US the "brokering" of charter flights thru sometimes up to three or four parties away from the actual operator of the flight is very much on foot and the subject of new regulations and very much increased regulatory oversight.

The principle though remains the same "is the person or entity from whom you are buying your air transport services the person or entity who holds the actual Certificate and in direct control of the flight you have bought.

It is a growing problem in OZ charter with some "apparently" large and impressive multi aircraft organisations "booking" large amounts of work and often taking large fees, being no more substantial than a well designed website and having as much "control" over the conduct of the flight as Mickey Mouse. :(

It's about the name of the Airline on the ticket, not any subcontract deal with Air Antarctica or whoever may be providing aircraft, meals, burgers fries and crew. Otherwise why have public liability insurance? Why have terms and conditions written on the back of the ticket? Why have an office when a PO box would do? and why have an AOC at all?

The airline's name is incorrect from my knowledge of events.

Sky News: "The manager responsible for setting those standards was relieved of his position and has since left CASA during the investigation……”

What Bob Murphie is trying to say is that the aircraft carried Aerotropics titles and the passengers purchased Aerotropics tickets on a scheduled air service which was advertised on Aerotropics web site.

The aircraft was registered to Transair and obviously operated on Transair AOC.

Thank you, now is anyone game enough to search the relevant websites to see if there is a political connection?

Who "owned" (controlled), the route?

The Bamaga to Cairns RPT service is identified as an RPT service on AOC N536421-29 issued to Lip-Air Pty Ltd (ABN 068 117 537, ARN 536421) trading as Aero-Tropics.

I have no idea whether the Bamaga to Cairns service was identified as an RPT service on Transair's AOC.

Don't know how they do (did) things in the Brisbane office of CASA, but our FOI is a real Rotweiler, as he should be.

No matter how much we bitch and moan about surveilance, the fact remains that the responsibility for the innocent lives that we carry are well,.... everybody's responsibility, and certainly not least of all the regulator.

I said it on this forum when the interim report was released, why didn't Brisbane office shut these clowns down years ago? It's not like the evidence wasn't there. Some of the responses were puzzleing to say the least. Some armchair laywers suggested all sorts of nonsense as to why CASA was unable to act...! B.S.

Well duck for cover boys, because If there is any justice in this world, a huge shake-up is coming.

Mind you I saw this 14 years ago, It involved a name change and a sacrificial head on a platter. With a bit of luck we may see some more substance this time around.

I agree 100% with the sentiment that the public should know what they are REALLY buying.
Who is REALLY operating between Gove and Darwin when you book through the qf website, or between Brisbane and POM when you book Airlines PNG, or between Cairns and Singapore when you think you're flying Jetstar. Then there is the other issue of foreign cabin crew caring for unaware pax on long haul sectors for qf also...
Outsourcing has and will continue to occur as airlines try to rationalise costs.
I have no answers, but the public should know WHAT they are buying, especially if people spend money based on assumed safety or levels of service.
Forgetabowdit
BTW, in 1990, I bought a Holden Nova, only to find it had a toyota engine in it. When it blew up, who should have fixed it... I wanted a Holden after all.

Quote Bloogs: "Yes I do. I am not suggesting that the FAF be removed, I am suggesting that the waypoint depicting it be removed."

Bloggs,

I don't think you do Bloggs. Tell us here on PPRUNE what you think the FAF is for Bloggs.

BUT.

There will be some other qualified BLOGGS that will want something else.

You are just a pilot Bloggs. ie disposable taxi driver.

Let the experts keep you safe by following their instructions.

The RNAV(GNSS) approach methodology works, for those that are trained and maintain currency.

Its just the way that pilots interpret the plate, way outside the bounds of reality or the training that they have received, that causes the fare paying public to get incinerated.

"Oh my gosh, lets dive through that hole and get in and be the hero by busting the stupid procedure."

"I think I can, I think I can."

"That blonde in Row 3 will thank me for getting in on time and buy me a drink...she might even invite me back to her place."

"I think I can, I think I can."

LISTEN to your instructors, read and UNDERSTAND the GPS operations manual, do not deviate from the recommended procedures and you will not hit the hill 1000ft, 500ft or 250ft below the altitude you are supposed to be at.

If you are not rated to conduct RNAV approaches, don't do them.

If you think they are not safe enough to get you home to your kids, then don't do them.

If you don't get into the airport because you won't fly an RNAV approach and you spend the bosses money going to a divert, then tell your boss that you don't like having a FAF waypoint and won't do these approaches.

Have fun driving a taxi when the boss tells you not to bother turning up on Monday.

We all have to start out as a Bloggs so just be a good Bloggs and follow the instructions and you might grow up to be the pilot of a real aircraft one day.

IMO the branding issue is just a bit of a side issue.

In this case aerotropics was purely a piston engine operation, whereas Transair was predominately a turbine operation.

Therefore, Transair had the experience and checks and balances in place for a turbine > 57000kg operation already in place, whereas Aeroptropics would/did not have.

As to knowing who you really are flying with, well that’s fine and beaut but the reality is that when you buy a ticket for travel on any airline you should expect the same level of safety on brand X as brand Y as brand Z.

In other words it really shouldn’t matter who provides the service as the Regulator should have ensured the premise of equal safety.

Bob Murphie, Gaunty and others,

Thanks for the clarification regarding the "branding issue" I couldn't understand Bob's concerns so subtlety put initially. The roles of Transair and Aerotropics seemed (seem) clear enough to me from the report.

Anyway, I agree with Jet and Ejector and others that this is all a bit of a diversion. So what if passengers thought they were on an aircraft operated by Aerotropics when it was actually Transair? How many of them would not have boarded the flight had they known? I'm sure some of you Ppruners might have had second thoughts. But the average Jo Blow flying on RPT services around Australia would not have a clue. (With all due respect)

They rely on CASA to ensure the flight is safe - regardless of who operates it or from whom they purchased their ticket. Don't they?

Di :confused:

Lockhart River crash pilot may still be flying

From correspondents in Papua New Guinea
April 04, 2007 04:44pm

AUSTRALIA'S aviation safety watchdog will give Papua New Guinea its damning report into the fatal Transair plane crash because it fears the former airline's principal is now flying in PNG.
Fifteen people died when a TransAir-operated Fairchild Metroliner plane, en route from Cairns to Bamaga, crashed into a mountain near Lockhart River in far north Queensland in May 2005.
Earlier this year, it was revealed Transair principal Les Wright was living in PNG, and possibly still working as a pilot.
Today, Australian Transport Safety Bureau executive director Kym Bills confirmed PNG's Air Safety Investigation Bureau (ASIB) would be given the report.
"We will make sure PNG has a copy of this report," Mr Bills said.
The first stage of another investigation, a coronial inquiry, is due to begin in Brisbane tomorrow.
Barry Auwi, chief of the ASIB was unavailable for comment today.


From News.com. Slightly misleading headline - but interesting article anyway.

Di :O

Di

I have no idea of exactly what Bob is talking about, but I think he is suggesting there is some underhanded connection with the route flown and by whom it was flown.....some political link perhaps.

Just an observation from afar, but it would certainly be interesting reading if somone has some facts and is prepared to share them.

J

Lockhart River crash pilot may still be flying
-----------------------------------------------------------------
I thought that the PIC of the Lockhart River crash perished with all the others. Is this just another example of the poor standard of journalism?

Erm, did I read correctly that this approach was approved even though it triggered the GPWS action even if flown correctly?

Dog

Ejector Pump

Quite so, but not the point. If you take that argument to its logical conclusion then we don't need more than one universal AOC upon which everyone can operate.

CASA can only set a minimum acceptable standard.

GORN ROUND

You should be careful whom you patronise around here. I note you are a new PRRuNer altho it is possible you have another more "experienced" nic. Either way the beauty of this forum is that your argument rises and falls on the quality of its presentation and how it is argues. So far IMHO you are not doing too well.

Not sure where you are coming from but we have had a very lengthy discussion here on the subject of FAF, GPS and Manufacturers interpretation.

You will find it in the search function.

GORN ROUND,

Looking at your last post and your age - are you dyslexic?

Di :O

Don't throw stones at me boys. :ouch:

I'll have to run off and tell my mum.

Gorn,
It doesn't matter two hoots what I think the FAF is for. Again, my (and other professional pilots) beef is with the GPS NPA waypoint that depicts the FAF.

Gaunty,
I am not saying the fare paying public should not know who they are flying with; what I am saying is that I believe that a standard set by CASA should ensure that a crash such as this shouldn’t happen, regardless of who the actual operator of the aircraft is.
Cross charter, code share, etc are a fact of life and a CASA accredited AOC should be sufficient justification to consider the airline safe. If not the AOC should be removed and that can only be achieved by constant diligence by the authority.
As to” brokering”, this crash doesn’t really relate to “brokering” in the real sense BUT even if it did I can’t see that it should have any bearing. Brokers are only dealing with aviation companies that CASA has authorised to operate and thus are deemed to be of a suitable standard.
As to “one universal AOC” as being the logical conclusion, I have to disagree; each operator still exists as an individual identity no matter how they are contracted.
I note your term “minimum acceptable standard” but that term should not be seen as being just above “just above dangerous,” as I am assured that the two standards are quite some distance apart.

DA,
Foxtrot has been widely discussed at length here on Prune but in a nutshell, it unnecessarily complicates what should be, as an evolution of the NDB then VOR NPA and utilising the latest technology, very very simple. In my experience, it is not. This view is not held universally, obviously, and there are some quite vociferous defenders of it.

However, in my (and as I have said quite a few others) opinion, Foxtrot makes the approach more complicated because you never know, at a glance, where you are WRT the runway. You only know where you are WRT to the next waypoint. Right at the gravy stroke, probably going thru the MSA for the first time, gear going down, flap going out, scans & checklists to be done, radio calls to be made, perhaps altitude restrictions on the way down, we have a waypoint/distance reference change. Looking at the graph that was presented on the CASA website, it would not surprise me that the Metro crew thought they were past Foxtrot when in fact they weren't. Why on earth would a crew with a bunch of pax on board conduct such a "scary" approach? There are probably lots of factors involved, and IMO the unnecessary complexity of the approach itself was one of those factors.

I reject the assertion that GPS NPAs are easier than say a VOR/DME. Why? Because on a VOR/DME you have a distance reference from the top of descent/start of the approach all the way to the runway plus or minus a bit. this makes life so much easier. If it wasn't for the fact that most of our VORs are slightly offset and GPS NPAs leave you on the centreline at the MDA, I'd be doing VORs in preference.

Situational Awareness is not enhanced having the FAF as a waypoint. When all is going swimmingly, all will easily cope with a GPS NPA. Unfortunately, that is not always the case, and it is then that the "system" needs to be a simple as possible.

Perhaps in the very early days Foxtrot was needed by the technology (an argument I do not accept and never will). That is now not the case and it should be removed, providing us with only one distance reference TO THE THRESHOLD on the extended centreline from the MSA. If you don't have a VDI, then the chart would provide a simple, profile from the MSA all the way down to the MDA.

I have no doubt that those guys were brought undone in part by the complexity of the GPS NPA they were flying.

PS: I started reading the ATSB report after making the above comments.