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VH-PGW ATSB report

Old 30th Nov 2012, 20:54
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VH-PGW ATSB report

Expected release Q1 0f 2012

Update to Q2 of 2012

Almost 2013.

Any ideas?
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Old 30th Nov 2012, 22:12
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I think the delay is scandalous. I think it reveals that the ATSB has no real interest in improving safety. I think it is a demonstration of a number of areas of the public service where (for whatever reason) the government departments are simply not doing what we are paying them to do.

I made a post asking about the delay in the report of the Angel Flight Cherokee near Horsham (15 months and counting). In response someone suggested that the reason was the beating the ATSB are getting in a senate committee over the Pel-Air report.

If you scroll there the released reports of the last 3 or 6 months, I think 3 things are apparent:
1. Reports seem to be released in groups only once or twice a month, usually most reports come out in the last days of the month. I wonder if they sit on someone's desk for approval?
2. The list of incomplete or pending reports is growing. They are not keeping up with the workload.
3. Most reports that are being released are minor in nature. There doesn't seem to be any reports of substance that might contain lessons that have been released in ages - maybe even since Norfolk Island.

I don't know what happened to the credo of "frank and fearless advice".
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Old 30th Nov 2012, 22:46
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Agreed Akro...sadly!

The Cherokee crash, as tragic as it is, is mostly a repeat of the same things for the umteenth time. Just like the dragon. I am trying to be realistic here. From a few early details, an initial study of what happened, I think we can group all these types of accidents, regardless of the loss of life, and say...nothing new here.

The PGW and for that matter the the Norfolk ditching are somewhat more worthy of spending time and money on. FFS they did not and still have not pulled the recorders.

Benalla and Lockhart are reports I am starting to wonder about given some things were not thoroughly explored.

Without harping on, if you accept the botching up of the Whyalla report, which will forever be a huge embarrassment to the bureau, as being a litmus test, there does indeed raise doubt over the rest of the reports.

It seems to me that the mundane ones get churned through easily, the kinds of things like airliners getting too close, plenty of easy to diagnose data available, but for anything else....where some really clever stuff is needed, it is a coin toss.

Don't for one minute assume I think I am in any way an accident investigator of worth, but I do wonder if the few really good ones we have are always on the ball due to other pressures.

And it does seem ironic that the priorities of what is looked at closely and what is not, what is actually reported in detail, are becoming less than consistent. Like as if there are greater forces at play. Agendas to meet.

Maybe this is less of a mystery to some, but it is not looking like a logical well executed service to industry and the public. Budgets are tight, sure, but where the money is spent is what puzzles me most.
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Old 2nd Dec 2012, 13:24
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So close on the heels of the aftermath of the on going, slightly embarassing Pel Air enquiry; I wonder if they dare? Canley Vale closely followed by Hempel. Woo hoo – bring on the New Year, I've got my Christmas present.

Fee-fi-fo-fum,
I smell the blood of an Englishman,
Be he live, or be he dead
I'll grind his bones to make my bread.

Amend to suit -

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Old 2nd Dec 2012, 18:52
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Why do you need a report?

Following on from the Pel AIr/ Norflk Island performance:

1. The ATSB has no safety recommendations.

2. CASA says its all the pilots fault.

Case closed.

Last edited by Sunfish; 2nd Dec 2012 at 20:44.
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Old 2nd Dec 2012, 20:42
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Sunfish,
You might have missed #3 that CASA inspectors have had a number of longstanding unspecified concerns about the procedures and safety of the operator that were not communicated to the operator, but will be leaked to the press.
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Old 3rd Dec 2012, 00:51
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Tautology, Beakerology and incompetence

Old Akro,
If you scroll there the released reports of the last 3 or 6 months, I think 3 things are apparent:
1.
Reports seem to be released in groups only once or twice a month, usually most reports come out in the last days of the month. I wonder if they sit on someone's desk for approval?
Corect. Usually at the end of the month to 'prove' that work has and is being carried out at the ATSB. It's an old smoke n mirror trick and is meant to make the taxpayer feel warm and fluffy, that his money is being robustly and well spent. And yes, reports often have to be given the green light first by the Minister, the Beaker, and a few other filtering levels and even discussed with the operator prior to going public. A final investigation report for instance could take 12 months to complete, but it could then sit in the sweaty palms of some postulating trough dwellers for another 12 months before getting the final ok. You know, the lawyers have to disect each word and ensure no that government entity is included in any of the blame. Can't have government or the Minister looking bad can we? It wasn't as bad as this 4 years ago.
Team Beaker = FAIL

2. The list of incomplete or pending reports is growing. They are not keeping up with the workload.
Nothing new in that statement brother. A growing aviation environment, coupled with the fact that our current one is slipping to a standard that even raises ICAO's and FAA's eyebrows means the fronline Investigators work is growing due to increasing incidents and accidents. Of course funding is growing, but only enough to satisfy management's hunger for huge salaries, bonuses and trips abroad, and for filling back offices with more mid-level management. The frontline always misses out. It wasn't as bad as this 4 years ago.
Team Beaker = FAIL

3. Most reports that are being released are minor in nature. There doesn't seem to be any reports of substance that might contain lessons that have been released in ages - maybe even since Norfolk Island.
Another bureaucratic ploy - spin, smoke n mirrors and polishing the turd 101.
Releasing a bunch of low level investigations puffs up the numbers on paper and makes it look like they are keeping up with the workload and managing sufficiently. But it is a carefully scripted stage show. The true facts always come out, and they do when you look at stats on how long it takes to produce a high level report, how many of those reports make it to public within a reasonable time frame, and the quality and accuracy of the report. The decline commenced 4 years ago, blind Freddy can see that. Again, protecting governments, gravy trains and one's own spotty botty takes precedence over real facts, lessons learned and the truth.
Team Beaker = FAIL

Aagh Jaba san,
Benalla and Lockhart are reports I am starting to wonder about given some things were not thoroughly explored.
Praise the Lord my scholared non-tautological friend! You have seen the light!You have smelt the pooh! AMEN!!
Seriously, correct Jaba. If you take a look at those previous investigation reports (prior to Team Beaker) you will see, I guess for better words, some interesting reporting. However, if you look primarily at Lockhart through the eyes of government and the Regulator you will see that some of the findings and reporting match perfectly with their devious, fact spinning, deflecting methodology.
Don't let facts stand in the way of a good story type of mischief. CASA was scrutinized over Lockhart, and concerns were raised and pointed in their direction regarding approach plates and 'inspector oversight' by way of surveillance and audit, but of course they escaped, 'scott-free', as usual. Keeping in mind the 'James Reason' Tasmanian cheese model you will no doubt recall that there is virtually always a number of causal factors. And that is precisely what occurred at Locakhart.
And one of the clever ploys they adopted as part of the post accident ruse? Adopting SMS. Now SMS in itself is an interestig discussuion point which doesn't belong here, but SMS, when used incorrectly, is a great tool for ensuring the government remains at arms length from any blame when something goes tits up! They can say - Safety is your responsibility. It is all your fault.

Last edited by gobbledock; 3rd Dec 2012 at 01:13. Reason: Got stuck crossing the River Acheron. Seems the rainy season has commenced, maybe I shall try Styx instead!
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Old 3rd Dec 2012, 08:10
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The "safety management system" I remember from my Exxon/esso days was designed to:

(a) ensure any troublemakers with a genuin concern for safety were identified and removed.

(b) ensure any accident or incident could be successfully blamed on a low level employee/victim.

(c) ensure that the company and senior management escaped any responsibility via plausible deniability, usually proven by the existence of lovely manuals and an internal reporting scheme.

The actual intent of the scheme was the exact reverse of the published purpose to whit forcing employees to cut corners to save money and ensuring they wore the blame for the resulting incidents and accidents.
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Old 14th Dec 2012, 02:27
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PGW and Canley Vale

The initial report from atsb says:

The investigation is continuing and will include:

1. An ongoing examination of operational issues including pilot training and checking

2. Continued analysis of recorded radar data and voice transmissions

3. An ongoing human factors review.

It is anticipated that the final investigation report will be released to the public in the first quarter of calendar year 2012.
Item 3 did not occur with the Norfolk Island "investigation" by atsb, it will be interesting to see if it has happened with PGW.

and if not, WHY NOT
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Old 14th Dec 2012, 03:36
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atsb and attitude to accidents

Since 15th June 2010, there are 98 un-completed investigations. The oldest appears to be PGW and a general report on R22 belt systems from 2009.

The completed column over the same period shows around 215 reports "completed", of all incidents, so over that period, only 2/3 have a "completed" sticker and we know the extent of some of these such as the Westwind ditching at Norfolk and the problems inherent in this with the Senate inquiry.

Last edited by Up-into-the-air; 14th Dec 2012 at 03:41. Reason: More info and "can't spell"
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Old 14th Dec 2012, 04:00
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Its a bit worse than it looks because many of the 215 "completed" reports are small investigations or records of assisting other bodies.
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Old 14th Dec 2012, 04:15
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atsb and attitude to accidents

As I said "completed" and if you take out all the "easy" reports, atsb is not doing much at all.

The attitude in the Norfolk one, where there appears to a be too cosy a relationship with casa strikes me as a real problem for long term air safety.

Maybe the FAA was right in their assessment some years ago, with the un-answered compliance notices. I can repost the link if you are un-aware of this.
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Old 14th Dec 2012, 13:17
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Next Thursday, great timing

This thread will be 16 pages long by the time they get back to fix up all the errors we find here on pprune.

My guess is the company, the senior management and many of the crew will be ducking and weaving and hoping the ATSB don't do a good job. Sorry, ex company and management will be.

Just a long shot. But if I am anywhere near accurate in my suspicions the CASA will be likewise hoping the ATSB do a poor job, otherwise it will be Lockhart, Archerfield/Straddie, Norfolk, Botany, Bankstown.......... Surely it is just coincidence.

Stop calling me Shirley

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Old 19th Dec 2012, 23:09
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ATSB Final Report has issued

Have to feel for the pilot a bit. Took the "normal" descent profile but when he found he had to hold his altitude he couldn't do it. Very sad.

Last edited by bentleg; 20th Dec 2012 at 05:24.
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Old 20th Dec 2012, 08:18
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131 weeks to write 56 pages.
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Old 20th Dec 2012, 08:38
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The PA31 is one of the worst single engine performers in the light twin category.

1" of manifold pressure, couple of degrees of bank, position of dead enging cowl flap, even the condition of the paint and props all contribute to the difference between climb, level flight and descent.

Any endorsement process that didn't ram this into the candidate to the point where they had a healthy fear of the machine certainly shouldn't qualify as "not a bad endorsement".

Nothing alerts a pilot more to the limitations of this aircraft OEI, than the VSI whilst holding Vyse and opening the cowl flap.

I feel this pilot may have slipped through the cracks. Cracks that CASA let grow for far too long.

I also feel that this pilot, the organisation he worked for and the culture of GA, probably all saw the endorsement process as a box ticking exercise in order to get a job, not a process whereby you learn things that may one day save your life. If only he'd been trained properly, by a proper aviator who saw the bigger picture and took the time to prepare this young man to operate this aircraft safely. Unfortunately he's now another statistic; another young pilot who didn't make it through GA.

Light twin drivers take note.
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Old 20th Dec 2012, 12:00
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strim

It would seem most of the nails have been hit on the head. And CASA will once again have a lot to answer for.

The operator, the CP, the C&T folk....everybody involved in this outfit will no doubt be ducking for cover. Remember the court cases when they were shut down.

This will not end here. I can see Justice Seeker getting wound up big time.

This poor pilot made all sorts of poor decisions, we have done them over in previous posts. Not much new has come out here. The system that allowed this to happen is another matter.

Why is it CASA will chase a PVT operator almost to jail over a Beech rudder pedal inspection two days over due, yet this kind of outfit gets away with years of non conformance, plus a Metro and Mojave crash......and numerous other "incidents of serious natures" and nothing happens.

They should have been working closely to achieve an outcome, not doing an audit and saying fix this, and not seeing it through.

And not that it changes much, but does anyone else find the ATSB's summation of the engine anomaly a little bit.....like.....errr.....Bull****?

About time compulsory EMS fitment and PROPER education in what they are telling you. Not the crap printed in CPL texts and CASA exams
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Old 21st Dec 2012, 01:02
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Angry Jabba

G'day,
From the mid eighties, and for years and years "the Operator" concerned tried to have a formalised Check and Training org put into place. The CASA continually replied that because it (C&T) for under 5700 kg wasn't in the regs, it would therefore not be approved by CASA, and if the Operator were to include that in their COM, well the COM would not be recognised. On that matter, the operator wrote to the then Minister, asking for an explanation as to why they (the Operator) were being denied the opportunity to improve safety.
As I understand, the Operator still awaits a reply.
In reference to "working closely", you obviously are not "Bankstownised".
At an Audit conducted by Casa on the Operator, at the opening meeting, the then CASA Area Manager stated, and I quote :-
"We are not here to help you, assist you, or advise you. We are here to audit you and prosecute you. You had better watch out".
To say that there was a stunned silence at the end of that diatribe would be an understatement.
The company went very close, at that time, to ask the CASA team to leave the premises. In fact, subsequently, that team leader was declared "persona non grata" on those premises.
The non conformance issues you mention were very real, yet it seems that the main players in the saga have almost escaped attention.
Why have these persons been let off the hook?
And yes, I agree with you, the ATSB report leaves a lot to be desired.
Why was this report written in the way it has been?
Why were several warnings by senior pilots to both CASA and the company ignored?
There should be more to this report.
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Old 21st Dec 2012, 01:48
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kim,

you are correct, I am not in the slight bit interested in going to Bankstown, although I should have flown there and back yesterday instead of going via an airline, as the YBBN holding is beyond the joke...but back to topic.

As for all the goings on with the operator have no axe to grind, but from the previous threads, the court transcripts of them being shut down there seems to me to be two sides to the story and both are bad.

CASA and whoever the persons concerned are I have no idea, but clearly they were not doing their job, despite what they were actually doing. The operator it seems from what I can tell was also not doing their job.

It seems to me that the ATSB again have not done a very good job, and it seems like all three organisations should be shut down. So far only one has!

I am really disappointed, actually completely pissed off at the ATSB report. Sure focus on all the lack of training and all the things done poorly. I would take a lot of convincing that the operator was doing a good job. There is no way all the bad stuff that happened to them over the last several years was just "unlucky". The message I get is there was a lot of sub standard stuff going on and many of the young pilots would not have known any better.

CASA clearly has not been doing a "GOOD" job. They were obviously doing a job. But when you measure QUALITY by assessing the OUTCOME.... FAIL!!!
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Old 21st Dec 2012, 04:32
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My sentiments exactly...

WRT ATSB report... I am a bit incredulous. Faster than single engine climb speed and you cannot maintain altitude??? Is this in the context that any faster than Vyse is a waste of limited available power...meaning you are going downhill?

Last edited by OZBUSDRIVER; 21st Dec 2012 at 04:34.
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