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VH-PGW ATSB report

Old 30th Nov 2012, 21:54
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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, 23:12
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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, 23:46
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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, 14:24
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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 -

Last edited by Kharon; 2nd Dec 2012 at 14:25.
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Old 2nd Dec 2012, 19:52
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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 21:44.
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Old 2nd Dec 2012, 21:42
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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, 01:51
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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 02:13. 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, 09:10
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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, 05:00
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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, 14:17
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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 20th Dec 2012, 00:09
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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 06:24.
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Old 20th Dec 2012, 09:18
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131 weeks to write 56 pages.
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Old 20th Dec 2012, 09:38
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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, 13:00
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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.....Bullshit?

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, 02:02
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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, 02:48
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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, 05:32
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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 05:34.
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Old 21st Dec 2012, 06:14
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I will be interested to see what the CASA puts out in regard to the recommended additional OEI guidance material for engine handling.

The final report is,.. well a report, thorough in some areas wanting in others, no doubt the condition of the wreckage made it very difficult.

But the thoroughness seems focused on audit outcomes and C&T processes, relevant yes, but I really wanted to learn and understand more about the mechanical issues at play. Particularly in light of the history of so many in flight engine issues recorded in the last 4 years, including surging.

Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.

This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.

I cannot help but feel that the aircraft themselves should be subject to some form of compliance process other than just a CAO statement that it must achieve 1% gradient to 5000’. The pilots get grilled over and over again on performance, but what about the aircrafts performance.

Perhaps a phase in of a structured ongoing audit process on commercial low performance twins where they physically demonstrate the ability to achieve book figures. Those that fall short have a MTOW penalty imposed and an amended MTOW inserted into the AFM. Perhaps a two tier requirement non pax and pax services.

If I were a pax on board I would like to know that the young hour building pilot up front of a low performance twin had at least an aircraft that will afford him a modicum of performance on one.
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Old 21st Dec 2012, 10:01
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Obid,

Funny you should say this.
This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.
Well I was wondering if I should post the private correspondence I had over night with the very folk you mention. But seeing you make mention here goes, and to be fair I will post my email to the guys last night after I read the report.

Is this another ATSB report like the Whyalla report?

OK, not a bunch of fare paying pax, but a flight nurse, and an under trained pilot are dead.

Initial problem a “surging prop”

ATSB accept Lycomings response being surging from a fuel distribution problem.

Cause of the engine surging
The engine manufacturer advised that the surging identified by the spectral analysis of radio transmissions during the accident flight was ‘consistent with uneven fuel distribution to the cylinders’. The propeller manufacturer advised that it had ‘yet to find a causal factor in surging that was clearly identified as being from the propeller or governor, especially for a report of a large RPM excursion’.

I am perplexed at how this could be, in the climb with a TC engine surely full rich, the partial plugging of an injector would mean no noticeable power surging (if EMS equipped a rising EGT, TIT, and CHT on the affected cylinders) and not sufficient power loss that RPM variations occurred. If the injectors to one or more cylinders were such that they went excessively LOP and or beyond operational flows, it would have vibrated liked paint can mixer.

I find that hard to believe. Maybe I have a lot to learn.

In this case the PIC handled the whole event poorly, very poor on a number of fronts, and should not have shut it down completely and not descended at all until overhead YSBK. That aside….have the ATSB cocked this up like MZK?

Another good case for charter ops to have a fully functioning EMS and pilots educated to use and understand it.
And here is John Deakins reply, and I must say he has a few very interesting observations about what to do in such an emergency. If only I could learn half of what he has forgotten.
Your analysis is "spot on."

CASA (typo should be ATSB)discounts the effect of the landing gear warning horn (one throttle back, gear not down). From personal experience, I can tell you that can have a MAJOR effect on the human brain, and if loud enough, the noise alone can be utterly incapacitating. And I do mean incapacitating. I cannot help wondering if he'd just advanced the throttle on the feathered engine to get rid of the horn, the whole thing might have been avoided.

There's no mention at all of any ACTUAL shutdowns performed during training or proficiency checks, and a passing reference to the Chief Pilot not being an instructor, and therefore not authorized to conduct such training. The young pilot may not have been aware of what that horn was, or how to get rid of it.

Of course, there was apparently no reason to shut the engine down in the first place for the minor surging alone.

The surging sounds more like a problem with the prop governor or the flow of oil to/from the prop. Lycoming was willing to blame it on "something, anything else" to avoid liability.

They said that not having the correct bank angle probably would cost 20 to 30 feet per minute difference. I'd dispute that strongly, this alone might have had 200 to 500 fpm difference. The manual also suggests 5 degrees as optimum, which is not correct. That's a certification allowance for CONTROL at Vmc.

The whole report strikes me as self-serving for CASA. They have set forth massive requirements for Airmen of all levels, and specified paperwork and forms to be completed to show compliance. Many "Manuals", and other documents, most requiring some repetitive action within close time frames. They go into loving detail for all this, for 68 pages. It goes on and on, and it means nothing, distracting from the "real mission," which is to get there, safely.

Disgusting.

Best...
John Deakin
Advanced Pilot Seminars
So along with that one and a few others, who likewise are struggling to see what value there was in this report, as it was not helpful in preventing further crashes, it was more like a police report to a coroner, which makes me think, whose job are they doing here?

A pilot and a flight nurse lost their lives here...surely they deserve better than this???

There was this comment from from Walter Atkinson, John Deakins associate at APS, who understands my position on all commercial ops having an EMS and pilots specifically trained how to understand what they display and not just stare and blinking numbers and bars.
The presence of an engine monitor would have confirmed this and given the pilot useful info about a confusing situation. When are the Aussies gonna figure this EMS issue out?

Seems they share the same frustration.

‘consistent with uneven fuel distribution to the cylinders’.

Poor fuel distribution my arse, supply maybe If the wreckage was that bad, that they could at best come up with that conclusion, they should not have been making any. Lycoming I think the prop people are the only sensible ones in this bit.

Rant over for now....not happy Jaba is going home from the office to cool down. Merry Christmas Y'all.
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Old 22nd Dec 2012, 01:44
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I have printed the report but not yet read it. On first glance, I suspect that the ATSB has side stepped the more difficult issues that might have delivered some lessons.

Top in my mind, is that I can't imagine a pilot who has been dealing with an issue for several minutes and has a descent rate that knows is a problem is not going to push the throttle forward at some point. You might start out trying to be nice to the engines, but at some point I struggle to believe that desperation won't kick in and you'll push everything forward. I'm expecting to see some gaping gaps in logic from the ATSB here.

I disagree with the EMS bit. It wouldn't have changed a thing. The experience of the engine surging is going to over-ride what any instrument says. Either you can deal with the engine misbehaving to gain whatever residual power it will produce or you wont. EGT's can't help assess that.

We tend to think of aircraft fuel injection as more complex than it is. It is what the car racing guys call "piss & dribble". The injector is a brass fitting with a hole in it. It continuously sprays fuel into the inlet manifold at the back of the inlet valve. I'm going to read the ATSB analysis of this with interest.
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