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ATSB reports

Old 7th Nov 2013, 21:29
  #21 (permalink)  
 
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Dodgy ATSB final reports

The latest round of ATSB reports are a bit of a joke and don't provide any real information to improve safety. However, this one takes the cake:

Investigation: AO-2013-128 - Collision on the ground involving a Cessna 172R, VH-IMS, at Sunshine Coast Airport, Queensland on 2 August 2013

A Cessna hits a light pole while taxing and it is worthy of the ATSB to investigate? Reading the report, they much have given it to an intern to investigate.

"The pilot learnt a valuable lesson" - what a crock of crap.

In another report about a TCAS RA the outcome is that pilots need to maintain situational awareness - no shite Sherlock. They knew about each other, the SA was there, how about some real recommendations.

Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole?
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Old 7th Nov 2013, 21:39
  #22 (permalink)  
 
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Well, they should submit that report for judging. A possible award for such an industry changing revelation. My congratulations to whomever approved this investigation. Rome burns but they are holding their focus like the steely eyed missile men they are.
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Old 7th Nov 2013, 21:44
  #23 (permalink)  
 
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I'd be very surprised if reports weren't submitted, especially as ATC we notified of the situation (according to my source). But then again, a Q400 tail scrape must be a bigger problem for the ATSB than an in flight fire...
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Old 7th Nov 2013, 22:24
  #24 (permalink)  
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The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.
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Old 8th Nov 2013, 02:01
  #26 (permalink)  
 
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Still waiting for the final report on this one
We all know what that one is going to say. I feel like sometimes they take a long time to release them when the words of the truth are difficult to put on paper.

Although the reasons for the flight path have not yet been determined, the ATSB is concerned about the conduct of visual flight rules (VFR) flights in dark night conditions – that is, conditions with minimal celestial illumination, terrestrial lighting cues or visible horizon. The ATSB is reviewing the regulatory requirements and guidance for the conduct of night VFR flights, and the training and ongoing assessment of pilot skills to conduct such flights. The ATSB is also preparing an ‘Avoidable Accidents’ educational report focussing on night VFR accidents.
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Old 8th Nov 2013, 03:00
  #27 (permalink)  
 
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TWT - 14th November I understand, received a note from the ATSB today
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Old 8th Nov 2013, 05:49
  #28 (permalink)  
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Thanks very much for that walschaert-valve !
I am amongst a lot of people that will be very glad to find out more on that one.
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Old 8th Nov 2013, 19:18
  #29 (permalink)  
 
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FTS #24 –"Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole?
I could completely understand a report like the A 380 incident, or AF taking a couple of years; big, multi discipline, multi jurisdictional investigation. Forensic, engineering, design, operating and future solutions take time and I'm glad they do. That sort of stuff needs to be spot on.

Looking back at coroner recommendations and ATSB reports is a tedious business, but when you do the home work a couple of things stand out. One of the most appalling (IMO) is the lack of educational information passed on to the troops. OK, there has been a fatal, not only do we need to know the what, why and how of the thing; we need to know how to prevent the thing happening again. Take CFIT for example; the FSF and other serious safety bodies have done some great work, produced invaluable material and made it freely available. Will it prevent all CFIT?, of course not; but those who take their responsibilities seriously, will have taken an hour of two, watched the video, read the material and are now aware of the risks.

The light weight, compromised, technically pathetic dribble presently being served up to industry achieves nothing but an increasingly large pile of glossy 'feel good' stuff, which probably convinces the public that ATSB has it all in hand, bit like the adverts on TV. "Buy one of these and all your dreams will come true". Problem is, some mugs do believe it.

The shameful travesty of Pel Air puts the current iteration of the ATSB in the class of snake oil salesmen. I hope they manage to straighten up their game before the whole sorry mess is exposed, yet again, at yet another inquiry into yet another preventable accident. Prevention has always been better, cheaper and more effective than cure. Stuff the budget, man up, do your job and regain the faith and trust of industry.

"Ave, Imperator, morituri te salutant" Suetonius reports that Claudius replied "Aut non" ("or not")......Translation here....:
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Old 8th Nov 2013, 20:42
  #30 (permalink)  
 
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The Beaker years – ‘beyond all sensible reason’ (addendum to “K” #32 )

Glad to see the mods have merged these two threads it kind of sets a background to the demise and hit to the reputation of the once proud aviation safety watchdog, the ATSB/BASI.

The bureau, much like Fort Fumble, has always had its detractors but even the critics would (once upon a time) grudgingly admit that on the whole the ATSB generally get it right and make a worthwhile contribution for the betterment of aviation safety. However IMO in the last 5 years they have seriously lost their way. The evidence of this was very much on display throughout the Senate Inquiry (hence *Recommendation 8). Also, as posters on here are noticing, through the quality of the reports being produced. The mantra now appears to be…politically correct and on budget.

*R8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Note: Beaker attempted to placate the Senators by bringing in the Canucks but Senator Fawcett rather scathingly struck back with this comment in a press release…
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation processes as identified in the Senate report including the Canley Vale accident.”


Some would say this decline of the bureau can be tracked back to the Lockhart River investigation with the subsequent Coroner’s findings through to the Miller review. However IMO, despite all those troubling times, the bureau on the whole could still hold their heads up high till at least the middle part of 2008.

Perhaps to highlight this there were two important report publications put out by the ATSB in 2008-09, one was the decade review; Australian Aviation Safety in Review: 1998 to 2007 and the other (internationally recognised) wasthe worldwide review of commercial jet aircraft runway excursions.

In the foreword of the Aviation Safety Review the former and last Executive Director Kym Bills (rather proudly) had this to say:
It has been an exciting and progressive year for air safety in Australia. The December 2008 release of the National Aviation Policy Green Paper established the future direction of the aviation industry, asserting the Government’s position on air safety in Australia as the number one priority. This includes the establishment of the Australian Transport Safety Bureau (ATSB) as a statutory agency with a Commission structure to enhance its independence. Legislative amendments to the Transport Safety Investigation Act 2003 to give effect to the governance changes have been passed by Parliament and the new Commission will come into place on 1 July 2009.

I am delighted to release the third edition of the ATSB’s Australian Aviation Safety in Review. The format of this edition departs from that of the first two editions to provide a range of new information not previously presented. The report provides an overview of the aviation industry with a focus on safety data derived from aviation occurrences reported to the ATSB. It covers a
10-year period (1998 to 2007) and describes trends and analysis of both aviation incidents and accidents.

The first chapter deals with the structure and size of Australia’s aviation sector, including the number of aircraft registered and numbers of pilots and engineers licensed, and the amount aviation activity in different sectors. The next two chapters delve into measures of aviation safety. Chapter 2 examines the trends across 10 years for the number of fatal accidents, accidents and incidents, and their rate expressed as a proportion of annual flying hours. Chapter 3 takes a closer look at the nature of aviation occurrences (incidents and accidents) in Australia through an analysis of what occurred. Chapter 4 looks at why they occurred. That is, what human actions and technical failures contributed to the occurrences. Aviation occurrence reporting requirements and procedures are described in Chapter 5, and in Chapter 6, the special topic covered is the issue of birdstrikes in airline operations.

The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety.

I commend the report to you.

Kym Bills
Executive Director
Australian Transport Safety Bureau

Note: I wonder on reflection whether KB would have made the same statement today?? And does he feel somewhat betrayed by the turn of events that was to occur since the end of his tenure at the ATSB??
The other report/review is still highly regarded internationally as a reference for jet runway excursions and is incorporated into an ICAO/FSF report on Reducing the Risk Runway Excursions.

As an example of the worth of this excellent proactive report and the knock on safety benefits, lessons learnt etc..etc our fellow Canuck comrades, the TSB Canada, have just released a final report into a Quebec runway excursion by an American Airlines 737: Aviation Investigation Report A10Q0213.

Note: This excellent and very informative report is worth taking the time to read and you will find that in the web portal format is extremely easy to navigate around. You will also observe that the ICAO/FSF is listed as a reference and that the ATSB database on similar B737 incidents is referred to in appendix G.

Extract from Safety Action section of this report:
Safety action taken
American Airlines

In April 2011, as part of its pilots’ recurrent training, human-factors class, American Airlines introduced a simulation and discussion of this Boeing 737 runway excursion. This training is given to company pilots to educate them on the possibility of a runway excursion due to a nosewheel steering problem on landing roll-out after a normal approach and landing.
Safety concern

Despite efforts in analyzing past nose-gear steering, low-slew rate-jam events and carrying out post-event valve examinations, the cause of these uncommanded steering events remains uncertain. The safety review process completed by the manufacturer and based on a quantitative, cycle-based occurrence rate of 1 X 10-7, classified this event as an extremely remote probability, and gave it an acceptable risk level, combined with a major severity level. An occurrence rate of 1 X 10-7 meets the Federal Aviation Regulations (FARs) certification requirements. Additionally, an acceptable level of risk does not require further tracking of the hazard in the Federal Aviation Administration (FAA) Hazard Tracking System. Consequently, other than flight data analysis and valve examination, the manufacturer has not taken further action following the 11 known nose-gear steering rate-jam events that have occurred over the past 21 years.

Rate of occurrence determines whether a manufacturer needs to take safety action. In order to determine the rate of occurrence, there is a need to capture as many events as possible. This capture allows identification of possible safety deficiencies, and aids in the application of risk-mitigation strategies. Since no defences have been put in place to mitigate the risk of a runway excursion following a rate jam, damage to aircraft and injury to aircraft occupants remains a possibility.

The present known low rate of nose-gear steering rate jams may be explained by the fact that, directional control difficulties on take-off or landing would not often result in an excursion and/or damage or injury, and therefore would not be reported. The lack of reporting may also be due, in part, to the fact that operators, flight crew and maintenance personnel have not been made aware of the possibility of rate-jam events, nor have they been provided information on how to recognize, react or troubleshoot. The rate of occurrence would have to show a significant increase to validate corrective action, as safety action is based on FARs certification and in-service fleet following requirements.

Despite technological advancements in recording devices, many Boeing aircraft do not record nosewheel steering system parameters. Boeing models affected include 707/720, 727, 737, 747 (some models), 757, 767, and 777.

The cause of these low-slew, nose-gear steering rate jams over the past 21 years remains uncertain. A lack of recognition and reporting prevents adequate data collection, analysis, and implementation of risk-mitigation strategies if necessary.
The Board is concerned that, in the absence of information as to the cause of uncommanded steering events due to nose-gear steering rate jams, there remains a risk for runway excursions to occur.
The safety action section shows the benefits or flow on affect of compiling worldwide information, including the ATSB review and draws attention to a possible safety issue on B737 aircraft that will now be noted (at least) on the TSB database. It also reinforces the ICAO/FSF initiative to create a Runway Excursion Database.

So the question is can our bureau recover from the Beaker years and return to some of its former glory as a proactive AAI organisation at the forefront of contributing to aviation safety worldwide, or are we to continue with these politically correct, fiscally accountable, dribble of reports that have no substance or relevant safety recommendations attached?? If it is the latter then industry and taxpayers deserve a refund and our once proud safety watchdog should be disbanded! Minister it is your call but please take account of the disturbing findings in the PelAir inquiry and action a government response to the partisan Senators recommendations ASAP…
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Old 8th Nov 2013, 21:37
  #31 (permalink)  
 
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Well done boys.

2008 AART - Recommendation 1: The Minister and CASA commit to achieving completion of the development of the priority Regulatory Parts by submitting all drafting instructions to OLDP by the end of 2008 and full implementation of these Parts by 2011.

2008 Senate - Recommendation 2 The committee recommends, in accordance with the findings of the Hawke Taskforce, that CASA's Regulatory Reform Program be brought to a conclusion as quickly as possible to provide certainty to industry and to ensure CASA and industry are ready to address future safety challenges
.

2011 Senate – Recommendation 4 (2.281) The committee recommends that Civil Aviation Safety Regulation (CASR) Part 61 ensure that all prospective regular public transport (RPT) pilots be required to complete substantial course-based training in multi-crew operations and resource management (non-technical skills) and human factors training prior to, or in reasonable proximity to, initial endorsement training; the committee recommends that the Civil Aviation Safety Authority (CASA) expedite, and assign the highest priority to, the implementation of CASR Part 61.

2011 Senate -Recommendation 7 (2.288) The committee recommends that the Civil Aviation Authority (CASA) expedite, and assign the highest priority to, the implementation of Civil Aviation Safety Regulations (CASR) Part 141 'Flight Training Operators' and Part 142 'Training and Checking Operators'.

2011 Senate -Recommendation 10 (3.146) The committee recommends that the Minister for Infrastructure and Transport provide a report to Parliament every six months outlining the progress of the Civil Aviation Safety Authority's (CASA) regulatory reforms and specifying reform priorities, consultative processes and implementation targets for the following 12-month period.

2013 Senate - Recommendation 13 (6.58) The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.

The ever more pressing need for the regulators to complete the 25 year gestation of the Australian regulations is most clearly apparent in safety recommendations from coroners, ATSB and industry, held in abeyance, dependent on the reformation. Lockhart River occurred in 2005, since then many coroner recommendations have relied on promised reforms to the pertinent regulation. Reformed regulation to minimise as far as legislatively possible, the percentage chances of accident reoccurrence. This has not transpired, despite scores of recommendations related to fatal accidents. Further, there is an almost complete lack of educational information distributed which may, from the lessons learnt, prevent a future occurrence.

"K" – I have persuaded P1 to release the draft notes of one contribution made to a final report being prepared. I regret the 'Venn' report cannot be provided. I am asked to remind all that the document provided is not to be relied on legally, is only a draft of working notes, remains unedited (unaccredited) and is provided solely to promote discussion. It has been parked on Zippyshare, usual caveats. DOWNLOAD NOW button only, click once to avoid the spam etc.

Working draft – Coroner inquiry.

P7. a.k.a. The Old Man (TOM)....

Last edited by PAIN_NET; 8th Nov 2013 at 21:50. Reason: Yes, the usual would be most welcome.
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Old 9th Nov 2013, 11:17
  #32 (permalink)  
 
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No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers
Interesting observation re the vast experience needed nowadays to write a report. I am sure it has changed now in the RAAF but during my time there in another era, accident investigations were over and done with within one month to three months.

Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could.

One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around.
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Old 9th Nov 2013, 19:51
  #33 (permalink)  
 
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"true dat".

C#35 –"One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around."
I'm always surprised that the fundament hasn't given up the uneven battle and collapsed, given the number of escape tunnels dug. The acquisition of 'wriggle room', safe cocoons, legal escape pods: etc. It's an art form now, applauded, rewarded and actively encouraged by the experts above. Circuit breakers of the world united.....
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Old 9th Nov 2013, 22:07
  #34 (permalink)  
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No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.
It takes years of experience to apply a wind vector as a tailwind before & after a 180 deg turn? Or produce different wording for the transcripts of radio calls between the initial, preliminary and final reports?

Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review.

Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports.

This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k.
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Old 10th Nov 2013, 18:26
  #35 (permalink)  
 
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Longish post warning

OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa.
It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).

"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.

The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.

I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.

When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.

It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.
The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..

Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did.

Senator FAWCETT: Does this report make any recommendations for improvements?

Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.

Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.
I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions....

Last edited by Kharon; 10th Nov 2013 at 18:42.
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Old 11th Nov 2013, 02:15
  #36 (permalink)  
 
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For "K" - Klouth contribution to last two Senate Inquiries

In all the 'white noise'...mumbling and stumbling of mi..mi..mi Beaker and the shear arrogance and blatant Sociopath behaviour of the DAS in the AAI inquiry, you kind of forget about the worthy contributions from 3rd parties.

Geoff Klouth in representing AIPA was one of these and he gave a rather unique perspective as he is an operational Captain and a former Senior Transport Investigator with the ATSB.

However I think GK's contribution in a 'private' capacity at the pilot training inquiry was more noteworthy. Shame his contribution, along with many others, was white washed by Albo's Great White Elephant Paper (the GWEP)..

So for Kharon's benefit, & anyone who is interested, here are some links to highlight GK's contribution to the last 2 inquiries...


Rural and Regional Affairs and Transport References Committee - 22/10/2012 - Aviation accident investigations – AIPA Hansard

RURAL AFFAIRS AND TRANSPORT REFERENCES COMMITTEE - 15/02/2011 - Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 – Geoff Klouth Hansard


Mr Geoff Klouth (PDF 51KB)
Supplementary Submission(PDF 43KB)

Pilot training and airline safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 – Inquiry page.
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Old 11th Nov 2013, 03:29
  #37 (permalink)  
 
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That is about an hours work, really sad that the ATSB is reduced to this level of reporting.
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Old 11th Nov 2013, 03:41
  #38 (permalink)  
 
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K Bills "The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety."

Kym Bills - Current
· Chair at Australian Centre for Natural Gas Management
· CEO at Western Australian Energy Research Alliance
· Board member at National Offshore Petroleum Safety and Environmental Management Authority

I wonder if he ever looks back at what he built, probably not. Come home Kym – all is forgiven;your Mum's worried, the dog won't eat, the cat's out of the bag and there's hell to pay with the Senate.
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Old 12th Nov 2013, 03:47
  #39 (permalink)  
 
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Devil Bumping up the numbers or is Beancounter Beaker a genius??

To be fair to the ATSB the two (best described as desktop investigations) shite reports under the spotlight were both part of the October edition of the short investigation bulletin (Aviation SIB – Issue 23). I should clarify I do not question the bods on the ground that they are only doing what they are told, with the allocated (limited) resources given to them. However I am very sceptical about the true motives behind the ATSBeaker short investigation process??

Maybe Old Akro has hit the nail on the head…“The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.”

So what exactly is the bureau methodology behind the short investigation process?? Ok if you refer to the ATSB page Terminology, investigation procedures and deciding whether to investigate and under Background it says…

“Following the initial assessment of a notification, a decision is made whether or not to conduct an investigation. Some occurrences may be subject to a limited scope Short fact gathering investigation. These short investigations are published periodically in Short Investigation Bulletins, which include about 10 individual reports each issue. Refer to the investigation levels in Classifying.”


….then under Classifying and the heading ‘Three Ways to action’ it goes on to say..


2. A report of an occurrence that may not warrant a full investigation but which would benefit from additional fact gathering for future safety analysis to identify safety issues or safety trends.”


…further down the page under ‘Pros and cons of the second approach’

“The advantage of the second approach is that a richer data set for a greater number of occurrences is generated with minimal resource overhead which, in turn, is likely to result in improved future research and statistical analysis outcomes. These short, fact gathering investigations also provide an opportunity to upgrade to a full investigation when the initial fact gathering suggests that the issues are more complex and warrant more detailed examination and analysis.” {Note on above in bold : Wonder how many times that has actually happened??}

It is worth comparing the difference in methodology for the classification of investigations with the TSB Canada: TSB Canada- Occurrence Classification Policy

Similar methodology perhaps ..but subtle differences in the wording plus the TSB don’t label investigations as ‘short’, ‘long’ or ‘otherwise’ and on the whole their policy is much more straightforward and transparent.

Okay so does the bureau system achieve the stated objectives or is it, as OA said above, a matter of bumping up the numbers to meet KPIs?

Well without a detailed knowledge of the ATSB database and how the individual short investigations are tagged it is very hard to assess. But going on the wide and varied quality of the short investigations I am somewhat suspicious!!

My bigger concern though is that this system may mask what could be future or developing significant safety issues. By pigeon-holing a serious incident to a less resourced short investigation, therefore (by definition) a shorter summarised final report, are the ATSB running the risk of minimising what could be in other jurisdictions (internationally) a trending significant safety issue???

Hmm..perhaps someone can pick out some examples of the potential for the ATSB investigation classification policy masking significant safety issues from the SIB list??

ATSB ASIB Archive (hint a good place to start is item 9)
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Old 13th Nov 2013, 20:31
  #40 (permalink)  
 
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Devil RRP - 'time expired'???

Section 25A of the TSI Act reads...

"25A Responses to reports of, or containing, safety recommendations

(1) This section applies if:

(a) the ATSB publishes a report under section 25 in relation to
an investigation; and
(b) the report is, or contains, a recommendation that a person,
unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action.

(2) The person, association or agency to whom the recommendation is made must give a written response to the ATSB,within 90 days of
the report being published, that sets out:

(a) whether the person, association or agency accepts the
recommendation (in whole or in part); and
(b) if the person, association or agency accepts the
recommendation (in whole or in part)—details of any action
that the person, association or agency proposes to take to
give effect to the recommendation; and
(c) if the person, association or agency does not accept the
recommendation (in whole or in part)—the reasons why the
person, association or agency does not accept the
recommendation (in whole or in part).

(3) A person commits an offence if:

(a) the person is someone to whom a recommendation is made in
a report published under section 25; and
(b) the person fails to give a written response to the ATSB
within 90 days setting out the things required by
paragraphs (2)(a), (b) and (c) (as applicable).
Penalty: 30 penalty units.

(4) Subsection (3) applies to an unincorporated association as if it were
a person.

(5) An offence against subsection (3) that would otherwise be
committed by an unincorporated association is taken to have been
committed by each member of the association’s committee of
management, at the time the offence is committed, who:

(a) made the relevant omission; or
(b) aided, abetted, counselled or procured the relevant omission;
or
(c) was in any way knowingly concerned in, or party to, the
relevant omission (whether directly or indirectly or whether
by any act or omission of the member)."

Remember this..?? Flight control system event involving Cessna 210N, VH-JHF

Well...

AO-2011-115-SI-01 - 'time expired'

AO-2011-115-SI-02 - 'time expired'

'Tick..tock!'
Sarcs is offline  

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