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ATSB reports

Old 17th Dec 2013, 11:50
  #81 (permalink)  
 
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Study and study harder……. lost more to find.

To be fair, it was not all that hard for ATSB and CASA to bluff their way out of it. Who was there going to do the critical thinking and challenge the BS presented. Sir Doug (deserves a knighthood for this and many other things) singlehandedly exposed the can of worms. History of this would be very different had he not.

I would like to write a book on it, and I best do so in the next year or three while folk remember what happened. I might sell 300 copies even.

When I bought JD's ticket earlier this year for a trip down under we joked about a fake name….just so he could sneak into Oz undetected by ATSB/ CASA. At the first course one CASA guy was there, but fortunately he was one of the good guys We seriously joked about it……I am sure there are some that wish that article never saw the light of global aviation media day.
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Old 18th Dec 2013, 00:10
  #82 (permalink)  
 
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Jabba #82 –"Study and study harder……. lots more to find.
To me, it's not the finding as much as how the interpretation is framed. Compare the Pel Air and Whyalla "investigations" and three points shriek at you.

Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'.

The industry would be placed at an increased risk level by accepting and following the 'expert' results.

The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk.

It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away.

Strewth. I'll have a pint of whatever he's drinking; must be bloody good stuff.
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Old 18th Dec 2013, 00:23
  #83 (permalink)  
 
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Bringing JD out here was a stroke of genius, it is difficult for the alphabet soup ATSB to deny factual evidence from internationally recognised experts no matter how hard they try to obfuscate.
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Old 18th Dec 2013, 02:24
  #84 (permalink)  
 
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Thanks T28D, but that was for the launch of Advanced Pilot Seminars Australia, not anything to do with ATSB.

George on the other hand did come out here about 7 years back……he must have been ducking and weaving too

They were a team effort, George with the Dyno data, and JD with the mightier than sword pen! Great result though! And Doug Sprigg (Sir Doug ) should not be left out of that either.
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Old 18th Dec 2013, 06:24
  #85 (permalink)  
 
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Just the fact JD was here would grab their attention
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Old 18th Dec 2013, 10:26
  #86 (permalink)  
 
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It should, but you are smart enough to know that it might be expecting a bit much
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Old 19th Dec 2013, 01:16
  #87 (permalink)  
 
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Leave it to the experts!

Jaba:
I strongly suggest you read the George Braly evidence provided to the SA coroner.
Yes it is a fascinating read and it was duly noted by the Coroner and ended up being the basis of his very damning findings into the actions, inactions/obfuscation in regards to the ATSB, CAsA and their involvement in the Whyalla crash investigation.

Couple of passages from the Whyalla Coroner's report :
12.80. Mr Braly outlined his opinions about the sequence of events leading to the ditching as follows:

'The following is a short summary of the sequence of events that, based on known hard engine operating data and the known objective findings surrounding the fatal crash, is what most likely happened in connection with this fatal crash:

1) The left engine crankshaft failed. The cause appears most likely to be related to improper installation of the connecting rod on the number six cylinder.

2) The pilot feathered the left engine and increased the manifold pressure on the remaining right hand engine from a normal 30" to some larger value in the 34 to 40" MP range. The pilot most likely failed to also increase the mixture on that engine to a suitably rich mixture.

3) The indicated airspeed (IAS) of the aircraft was reduced due to the left engine being feathered and the loss of nearly 50% of the previous available cruise power. The combination of the lowered cruise speed and the increased power on the right engine left the right engine in an environment very similar to a "climb condition". That is, the engine was enjoying minimal cooling air flow due to the reduced cruise speed and suffering from higher than normal power settings, both of which are typical of operating conditions encountered during routine climbs.

4) The crucial operational error was the likely failure of the pilot fully (or adequately) to increase the mixture on the right hand engine during this engine out cruise condition. Had the pilot simply and properly increased the mixture during this critical phase of the flight, as normal training and good engine operating practices would dictate, the right engine would not have failed and the aircraft would have, more likely than not, continued to a safe landing at Whyalla.

5) Something as simple as a small excess overhang of a helicoil tang at one of the spark plugs in cylinder 6 of the right engine could have dramatically increased the susceptibility of that cylinder to pre-ignition. The photographs in the ATSB report do not detail this area of the cylinders in sufficient detail to evaluate this not uncommon cause of pre-ignition.

6) One can readily demonstrate that even a newly built or overhauled TIO-540J2B engine, in perfect mechanical condition will, under the conditions described in paragraphs 2-4 above, operate in light to medium detonation and if left unresolved, that light to medium detonation will steadily raise the cylinder head temperature to the point that pre-ignition begins. After the pre-ignition begins, the engine will suffer catastrophic failure, usually within a matter of one to five minutes, unless the pre-ignition is promptly corrected. The author of these comments invites an appropriate representative of the ATSB to visit the author’s test facility and to observe the operation of the TIO-540J2B engine in any combination of power and mixture settings desired, in order to verify each and every observation about the operation of that engine described in these comments.

7) Notes:

a) The various different cruise mixture settings used by Whyalla and the other operators of these engines described in the ATSB report had no effect what so ever on this crash. At the reported normal cruise power settings, it is virtually impossible to cause one of these engines to detonate or pre-ignite, if the engine and the associated ignition system are in proper operating condition.
b) The climb mixture settings used by Whyalla (as distinguished from the descriptions of the power and mixture settings used by all other operators surveyed by the ATSB) were highly improper and likely caused one or more cylinders on both engines to frequently operate in light or medium detonation during portions of each climb.
c) The description of "deposits" on the pistons set forth in some detail in the report is essentially unrelated to any aspect of the cause of this crash. This extended pursuit of this subject is largely a red herring. For example, the deposits such as are described and displayed in the limited photographs in the ATSB report appear, from those photographs, in actuality, to be rather more accurately described as minimal as compared to most engines with similar operating time. In fact, they generally appear to be so minimal as to support the notion that the Whyalla engines were, in fact, frequently operating for short periods of time (probably during climbs, given the reported Whyalla engine operating technique during the climb phase of flight) in light to moderate detonation and this periodic condition actually cleaned the piston domes of some of the otherwise normal deposits. A better collection of photographs of the pistons and cylinder domes would provide still more accurate information on this subject.
d) In common pilot & mechanic operating terminology, when one "leans" the mixture, one reduces the ratio of fuel to air via use of the mixture control. However, when one thus "leans" the mixture to a condition that most pilots and mechanics would routinely call a "lean" mixture, the mixture remains a stoichiometric rich mixture. (The mixture is chemically a rich mixture until the exhaust gas temperature - - as indicated by the turbine inlet temperature gage [sic] during gradual reductions in fuel flow, - - has reached a maximum value and started to decline.) The confusing terminology in this area is responsible for an enormous misunderstanding in the pilot and mechanic community of the true implications of chemically rich and lean mixtures with respect to the operation of high powered piston aircraft engines. At one point, the ATSB report on this crash attempts to accurately define these terms, but then, in other areas, fails to accurately apply the correct terminology to the operation of the engines in question, and thus, compounds the confusion for pilots and mechanics who may read the report.

In its criticism of the routine use of so called "lean" mixtures, the ATSB fell into the common trap of mis-characterising stoichiometric "rich" mixtures as being "lean" mixtures. Worse, the lay press has grabbed onto this aspect of the report and has compounded the confusion in this area with published reports that completely mischaracterize the issue, blaming the crash on the use of "lean" mixtures, with an express or implied suggestion that the airline operators of this type aircraft were trying to skimp on fuel in order to save money at the expense of operating safety. (C196a, p4-6)

Some of Braly's findings etc (as stated above) were revised somewhat, after some of the assertions and conclusions made in the original ATSB final report were proved to be distorted and not entirely based on fact.... However the basic premise of Braly's review was largely applauded by the Coroner and enabled him to totally debunk the ATSB Final Report conclusions in regards to the reasons for the catastrophic double engine failures of VH-MZK.

Mr Braly's hypothesis for the causal chain from the time VH-MZK diverged right reads very similar to John Deakin's analysis article:
Reference pg 140 para 12.93:
'At the point where the aeroplane diverged right on page 3 at 1847:15, I think the pilot had been wrestling with problems with the right engine since some point in the climb. I believe at about that time he decided to simply throttle the engine. He could do that, and it’s my opinion that at that point in time he had experienced an episode of pre-ignition on the right engine. Whether or not it had already put a hole in the piston is debatable, but he did not, unlike the gentleman that was shown in the recreation of the data yesterday, the benefit of that sort of instrumentation and he would not have likely been able to stop the event before it did damage to the cylinder and, as indicated yesterday, once that sort of thing starts to happen in the cylinder, even if he throttled the engine, if you later reapply power, it’s going to happen again, assuming he had a hole in the piston already.

It is my opinion that the pilot decided simply to throttle the right engine and, in the process of that, the aeroplane yawed to the right slightly. In my experience teaching multi-engine pilots to fly during training, a momentary lapse in the heading control of the aircraft during major left/right power discrepancies is more common than not, even among good pilots, and I think the right-hand turn data is consistent with that, and a prompt re-correction back on course is consistent with him having done that and then retrimmed the aeroplane by use of the rudder trim control and what not to put the aeroplane back on course.

At that point in time the pilot had an unknown problem with the right engine, but it was still operating, and he had a 250- or 260-hour left-hand engine, and he made the decision to continue on. In the process he would have likely pushed up the power on the left-hand engine to something approaching climb power. He may have in fact used climb power - that would be a common training scenario for a multi-engine pilot, that if you lose an engine, you put the other engine up to climb power. That’s not necessarily the most optimal training exercise, but it’s a common method of teaching multi-engine pilots.

So I believe he increased the power on the left engine as he reduced the power on the right engine, and pressed on.

Some time just before 1901:10 when the MAYDAY was transmitted I think the crankshaft failed on the left engine. When the aircraft hit the water the left engine was feathered - I think the left engine would have virtually auto-feathered from the oil pressure loss. The right engine was still turning and not feathered, which is consistent with the previous power reduction.

I think if he had not already had a hole in the piston at the time - 1847:15 - when he throttled that engine, or when he tried to power up the right engine after the failure of the left, that he would have holed it promptly, because it would have gone back into pre-ignition.

It would have been a very confusing and difficult situation for the pilot.

They simply do not train for simultaneous engine failures, and they certainly do not do it at night with a full load of passengers over water.' (T3221-23)
Very sobering indeed...

There is no doubt the Coroner's report is a truly fascinating read (if you've got the time..), but the devil is always in the detail andwith most Coroner's reports that is contained in the findings and recommendations. In the case of Coroner Chivell his findings & recommendations underlined his frustration and consternation with the obvious bungling, obfuscation and disturbing shennanigans by the ATSB and to a lesser extent Fort Fumble. Perhaps this consternation is best illustrated from paragraph 15.5 (pg 181) to paragraph 15.13 (pg 183) {Note: Remembering that this was prior to the introduction of the TSI Act}.

Coroner report quote paragraph 15.10:
15.10. It follows, then, that I reject any suggestion that the ATSB were constrained or limited by section 19CA of the Air Navigation Act, 1920 in this investigation. In my opinion, the remarks of the Director of the ATSB, Mr Kym Bills, to the Australian Senate on 11 February 2003 reflect this misconception:

'For many years there have, from time to time, been difficult issues in some state and territory coronial inquests. The ATSB has been seeking better mutually cooperative relationships with coroners in the context of the legislation currently before the parliament and will continue to do so.

However, problems remain when the bureau is criticised at inquests for not spending more money on a particular investigation to satisfy
legal queries such as those relating to future civil litigation; when the high cost of inquests redirects our resources from higher safety priorities; where a particular inquest encounters difficulties with the Commonwealth no-blame legislation; under which we operate in accordance with international agreements; or where legal certainty is sought from an investigation, whereas the evidence often does not allow this and the ATSB’s focus is on the action necessary for future safety.'

The notion that ‘legal certainty’ (by which I assume Mr Bills means the finding of a fact to the requisite standard of proof) is somehow inconsistent with the ATSB’s role to ensure ‘future safety’ is not in accordance with logic. Surely an investigation must demonstrate, to an appropriate degree of certainty, that an incident has occurred in a particular way before remedial or preventative measures can be taken.
Hmm..interesting and what of the Coroner's well considered recommendations?? Have they been embraced by the regulator and promoted by the watchdog......well I'll let some one else be the judge of that...

IMO another (in a long line) of missed opportunities to advance our learning from a serious accident tragedy and to ultimately enhance aviation safety has been missed... As Gobbles quite often....said TICK..TOCK!
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Old 21st Dec 2013, 00:46
  #88 (permalink)  
 
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The holes in the cheese are aligning...TICK..TOCK!

Kharon:
To me, it's not the finding as much as how the interpretation is framed. Compare the Pel Air and Whyalla "investigations" and three points shriek at you.

Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'.

The industry would be placed at an increased risk level by accepting and following the 'expert' results.

The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk.

It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away.


Whyalla may or may not have been the catalyst for where we find ourselves today but it is now somewhat academic. A couple of recently released bureau reports, plus Kharon's succinct post above, IMO perfectly highlight the current status quo within aviation safety regulation & accident/incident investigation in this country and add further evidence that we are fast approaching critical mass (the holes are aligning)!

First cab off the rank is the prelim report for the wx related 'Serious Incident' involving two 737s diverting into Mildura due fog at YPAD. Link to my post on the subject (incident) on ANZ&P forum: "From the sublime to the ridiculous???"

In that post I put my thoughts & disgust in fairly plain language on the ATSB downplayed prelim report...IMO truly disgusting for an incident that has enormous implications to the whole industry not just the airline sky gods!

Perhaps the more understated comment by wildsky (Ben's article) points to the true potential knock-on effects of the ATSB (dis)missive, prelim report and their future investigation activities into the incident.

...."I guess this “safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally” and the “research study into the unreliability of aviation meteorological forecasts” will be rolled out eventually as the Government response to:
“Recommendation 24
9.106 The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.”
Despite the Chief Commissioner selectively quoting the Bureau of Met’s Norfolk forecasting reliability data to disguise the real and identified risk levels, the reality was that all of the clues were presented to the ATSB and CASA that we had, and still have, a significant operational problem. Mildura, or many other mainland aerodromes, do have lower risks of forecasting errors than remote islands – but the risk still exists and the Mildura event showed just how quickly things can change from risk to actual danger to life and limb.
Safety forums and research studies are what you do when you don’t really want to do anything – they are nice shows of interest but have no weight in achieving change.
Makes me so glad every time I hear “safety is our number one priority”…

The next report was also covered by Ben, see here: Virgin 737 cleared to fly through paratrooper drop: ATSB

On the surface this report was fairly reasonable and it would appear that all DIPs have taken on-board the Bureau's concerns and are progressively addressing the significant safety issues. But again the devil is always in the detail which, as we all know, in bureau reports is (usually) contained in the Safety Issues/Actions section. This particular report has led to the bureau (surprise..surprise..) actually promulgating two safety issues on their Aviation safety issues and actions database, see here:AO-2012-142-SI-01 & AO-2012-142-SI-02

Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then?? I know..I know it is all about Beaker's touchy, touchy feely, feely, beyond all sensible reason methodology... But it just leaves the man at the back of the room asking.."what else are the hiding??"

Note: Ironically, in the case of the YMIA incident, even certain DIPs (in this case ASA) are still waiting for the ATSB to follow normal accepted practice and submit safety recommendations to frame a ASA MAP (Management Action Plan).

Reference QON 161 AA 02 CHAIR Maintenance of AWIS (Sen Estimates 18/11/13)....

"....Mr Hood: There are over four million aircraft movements in Australia a year, very few of which cause us significant concern. I think it is fair to say this is a concerning incident. We are cooperating fully with the ATSB. It is our hope that the ATSB will establish all of the facts and make appropriate recommendations, on which we will act...."

Unless the Beaker suggestion of having a 'love in'is to be regarded as a serious SR from the bureau, it would appear that Hoody could be waiting a while... FFS the bureau in it's present form is a disgrace!

More to follow...
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Old 21st Dec 2013, 03:31
  #89 (permalink)  
 
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To be honest, Hoody should just go ask some questions of those involved, formulate a plan with those at the coal face, put it in place and move on. Waiting for the ATSB or CASA would be futile and as beneficial as holding ones breath.

I do think he would get it sorted, but if left to others lord only knows.
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Old 21st Dec 2013, 09:33
  #90 (permalink)  
 
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ATSB - everybody leave your car keys in the glass bowl!

The ATSB has gone from downright lame to unimaginably pathetic. Now their solution to 'every event of a safety nature' is to have a 'love in'
So Beaker, should attendees wear name tags as well? Plenty of bowls of lollies on the table as robust tendentious discussions take place, followed by some dry humping of each other's legs, some back patting and star jumps, a game of UNO and a look at some historic Wright Brothers footage? Then it is 'party over, all go home, nothing left to see here'.
I really didn't think it could get any worse (well perhaps Sunfish's smoking hole is worse), mi mi mi Beaker has lost the plot completely.
Please please ICAO, FAA, Communist Party of China, AOPA, anybody really, come in and fix our Aviation system, please!!!
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Old 21st Dec 2013, 19:34
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The portrait of Dorian Gray.

There have been three important ATSB reports published lately; the slightly hysterical Tiger go-around at Avalon; the secretive Meat bombs v Virgin; and, the Mildura Met Muddle. Each, in it's own way significant. Once you have read and inwardly digested, just for fun, isolate the individual issues into short sentences and see what sort of picture you get and it ain't pretty. Then, if you can stomach it, line up the considered responses aimed at preventing a reoccurrence of any one of the three potentially serious incidents and time line it from start to finish. The question 'have we done enough to minimise the risks?' is nugatory. 'Have we done anything positive in a timely manner at all?, has the ascendancy: the answer being a resounding NO.

The emerging picture reminds me of the Dorian Gray story, written by Oscar Wilde.

Wiki - Realizing that one day his beauty will fade, Dorian (whimsically) expresses a desire to sell his soul to ensure the portrait Basil has painted would age rather than he. Dorian's wish is fulfilled, and when he subsequently pursues a life of debauchery, the portrait serves as a reminder of the effect each act has upon his soul, with each sin displayed as a disfigurement of his form, or through a sign of aging.
“Words! Mere words! How terrible they were! How clear, and vivid, and cruel! One could not escape from them. And yet what a subtle magic there was in them! They seemed to be able to give a plastic form to formless things, and to have a music of their own as sweet as that of viol or of lute. Mere words! Was there anything so real as words?”. Oscar Wilde.
Today's MG Word - Aphorism. [The] term was later applied to maxims of physical science, then statements of all kinds of philosophical, moral, or literary principles. In modern usage an aphorism is generally understood to be a concise statement containing a subjective truth or observation cleverly and pithily written.

Last edited by Kharon; 21st Dec 2013 at 19:45.
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Old 22nd Dec 2013, 09:33
  #92 (permalink)  
 
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What was slightly hysterical about the Tiger report?
What was secretive about the parachute report?
Have you got anything except your secretive hysteria?
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Old 22nd Dec 2013, 18:50
  #93 (permalink)  
 
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Homework help.

Tiger’s A320 could have become a smoking hole in a suburb on this Avalon airport approach in 2011, and for CASA it was the last straw, causing it to ground the airline two days later.
Ben Sandilands is an experienced aviation journalist and commentator not easily fooled. Have a read of the article – HERE – in which the procedure used by the Tiger crew is described as "the final straw", causing CASA to ground Tiger. An ATSB report which can con a bloke like Sandilands into writing such an article smacks of mild hysteria. Grab the YMAV VOR RWY 36 (or RNAV as pleases) and run the executed visual approach 'picture' over the approach (remember visual circuit) see how the flight path sensibly intercepts the IAL procedure for 'final'. Then work out where the circling area limits boundary ends and 'circling minima' then have a look at the IAL not below heights. The Tiger approach may 'arguably' be 'subjectively' claimed as technically illegal, but to say 'operationally unsafe' is a slightly hysterical over reaction, IMO used to justify the CASA politically motivated actions.

Sarcs # 94
"Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then??
Now –Sarcs #94 – raises issues which may be described as 'secretive'; making the point that as far as anyone knew, there were no SR issued and no procedures developed to prevent the incident reoccurring the next day. Not to say procedural changes weren't made, just that they weren't made public. Once again look at all the factors leading up to what could have been a very serious accident. Maybe it's just me, but a meat bomb through the front wind-screen, cabin or engine would rate as a fairly significant event. Perhaps even demanding an immediate concerted public effort by all parties concerned. The effort may well have happened, but two years (AO-2011-142 - Nov 5, 2011) of waiting to know how the system was changed to eliminate potential meat bomb FOD is just a bit rich of peak.

Sandilands - ATSB

Anyway OB, that's my two bob's worth; no matter how I choose to express it.

Last edited by Kharon; 22nd Dec 2013 at 19:03.
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Old 23rd Dec 2013, 05:06
  #94 (permalink)  
 
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Perhaps a more robust PFI of Santa's sleigh this year...??

Well Fort Fumble may have knocked off till next year but it appears the bureau boys'n'gals on the coalface are busy working on Beaker's bonus...

Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..:
AO-2013-226
In-flight breakup involving de Havilland DH-82, Tiger Moth, VH-TSG, near South Stradbroke Island, Qld on 16 December 2013
16 Dec 2013
Pending
23 Dec 2013

AO-2013-187
In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013
24 Oct 2013
Interim Factual
23 Dec 2013
The fire fighting Dromader tragedy has also apparently led to the bureau generating a Safety Advisory Notice, see here: AO-2013-187-SAN-005

Also released within the last few days was..

VFR flight into IMC involving de Havilland DH-84 Dragon VH-UXG

{Note: Interesting point that from accident to Final Report only took 445 days}

This accident has also generated an addition to the ATSB Aviation safety issues and actions database: AO-2012-130-SI-01

But in keeping with the Beaker BASR methodology.. it was only a significant safety issue and no SR was issued.To be fair I guess it is a bit hard to justify the issuance of an SR over a year after the accident... (check highlighted dates in following):
Proactive Action

Action organisation:Airservices Australia
Date:19 December 2013
Action status:Monitor

Following notification of the safety issue by the ATSB, on 11 October 2013 Airservices Australia advised that:

In response to the incident, Airservices conducted a managerial review of In-Flight Emergency Response (IFER) procedures. The review identified potential opportunities for improvement relating to the operational interface and transfer of responsibility between Airservices and AMSA [the Australian Maritime Safety Authority] (i.e. ATC [air traffic control] and SAR [search and rescue] aircraft). As a result Airservices and AMSA have agreed to conduct a comprehensive review of the existing MoU [Memorandum of Understanding] to ensure the effectiveness of collaborative Airservices-AMSA IFERs. The review is anticipated to be completed by the end of Q1 2014 [the first quarter of calendar year 2014].


Proactive Action

Action organisation:Australian Maritime Safety Authority
Date:19 December 2013
Action status:Monitor

Following notification of the safety issue by the ATSB, on 14 November 2013 the Australian Maritime Safety Authority advised that:

AMSA and Airservices have agreed to conduct a comprehensive review of their existing Memorandum of Understanding (MoU), including the air traffic service requirements for support from Search and Rescue (SAR) aircraft, to ensure the effectiveness of collaborative in-flight emergency responses. The review is anticipated to be completed during the first quarter of 2014.
AMSA will also update its SAR procedures manual in consultation with Airservices and if appropriate will issue updated guidance on communications between SAR aircraft and the air traffic service.

ATSB action in response:

The ATSB is satisfied that a joint review of inter-agency agreements, with a focus on coordination of in-flight emergency responses and communication, should lead to improvements that adequately address the safety issue. The ATSB will continue to monitor the safety issue.
Ho..ho..ho..Merry XMAS!

ps err..what vintage is Santa's sleigh maybe his gingerbeer elf and loadmaster elf better beef up their preflight procedures prior to departure??
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Old 23rd Dec 2013, 05:22
  #95 (permalink)  
 
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QUOTE AMSA and Airservices have agreed to conduct a comprehensive review of their existing Memorandum of Understanding (MoU QUOTE


I wonder who will write this one up?
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Old 28th Dec 2013, 04:50
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TSBC in-flight breakup report a benchmark for ATsB??

Hmm..has Beaker inadvertently provided us with a template for a future re-modelled ATsB??

Most of us have been dubious (including Senator X #34) of Beaker's real intentions for calling in TSB Canada, whatever his original intentions it has been enlightening to look at how another TSI agency operates.

The TSBC are a no fuss, principled, extremely competent AAI agency that goes about it's business without fear nor favour nor fanfare...

In reference to my previous post:
Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..:
Quote:
AO-2013-226
In-flight breakup involving de Havilland DH-82, Tiger Moth, VH-TSG, near South Stradbroke Island, Qld on 16 December 2013
16 Dec 2013
Pending
23 Dec 2013

AO-2013-187
In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013
24 Oct 2013
Interim Factual
23 Dec 2013
The TSBC recently released a final report into another tragic in-flight breakup accident, that IMO should set the benchmark for the two ATsB investigations mentioned above....

Aviation Investigation Report A11W0048

With equal weight the TSBC systematically examine all the possible causal factors (all the holes in the cheese) and end up with the following in their safety action section:
4.0 Safety action

4.1 Safety action taken

4.1.1 The Federal Aviation Administration

On 25 May 2011 the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2011-12-02. Effective on 02 June 2011, the AD applied to Viking Air Limited Model DHC-3 Otter airplanes (all serial numbers) that were equipped with a Honeywell TPE331-10 or -12JR turboprop engine installed per Supplemental Type Certificate (STC) SA09866SC (Texas Turbines Conversions, Inc.) and certified in any category.

The AD was prompted by analysis that showed airspeed limitations for the affected airplanes were not adjusted for the installation of a turboprop engine as stated in the regulations. The AD was issued to prevent the loss of airplane structural integrity due to the affected airplanes being able to operate at speeds exceeding those determined to be safe by the FAA.

The AD imposed a maximum operating speed (VMO) of 144 mph for DHC-3 Otter land/ski aircraft and 134 mph (VMO) for DHC-3 Otter seaplanes. Footnote 17

On 19 August 2011 the FAA issued AD 2011-18-11, which became effective on 03 October 2011. The AD applied to all Viking Air Limited Model DHC-3 Otter airplanes that were certified in any category. The AD resulted from an evaluation of revisions to the manufacturer's maintenance manual that added new repetitive inspections to the elevator control tabs. The AD stated that if these inspections were not done, excessive free-play in the elevator control tabs could develop. That condition could lead to loss of tab control linkage and severe elevator flutter, which could lead to a loss of control. Footnote 18

4.1.2 Black Sheep Aviation & Cattle Co. Ltd.

As a result of this accident Black Sheep Aviation established a system that correlates flight duty times to flight ticket invoice numbers. The information is entered on a new flight duty form which is delivered to company dispatch daily and and entered into company Flight Time/Duty Time/Rest Period records daily.

4.2 Safety action required

In June 2012, there were 6957 commercially registered aircraft listed on the Canadian Civil Aircraft Register, of which 5453 (78.4%) weighed less than 5700 kg. Most commercial aircraft weighing less than 5700 kg are operated under CARs subpart 702 Aerial Work and CARs subpart 703 Air Taxi Operations. These operations accounted for 88% of all accidents, 87% of all fatalities, and 82% of all serious injuries involving Canadian registered commercial aircraft in the past 10 years. If accidents involving commuter operations under CAR subpart 704 are added, the number of commercial air accidents jumps to 94% and the number of commercial air fatalities to 95%. Many of the aircraft operated by these companies are not required to be fitted with any type of flight recorder.

These smaller operators face challenging conditions, such as difficult terrain, and typically operate into smaller, more remote airports with less infrastructure. They often fly smaller, older aircraft with less sophisticated navigation and warning systems, which cause higher workloads for crew. Flight crews working for these operators are often working their way up in the system; they may have less training and experience, and often do not benefit from mentors able to pass on their experience.

In contrast, from 2001 to 2012, Canada's large carriers operating under CARs Subpart 705 have had only 1 fatal accident on home soil. Footnote 19 These large commercial carriers are required to have safety management systems (SMS), cockpit voice recorders (CVR), and flight data recorders (FDR). Many of these operators routinely download their flight data to conduct flight data monitoring (FDM) of normal operations. Air carriers with flight data monitoring programs have used flight data to identify problems such as unstabilized approaches and rushed approaches; exceedance of flap limit speeds; excessive bank angles after take-off; engine over-temperature events; exceedance of recommended speed thresholds; ground-proximity warning systems (GPWS)/terrain awareness and warning system (TAWS) warnings; onset of stall conditions; excessive rates of rotation; glide path excursions; and vertical acceleration. Footnote 20

Flight data monitoring has been implemented in many countries, and it is widely recognized as a cost-effective tool for improving safety. In the United States and Europe—thanks to ICAO—many carriers have had the program for years. Some helicopter operators have it already, and the FAA has recommended it.

Worldwide, FDM has proven to benefit safety by giving operators the tools to look carefully at individual flights and ultimately at the operation of their fleets over time. This review of objective data, especially as an integral component of a company safety management system, has proven beneficial in the proactive identification and correction of safety deficiencies and the prevention of accidents.

Several stand-alone lightweight flight recording systems which can record combined aircraft parametric data, cockpit audio data, airborne images and/or data-link messages are currently being manufactured. ED-155 MOPS for Lightweight Recording Systemspublished by the European Organization for Civil Aviation Equipment (EUROCAE) defines the minimum specifications for lightweight flight recording systems. While performance standards and TSOs exist, there is no requirement for aircraft not governed by CARs 605.33 to be fitted with any type of flight recorder, and Transport Canada does not intend to extend those requirements to smaller aircraft.

The development of lightweight flight recording system technology presents an opportunity to extend FDM approaches to smaller operations. Using this technology and FDM, these operations will be able to monitor, among other things, standard operating procedure compliance, pilot decision making, and adherence to operational limitations. Review of this information will allow operators to identify problems in their operations and initiate corrective actions before an accident takes place. In short, a whole new and promising avenue is now available to improve operational control and safety beyond CARs subpart 705 operations. In Canada, some companies have already decided to fit their aircraft with lightweight flight recording systems.

The Board acknowledges that there are issues that will need to be resolved to facilitate the effective use of recordings from lightweight flight recording systems, including questions about the integration of this equipment in an aircraft, human resource management, and legal issues such as the restriction on the use of cockpit voice and video recordings. Nevertheless, given the potential of this technology combined with FDM to significantly improve safety, the Board believes that no effort should be spared to overcome these obstacles.

Given the combined accident statistics for CARs Subparts 702, 703, and 704 operations, there is a compelling case for industry and the regulator to proactively identify hazards and manage the risks inherent in these operations. In order to manage risk effectively, they need to know why incidents happen and what the contributing safety deficiencies may be. Moreover, routine monitoring of normal operations can help these operators both improve the efficiency of their operations and identify safety deficiencies before they result in an accident. In the event that an accident does occur, recordings from lightweight flight recording systems will provide useful information to enhance the identification of safety deficiencies in the investigation.

Therefore the Board recommends that:

The Department of Transport work with industry to remove obstacles and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems for commercial operators not required to carry these systems.A13-01
Tough act to follow...where's your money on the bureau, in it's current diabolical state of disfunction under Beaker, showing the same due diligence of the two in-flight breakup accident investigations listed above??
Sarcs is offline  
Old 28th Dec 2013, 05:40
  #97 (permalink)  
 
Join Date: Jan 2008
Location: Australia
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sarcs, maybe I am a pessimist, but your:

Most of us have been dubious (including Senator X #34) of Beaker's real intentions for calling in TSB Canada,


Has been on my mind for some time, is the "fix" in ? one might be a little concerned given the number of Montreal trips and the close association of the witch doctor in Montreal that the "fix" is indeed well and truly "in" we hope not but hope is a slippery thing to hold onto.
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Old 24th Jan 2014, 22:27
  #98 (permalink)  
Thread Starter
 
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Location: Melbourne
Posts: 1,658
Just reading the Feb 20 batch of ATSB reports.

Seriously, have they sub contracted this to Mills & Boon? Or is the work experience kid writing them?

I understand the ATSB's new no-fault policy. But surely if there is no learning or lessons from a report - then why are we bothering?

After a mid air collision is the best advice / recommendation we can muster to read a 5 year old ATSB brochure "A pilot’s guide to staying safe in the vicinity of non-towered aerodromes."

And of course the really funny thing is that the ATSB report

http://www.atsb.gov.au/media/4533008...-205_final.pdf

has a dead link to its recommended "safety message" document. Are we really paying these people?

I've tried searching the ATSB site on both the title of this publication and its ATSB publication number with no luck. It appears that it has been removed from their website. Really doesn't look like they care much, does it?

Surely a mid air collision at a significant capital city airport airport deserves something more insightful? Where is the value in producing this type of report at all? Why not save the money and just stop doing these mindless investigations?
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Old 25th Jan 2014, 05:39
  #99 (permalink)  
 
Join Date: Jul 2007
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Good start.

Monarch
Whyalla
Benalla
Lockhart River
PelAir
Canley Vale
Airvan engine failure at night NT.
Jabawocky is offline  
Old 25th Jan 2014, 06:56
  #100 (permalink)  
Man Bilong Balus long PNG
 
Join Date: Apr 2002
Location: And once again, the fun and good times having come to an end for yet another year, back in the cold, cruel real world and continuing the seemingly never ending search for that bad bottle of Red
Age: 65
Posts: 2,537
Is Mac Job still around? If so, maybe if enough of us ask him nicely, he may pay the ATSB a visit and give them a few lessons on just how an accident should be investigated and the subsequent report written!

Well.....I can dream....can't I?

Oh, and bring back the Safety Digest whilst he's at it!
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