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ATSB reports

Old 25th Jan 2014, 09:06
  #101 (permalink)  
 
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As a matter if interest who was the Director at the time of the Monarch accident? Who was one of the senior investigators and why was it an example of the litany of poor investigations conducted?
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Old 25th Jan 2014, 09:36
  #102 (permalink)  
 
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You're a knowledgable person CJ, why is Monarch on that list?
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Old 26th Jan 2014, 04:26
  #103 (permalink)  
 
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A reply worthy of a CASA delegation at a Senate Inquiry CJ. Seeing as he has given you a hospital pass UITA maybe you can explain why Monarch is in your list of incompetent investigations? No CASA like obfuscations please.
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Old 26th Jan 2014, 08:59
  #104 (permalink)  
 
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UITA out of line on BASI Monarch report.

Warning: Longish post following

UITA:
Go read the report, ask some questions of non-casa peple that you don't appear to frequent with (based on your comments and answers) [and when you give them]

Then form a real opinion as the whether atsb was correct, or Monarch just joins my list.
Hmm...took your advice UITA and reviewed the BASI report 9301743, & subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one...

Maybe the report wasn't exemplary (for the then BASI standards) and FF eventually rolled over the top of most of the recommendations when reincarnated as CAsA but I really can't see where BASI have been negligent in the Monarch crash investigation...??

Ok let's go through the motions and cut to the chase of AAIR199301743 i.e. the Safety Actions section:
4. SAFETY ACTIONS

4.1 Interim Recommendations

During the course of this investigation a number of Interim Recommendations were made.

The IR documents included a ‘Summary of Deficiency’ section in addition to the actual interim recommendation. The texts of the interim recommendations are detailed below, with each IR commencing with its BASI reference number. The pertinent comments from the CAA
in response to the recommendations are also reproduced.

IR930214: The Bureau of Air Safety Investigation recommends to the Civil Aviation Authority that when an operator requests the issue of a Permissible Unserviceability to continue flight operations with inoperative equipment listed as an MEL item, then the terms of the Permissible Unserviceability should provide an extension of all MEL conditions for a specified period.

CAA response:
The recommendation reflects CAA policy. The Authority does not accept the finding in paragraph 5 of the Summary of Deficiency in that the Permissible
Unserviceability could be read as permitting “continued operations with a
significantly reduced level of safety (ie autopilot components removed) than that provided by the Minimum Equipment List”.


IR930223: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority;
1. Review the need for approved maintenance controllers to hold maintenance qualifications appropriate to the position,
2. Restrict persons acting in the position of maintenance controller from acting in other positions that will detract from their ability to adequately perform their maintenance controller duties, and,
3. Review the need to limit periods of validity for certain approvals, such as
maintenance controller, and renew such approvals only when specified criteria are met which demonstrate adequate performance.

The CAA response in part stated:
Interim Recommendation 1 : The Authority has reviewed the need for maintenance controllers to hold maintenance qualifications and we have concluded that this is neither necessary or appropriate. It is essential that anyone approved as a maintenance controller has the ability to plan and co-ordinate maintenance activities but this does not extend to being qualified to carry out the actual work. The Authority believes this would be an unnecessary imposition on industry.
Interim Recommendation 2 and 3 : The Authority agrees in principle and these matters are being addressed.

IR930224: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority reviews its procedures in respect to the issuing of Air Operators Certificates. This review should be conducted with a view to restricting the validity of Air Operators Certificates to a specified period, with the AOC renewal to depend on the operator’s previous performance and the demonstrated capacity of the operator to continue to meet the relevant standards specified in the CAA Manual of Air Operators Certification.

The CAA response in part stated:
While it has been Authority practice in the last few years to issue “open ended” AOCs, recent legal opinion advises that the Authority should issue AOCs for a finite period.


BASI comment:
The CAA “Aviation Bulletin” dated February 1994, states that AOCs issued
without a specific period of validity will have to be renewed on 1 July 1994, with all re-issued AOCs being of a fixed term.

IR930231: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review:
(a) the adequacy of instructions to flight crew for maintaining a safe height
above terrain at night.
(b) the phraseology used in AIP/DAPS IAL 1.5 with a view to making it less
susceptible to misinterpretation.

The CAA response in part stated:
The Authority believes that the requirements for descent below MDA specified in AIP DAPS IAL 1.5 are clearly enunciated and notes that it is more comprehensive than the guidance provided in ICAO documentation or by either the UK or USA.
The Authority will be monitoring more closely the conduct of Instrument Rating Tests and renewals to ensure that where incorrect training is occurring that it is corrected. The subject will also be covered by an educational article in Aviation Bulletin.


Further BASI correspondence to the CAA stated:
The Bureau believes that the DAPS IAL 1.5 ‘Note 1’ does not adequately describe where visual reference must be maintained. To achieve the required obstacle clearance along the flight path it would follow that visual reference must be maintained along that path. Note 1 specifies that ‘visual reference’ means in sight of ground or water, however it does not specify where this ground or water is to be. The Bureau believes that visual reference to ground or water directly along the aircraft’s flight path must be maintained and recommends that Note 1 be expanded to state that ‘visual reference’ means clear of cloud, in sight of ground or water along the flight path and with a flight visibility not less than the minimum specified for circling.

The CAA response in part stated:
There is no objection to the addition of the words “along the flight path” to note 1 as you suggest, and this will be done as part of the next AIP amendment.


IR930234: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review the obstacle terrain guidance information provided for flight crew in ‘other than high capacity RPT operations’. This review should ensure that flight crew have adequate knowledge of the terrain associated with the route flown, including the obstacle terrain information for non-precision and circling approaches.

The CAA responses state in part:
CAR 218 (1) (C) details the qualifications required of a pilot conducting RPT
operations, regardless of whether high or low capacity aircraft are involved. This includes knowledge of the terrain at the aerodromes to be used. This knowledge is normally acquired by conducting the flight required by CAR 218 (1) (b) supplemented by pre and inflight briefings.

The requirement to avoid obstacles by 300 feet is to be complied with using visual reference only, i.e. the pilot must be able to ensure all obstacles lit or unlit are avoided visually. At night this may not be possible. Thus the pilot may only be able to descend when he is aligned with the landing runway and able to use the documented obstacle limitation surface, and,
The CAA will review the practices of other authorities in respect to the provision of terrain information on instrument approach charts with a view to determining whether our current practices need to be changed.


IR930244: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. review the current rates of surveillance to determine whether the target levels of the Annual Surveillance and Inspection Program detailed in the MAOC are being met for all RPT AOC holders; and
2. review the adequacy of the Annual Inspection and Surveillance Program in
the MAOC for RPT AOC holders.

CAA Response:
The Authority notes your recommendations and advises that a review of the Annual Surveillance and Inspection Program is currently being conducted.


4.2 Final Recommendations
With the conclusion of the investigation into this occurrence, the following final recommendations are now made:

R940181: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:
1. develop a system for CAA officers to advise DASR of known adverse financial situations of AOC holders;
2. ensure that surveillance and inspection action responds to reported adverse financial situations of AOC holders with particular reference to their ability to conduct safe operations; and
3. develop a system to provide an ongoing assessment of the safety health of AOC holders as part of routine surveillance activities.

R940182: The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority implement as a matter of urgency the ICAO PANS-OPS requirement for an instrument approach procedure which provides for a straight-in approach aligned with the runway centreline at all possible locations.

4.3 Safety Advisory Notice
The following Safety Advisory Notice is issued:
SAN940184: The Bureau of Air Safety Investigation suggests that the CAA review the final outcome of the United States National Transportation Safety Board 1994 study of commuter airline safety with a view to assessing the applicability to the Australian industry of the findings and recommendations.
Note: For those interested in the NTSB 1994 study report mentioned above here is a link: NTSB Commuter Airline Study


It is also worth noting that the Monarch Airlines crash at Young was extensively referred to in the very comprehensive Regional Airline Safety Study released by BASI in 1999. A further point is that in that safety study report R940181 (mentioned above) was further highlighted/reviewed by BASI. Although where the recommendation ended up is anyone's guess....as the ATsB internet database records no longer go that far back...

So UITA please explain to me how the Monarch BASI report is as defective/useless as per the ATsBeaker version of reporting these days...
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Old 26th Jan 2014, 18:06
  #105 (permalink)  
 
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LL 1 – UITA 0.

Sarcs # 118 –" [&] subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one.
Not only with LL, but with CAA this time. Some of the BASI IR are bumptious and have the potential to create more red tape with little increased safety value. Was there (from memory) some fairly heavy political heat surrounding this event?, can't remember – anyone?.

Seems the BASI boys back then at least remembered what accident investigation meant, can't see the Monarch investigators leaving an aircraft in the ocean of not recovering the CVR/FDR equipment.

Australia is a signatory to the Convention on International Civil Aviation (Chicago 1944), which established the International Civil Aviation Organisation. Article 26 of the Chicago Convention obligates the governments of countries that are signatories to the Convention to conduct investigations into aircraft accidents in their territories which involve specific aircraft from other countries which are signatories to the Convention. Article 37 (k) of the Convention recommends that, as far as the law of individual countries permit, member countries should adopt uniform international standards and practices for aircraft accident investigation. The international standards and practices for aircraft accident investigation are described in Annex 13 to the Convention.
Australia has given domestic legal effect to its international obligations under the Convention by incorporating the articles of the Convention within the Air Navigation Act of 1920. Part XVI of the Air Navigation Regulations (ANRs) of that Act provides the legal authority for the Secretary of the Commonwealth Department of Transport to require the investigation of aircraft accidents and incidents occurring within Australia. The authority to conduct aircraft accident and incident investigations is delegated by the Secretary to the Director and other designated officers of the Bureau of Air Safety Investigation.

Australia has by historical practice applied the standards and practices of Annex 13 to all aircraft accident and incident investigations. In doing so, the fundamental objective of the investigation is the prevention of aircraft accidents and incidents.

In accordance with the principles of Annex 13, it is not the purpose of this activity to apportion blame or liability. The sole purpose of the Bureau’s operations is the maintenance and enhancement of flight safety.
It seems to me the 1993 statement below has a repetitive sound: May 7, 2005 qualified and prompted the renamed ATSB to finaly produce their CFIT report. The Monarch CFIT occurred in 1993

The investigation found that the circumstances of the accident were consistent with controlled flight into terrain. Descent below the minimum circling altitude without adequate visual reference was the culminating factor in a combination of local contributing factors and organisational failures. The local contributing factors included poor weather conditions, equipment deficiencies, inadequate procedures, inaccurate visual perception, and possible skill fatigue. Organisational failures were identified relating to the management of the airline by the company, and the regulation and licensing of its operations by the Civil Aviation Authority.
Pages 27 to 28 provide the FOI statement which are worth reading and some consideration.
He said at no stage was he aware that VH-NDU was being operated with the RMI and HSI inoperative. If he had known he would have stopped the operation.
To my mind, if the FOI would have known and stopped the operation, then CP who did know all about the equipment situation should not have authorised the flight.

In fairness, I can't see what CAA or BASI could have done more than they did; the FOI statement seems to be 'fair and reasonable'. The CAA response seems to be plausible, if anything for my two bob's worth, the BASI seem to be playing the CAA bashing game just a little too loudly if anything. There is a lot of post event 'posturing' and bum covering going on, but page 30 gives you the clues.

A letter to cancel the approval of the Chief Pilot was subsequently prepared but not sent, as he resigned from that position on 17 May 1993. A new Chief Pilot was approved on the same day.
Memories faded now, but it seems to me this CP eventually ended up working for CASA and has aspired to some 'senior' position, but don't bet the house on that; it was a long time ago.

The chronology starting at page 31 is worth half a coffee and, for me more clearly defines the issues; but here again, the retrospective analysis shows what should have been done before hand; but there are few 'cures' initiated to reduce the probability of this reoccurring again, 10+ years later, in 2005 at Lockhart River. Bad response all around – Yes; poor BASI report – No.

Check paragraphs 1.19.4 (p 36) and 1.19.8 (p 40) valuable in 1993 priceless in 2004. In fact, when you get down to 1.20 (p 41) there is some very good informative data. No, (IMO) we need to remove Monarch from the list of poor investigation.

Last edited by Kharon; 26th Jan 2014 at 18:20.
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Old 26th Jan 2014, 20:20
  #106 (permalink)  
 
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While you are reading the Monarch report again UITA you might also like to get a hold of James Reasons book where he goes into a fair bit of detail on why the Monarch investigation was an excellent example of an organizational accident.

As I suspected you still haven,t explained why Monarch is on your list other than for reasons of hysteria and bias. The other issue is the discussion about how good accident investigation was in this country when Rob Lee and Alan Stray were at the helm. Monarch occurred under their watch so you can,t have it both ways. The investigation was either conducted by two very competent investigators or you are full of hot air?
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Old 27th Jan 2014, 02:16
  #107 (permalink)  
 
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It's a curiosity.

Just thinking out loud here, but this quote from the then BASI, morphed into ATSB had real relevance in 1993.

The investigation found that the circumstances of the accident were consistent with controlled flight into terrain. Descent below the minimum circling altitude without adequate visual reference was the culminating factor in a combination of local contributing factors and organisational failures. The local contributing factors included poor weather conditions, equipment deficiencies, inadequate procedures, inaccurate visual perception, and possible skill fatigue. Organisational failures were identified relating to the management of the airline by the company, and the regulation and licensing of its operations by the Civil Aviation Authority.
The same quote would have applied equally well to Lockhart in 2004 and it's not too long a stretch to apply it to Pel Air. The thing is, (IMO) the change in the ATSB attitude, they fought like hell during Lockhart to make the same point and got stuck with Miller and MOU for their pains, the ANA was side stepped and CASA slowly but surely gained the upper hand. It does not seem to be too outlandish to suggest that by the time PA came up (or went down, as you like) the ATSB had just about given up the uneven battle, beaten down by money, power and ever increasing political clout of the CASA. Just a Sunday thought on a lazy Monday, to idle to dig out the research, but the dots seem to join up OK.

Back to the BBQ, RDO should not be spent banging away on PPRuNe, anyway the snags are on fire.
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Old 27th Jan 2014, 05:30
  #108 (permalink)  
 
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Nice thought bubble Kharon. Monarch was the first aircraft accident investigation that included organizational issues as contributing factors. It's why Reason includes it as a case study in the book "Managing the Risks of An Organisational Accident". Unfortunately the ATSB have taken it as a methodology rather than as a model which is what Reason himself was horrified by.

Since Lockhart the ATSB has indeed had its independence compromised to the point that it's reports are more "touchy feely" than inciteful. CASA has unfortunately won the battle of politics, money and power. None of which will change under the current leadership.
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Old 28th Jan 2014, 00:42
  #109 (permalink)  
 
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The tragedy of Flight 301.

There's the chilling lesson, as detailed in the BASI report, that Australia cannot afford to follow the example of other nations where dollars are more important than life. There's also the sad reminder that the seven deaths accounted for about one third of the 23 deaths in our skies last year.


Plane Deaths A Costly Reminder To Heed Warning Signs


Since 1993 we appear not to have heeded this advice in that red tape is stifling the industry and grinding it into insolvency. People still try to save their business while the regulator tries to ruin them. The cost is enormous in time, money and lives.


I personally see these similarities with the prior mentioned tragedies.

Last edited by Frank Arouet; 28th Jan 2014 at 00:52. Reason: link to story.
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Old 28th Jan 2014, 03:24
  #110 (permalink)  
 
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. . . . . . . and now we await some sign that the Abbott government will more than take note of the last year's Senate Inquiry findings. Be moved to implement key recommendations of that Inquiry, from Senator Fawcett et al. The pundits on p prune seem to be saying "fat chance".
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