ATSB reports
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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.
Bumping up the numbers or is Beancounter Beaker a genius??
To be fair to the ATSB the two (best described as desktop investigations) ****e 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)
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)
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!'
"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!'
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I have to agree with T28D, although he is being generous with the hour. Much was a copy and past exercise of others work.
Hang on a minute, can I rewrite this in under 5 minutes and let ppruners be the judge of whether my version would make a better conclusion.
When the insurance assessor arrived on site, the helicopter engine was started and performed without fault. No fuel contamination was found. Other than the damage sustained in the accident, the helicopter was reported to have been well maintained and in excellent condition.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.
At the time of the accident, the conditions conducive to carburettor icing existed, and despite the popular myth than an engine will run rough, this is not true if the Fuel/Air ratio's are consistent across all cylinders and simply the engine power is reduced due to a significant loss in mass air flow to the engine.
Safety message to pilots: At the onset of a power loss and noting the insufficient carburettor heat by indication of the instrument, if the non normal state is unexplained, (i.e. heat was applied but instruments show otherwise) treat the instruments as correct and suspect an imminent engine failure, take appropriate measures immediately. Do not continue the flight until the anomaly is resolved.
Safety message to engineers, and pilots: Know your systems and the critical nature of certain elements and ensure they are 100% functional. Trust your instruments
Took 5-10 minutes, and perhaps provides a better safety message.
Another waste of a report, and possibly only achieves one thing, KPI's. Attribution to AKRO
When the insurance assessor arrived on site, the helicopter engine was started and performed without fault. No fuel contamination was found. Other than the damage sustained in the accident, the helicopter was reported to have been well maintained and in excellent condition.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.
When the insurance assessor arrived on site, the helicopter engine was started and performed without fault. No fuel contamination was found. Other than the damage sustained in the accident, the helicopter was reported to have been well maintained and in excellent condition.
The insurance assessor considered that the weather conditions were an incipient cause of the incident. At the time, the temperature and dew point indicated a risk of serious carburettor icing. The pilot reported that he would have expected the engine to run roughly if carburettor icing was present.
At the time of the accident, the conditions conducive to carburettor icing existed, and despite the popular myth than an engine will run rough, this is not true if the Fuel/Air ratio's are consistent across all cylinders and simply the engine power is reduced due to a significant loss in mass air flow to the engine.
Safety message to pilots: At the onset of a power loss and noting the insufficient carburettor heat by indication of the instrument, if the non normal state is unexplained, (i.e. heat was applied but instruments show otherwise) treat the instruments as correct and suspect an imminent engine failure, take appropriate measures immediately. Do not continue the flight until the anomaly is resolved.
Safety message to engineers, and pilots: Know your systems and the critical nature of certain elements and ensure they are 100% functional. Trust your instruments
Took 5-10 minutes, and perhaps provides a better safety message.
Another waste of a report, and possibly only achieves one thing, KPI's. Attribution to AKRO
Thread Starter
Jaba
You forgot to add..."when in doubt about weather conditions or other operational considerations, call your local insurance representative"
Unbelievable.
What's the bet the insurance assessor is ex CASa or BASI and left because he got sick of the young preppies that didn't know anything.
You forgot to add..."when in doubt about weather conditions or other operational considerations, call your local insurance representative"
Unbelievable.
What's the bet the insurance assessor is ex CASa or BASI and left because he got sick of the young preppies that didn't know anything.
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atsb - Reports
Finally..only took 27 months!!
Not too many surprises there I guess??
It is interesting that the ATSBeaker have issued yet another SR (AO-2011-102-SR-59)to Fort Fumble, that would be 5 for 2013. Considering prior to March (refer here: Safety Recommendations for 2013) there was only one SR issued to FF within the last 5 years, that is somewhat of a world record for ATSBeaker.
Speaking of Beaker just heard him mi..mi..mi-ing on the wireless
talking about that particular SR (above)...hmm wonder if he is aware the two mentioned in my previous post have expired???
It is interesting that the ATSBeaker have issued yet another SR (AO-2011-102-SR-59)to Fort Fumble, that would be 5 for 2013. Considering prior to March (refer here: Safety Recommendations for 2013) there was only one SR issued to FF within the last 5 years, that is somewhat of a world record for ATSBeaker.
Speaking of Beaker just heard him mi..mi..mi-ing on the wireless
talking about that particular SR (above)...hmm wonder if he is aware the two mentioned in my previous post have expired???
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!'
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!'
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Nice pick up Sarcs. No doubt Beaker is churning out the work knowing for several months now that his mi mi mi empire would end up coming under the spotlight. I'm still looking forward to the Canadians releasing the results of their review next year. Not sure why though as nothing will get done with the findings.
It will be interesting to see the outcome of Truss's initiative next year with the 'independent' review. No doubt the report will be handed to the minister in which the government will respond to each recommendation with 'the government acknowledges that recommendation'. The usual carefully crafted responses in which the government doesn't actually agree to implement any changes, it just acknowledges that changes have been recommended.
Political school of bull**** 101.
Time will tell, but none of this would have been made possible without the growing number of IOS (and don't forget that Mr Truss's international panel of experts will themselves receive the opportunity to earn an honorary place among the IOS), or without the savvy Senators who have refused to allow polish to be applied liberally to the turd.
I would recommend that the review panel spend time with the good Senators and discuss the mystique of Australian aviation with them. I suggest Senator Nash's office, that way they can meet pot plant Pete.
It will be interesting to see the outcome of Truss's initiative next year with the 'independent' review. No doubt the report will be handed to the minister in which the government will respond to each recommendation with 'the government acknowledges that recommendation'. The usual carefully crafted responses in which the government doesn't actually agree to implement any changes, it just acknowledges that changes have been recommended.
Political school of bull**** 101.
Time will tell, but none of this would have been made possible without the growing number of IOS (and don't forget that Mr Truss's international panel of experts will themselves receive the opportunity to earn an honorary place among the IOS), or without the savvy Senators who have refused to allow polish to be applied liberally to the turd.
I would recommend that the review panel spend time with the good Senators and discuss the mystique of Australian aviation with them. I suggest Senator Nash's office, that way they can meet pot plant Pete.
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No more spinning – I'm dizzy.
Well, in all probability, the pilot probably stacked the chopper, we probably should have sent the insurance investigator (QBE 1) who would have probably made it probable that the chopper was probably pranged. But no matter CASA will probably redefine "probable darkness" and all will probably be well. But it's probable that we have conned the ABC, probably shut down the probability of bad press, which cannot in any probable cause case, end up with my resignation.
Long live short reports, long waits and great KPI bonuses. Thank the gods for the remote control button, new TV's are expensive.
Mi Mi "That's a great relief, glad we have the beyond reason probability model and a simpering nodding interviewer who probably swallowed the guff".
Last edited by Kharon; 14th Nov 2013 at 19:08. Reason: Manfully ignoring the "pukey' icon, that's why.
Linking the links i.e. accident(s) causal chains (back to reason)!
Having now read the report (AO-2011-102), scrolled through numerous media articles and video coverage, including the ABC 7:30 report (Report on ABC helicopter crash urges overhaul of regulations), I'm quite disturbed by some very interesting parallels coupled with some déjà vu(flashbacks) to episodes in the Senate Inquiry and previous Senate Estimates.
{Note: The 7:30 vid is well worth watching but warning you'll have to put up with large sections of Beaker fumbling along mi..mi..mi-ing. However it is not quite as bad as his appearances at the Senate inquiry/Estimates or the 'head buried in the sand' interview on 4 corners..see here- 4C Beaker interview}
So for a setting the scene here's a quote from the 7:30 Report transcript(my bold):
This is where the neurons started pinging around, so I then referred to the report and in particular Appendix F – Accidents involving night VFR operations. In table F1 (halfway down the page) there was this entry:
17 Oct 2003
200304282
Bell 407 helicopter, VH-HTD, aerial work (emergency medical services) en route from Mackay to Hamilton Island, Qld. Loss of control en route. Dark night conditions. 3 POB, all fatally injured.
It was then that it all started to gel and drew my attention to a recent post from PAIN post #34 , that linked to some working notes and this is where it gets interesting, from the PAIN notes:
Ok so if you then download the 2003 ATSB report (link above) and put that report alongside the AO-2011-102 report you will see some remarkable parallels..especially in the areas that deal with spatial disorientation and in the Safety Actions/Recommendations section (pg 71 onwards from 2003 report).
{Hmm..kind of makes you wonder why the ATSBeaker needed to rely on the United States Army Aeromedical Research Laboratory when they had already done the hard work back in 2003.}
On a final note here is a quote from the PAIN working notes from Coroner Henessy's findings/recommendations:
Starting to join the dots?? More to follow..Sarcs (K2)
Addendum:
CASA SRs for AO-2011-102: AO-2011-102-SI-02 , AO-2011-102-SI-03
CASA SRs for air200304282: R20040053,R20050002, R20010195, R20030213.
Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker...27 months was it??
{Note: The 7:30 vid is well worth watching but warning you'll have to put up with large sections of Beaker fumbling along mi..mi..mi-ing
. However it is not quite as bad as his appearances at the Senate inquiry/Estimates or the 'head buried in the sand' interview on 4 corners..see here- 4C Beaker interview} So for a setting the scene here's a quote from the 7:30 Report transcript(my bold):
PHILIPPA MCDONALD: The crash and subsequent fire was so intense that Air Transport Safety investigators feared they'd never determine exactly what happened. But an intense two-year forensic investigation uncovered far more than ever anticipated, with vital information provided by the United States Army Aeromedical Research Laboratory.
MARTIN DOLAN: One of the key things they did for us was to feed into some modelling of human perception the flight data that we had for this flight which showed that the sort of increasing bank associated with this helicopter and this accident would probably until very late in the stage not have been detectable without visual reference or without reference to instruments.
PHILIPPA MCDONALD: Investigators believe the pilot experienced what's called spatial disorientation. In the dark of night, with no visible horizon, he couldn't recognise the chopper's spiralling descent in time to recover.
Fellow chopper pilot and friend, David Wilson, knows how spatial disorientation can unhinge the senses.
DAVID WILSON, CHANNEL NINE PILOT: I don't think there'd be a pilot out there today who couldn't say he has never suffered from spatial disorientation. It's a matter of firstly recognising it and then doing something about it because it fights all your senses. You think you're sitting bolt upright, whereas you're actually leaning at 45 degrees.
PHILIPPA MCDONALD: Gary Ticehurst was considered one of the nation's best helicopter pilots and was qualified to fly under the conditions that night. But the Australian Transport Safety Bureau says this tragedy shows aviation regulations need to be tightened.
MARTIN DOLAN: We're saying we're not sure that flight in dark-night conditions, that the standards of safety are necessarily at the level they should be and we're asking the Civil Aviation Safety Authority to take a close look at that.
PHILIPPA MCDONALD: The Civil Aviation Safety Authority says things will change. In future, all helicopters flying at night with passengers will have to be fitted with an autopilot or have a two-pilot crew.
MARTIN DOLAN: One of the key things they did for us was to feed into some modelling of human perception the flight data that we had for this flight which showed that the sort of increasing bank associated with this helicopter and this accident would probably until very late in the stage not have been detectable without visual reference or without reference to instruments.
PHILIPPA MCDONALD: Investigators believe the pilot experienced what's called spatial disorientation. In the dark of night, with no visible horizon, he couldn't recognise the chopper's spiralling descent in time to recover.
Fellow chopper pilot and friend, David Wilson, knows how spatial disorientation can unhinge the senses.
DAVID WILSON, CHANNEL NINE PILOT: I don't think there'd be a pilot out there today who couldn't say he has never suffered from spatial disorientation. It's a matter of firstly recognising it and then doing something about it because it fights all your senses. You think you're sitting bolt upright, whereas you're actually leaning at 45 degrees.
PHILIPPA MCDONALD: Gary Ticehurst was considered one of the nation's best helicopter pilots and was qualified to fly under the conditions that night. But the Australian Transport Safety Bureau says this tragedy shows aviation regulations need to be tightened.
MARTIN DOLAN: We're saying we're not sure that flight in dark-night conditions, that the standards of safety are necessarily at the level they should be and we're asking the Civil Aviation Safety Authority to take a close look at that.
PHILIPPA MCDONALD: The Civil Aviation Safety Authority says things will change. In future, all helicopters flying at night with passengers will have to be fitted with an autopilot or have a two-pilot crew.
17 Oct 2003
200304282
Bell 407 helicopter, VH-HTD, aerial work (emergency medical services) en route from Mackay to Hamilton Island, Qld. Loss of control en route. Dark night conditions. 3 POB, all fatally injured.
It was then that it all started to gel and drew my attention to a recent post from PAIN post #34 , that linked to some working notes and this is where it gets interesting
, from the PAIN notes: 1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003.
Report - R20050002.
Issue date 14 March 2005.
http://www.atsb.gov.au/media/24411/a...304282_001.pdf
Recommendation R20050002
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS
operations.
Report - R20050002.
Issue date 14 March 2005.
http://www.atsb.gov.au/media/24411/a...304282_001.pdf
Recommendation R20050002
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS
operations.
ATSB Safety Recommendation.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2)
operational procedures and (3) minimum equipment for conduct of such operations at night.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2)
operational procedures and (3) minimum equipment for conduct of such operations at night.
{Hmm..kind of makes you wonder why the ATSBeaker needed to rely on the United States Army Aeromedical Research Laboratory when they had already done the hard work back in 2003.}
On a final note here is a quote from the PAIN working notes from Coroner Henessy's findings/recommendations:
16. The Coroner supports CASR draft regulations point 61 and 133 becoming final.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.
More to follow..Sarcs (K2)Addendum:
CASA SRs for AO-2011-102: AO-2011-102-SI-02 , AO-2011-102-SI-03
CASA SRs for air200304282: R20040053,R20050002, R20010195, R20030213.
Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker...27 months was it??
Last edited by Sarcs; 16th Nov 2013 at 22:20. Reason: Addendum: SR Links
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casa is out of touch with the Aviation Industry and so is mccormick
Good brief sarcs.
The following is the history of the PART 133 [seven years have passed in this one, since the atsb SR] and still not complete, yet casa are loading the industry with a bunch of rubbish regs in this process:
CASR Part 133 – Australian air transport operations - rotorcraft -
Consultation history
Consultation updates in 2012 CASR Part 133 - Consultation Draft of CASR Part 133 - Australian Air Transport Operations - Rotorcraft Comments now closed.
26 Jun 2012 Briefing on CASR Part 133 - May 2012 Updated briefing on CASR Part 133 - May 2012
17 May 2012 Consultation updates in 2009 NPRM 0811OS - Passenger Transport Services, International Cargo and Heavy Cargo (above 8640kgs MTOW) - Rotorcraft This NPRM is now available.
6 May 2009 Consultation updates in 2008 NPRM 0807OS - Passenger Transport Services: terminology in and application of new CASR Parts 119, 121, 129, 131, 133 and 135 This NPRM closed for comment on 6 February 2009.
11 Dec 2008 Consultation updates in 2003 NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft has been published. Your comments are invited by 30 May 2003.
27 Mar 2003 Consultation updates in 2002 MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft Draft Chapter 11 titled Airworthiness and Maintenance Control to Manual of Standards - MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft, has been published. Your comments are invited.
6 Aug 2002 Consultation updates in 2001 New technical working draft regulations for CASR 133 maintenance aspects CASR Part 133 maintenance aspects of the regulations have been developed and are available for review.
18 Oct 2001 Consultation updates in 2000 DP 0006OS - Commercial Air Transport Operations — Rotorcraft DP 0006OS - Commercial Air Transport Operations — Rotorcraft response period has been extended to close on 31 January 2001.
6 Dec 2000 DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft has been published. Your comments are requested by 8 December 2000.
And still not finished
From the atsb site:
Recommendation issued to: Civil Aviation Safety Authority
Output No: R20050002 Date issued: 14 March 2005 Safety action status:
The following is the history of the PART 133 [seven years have passed in this one, since the atsb SR] and still not complete, yet casa are loading the industry with a bunch of rubbish regs in this process:
CASR Part 133 – Australian air transport operations - rotorcraft -
Consultation history
Consultation updates in 2012 CASR Part 133 - Consultation Draft of CASR Part 133 - Australian Air Transport Operations - Rotorcraft Comments now closed.
26 Jun 2012 Briefing on CASR Part 133 - May 2012 Updated briefing on CASR Part 133 - May 2012
17 May 2012 Consultation updates in 2009 NPRM 0811OS - Passenger Transport Services, International Cargo and Heavy Cargo (above 8640kgs MTOW) - Rotorcraft This NPRM is now available.
6 May 2009 Consultation updates in 2008 NPRM 0807OS - Passenger Transport Services: terminology in and application of new CASR Parts 119, 121, 129, 131, 133 and 135 This NPRM closed for comment on 6 February 2009.
11 Dec 2008 Consultation updates in 2003 NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft NPRM 0301OS - Air Transport and Aerial Work Operations - Rotorcraft has been published. Your comments are invited by 30 May 2003.
27 Mar 2003 Consultation updates in 2002 MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft Draft Chapter 11 titled Airworthiness and Maintenance Control to Manual of Standards - MOS Part 133 - Air Transport & Aerial Work Operations - Rotorcraft, has been published. Your comments are invited.
6 Aug 2002 Consultation updates in 2001 New technical working draft regulations for CASR 133 maintenance aspects CASR Part 133 maintenance aspects of the regulations have been developed and are available for review.
18 Oct 2001 Consultation updates in 2000 DP 0006OS - Commercial Air Transport Operations — Rotorcraft DP 0006OS - Commercial Air Transport Operations — Rotorcraft response period has been extended to close on 31 January 2001.
6 Dec 2000 DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft DP 0006OS - Commercial Air Transport and Aerial Work Operations - Rotocraft has been published. Your comments are requested by 8 December 2000.
And still not finished
From the atsb site:
Recommendation issued to: Civil Aviation Safety Authority
Output No: R20050002 Date issued: 14 March 2005 Safety action status:
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Post of the year award.
Can someone make sure the idiot reporters at the ABC get a copy of Sarcs # 53 where he does their job for them, properly and almost writes their story. What a sorry tale ABC investigative journalism makes, how sad that our national "razor sharp" press cannot research and develop a story that is very much in the nations interest. Why would they bother, it's probably more self indulgent and PC to publicly weep and wail over a lost comrade, rather than to try to understand why he's dead, why the ATSB and CASA are full of it and why entire industry is seriously pissed off. Wakey wakey Aunty....
I'll stick my neck out and say that the Sarcs post more clearly defines, in one page the need for reform than all the bloody awful polly chatter, CASA waffle and ATSB probability statements ever printed. Nicely played Sarcs, please accept my vote for the post of the year award. Bravo......Indeed, well done sirrah.
I'll stick my neck out and say that the Sarcs post more clearly defines, in one page the need for reform than all the bloody awful polly chatter, CASA waffle and ATSB probability statements ever printed. Nicely played Sarcs, please accept my vote for the post of the year award. Bravo......Indeed, well done sirrah.
Captain 49'er & Beaker's Pink Elephant insulation scheme cont/-
Aw shucks "K"..
but..but..but I'm not finished yet!!
From the Hansard Rural and Regional Affairs and Transport Legislation Committee 23/05/2012 Estimates (my bold):
History will show that the 'Machiavellian One' completely obfuscated the good Senator's question until it was lost in all the 'white noise' of politics and parliamentary process.
That is of course until it was (in part) brought up again in the PelAir inquiry. The committee, with all available evidence presented, considered this enough of a 'significant safety issue' that they wrote no less than 5 recommendations to adequately address:
The crash of VH-NTV provides the perfect example of why the PelAir report should not and cannot be flippantly ignored..10 years of procrastination and no lessons learnt!
The DAS & Chief Commissioner have closed the loop alright, they've closed the loop so that we are insulated from the rest of the world. How many more clearly preventable deaths will there be while these type of individuals continue to bluff the community with the mystique of aviation safety?? TICK..TOCK!
but..but..but I'm not finished yet!!From the Hansard Rural and Regional Affairs and Transport Legislation Committee 23/05/2012 Estimates (my bold):
Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?
Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.
Senator FAWCETT: Who should have that role then?
Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.
Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?
Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.
Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?
Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.
Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?
Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.
Senator FAWCETT: Thank you.
Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.
Senator FAWCETT: Who should have that role then?
Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.
Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?
Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.
Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?
Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.
Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?
Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.
Senator FAWCETT: Thank you.
That is of course until it was (in part) brought up again in the PelAir inquiry. The committee, with all available evidence presented, considered this enough of a 'significant safety issue' that they wrote no less than 5 recommendations to adequately address
:
Recommendation 17
9.18 The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.
Recommendation 18
9.40 The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.
Recommendation 19
9.42 The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.
Recommendation 20
9.44 The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.
Recommendation 21
9.45 The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
9.18 The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.
Recommendation 18
9.40 The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.
Recommendation 19
9.42 The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.
Recommendation 20
9.44 The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.
Recommendation 21
9.45 The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
The DAS & Chief Commissioner have closed the loop alright, they've closed the loop so that we are insulated from the rest of the world. How many more clearly preventable deaths will there be while these type of individuals continue to bluff the community with the mystique of aviation safety??
TICK..TOCK!
Addendum to post #44
Better late than never I guess??
Regulatory requirements for class B aircraft maintenance
Correspondence
Date received:11 November 2013
Response from:Civil Aviation Safety Authority
Response status:Monitor
Response text:With regard to Recommendation AO-2011-115-SR 050 you have recommended that CASA address the safety issue that the Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer's maintenance schedule exists.
You remain concerned that this safety issue may not be adequately addressed and have issued the recommendation that CASA proceed with our program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type.
I accept this recommendation and CASA will address this issue, work has commenced and again it will involve consultation with industry. As this is likely to be a protracted process; CASA is not in a position to specify a specific completion date at this time.
ATSB action in response:The ATSB recognises the acceptance of the recommendation by CASA. The ATSB will continue to monitor the ongoing work by CASA until the issue has been satisfactorily addressed.
Regulatory requirements for class B aircraft maintenance
Correspondence
Date received:11 November 2013
Response from:Civil Aviation Safety Authority
Response status:Monitor
Response text:With regard to Recommendation AO-2011-115-SR 050 you have recommended that CASA address the safety issue that the Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer's maintenance schedule exists.
You remain concerned that this safety issue may not be adequately addressed and have issued the recommendation that CASA proceed with our program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type.
I accept this recommendation and CASA will address this issue, work has commenced and again it will involve consultation with industry. As this is likely to be a protracted process; CASA is not in a position to specify a specific completion date at this time.
ATSB action in response:The ATSB recognises the acceptance of the recommendation by CASA. The ATSB will continue to monitor the ongoing work by CASA until the issue has been satisfactorily addressed.
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Sarcs, your post addendum to #44 had me vomiting over the floor and hiding my head ashamedly from public view. That dual response is nothing short of embarrassing, pathetic, and an outward statement of 'we have done bugger all, intend to do bugger all, so you can all bugger off'.
If that is the best that the CAsA and ATSBeaker have to offer then we are overwhelmingly in deep sh#it.
If that is the best that the CAsA and ATSBeaker have to offer then we are overwhelmingly in deep sh#it.
With regard to Recommendation AO-2011-115-SR 050 you have recommended that CASA address the safety issue that the Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer's maintenance schedule exists.
Whoever made and supports that recommendation obviously had and have no clue what the CASA maintenance schedule and manufacturers’ maintenance schedules actually contain and require, in the context of the regulatory framework of which they are part.
