ATSB reports

[Kharon]

Probably - he just likes to watch.

Estimates Hansard – 18/11/13. P.71 PDF - P. 67 Hansard.(My bold)

Senator FAWCETT: You recently released a report about the crash of the ABC helicopter, which I commend you for. I am a little disturbed when I look back at the report about the helicopter that crashed off the Queensland coast some years ago—basically it was a controlled flight into water, with the understanding that there had been disorientation. Very similar recommendations came out of that in terms of changing the regulations to look at either augmentation of stability systems or two crew, et cetera. What gives you confidence that we will see action in response to this latest report when clearly nothing occurred in response to your last report?

Here is where the pictures were brilliant – Now, I don't know whether the poor man had wind, or if the bloke alongside has just let rip. But I got a top screen shot of his face, (I regret NFP here). The print, now a glossy, framed 8" x 10" is hanged (yes) behind the bar of the BRB favourite water hole; priceless. But I digress:-

Mr Dolan: What gives us increased confidence is that Civil Aviation Safety Regulation part 133 is almost in place and involves for passenger carrying air transport operations a requirement for an autopilot in helicopters.

Mr Dolan: Not under the regulations as they stood at the time, but we are also advised by CASA that they are going to redefine the classification of operations, particularly in relation to aeromedical work. We agree. In 2004 we made a recommendation in relation to autopilots for a range of helicopter activities, not just passenger transport. We will continue to watch to ensure that the intent of that recommendation is met through the regulations CASA is putting into place.

Senator FAWCETT: Sure. As I, hopefully, indicated at the start, I fully support your indication; having flown unaided and aided, I can see that there is clearly a safety benefit in that. My concern is that good intentions did not fix it from 2004 and good intentions will not fix it now. I am interested in what concrete actions ATSB are going to take to try to bring either to CASA or to your secretary or the minister an awareness of where these gaps are such that we achieve a safe outcome.

Mr Dolan: Our starting point will be CASA's response to that particular investigation report on the ABC helicopter you are talking about. We certainly want to understand better the new CASA part 133 and what that means not just for passenger operations but more broadly. Depending on what happens with that, the commission reserves the right to make recommendations after receiving responses from various organisations, but we do not have any power to direct any organisation. We only have the power to recommend.

Senator FAWCETT: Chair, can I clarify: in the previous discussion Senator Xenophon was asking CASA for a copy of the advice that was provided to the previous minister?

CHAIR: For which there is no impediment.

Senator FAWCETT: So I relay the same request to ATSB: that we see a copy of the response to the Senate report into the air accident investigation that was provided to the minister.

Well done Pprune, well done Sarcs and Bravo Senator Fawcett.........

Oh - Has anyone woken Aunty up yet??.....

[Sarcs]

ATsBeaker wet letter response vs TSBC 'name & shame'!

ATSBeaker:

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.

The wet lettuce response from mi..mi..mi Beaker got me thinking how do our Canuck counterparts admin and follow up SRs and is it more effective and possibly more transparent???

To begin with let's compare the two versions of the respective Acts on the subject of SRs.

TSI Act:

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).

Canadian Transportation Accident Investigation
and Safety Board Act Section 24:

(5) The Board shall
(

a) during its investigation of a transportation occurrence, notify forthwith in writing any minister or person who, in the opinion of the Board, has a direct interest in the findings of the Board of any of its findings and recommendations, whether interim or final, that, in the opinion of the Board, require urgent action; and

(

b) on completion of its investigation of a transportation occurrence, notify forthwith in writing any minister or person who, in the opinion of the Board, has a direct interest in the findings of the Board of its findings as to the causes and contributing factors of the transportation occurrence, any safety deficiencies it has identified and any recommendations

resulting from its findings.

Minister to reply
to Board
(6) A Minister who is notified of the findings and recommendations of the Board under paragraph (5)(a) or (b) shall, within ninety days after being so notified, (a) advise the Board in writing of any action taken or proposed to be taken in response to those findings and recommendations, or (b) provide written reasons to the Board if no action will be taken or if the action to be taken differs from the action that was recommended, and, in either case, the Minister shall make that reply available to the public.

&

Extension of
time

(8) Where the Board is satisfied that a Minister is unable to reply to the Board within the period referred to in subsection (6), the period

may be extended as the Board deems necessary.

Well on first assessment there appear to be a number of similarities but to my mind the big difference is that the Canucks cut out the middle man and address SRs direct to the Minister...hmm worth noting that?

Next do the Canucks just accept the responses as given i.e. the wet lettuce approach (above). Well trolling through the TSBC website I came across a news release, although dealing with rail SRs, would seem to indicate that the TSBC is not afraid to name and shame when they're "not happy Jan"! :

Transport Canada falls short in response to Board recommendations issued from VIA Rail Burlington accident investigation

Gatineau, Quebec, 15 November 2013 — Citing a lack of firm action, the Transportation Safety Board of Canada (TSB) is concerned there is no clear strategy in place to address the rail safety issues identified by the Board.

Today, the TSB released its assessment of Transport Canada's response to the three recommendations it made following its investigation into the February 2012 VIA Rail Burlington accident (investigation report R12T0038). In that accident, three locomotive engineers died and dozens of passengers were injured when VIA No. 92 derailed at a crossover en route from Niagara Falls to Toronto.

“We think the TSB has made a compelling case for these recommendations. They are definitely aimed at improving safety,” said Wendy Tadros, Chair of the TSB. “Two of these recommendations are on our Watchlist (Following signal indications and On-board voice and video recorders) and their implementation will bring down the risk of another accident like Burlington.”

The first recommendation called upon Transport Canada to require physical fail-safe train controls, beginning with Canada's high-speed rail corridors (R13-01). Transport Canada is taking some action to study the issue, but the TSB cautions that this study needs to result in a clear and definitive action plan to ensure trains will automatically slow down and stop when they are supposed to.

While Transport Canada accepted the second recommendation on in-cab video cameras in locomotives (R13-02), it stopped short of requiring them, and instead as with voice recordings, is encouraging voluntary installation.

The TSB believes a voluntary approach does not go far enough and will not ensure that the vast majority of locomotives in Canada will be equipped with essential recorders.

On the other hand, the TSB is optimistic with the proposed action on its third recommendation. Transport Canada plans to start the regulatory process by March 2014, requiring that crashworthiness standards for new locomotives also apply to rebuilt passenger and freight locomotives (R13-03).

“While it is positive that Transport Canada accepts the recommendations,” added Tadros, “Canadians deserve a clear strategy and timely action plan to implement these recommendations.”

The TSB will continue to monitor progress on these recommendations and will reassess them on a regular basis.

So like chalk and cheese I reckon ...hmm Minister perhaps a slight adjustment to the TSI Act could be warranted here??

[Kharon]

Babes in the woods.

But sir, there is no culture of fear in Canada, it's an alien concept: just try to bully or bull**** a Canadian and see where you wind up. Probably on your arse in a pile of bear pooh. They are used to accountability, sane legislation and for the most part, men of good will running the show. The Canucks will need a refresher course on snake pit survival, seeing through smoke, avoiding mirror induced blindness and their own specialist anti voodoo hoodoo protection team.

Yup, I'd love to see our CASA and ATSB try to run Canadian aviation: I truly would. I reckon I'd still be laughing when booze and old age carried me off. It is truly a happy thought....

[Sarcs]

mi..mi..Beaker(coached by McSkull & GWM) & the art of good spin bowling!

It would appear that mi..mi..mi Beaker (ably coached by McSkull and the GWM) has been working on his googly, not only has he mesmerised Aunty but it seems his spin (ozfuscation style) has bamboozled the poms as well...(my bold):

Australia tightens rules for helicopter night flying

Australia is tightening up rules for flying helicopters at night following the release of the final report into the August 2011 crash of a Eurocopter AS355F2 Twin Squirrel helicopter at Lake Eyre in South Australia.
Helicopter air transport operations with passengers at night will be required to have an autopilot fitted or operate with a two-pilot crew.

The helicopter, which was carrying a film crew for Australian broadcaster ABC, crashed, killing the film crew, comprising a reporter and cameraman, and well-known and respected helicopter pilot Gary Ticehurst.

The helicopter was conducting a 30min flight after last light and although there was no low cloud or rain, it was a dark night, according to the Australian Transport Safety Bureau.

After take-off, the helicopter levelled at 1,500ft (460m) above mean sea level, shortly after which it entered a gentle right turn and began descending. The turn tightened and the descent rate increased, resulting in it hitting the ground at high speed with a bank angle of about 90 degrees. The crew were fatally injured and the helicopter destroyed.

The ATSB determined that before departure, the pilot had selected an incorrect destination on the global positioning system. After initiating the right turn, the pilot probably became spatially disorientated. Contributing factors were the dark night conditions, high pilot workload associated with establishing the helicopter in cruise flight and probably trying to correct the incorrect GPS input, the pilot’s limited night flying and instrument flying experience and the fact the helicopter was not equipped with an autopilot.

The ATSB identified safety issues with existing regulatory requirements, whereby flights for some types of operations are permitted under visual flight rules in dark night conditions that are effectively the same as instrument meteorological conditions, but without the same level of safety assurance as provided by requirements under instrument flight rules. {Note: Forgot to add that the bureau identified the same issues a decade ago}

New regulations being introduced next year will require all air transport flights in helicopters with passengers operating at night to be equipped with an autopilot or a two-pilot crew. While this extends the range of operations required to have such risk controls, the ATSB notes it does not address the situation for other helicopter operations, namely those not carrying passengers.

Now back to the Adelaide Oval where the Poms are all out for 133 and mi..mi..mi..Beaker finished up with figures of 2 for 10!

[Paragraph377]

Mi mi

New regulations being introduced next year will require all air transport flights in helicopters with passengers operating at night to be equipped with an autopilot or a two-pilot crew. While this extends the range of operations required to have such risk controls, the ATSB notes it does not address the situation for other helicopter operations, namely those not carrying passengers.

The 'fix' is dependant then upon the new regs next year? And what happens when the new 'regs' (as robustly promulgated by our Capital 'R' Regulator) don't come to fruition for another decade?? Which is the norm by the way. The risks remain and life as they say goes on. Good old Beaker and his wet lettuce move on to the next investigation in which CASA will obviously once again escape unharmed if found to be part of the root cause, or at least be found to have inefficient regulations?

As creamy would say 'talk talk talk'. Mi mi mi Beaker and his tautological outcomes, all folly. As for Fort Fumble they don't like those pesky whirlybirds anyway, the more that crash the less there are to regulate!!

[Kharon]

377 -"Good old Beaker and his wet lettuce move on to the next investigation in which CASA will obviously once again escape unharmed if found to be part of the root cause, or at least be found to have inefficient regulations?"

In vainglorious hope that the Pel Air fiasco has been lost in the mists of time. Tick tock and it won't be too long before the piper must be paid. I wonder if this crew is just too dumb to get out of the rain, or like King Canute reckon they can simply stem the tide. I quite enjoy a good mind boggle; but one step beyond boggle, what then??....

[Sarcs]

IOS elephant propping up the bar at the LBGYC!

It would appear that McScreamer is testing the waters..here is an excerpt from his latest missive included in the monthly propaganda from Fort Fumble ...
"CASA understands and values the importance of our relationship with the Australian Transport Safety Bureau and we {is that a royal "WE"??} have processes in place{ that would be the ubiquitous, behind the scenes Mr ALIU } to ensure the outcomes of the Bureau’s investigations are carefully analysed and appropriate regulatory and safety actions are taken {or ozfuscated as the need is required}. Any steps that can be taken to further {ozfuscate} develop our relationship with the Australian Transport Safety Bureau, and other aviation agencies, will be positive both for CASA and further buggerise the aviation safety system."

Hmm ..kind of like saying to the Minister..." WE understand that you've been forced to do this (TASRR) but WE really have it all under control Minister".

However there is the small hurdle of the imminent government response to the Senator's PelAir report/recommendations (IOS elephant ), so in keeping with the theme of the thread here is a gentle reminder of some of those recommendations:

Recommendation 14
7.15 The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:

• advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
• provide the ATSB with the relevant review report as soon as it is available.

Recommendation 15
7.16 The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.


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.

OK slight drift...Para377:

As creamy would say 'talk talk talk'. Mi mi mi Beaker and his tautological outcomes, all folly.

It would appear that McScreamer and Beaker are swapping ozfuscation notes..from DAS speech at Clive's dinosaur park...

"The recent claims made by some sections of the industry appear to compare the standby requirements specified in the new CAO 48.1 with foreign regulators’ airport standby arrangements. However, these are two very different concepts, and comparing them is tendentious and misleading."

Err..Minister a leopard does not change its spots!

[Kharon]

Spots - what spots.

Err.. Minister a leopard does not change its spots!

That's a Yes Minister – not in my jungle they don't. Thing that really gets the elephants panties in a bunch is that the glove puppet actually thinks that anyone, without a lobotomy that is, could believe the constant flow of carefully polished propaganda....

[Paragraph377]

Tick tock and it won't be too long before the piper must be paid.

Tick Tock indeed Government cronyism, cover ups, malfeasance and incompetence is a sort of favourite past time of mine. I have experienced it first hand, under two different countries who operate under the Westminster system, so I have an ongoing interest in the rights of the little bloke.

One thing is for certain in Australia this time around, the stakes are higher friends. There are some very serious aviation concerns being raised about Australian aviation oversight by other highly ranked Aviation entities external to Australia. The concerns are of such a nature that for these entities to mitigate, well I will put it this way, it will become a parlous financial blow to the Australian economy. These powerful entities have and are avoiding this potential mess as best as they can, but the length of rope has finally run out.

The other difference at the moment lays with the Australian Senators work. Sure, they have done a pretty good job up til now, and admittedly there have been inquiries before, but thiS time around the CAsA, the former Alabanese and the now Truss have under estimated the veracity of Xenophon and Fawcett, as well as under estimated the Senators determination, will, conscience and intelligence. If people think the situation in Australia has been ozfuscated into the history pages as well this time around, think again. There is a storm front coming that may even shock the most ardent CASAsexual, onlookers or even the IOS!

Watch this space

[Jabawocky]

Maybe I am missing the point here, I confess to only skim reading the last few posts. Tell me how on earth ANY rule changes would have made any difference to that ABC crash, or any other.

Operating under the IFR you still need to take off, and hand fly at least a little bit, and the crash happens in that phase of flight.

The only rule that will prevent crashes like this is to ban night flight in all instances. And we all know how practical that is.

Is this just a media beat up? Did the ATSB suggest something that was….errr dumb?

[Pinky the pilot]

Thank you,Jabawocky.

I was wondering much the same thing but thought that I had indeed missed something.

[VH-XXX]

Maybe I am missing the point here, I confess to only skim reading the last few posts. Tell me how on earth ANY rule changes would have made any difference to that ABC crash, or any other.

The pilot of the ABC machine was not instrument rated and never had been from a Civil perspective. Unless I am mistaken he also wasn't current by the company's SOP's. Mandating an IFR rating for dark nights or similar, perhaps two pilots minimum would have enhanced the safety of the flight and the outcome.

[Sarcs]

Media beat up or missed point (MP1)??

MP1: Media beat up...no IMO Aunty has missed the point!

MP2: It is not whether the ATsB SR is good, bad, a total WOFTAM or (ironically) if it would have made any difference to the tragic outcome of the Aunty Chopper accident .

Here's a quote from the tail end of my post #53:

Quote:

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.

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??

So if the original SR's from 2001, 2003, 2004, 2005 (as listed above) were more appropriately addressed (instead of ozfuscated ) then the new ATsB SR issued for the ABC chopper crash wouldn't have been necessary and maybe (big maybe) this accident may not have occurred...why you ask? Well because the risk of spatial disorientation would hopefully have been highlighted and learnt from, leading to a risk mitigator like for example better SOPs from the operator; or better currency rules from the operator; or incorporated recurrency training for similar scenarios...the list goes on.

Even if the accident still occurred we would still be a decade ahead and looking at other risk mitigators..

[Paragraph377]

Sarcs, very very succinctly put
What we often (or used to have) were good ATSB reports and SR's. These on occasion would be followed up by a Coroner recommendation. So now we have two sources recommending changes within a system that failed. Then as the third link in the chain we have..........Fort Fumble. The lazy, laconic, inept ozfucator. They then decide that the ATSB and Coroner recommendations be, dare I say, 'taken on notice'. In other words nothing gets done, and in a lesson in fate, tautology and Groundhog Day the same accident/incident occurs again (for example study the Robbo fuel tank issue and how innocent people have been burnt alive).
In many instances had the 'R'egulator introduced the SR's as recommended by the ATSBeaker or the Coroner, history may have never repeated itself, lives might have been saved, families could have avoided the heartache and pain that they were caused.

So yes, there is a link between rules and regulations and incidents and accidents. Transair at Lockhart is a prime example of how the risks were identified several years before the accident. Fort Fumble ignored the glaring red flags, sat on their collective asses and then ran like cockroaches when all hell broke loose.

[Old Akro]

The backlog grows

In November there were 10 new occurrences vs 8 reports released. October was 24 vs 17. September 19 vs 15. So in the last 3 months alone the backlog of reports has gown by 21.

This is a body with 116 employees and an annual budget of about $25m for an average cost of about $150k each. Surely lack of resource is not the reason.

[VH-XXX]

Would love to know where to find out more.

116 total.

CEO, CIO, CFO and C something... take away 4 or more.

Payroll, admin, reception, legal, hr... hmmm... 15 (conservatively).

Take away 1.5 for maternity leave.

Take 88% of what's left for annual leave and sick leave.

Take away 1.0% that are on long service leave.

Let's conservatively take away 3 more that sit there collating the monthly lists of incidents, following up etc.

116 - 15 - 1.5 * .88 - 1% - 3 = ~80.

Last 3 months of occurences, 10+24+19 = 53.

That's 53 accidents / incidents in the last 3 months that require detailed analysis.

With 7.5 hours in the public service working day across the remaining conservative 80 employees.

80 employees across Aviation, Marine and Rail. 80/3 = 26.

Based incorrectly on 20 working days per month, we have 60 working days across 3 months for the remaining 26 employees....

3,900 man hours per month.
3900 / 53 = 73 hours per incident per person. 73 / 37.5 hours per week = 1.95 weeks....

1 incident per investigator for 2 weeks.

Hardly enough eh?

So many unknowns... I'll bet there are a string of admins that I haven't accounted for and I'd be surprised if those remaining are all of investigator type qualifications. We also don't know the split if aviation versus rail and shipping.

I'm not surprised at your figures then Old Akro.

Would love to know more!

[Kharon]

And, so say all of us.

Triple X # 76 –"Would love to know more!".

Sen McDonald seems to be a bear on the CASA annual report (see the RAAA for comments on the obscene profit margins); perhaps it's time the ATSB was looked at in a similar light. Some old thoughts:-

Everyone enjoys a good story, well told; it is a deeply entrenched part of human kinds development from its origins. Mostly, human beings relate to a clearly defined entertaining story, the lesson or objective of the story is most apparent and easily understood then.

During some of the darker periods in history, it has not been possible for many authors to tell their story in a clear, concise manner thus the message and lesson must be camouflaged and the informed reader must glean the true meaning by being able to interpret or 'read' the subtext and extract the subtle messaging from under the cover of the outer, defensive layers.

Australian Transport Safety Bureau (ATSB) seems an unlikely candidate for this form delivery; their report with the mundane title 200501977 appears to be the least likely candidate to tell a story which has all the ingredients of a first class thriller. But it has; in spades. Properly read, it provides all the essential elements of a classic; although the purist would decry the lack of a love interest, this is the only element missing.

200501977 contains a modest two hundred and forty six pages which can be skimmed through in about thirty minutes, the readers eyes glazing over somewhere during that period. This is a reader mistake. To properly read the report the reader must first understand the nature of a long running battle between two powerful entities for power, money, influence and kudos. The history of these rival groups is coloured, metaphorically speaking, in blood.

In today's world, the Civil Aviation Safety Authority (CASA) is in the political ascendancy, attracts the media attention, enjoys well filled coffers and basks in the security of public and political confidence. The ATSB is chronically under funded, attracts very little media attention and the general public have only a vague notion that it exists.

And so, the ATSB must be careful to protect it's rice bowl, not rock too many boats and mind it's manners.

How then can the ATSB weave the unpleasant truths about this aviation disaster into the fabric of the public lives, when their very existence is a daily struggle. Their answer is in subtle, cleverly camouflaged writing which, correctly interpreted, inevitably leads the informed reader to the correct answer.

Selah.

[Sarcs]

Squirrel accident comparison - VH-NTV v C-FBHN

I wonder if the Canucks (TSBC), while conducting their review of the ATSB, have touched on comparing investigation methodology with this just released TSBC Final Report on a Squirrel accident...

Aviation Investigation Report A12P0079

...to the ABC Lake Eyre accident??

AO-2011-102_final_1_.pdf

Although not perfect in comparison e.g. terrain, day v night etc it does have enough similarities to explore differences in investigative methodology and to review the end result over investigations that were being run over a similar period and timeframe.

NOTE: The following passage from the TSB report is very interesting and also draws some remarkable parallels to the ATSB Final Report and SRs from the 17 October 2003 Bell 407 Cape Hillsborough accident..

During the period of January 2000 through May 2012 in Canada, at least12 occurrences involved VFR helicopter flights colliding with terrain in instrument meteorological conditions (IMC). Of those occurrences, 4 involved a loss of control at sufficient height above the surface to result in collision with terrain in an unusual attitude. These 4 occurrences involved 9 persons, 7 of whom were injured, 3 fatally.

Previously, the Transportation Safety Board (TSB) had identified a safety deficiency associated with helicopter pilot instrument flying skills. On 13 November 1990, the TSB authorized the release of the following recommendation (A90-81):Footnote 7

The Board recommends that:
The Department of Transport require verification of proficiency in basic instrument flying skills for commercially-employed helicopter pilots during annual pilot proficiency flight checks.

On 05 September 2012, the TSB issued the following Board Assessment of Response to A90-81:Footnote 8

TSB does not dispute TC’s contention that “inadvertent” VFR into IMC events constitute a small percentage of the total VFR into IMC events. However, TSB believes that given the fatality rate of these events, TC’s efforts to date to reduce the causes of VFR into IMC events are inadequate.

Consequently, Recommendation A90-81 concerns itself with refreshing skills, acquired during licence training, which are designed to assist pilots in extracting themselves from a VFR into IMC event. The fact that the majority of VFR into IMC events may be preceded by poor pilot decision making does not diminish the value of maintaining piloting skills intended to deal with such an event.

TC’s response is critical of the 180-degree-turn procedure which is outlined in its TP9982E Helicopter Flight Training Manual. TC explains that, due to a combination of an unstabilized helicopter, a panicked pilot and the inherent difficulty in transitioning to instruments, the successful use of the 180-degree-turn procedure is unlikely. TC’s response suggests that this VFR into IMC situation is exacerbated by the pilot being “without any recency in instrument flight”. TSB understands that the instrument flying instruction as conducted during licence training does not qualify any pilot to fly IFR. However, the training emphasizes that the recommended 180-degree-turn procedure is to be used in an emergency and is characterized as the “safest and most expedient procedure” to transition back to VMC.
TC states that because Canadian regulations do not require day VFR aircraft to be equipped with the instruments necessary to safely fly in IMC, all such aircraft would need to be upgraded to accomplish manoeuvres such as a 180-degree turn. It concludes that implementing Recommendation A90-81 would be prohibitively expensive. TSB appreciates that the instrument flying taught during licence training is designed for a pilot who encounters a VFR into IMC event while flying a helicopter not suitably instrumented for IFR flight. The “basic instrument flying skills”, referred to in Recommendation A90-81, are those taught during licence training which does not require use of an IFR equipped helicopter. Therefore, a universal upgrade of the current day VFR helicopter fleet would not necessarily be required to implement Recommendation A90-81.

TC’s comparison between the U.S. and Canadian commercial helicopter experience operating under VFR into IMC focuses on the limitations of the U.S. air ambulance and a regional sightseeing phenomenon. The FAA’s NPRM, referred to in TSB’s assessment, is entitled Air Ambulance and Commercial Helicopter Operations, and the two referenced NTSB recommendations calling for enhanced training for commercial helicopter pilots resulted from accidents under flat light conditions involving commercial helicopters.

While TC believes there is value in including an instrument flying exercise as part of the licence training, its current analysis sees no benefit in enhancing recurrent training in the manner described in Recommendation A90-81. While it has stated a concern for the fact that 50% of VFR into IMC accidents result in fatalities, it maintains that the status quo in mitigating these risks is the obvious and most effective means of preventing these accidents.

Currently, the risks associated with VFR flight into adverse weather remain substantial and TC has not indicated it plans any action to reduce the risks associated with allowing a non-instrument rated commercial helicopter pilot’s basic instrument flying skills to deteriorate as described in Recommendation A90-81. Consequently the reassessment remains as Unsatisfactory.

Next TSB Action (05 September 2012):
The Board has determined that as the residual risk associated with the deficiency identified in Recommendation A90-81 is substantial and because no further action is planned by TC, continued reassessments likely will not yield further results.
The deficiency file is assigned a Dormant status.

The Canucks have definitely not moved on to beyond all sensible reason and they still heavily rely on past Safety Recommendations i.e. their SR database... Hmm now there's a point of difference in methodology!

[Kharon]

What a pleasure to read the TSB/TC debate; expert opinion and practical negotiated agreement, all designed to prevent recurrent accidents. No waiting 27 months for a response, no 10 year old promises to provide regulatory support, no coroners deceived into making soft, disregarded recommendations.

Sarcs you little gem, you have once again cheered me up. Wouldn't it be nice if someone on the Canuck threads were saying "Gee wiz Martha, those Aussie boys are on the ball".

Heigh Ho.

[Sarcs]

A 'point in time'..?? Page of quotes!

“We have come to a point in time where using common sense, speaking factual truths and asking honest questions have been deemed radical behavior. While in turn, manipulation, thoughtlessness and dishonesty is often rewarded and rules the day.” - G Hopkins

Kharon:

Australian Transport Safety Bureau (ATSB) seems an unlikely candidate for this form delivery; their report with the mundane title 200501977 appears to be the least likely candidate to tell a story which has all the ingredients of a first class thriller. But it has; in spades. Properly read, it provides all the essential elements of a classic; although the purist would decry the lack of a love interest, this is the only element missing.

And from the archives of Crikey (2008) a small inconsequential passage of text written by Richard Farmer (no not that Richard Farmer.. ) : Richard Farmer’s political bite-sized meaty chunks

Government and business are not the same. Public administration has gone through a period when governments, Labor as well as Liberal-National, were keen to flick a lot of responsibilities from ordinary departmental administration to what was believed to be a more efficient form based on a private enterprise model. Nowhere was this change more pronounced than in aviation where the once omnipotent Department of Civil Aviation was first merged into an overall Transport Department and then had most of its functions split off into separate corporations. Where once there was a Minister and a Departmental Secretary looking after everything from airports to air traffic control licensing of operators and setting and administering safety standards there are now privately owned airports, Air Services Australia with an eye to its profitability and failing to provide adequate numbers of air traffic controllers, a Civil Aviations Safety Authority setting the rules and regulations and an Air Traffic Safety Bureau still in the Transport Department headed by a chief executive with considerable independent powers. That there is a downside to all this deregulation and private enterprise methods is wonderfully (or should that be horribly?) illustrated in the recent report by Mr Russell Miller into the relationship between CASA and ATSB. The Miller inquiry followed critical comments made by the Coroner in his consideration of the Lockhart River aircraft crash and the report released by the Minister for Infrastructure, Transport, Regional Development and Local Government Anthony Albanese is quite an indictment of how badly the split system actually works in practice. A sensible Minister would put the whole system back under his own departmental control.

Sarcs quote: "Err...no comment!"