The Pacific: General Aviation & Questions The place for students, instructors and charter guys in Oz, NZ and the rest of Oceania.

ATSB reports

Old 1st Aug 2013, 22:50
  #1 (permalink)  
Thread Starter
 
Join Date: Feb 2006
Location: Melbourne
Posts: 1,658
ATSB reports

There was not the usual flood of reports at the end of July. There are now 87 outstanding reports. The oldest of which goes back to 30 June 2011 (Operational non compliance of VH-VNC near Avalon Airport). There were 10 new occurrences in July, but only 5 reports issued.

Even what look like simple reports (eg AO-2012-042 - PA34 descending below LSA at Townsville) are taking over a year.

If you take the ATSB budget and divide by the number of reports (air, sea & land) the average reports costs more than $200,000. Surely even McKinsey & Co would be cheaper and faster.
Old Akro is offline  
Old 1st Aug 2013, 23:07
  #2 (permalink)  
 
Join Date: Jan 2008
Location: Australia
Posts: 769
Mi Mi Mi Mi Mi Mi lost the password to the report generator.
T28D is offline  
Old 2nd Aug 2013, 01:36
  #3 (permalink)  
 
Join Date: Sep 1999
Location: Various
Age: 69
Posts: 371
Maybe they haven't got the right people to generate suitable reports. Anyone can get out and kick around busted up tin and map an accident site with a bit of training, however to to follow through with a full in-depth and and accurate unbiased technical report can be a challenge for your average subject expert, ie pilot, engineer, air traffic controller, etc, if they haven't done any report writing in the past.

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.
Waghi Warrior is offline  
Old 2nd Aug 2013, 13:48
  #4 (permalink)  
 
Join Date: Apr 2005
Location: Australia
Posts: 1,403
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers
Not criticising the above comment but it was different in the RAAF back in another life decades ago. With the rank of Squadron Leader I had just been posted to Directorate of Flying Safety at Department of Air, Canberra - and had been there a few days. My elderly and decorated Wing Commander boss (he had flown obsolete and out-gunned Brewster Buffalo fighters against the Japs during the war), says come into my office. He says a Macchi has just gone down near East Sale and two are dead. Get down there asap and give me a report within three days in case there are political issues. A Court of Inquiry has been convened and are there now.

But Sir...I haven't had any training.

Use your initiative my boy and get going.

But, but, Sir, how do I get to East Sale?

Use your bloody initiative boy...get a Dakota or something from Fairbairn. NOW,ON YOUR WAY!

It was called on the job training in those days. Not ideal but it worked most of the time. There were no FDR or CVR's. Just an experienced engineer usually and a pilot that used his initiative and flying experience to speculate how an accident happened. Mostly it was obvious. The more leisurely Court of Inquiry would have their completed report published within a month, normally.

Last edited by A37575; 2nd Aug 2013 at 14:00.
A37575 is offline  
Old 2nd Aug 2013, 22:03
  #5 (permalink)  
Thread Starter
 
Join Date: Feb 2006
Location: Melbourne
Posts: 1,658
Maybe they haven't got the right people to generate suitable reports.
I'm not indifferent to this argument. BUT;
1. Randomly select any 5 past reports and I'll bet that a final year engineering student could do better and
2. Most of the reports they do are not about serous accidents. Most are like one of the oldest outstanding report where a Seneca was directed to descend below LSALT by ATC. I doubt that one takes years of experience by trained investigators. It might take years of training to create the politically correct report - but that's hardly fitting the the "without fear or favour" mantra, is it?

Last edited by Old Akro; 2nd Aug 2013 at 22:04.
Old Akro is offline  
Old 2nd Aug 2013, 22:20
  #6 (permalink)  
When you live....
 
Join Date: Sep 2004
Location: 0.0221 DME Keyboard
Posts: 910
Randomly select any 5 past reports and I'll bet that a final year engineering student could do better
You clearly haven't hired any graduate engineers recently. At least ATSB reports have sentences that can be read and something approximating correct grammar and punctuation.

UTR
UnderneathTheRadar is offline  
Old 2nd Aug 2013, 22:29
  #7 (permalink)  
Thread Starter
 
Join Date: Feb 2006
Location: Melbourne
Posts: 1,658
You clearly haven't hired any graduate engineers recently.
Touche.

Although I might hope that a final year engineering report has the grammar corrected by a lecturer vs a graduate who is on his / her own.
Old Akro is offline  
Old 3rd Aug 2013, 01:10
  #8 (permalink)  
 
Join Date: Jul 2007
Location: in the classroom of life
Age: 51
Posts: 6,879
UTR...the glass half full

About all you can say though sadly.
Jabawocky is offline  
Old 3rd Aug 2013, 12:20
  #9 (permalink)  
 
Join Date: Aug 1998
Location: Ex-pat Aussie in the UK
Posts: 4,542
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.
Oh, I don't know - it only takes about two hours for an accident to be reported on PPRuNe before someone has posted:
  • the METARs for three hours before and after the accident
  • the TAF for the period
  • a picture of the correct aircraft from airliners.net
  • a link to the Jep chart for the approach
  • a Google Maps link to the airport concerned
  • the relevant ATC/Pilot radio recordings
  • the route of the flight number in question on a radar tracking site, and
  • the build number and previous owner history.

... and (most importantly) about three "most probable" causes


Last edited by Checkboard; 3rd Aug 2013 at 12:22.
Checkboard is online now  
Old 5th Aug 2013, 10:09
  #10 (permalink)  
 
Join Date: Nov 2000
Location: Salt Lake City Utah
Posts: 3,052
The Honourable Senators did not give a "direction" the ATSB to do anything.

The Honourable Senators do not have the power to direct the ATSB to do anything. The pieces of wet lettuce comprising the Senate Committee Report have been duly noted by the ATSB, and will be actioned appropriately.

Why is it beyond the wit and wherewithall of posters on PPRuNe to arrange for the removal of the FDR and CVR and delivery directly to the Canadian TSB?

Last edited by Creampuff; 5th Aug 2013 at 10:13.
Creampuff is offline  
Old 5th Aug 2013, 11:50
  #11 (permalink)  
 
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
TSBC & ATsBeaker differences in methodology and mandate.

If nothing else, and the terms of reference for the review of the ATsBeaker by the TSB Canada aren't expanded (as they should be), there is perhaps a lot to be learnt from the TSB in regards to its structure, true independence and its stated Mandate, not to mention the fact that the purse strings are not held by the Minister of Transport:
Mandate



The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework that governs TSB activities. Our mandate is to advance transportation safety in the marine, pipeline, rail and air modes of transportation by
  • conducting independent investigations, including public inquiries when necessary, into selected transportation occurrences in order to make findings as to their causes and contributing factors;
  • identifying safety deficiencies, as evidenced by transportation occurrences;
  • making recommendations designed to eliminate or reduce any such safety deficiencies; and
  • reporting publicly on our investigations and on the findings in relation thereto.
As part of its ongoing investigations, the TSB also reviews developments in transportation safety and identifies safety risks that it believes government and the transportation industry should address to reduce injury and loss.
To instill confidence in the public regarding the transportation accident investigation process, it is essential that an investigating agency be independent and free from any conflicts of interest when investigating accidents, identifying safety deficiencies, and making safety recommendations. As such, the TSB is an independent agency, separate from other government agencies and departments, that reports to Parliament through the President of the Queen's Privy Council for Canada. Our independence enables us to be fully objective in making findings as to causes and contributing factors, and in making transportation safety recommendations.
In making its findings as to the causes and contributing factors of a transportation occurrence, it is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board does not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board’s findings. No finding of the Board should be construed as assigning fault or determining civil or criminal liability. Findings of the Board are not binding on the parties to any legal, disciplinary, or other proceedings.
There is also a part that differentiates the TSB mandate from other transport related Federal agencies. And this helps to maintain the integrity of the TSB independence from these agencies i.e. no weasel worded MOUs for this lot:
The TSB and other organizations

The TSB's mandate is distinct from those of other organizations such as Transport Canada (TC), the National Energy Board (NEB), the Royal Canadian Mounted Police (RCMP), the Canadian Coast Guard (CCG), and the Department of National Defense (DND), all of whom play a role in the transportation field. As an independent federal agency, the TSB is not associated with any of these organizations, although we do work in cooperation with them when conducting investigations and making safety recommendations.
Transport Canada is concerned with developing and administering policies, regulations and services for transportation systems in Canada with respect to federally regulated marine, rail and aviation transportation modes. The National Energy Board is responsible for regulating pipelines under federal jurisdiction. This differs from the TSB's mandate of advancing transportation safety in the marine, pipeline, rail and air modes of transportation through the conduct of independent investigations, the identification of safety deficiencies, and the making of recommendations to eliminate or reduce such deficiencies.
When the TSB investigates an accident, no other federal department (except the Department of National Defense and the Royal Canadian Mounted Police) may investigate for the purpose of making findings as to the causes and contributing factors of the accident. Transport Canada and the National Energy Board may investigate for any other purpose, such as regulatory infractions.
In terms of methodology it would appear that the TSB has a point of difference to Beaker in regards to the importance of the safety recommendation system:
Recommendations

The Transportation Safety Board of Canada (TSB) is responsible for advancing transportation safety. One of the ways it does this is by making recommendations to federal departments and other organizations to eliminate or reduce safety deficiencies.
Under our Act, federal ministers must formally respond to TSB recommendations and explain how they have addressed or will address the safety deficiencies. Using an Assessment Rating Guide (which includes definitions for the status of recommendations), the Board evaluates the responses and their overall effectiveness. Each response is assessed as Fully Satisfactory, Satisfactory Intent, Satisfactory in Part or Unsatisfactory. Progress made to address TSB recommendations is assessed by the Board on an ongoing basis.


For recommendations and assessments made before January 1, 2005, please refer to our annual reports.
It is also worth reading the Canadian Transportation Accident Investigation and Safety Board Actfor a quick compare with the TSI Act 2003!

Last edited by Sarcs; 5th Aug 2013 at 11:51.
Sarcs is offline  
Old 5th Aug 2013, 21:05
  #12 (permalink)  
 
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,053
Box diving - for fun and profit.

Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered.

Send the Navy, I'm sure the boys and girls not on 'transport duties' could do a bang up job and enjoy the outing. I expect the experience and training opportunity would/ could be of some value for money.

Yeah I know, back to my knitting...

Last edited by Kharon; 5th Aug 2013 at 21:06.
Kharon is offline  
Old 5th Aug 2013, 22:38
  #13 (permalink)  
 
Join Date: Jun 2011
Location: Downunda
Posts: 559
Smile Beakers, non beakers, little orange boxes and comparisons!

Herr Kharon, you are correct. There are numerous legal implications for the unauthorised removal of the boxes that are currently gathering barnacles and being used to camouflage many varieties of orange reef fish. I will try to locate the specific dot points (now that the third test is finished ) . Suffice to say the 'evidence' would be classified as useless, tainted and potentially interfered with should the Styx Houseboat take up anchor, stealthily remove said boxes and whisk them away to the land of the maple leaf for a robust examination.

Also the downside is that although the boxes are at a moderate depth I don't believe they are deep enough to have been adequately preserved, such as with the AF boxes (something to do with presuure, oxygen levels, technical stuff like that). Perhaps Herr Sunfish the keen aviator, diver, and font of much knowledge could expand on this topic?

Interesting and succinct research and analysis Herr Sarcs. Also of interest is the following for comparison;

TSB Director, Investigations - Background as a pilot, director of flight operations and has hands on experience as an investigator.

TSB Director, Operational Services - Background in HF, he has a doctorate in the subject, and also has hands on investigation experience.

ATSB Commissioner Beaker - Comcare, workers comp, Ausaid and Agriculture and Fisheries, mi mi mi mi and likes playing with large pots of money.

I just hope that when the Maples visit they don't get dragged into the whirlpool of pooh and end up taking some of the residual stained matter back to the TSB and infect some of their own people with 'beyond Reason methodology', mi mi mi, poor investigative techniques and bureaucratic bullshit 101.

Last edited by 004wercras; 5th Aug 2013 at 22:40.
004wercras is offline  
Old 6th Aug 2013, 02:10
  #14 (permalink)  
 
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
Senate Inquiry rehash/revisit for Kharon's benefit

Kharon:
Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered.
I think what you say is essentially true "K", however I also think it depends whether the ATsBeaker have officially 49erd the OBR:

49 OBR ceasing to be an OBR under declaration of ATSB
(1) The ATSB may, by published notice, declare that a recording, or a
part of a recording, identified in the notice is not to be treated as an
OBR on and after a date specified in the notice.
(2) If the ATSB decides not to investigate the transport safety matter
to which an OBR relates, the ATSB must, by published notice,
declare that the OBR is not to be treated as an OBR on and after a
date specified in the notice.
(3) If:
(a) the ATSB decides to investigate the transport safety matter to
which an OBR relates; and
(b) the ATSB is satisfied that any part of the OBR is not relevant
to the investigation;
the ATSB must, by published notice, identify that part and declare
that part is not to be treated as an OBR on and after a date specified
in the notice.
(4) The ATSB cannot revoke or vary a notice published under this
section.
(5) When an OBR, or part of an OBR, ceases to be an OBR because of
a notice published under this section, then any related OBR
information also ceases to be OBR information.
Now if the box has been officially 49er'd then I think (Creamy can probably confirm this) then it could be fair game for anyone to retrieve??
It is also interesting to note that essentially an OBR only covers the CVR by definition and the Civil Aviation Act like-wise only places protections on the CVR. So the question there is: Would the FDR (by no protection) be also fair game if it was a stand alone unit?
Sarcs is offline  
Old 6th Aug 2013, 02:43
  #15 (permalink)  
 
Join Date: Jun 2011
Location: Downunda
Posts: 559
I thought '49erd'was a term use for The Skulls treatment of some of his fellow drivers at CX
004wercras is offline  
Old 6th Aug 2013, 06:31
  #16 (permalink)  
 
Join Date: Nov 2000
Location: Salt Lake City Utah
Posts: 3,052
If the recording or part of the recording on the CVR has been the subject of a Notice under s 49, the recording or the part of the recording the subject of the Notice is not treated as an OBR from the date specified in the Notice.

I can find only one s 49 Notice on the ATSB website. It does not relate to an aviation investigation.

I suspect the ATSB’s (Orwellian) reasoning will be that although the ATSB didn’t think it was worth retrieving the CVR from NGA, the ATSB is not satisfied the recording is not relevant to the investigation of the ditching. Therefore, it must remain an OBR subject to the TSI Act forever ….

But lots of people seems to be labouring under the misconception that because the CVR contains an OBR, no one (other than the ATSB) is allowed to touch or remove the CVR or listen to what’s on it in any circumstances.

The offences in the TSI Act are for adversely affecting an investigation (s 24) and for copying OBR information or disclosing OBR information (s 53). (There are also exceptions.)

If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken? If the person doesn’t copy what’s on it, or disclose to anyone what the person heard, the person hasn’t breached s 53. The person hasn’t adversely affected the ATSB’s investigation, even if the ATSB wanted to pretend it’s keen to know what’s in the OBR. Indeed, if the ATSB wanted to pretend it’s keen to know what’s in the OBR, the person could help the investigation by delivering the CVR to an independent body – surely the ATSB would have no hesitation in authorising an independent body to have access to the OBR, under s 52, so as to confirm what a great report the ATSB produced.

If the person puts the CVR back in the hull, Sunfish could then dive down and remove it from the hull (with the owner’s permission) listen to what’s on it, and then put it back without copying or damaging the OBR, and without disclosing what he heard. Then Sarcs goes for a swim ….

Eventually, lots of people would be able to wink knowingly at each other …
Creampuff is offline  
Old 6th Aug 2013, 07:28
  #17 (permalink)  
 
Join Date: Mar 2003
Location: NSW Australia
Posts: 2,348
If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken?
If the wreck has been abndoned, who owns it?

If the insurance company is asserting ownership over it, surely they can be forced to move it from the crown land it is presently cluttering up?

(Can't complain about fuel leaks and pollution I suppose... )
Horatio Leafblower is offline  
Old 6th Aug 2013, 23:44
  #18 (permalink)  
 
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
Senator Fawcett: "Not happy Jan...err Minister!

Phelan:
Election squabbling buries air safety recommendations

Liberal Senator David Fawcett says Transport Minister Anthony Albanese has failed to respond to the damning findings of the Senate Inquiry into the ATSB’s and CASA’s responses to the Norfolk Island ditching on November18 2009.
ATSB today confirmed that there would now be no action on the critical recommendations until after the election.
The Senate Committee’s report with 26 safety-related recommendations was released on 23 May, 2013. It highlighted serious concerns with the processes and conduct of both government agencies, and its recommendations were aimed at rectifying what it described as “the serious deficiencies that the committee had identified.”

The committee’s first recommendation was that the ATSB retrieve the accident aircraft’s flight data and cockpit voice recorders “without delays.”
The report said: “The committee understands that retrieval of the recorders would be particularly useful in this instance [and] that the ATSB has certain responsibilities, set out in ICAO Annex 13, when it comes to retrieval of aircraft involved in accidents. It is an assumption throughout Annex 13 that, where a FDR [flight data recorder] exists, the accident investigation body will prioritise its retrieval.”
Air safety specialists believe that the aircraft’s flight data and cockpit voice recorders could be recovered with relative ease, saying they do not understand why this recommendation is being ignored, especially as further delay might damage the equipment.
Also recommended were a reopening of the original investigation with a focus on organisational and systemic issues, a drastic rearrangement of the structures within which ATSB and CASA operate, the establishment of an ICAO Annex 13 independent panel to oversee ATSB investigations and reporting, and a referral to the Australian Federal Police to investigate whether CASA breached the Transport Safety Investigation act by withholding critical documents during the investigation.
During estimates hearings in May this year, Senator Fawcett specifically highlighted the risk of Government inaction before the caretaker period began, causing an unacceptable delay to implementing the recommended aviation safety reforms.
When asked during Estimates on May 29 if the department’s brief to the Minister would occur in sufficient time so that Mr Albanese could respond before the caretaker mode, Department Secretary Mike Mrdak replied:
“We already have officers in the department – and clearly me and senior officers – who have carefully read the report now. I have had discussions with my senior officers. We envisage being in a position to provide some initial advice to the minister, I expect, certainly within the next week to 10 days in relation to it. I envisage having conversations with the Civil Aviation Safety Authority CEO and the head of the Australian Transport Safety Bureau in the coming days to ascertain their views, to enable me to provide a comprehensive view to the minister, I would hope by the end of next week.” [two months ago.]
Senator Fawcett points out that the report was tabled on May 23, allowing the Minister a three month window to respond and that given its damning findings Minister Albanese should have made this his top priority, particularly given his promise that ‘nothing is as important as aviation safety.’
“Even the announcement today of an external review of the ATSB by the Canadian Transportation Safety Board (TSB) was not made by the Minister but by the agency in question, said Senator Fawcett, referring to ATSB announcement on August 2 that the transportation is safety board of Canada (TSB) will conduct an independent external review of the ATB’s investigation processes and publish the results. The review was announced jointly by TSB Chair Wendy Tadross and ATSB chief commissioner, Martin Dolan.
Sen Fawcett remains unimpressed: “This raises serious concerns about the efficacy of any resulting report unless the Minister ensures that the terms of reference (ToR) and Australian management of the audit are transparent and independent.”
We asked the ATSB whether a decision been made on recovery of the flight data and cockpit voice recorders of the Pel-Air aircraft, whether recovering the recorders would be an ATSB or departmental decision, and whether the investigation will be reopened as recommended in recommendation 9. We also asked if the Canadian review was a part-response to the Senate recommendations.
The ATSB would not comment on the recorders or reopening the investigation, but a spokesman said: “We’ve been in discussion with the Transportation Safety Board of Canada for some time, and it’s about benchmarking and comparison of our systems of investigation. This is an initiative of the ATSB’s chief commissioner and the TSB’s Chair, and the TSB has agreed that their benchmarking review will have regard to the Senate committee’s findings, so we’ll take those into account.
“In regards to your specific questions, it is the responsibility of the Government to respond to the recommendations of Senate committees. The ATSB has provided input to the preparation of a government response. The caretaker conventions that are now in place mean that a government response will not be finalised until after the federal election.“
Senator Fawcett again called on Minister Albanese to ensure that this review of the ATSB has the confidence of the aviation industry and the public by adopting Recommendation 8 of the Senate report:
8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation orocesses as identified in the Senate report including the Canley Vale accident.”
Can't really add anything to that!
Sarcs is offline  
Old 7th Aug 2013, 03:46
  #19 (permalink)  
 
Join Date: Nov 2000
Location: Salt Lake City Utah
Posts: 3,052
Regarding Senator Fawcett’s comments quoted by Mr Phelan, the sentence that’s missing from Senator Fawcett’s comments is again the one that starts:
If elected on 7 September, a Coalition government will move immediately to ….
Creampuff is offline  
Old 7th Aug 2013, 08:55
  #20 (permalink)  
 
Join Date: Jun 2011
Location: Downunda
Posts: 559
Great to see that 'safety' is a non essential item that really isn't worth a pint of panther piss during periods of caretaker governments.
May I also suggest that all road enforcement rules including the operation of speed cameras, along with aviation rules also not count during 'caretaker mode', that rape and murder receive a dispensation and that tax not need to be paid during caretaker mode.
Anything else? Oh yes, why not shut down the electricity and water grids along with sewerage treatment during caretaker mode??
Absolute fwits
004wercras is offline  

Thread Tools
Search this Thread

Contact Us Archive Advertising Cookie Policy Privacy Statement Terms of Service

Copyright © 2018 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.