ATSB to be reviewed by Canadian TSB
Thanks Greedy I can see what you are referring to but I'm not sure of the specifics. The report is a very big report and it could be mentioned in the body of the report. Interesting to compare the CASA response to a pilot complaint at Barrier Aviation to a complaint at Transair though.
LHR thread drift cont:
Lefty believe it or not I too have read and analysed the LHR report and Coroner's report several times. I totally agree with you about the LHR ATSB report being full and comprehensive, as it should have been considering the over 20 million dollars of taxpayers money it took to complete. I also agree the report does not hold back in it's criticism of CAsA's oversight of Transair, however the passages you quote also highlight what was the primary focus of the investigative team in regards to reviewing the Transair/CAsA relationship/management of the AOC i.e. the audit process and surveillance.
There is, as you point out Lefty, one example of the ATsB questioning an AOC variation approval process, where an AWI refused to approve the Brisbane to Inverell route approval on the grounds of inadequate (in his opinion) Company Maintenance Control (PDF page 154-156 of ef-121779 pdf). {Note: IMO this example was probably highlighted because it is the only instance (that I can see) in all the variations where an AWI or FOI has voiced a concern about the applied for variation/addition to the AOC}
But the one really crucial AOC variation, in light of the accident, that should have been heavily scrutinised was the port approval for LHR...so why wasn't it?
Was it maybe because the LHR port approval wasn't redflagged by a AWI or FOI (like the example above) and so didn't draw the attention of the ATSB investigators?
Or was it because the ATSB primary focus was on the CAsA audit/surveillance processes of Transair and not so much the AOC variations/additions?
Anyway enough of the thread drift here is a TSB you tube video that perhaps highlights their priorities in regards to OBRs (be it for trains):[YOUTUBE]
And in regards to accident/incident investigation methodology and subsequent safety actions/recommendations, perhaps the recently released report into a Beaver amphib crash (with additional links) highlights how the Canucks go about it
:
AVIATION INVESTIGATION REPORT
A12P0070 CONTROLLED
Watchlist issue identified in May 2012 floatplane accident near Peachland, British Columbia
Aviation Recommendation A12-01
Aviation Recommendation A12-02
As I said earlier there is a lot we could learn from the TSB Canada!
There is, as you point out Lefty, one example of the ATsB questioning an AOC variation approval process, where an AWI refused to approve the Brisbane to Inverell route approval on the grounds of inadequate (in his opinion) Company Maintenance Control (PDF page 154-156 of ef-121779 pdf). {Note: IMO this example was probably highlighted because it is the only instance (that I can see) in all the variations where an AWI or FOI has voiced a concern about the applied for variation/addition to the AOC}
But the one really crucial AOC variation, in light of the accident, that should have been heavily scrutinised was the port approval for LHR...so why wasn't it?
Was it maybe because the LHR port approval wasn't redflagged by a AWI or FOI (like the example above) and so didn't draw the attention of the ATSB investigators?
Or was it because the ATSB primary focus was on the CAsA audit/surveillance processes of Transair and not so much the AOC variations/additions?
Anyway enough of the thread drift here is a TSB you tube video that perhaps highlights their priorities in regards to OBRs (be it for trains):[YOUTUBE]
And in regards to accident/incident investigation methodology and subsequent safety actions/recommendations, perhaps the recently released report into a Beaver amphib crash (with additional links) highlights how the Canucks go about it
:AVIATION INVESTIGATION REPORT
A12P0070 CONTROLLED
Watchlist issue identified in May 2012 floatplane accident near Peachland, British Columbia
Aviation Recommendation A12-01
Aviation Recommendation A12-02
As I said earlier there is a lot we could learn from the TSB Canada!
If you have ever watched Ice Pilots Sarcs there is a lot we could learn from the Canucks about aviation in general! I think we are in furious agreement about LHR and if the opportunity ever presents itself and you buy the first round I'll tell you about the back story to the report. Cheers
While we're waiting!
Noticed that the ATsB have been busy promoting pooh tube vids..hmm wonder if it has something to do with the TSB pending visit?? The Canucks have been big on using pooh tube vids to highlight top transport safety risks for a number of years:TSBC Utube
I also notice that Beaker has gone all quiet on his personal blog
. The Canucks also have a blog but the big difference is that it is open to all employees to contribute to. As a consequence you get a lot more responses/comments and some really noteworthy blog pieces that everyone can learn from. Here's their latest article which is particularly relevant to the PelAir debacle
: Human Factors and Accident Investigation
Kind of refreshing hey!
Ok...back to waiting..waiting
I also notice that Beaker has gone all quiet on his personal blog
. The Canucks also have a blog but the big difference is that it is open to all employees to contribute to. As a consequence you get a lot more responses/comments and some really noteworthy blog pieces that everyone can learn from. Here's their latest article which is particularly relevant to the PelAir debacle : Human Factors and Accident InvestigationKind of refreshing hey!
Ok...back to waiting..waiting
Last edited by Sarcs; 7th Sep 2013 at 02:08.
But the have released effectively no reports in over 2 months. Only a couple of minor ones.
There are 105 pending reports. The oldest dates back to June 2011. 5 are over 2 years old. 21 are over 1 year old.
There are 105 pending reports. The oldest dates back to June 2011. 5 are over 2 years old. 21 are over 1 year old.
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Ah, but -
When there is so much CASA spin on the ball and the opposition batsmen have nutted out how to hit 'em for six, the options are limited. I doubt anyone, in the world will ever read an ATSB report and accept it as gospel. It's a sad, disgusting, embarrassing indictment, from which, without some serious house cleaning the existing organisation will not recover.
Dolan should resign, I can't see how he bear to be seen in public. Shamed, even before Canley Vale even gets aired and torn apart. Will he dare to sit, squirm and mumble through another Senate inquiry, holding hands under the table with his off sider and believing that you can fool all of the people, all of the time....
Finishes here, with some carefully selected, robust Anglo Saxon idioms. For example, did you know the word "****" come from the days when manure was bagged and transported to market gardens – and strangely, the boats kept exploding. Well, the ATSB of the day investigated and declared that bilge water (salty) mixed with the manure created methane gas and any old spark would trigger the resultant bang. So, in their wisdom, they insisted the bags be Shipped High In Transit and stencilled accordingly [sic] ****. Well, that's what I was told...
The good old days when not only did they resolve problems, you got a nice new expression to boot....Pete for PM - OK....
Dolan should resign, I can't see how he bear to be seen in public. Shamed, even before Canley Vale even gets aired and torn apart. Will he dare to sit, squirm and mumble through another Senate inquiry, holding hands under the table with his off sider and believing that you can fool all of the people, all of the time....
Finishes here, with some carefully selected, robust Anglo Saxon idioms. For example, did you know the word "****" come from the days when manure was bagged and transported to market gardens – and strangely, the boats kept exploding. Well, the ATSB of the day investigated and declared that bilge water (salty) mixed with the manure created methane gas and any old spark would trigger the resultant bang. So, in their wisdom, they insisted the bags be Shipped High In Transit and stencilled accordingly [sic] ****. Well, that's what I was told...
The good old days when not only did they resolve problems, you got a nice new expression to boot....Pete for PM - OK....
"Yes Minister I stand by my report!"
Kharon:
Maybe not Senate inquiry but it would appear that we will be privy, God help us , to another Senate appearance (Senate Supp Estimates 18-22 November) by the mi..mi..mi..bean counting Beaker..(ref:BBARF report
).
Perhaps Senator Edwards could resubmit his question and statement made in the inquiry....
Senator EDWARDS: "Chair, since we have started, there has been mea culpa after mea culpa after mea culpa in this thing. Now you are hearing evidence for the first time of what is supposed to be a forensic investigation. I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this. I think that the evidence that Senator Xenophon and Senator Fawcett are drawing out would suggest that. We haven't even got to the black box yet. Are you proud of this report?" {loved it then love it now!}
Well enough of the drift but Senator Edwards does bring up an interesting point.... "I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this."
So my question is what ever happened to the Canucks?? Did they come and go??? If so when can we expect the preliminary review report?? 
There seem's to be no mention of the TSB review in either the BBARF or annual report (page 106-108 under External scrutiny and participation). Maybe this is because the TSB review falls under the next financial year...but the ATsBeaker recent silence on the issue is deafening!
Dolan should resign, I can't see how he bear to be seen in public. Shamed, even before Canley Vale even gets aired and torn apart. Will he dare to sit, squirm and mumble through another Senate inquiry, holding hands under the table with his off sider and believing that you can fool all of the people, all of the time....
, to another Senate appearance (Senate Supp Estimates 18-22 November) by the mi..mi..mi..bean counting Beaker..(ref:BBARF report).Perhaps Senator Edwards could resubmit his question and statement made in the inquiry....
Senator EDWARDS: "Chair, since we have started, there has been mea culpa after mea culpa after mea culpa in this thing. Now you are hearing evidence for the first time of what is supposed to be a forensic investigation. I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this. I think that the evidence that Senator Xenophon and Senator Fawcett are drawing out would suggest that. We haven't even got to the black box yet. Are you proud of this report?" {loved it then love it now!
}Well enough of the drift but Senator Edwards does bring up an interesting point.... "I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this."
So my question is what ever happened to the Canucks??
Did they come and go??? If so when can we expect the preliminary review report?? There seem's to be no mention of the TSB review in either the BBARF or annual report (page 106-108 under External scrutiny and participation). Maybe this is because the TSB review falls under the next financial year...but the ATsBeaker recent silence on the issue is deafening!
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Sarcs, it is expected that the Beaker Files will be released in 2014. Obviously the report has to be massaged by the Canucks political interests before being massaged by the Australian government spin doctors including, as you would say, Mr Kingcrat, Beaker and his fellow commissioners and of course the mighty Truss bridge. Only then will the finely polished diamond be unveiled for all to admire? And I am sure that the Beaker made the Canadians pay for their own expenses while here, including sandwiches, office electricity and printer paper, so that he could keep his precious budget on track. Ever the diligent massager of finances is the Beaker.
ATSB poosroom release:
Media releases: 02 August 2013 - Canadian safety investigators to review and compare ATSB processes
An interesting comment by Creampuff on another thread indicates that with the induction of a new government there is a cancellation of previous enquiries that were undertaken in relation to the previous governments activities, for example the senate inquiry into aviation. Can anybody confirm whether this is absolute fact? Not doubting your word Creampuff, just trying to establish with accuracy the current state of play is.
I know that the Senators would be seething beneath the surface at the governments blatant whitewash of a very serious topic, that being the complete demise of our industry, especially somebody like Nick who actually cares about other people including those victim to injustice. And for the sake of the Australians killed in local accidents and their families and loved ones, as well as those who have lost their livelihoods by being bullied and harassed to the point of insolvency I am sure that Nick and Co would be at the very least considering how to re-open the Pandora's box
ATSB poosroom release:
Media releases: 02 August 2013 - Canadian safety investigators to review and compare ATSB processes
An interesting comment by Creampuff on another thread indicates that with the induction of a new government there is a cancellation of previous enquiries that were undertaken in relation to the previous governments activities, for example the senate inquiry into aviation. Can anybody confirm whether this is absolute fact? Not doubting your word Creampuff, just trying to establish with accuracy the current state of play is.
I know that the Senators would be seething beneath the surface at the governments blatant whitewash of a very serious topic, that being the complete demise of our industry, especially somebody like Nick who actually cares about other people including those victim to injustice. And for the sake of the Australians killed in local accidents and their families and loved ones, as well as those who have lost their livelihoods by being bullied and harassed to the point of insolvency I am sure that Nick and Co would be at the very least considering how to re-open the Pandora's box
PS to my last post for Para 377's benefit
Paragraph377:
ATsBeaker shows the way on your query Para 377....
From page 106 of ATsBeaker's annual report 2012-13:
Hope that helps??
Refer page 9 sub para 7.1 & page 11 sub para 8.1:Caretaker Government Conventions
An interesting comment by Creampuff on another thread indicates that with the induction of a new government there is a cancellation of previous enquiries that were undertaken in relation to the previous governments activities, for example the senate inquiry into aviation. Can anybody confirm whether this is absolute fact?
From page 106 of ATsBeaker's annual report 2012-13:
Response to Senate Inquiry
On 13 September 2012 the Senate referred the matter of aviation accident investigations to the Senate References Committee on Rural and Regional Affairs and Transport for inquiry and report. The terms of reference addressed:
Under Parliamentary convention, governments are expected to respond to committee reports within three months. However, the Caretaker Conventions stipulate that responses to outstanding parliamentary committee reports should be taken up with the incoming government.
On 13 September 2012 the Senate referred the matter of aviation accident investigations to the Senate References Committee on Rural and Regional Affairs and Transport for inquiry and report. The terms of reference addressed:
- the findings of the Australian Transport Safety Bureau into the ditching of VH-NGA Westwind II, operated by Pel-Air Aviation Pty Ltd, in the ocean near Norfolk Island airport on 18 November 2009;
- the nature of, and protocols involved in, communications between agencies and directly interested parties in an aviation accident investigation and the reporting process;
- the mechanisms in place to ensure recommendations from aviation accident investigations are implemented in a timely manner; and
- any related matters.
Under Parliamentary convention, governments are expected to respond to committee reports within three months. However, the Caretaker Conventions stipulate that responses to outstanding parliamentary committee reports should be taken up with the incoming government.
Refer page 9 sub para 7.1 & page 11 sub para 8.1:Caretaker Government Conventions
Last edited by Sarcs; 30th Oct 2013 at 02:20. Reason: Caretaker Govt conventions link
Caretaker Conventions stipulate that responses to outstanding parliamentary
committee reports should be taken up with the incoming government.
committee reports should be taken up with the incoming government.
The Government: The Senate? Oh no! Oh, herro. Great to see you again, Senate!
The Senate: Government, you were supposed to have responded to all our Committee Report Recommendations by today, but you haven’t done so.
The Government: Senate, Senate, Senate! We've been frew this a dozen times. The Government doesn't have any weapons of mass destwuction, OK Senate?
The Senate: Then let us look around, so we can ease the public’s collective mind. I'm sorry, but the Senate must be firm with you. Respond to the Recommendations, or else.
The Government: Or else what?
The Senate: Or else we will be very angry with you... and we will write you a letter, telling you how angry we are.
The Senate: Government, you were supposed to have responded to all our Committee Report Recommendations by today, but you haven’t done so.
The Government: Senate, Senate, Senate! We've been frew this a dozen times. The Government doesn't have any weapons of mass destwuction, OK Senate?
The Senate: Then let us look around, so we can ease the public’s collective mind. I'm sorry, but the Senate must be firm with you. Respond to the Recommendations, or else.
The Government: Or else what?
The Senate: Or else we will be very angry with you... and we will write you a letter, telling you how angry we are.
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The Senate: Or else we will be very angry with you... and we will write you a letter, telling you how angry we are.
Creampuff, your mirth and sarcasm would sadly appear totally justifiable. The only way to make the changes we all call for is via a revolution.
Last edited by Paragraph377; 31st Oct 2013 at 03:04.
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atsb is out of touch with the Aviation Industry and so is dolan
What will the moves be for Mr. Truss this week??
What will be his response be to the atsb annual report??
Will there be a response to the Senate, not just the specious comments in this report??
What will be his response be to the atsb annual report??
Will there be a response to the Senate, not just the specious comments in this report??
IOS support for TSBC review and a proposal for TSI amendment.
Continued from:Post #1651
Came across a TSBC blog article that is worth consideration as an IOS supported PelAir inquiry solution/recommendation to address the current embuggerance of our air safety watchdog..
I'm sure Beaker will be spinning the point that the bureau operates in much the same way to the TSBC. However Beaker's credibility is shot 
and coupled with the damning evidence presented in the AAI inquiry there is no doubt that the current executive regime within the bureau is only paying lipservice to the documented principles of the TSI Act.
Here is an idea that perhaps Sunny's beloved PMC (rather than the Minister's advisers) could do a feasibility study on...
Note: Love the way the Canucks are more than happy to allow team members to contribute to their blog...stark comparison to Beaker's blog hey!
Came across a TSBC blog article that is worth consideration as an IOS supported PelAir inquiry solution/recommendation to address the current embuggerance of our air safety watchdog..
Aren’t we just part of Transport Canada?
January 25th, 2013
Posted by: Ewan Tasker
The difference between Transport Canada and the Transportation Safety Board of Canada
Virtually every time I arrive at an accident site, I hear someone say “Transport Canada is here”. I occasionally spend a few seconds trying to clear up the misconception, but often don’t have the time to explain the differences, and why they are important.
In brief, Transport Canada (TC) is the department responsible for promoting transportation safety and security, which reports to the Minister of Transport. The TSB, however, is an independent agency—separate from other government agencies and departments—that reports directly to Parliament through the President of the Queen’s Privy Council for Canada.
TC’s mandate is vast and complex. The department is tasked to promote and ensure a safe, secure, efficient and environmentally responsible transportation system, which contributes to Canada’s economic, social, and sustainable development objectives. In contrast, the TSB’s mandate is solely to advance transportation safety. This difference might seem insignificant to some, but the distinctions occasionally leave our organizations in disagreement. Recommendations we make that are intended to advance safety have to be weighed by TC against their other objectives and responsibilities. Staying focused on a single objective, and not letting other factors influence our analysis, is one of the main reasons that we must maintain our independence.
Our singular focus on safety also means that we play no role in ensuring rules are followed, or assigning blame or liability. This misconception is probably the most common and unfortunate one that we, as investigators, face during an investigation.
Often people feel as though we are at the scene to determine what happened and whose fault it was. I assure you, this isn’t the case. Nobody wakes up in the morning with the intention of causing an accident, and likewise no TSB investigator wakes up the day after with the intention of placing blame.
Blaming someone for an accident is not only clearly outside of our authority, it is almost always completely ineffective at advancing safety. When mistakes or omission are made, slapping someone on the wrist does little to determine what caused the accident, and almost nothing to prevent it from happening again. Figuring out what happened and why however is essential.
On a more positive note, more commonly these days, we meet professionals who are involved in an accident and know exactly who we are and why we are there. They are usually just as interested in the outcome of the investigation as we are, as they themselves are unsure of what happened.
Once everyone knows our purpose and the fact that we’re not ‘out to get them’, the synergy and collaboration that can result makes identifying safety deficiencies and underlying issues immeasurably more accurate, and as a result, hopefully makes transportation safer.
And this is one area where the TSB and Transport Canada are exactly the same.
January 25th, 2013
Posted by: Ewan Tasker
The difference between Transport Canada and the Transportation Safety Board of Canada
Virtually every time I arrive at an accident site, I hear someone say “Transport Canada is here”. I occasionally spend a few seconds trying to clear up the misconception, but often don’t have the time to explain the differences, and why they are important.
In brief, Transport Canada (TC) is the department responsible for promoting transportation safety and security, which reports to the Minister of Transport. The TSB, however, is an independent agency—separate from other government agencies and departments—that reports directly to Parliament through the President of the Queen’s Privy Council for Canada.
TC’s mandate is vast and complex. The department is tasked to promote and ensure a safe, secure, efficient and environmentally responsible transportation system, which contributes to Canada’s economic, social, and sustainable development objectives. In contrast, the TSB’s mandate is solely to advance transportation safety. This difference might seem insignificant to some, but the distinctions occasionally leave our organizations in disagreement. Recommendations we make that are intended to advance safety have to be weighed by TC against their other objectives and responsibilities. Staying focused on a single objective, and not letting other factors influence our analysis, is one of the main reasons that we must maintain our independence.
Our singular focus on safety also means that we play no role in ensuring rules are followed, or assigning blame or liability. This misconception is probably the most common and unfortunate one that we, as investigators, face during an investigation.
Often people feel as though we are at the scene to determine what happened and whose fault it was. I assure you, this isn’t the case. Nobody wakes up in the morning with the intention of causing an accident, and likewise no TSB investigator wakes up the day after with the intention of placing blame.
Blaming someone for an accident is not only clearly outside of our authority, it is almost always completely ineffective at advancing safety. When mistakes or omission are made, slapping someone on the wrist does little to determine what caused the accident, and almost nothing to prevent it from happening again. Figuring out what happened and why however is essential.
On a more positive note, more commonly these days, we meet professionals who are involved in an accident and know exactly who we are and why we are there. They are usually just as interested in the outcome of the investigation as we are, as they themselves are unsure of what happened.
Once everyone knows our purpose and the fact that we’re not ‘out to get them’, the synergy and collaboration that can result makes identifying safety deficiencies and underlying issues immeasurably more accurate, and as a result, hopefully makes transportation safer.
And this is one area where the TSB and Transport Canada are exactly the same.
will be spinning the point that the bureau operates in much the same way to the TSBC. However Beaker's credibility is shot and coupled with the damning evidence presented in the AAI inquiry there is no doubt that the current executive regime within the bureau is only paying lipservice to the documented principles of the TSI Act.Here is an idea that perhaps Sunny's beloved PMC (rather than the Minister's advisers) could do a feasibility study on...
- Changing the TSI Act so that there is a Board rather than a Commission, using the TSBC as a template.
- Changing the TSI Act so that the ATsB purse strings are bound directly to the Parliament and the bureau would also be directly answerable to the Parliament (maybe facilitated through the Senate RRAT Committee).
Note: Love the way the Canucks are more than happy to allow team members to contribute to their blog...stark comparison to Beaker's blog hey!
Senator X questions veracity of the TSBC review?? & research report comparison.
While we're waiting for the New Year, a certain Government response and the suspect outcome of the TASRR maybe it is worth a pre-New Year cogitation or two...
From the last Senate Estimates hearing (18/11/13) NX has added some additional written QONs that I'm sure plenty on here would all appreciate the answers for..:
Suspicious bugger our Senator X...
However if we give Beaker the benefit of the doubt and remain on the assumption that his intentions are honourable for calling on the Canuck's, then in true IOS tradition let's continue to aid the TSBC with their unbiased, fully independent review..
Okay a couple of recent bureau research investigations and reports could certainly be helpful to the TSBC review.
First cab off the rank, with much chest beating from Beaker in the media (Media release) and on his personal blog (Night-flight warning), is the bureau research report Visual flight at night accidents: What you can’t see can still hurt you
It never hurts to remind aviators of the inherent risks of flying at night but is the report actually telling us anything new (i.e. that we didn't already know) and has the bureau planned further proactive initiatives to address this significant safety issue or are they merely going through the motions??
The TSBC comparison: I had to go back a fair bit (1990) to find a partly similar research report to compare but here it is: REPORT OF A SAFETY STUDY ON VFR FLIGHT INTO ADVERSE WEATHER
Now I know the reports are not directly comparable but the TSBC report does have this to say about the risks of NVFR which reads similar to the ATsBeaker report (remember TSBC/CASB report was 1990):
Point of difference: This TSBC report from 1990 led to a significant educational Safety Promotion initiative from Transport Canada and the promulgation by TSBC of no less than 27 Safety Recommendations. The ATsBeaker report has yet to see any initiative from CAsA but did lead to two wet lettuce SRs being issued that ironically strongly reflect previous (yet to be addressed) SRs from 2003-4.
Okay next ATsBeaker vs TSBC research report comparison: Back in October the bureau released their report into LOSA:Loss of separation between aircraft in Australian airspace, January 2008 to June 2012
A TSBC research report (again back in 1990): REPORT ON A SPECIAL INVESTIGATION INTO AIR TRAFFIC CONTROLSERVICES IN CANADA Quote from the executive summary:
..."Following a series of losses of separation between aircraft at Lester B. Pearson International Airport in Toronto in late 1988, the Canadian Aviation Safety Board decided to conduct a special investigation of the safety aspects of the current air traffic control situation in Canada..."
Point of difference(like chalk and cheese these two): The TSBC report led to the promulgation of 48 SRs which, according to the documented evidence, have all been proactively adopted and acted on by Transport Canada since. The ATsBeaker report led to 3 SRs, which again can only best be described as wet lettuce attempts to address some fundamental safety risk issues within the ATC system.
Well there you have it, a couple of comparable research reports with similar subject matters. Those of you with the interest and the time to read can be the judge of who has the better more proactive methodology/approach in compiling research reports....hmm perhaps pass on your thoughts to the TSBC..
From the last Senate Estimates hearing (18/11/13) NX has added some additional written QONs that I'm sure plenty on here would all appreciate the answers for..
:
144
ATSB 04
XENOPHON
Pel-Air
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
ATSB 04
XENOPHON
Pel-Air
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
However if we give Beaker the benefit of the doubt and remain on the assumption that his intentions are honourable for calling on the Canuck's, then in true IOS tradition let's continue to aid the TSBC with their unbiased, fully independent review..
Okay a couple of recent bureau research investigations and reports could certainly be helpful to the TSBC review.
First cab off the rank, with much chest beating from Beaker in the media (Media release) and on his personal blog (Night-flight warning), is the bureau research report Visual flight at night accidents: What you can’t see can still hurt you
It never hurts to remind aviators of the inherent risks of flying at night but is the report actually telling us anything new (i.e. that we didn't already know) and has the bureau planned further proactive initiatives to address this significant safety issue or are they merely going through the motions??
The TSBC comparison: I had to go back a fair bit (1990) to find a partly similar research report to compare but here it is: REPORT OF A SAFETY STUDY ON VFR FLIGHT INTO ADVERSE WEATHER
Now I know the reports are not directly comparable but the TSBC report does have this to say about the risks of NVFR which reads similar to the ATsBeaker report (remember TSBC/CASB report was 1990):
3.0 NIGHT VISUAL FLIGHT
Accidents occurring in other than daylight conditions comprised a disproportionately large number of VFR-into-IMC accidents. Approximately 10% of all Canadian accidents occur during the hours of darkness, which parallels estimates of the general level of night flying activity (also 10%). However, VFR-into-IMC accidents occurring during the hours of darkness accounted for almost 30% of the total study accidents. Analysis pointed to three issues: night VFR weather minima; the conditions for obtaining and maintaining a night endorsement; and weather briefings.
3.1 VFR Weather Minima
The consequences of flying in reduced visibilities are exacerbated when operating at night, in light conditions which do not permit sufficient warning for the pilot to see and avoid worsening weather conditions. Inadvertent entry into IMC when the actual conditions can not be seen can be minimized by reducing the possibility of occurrence.
Other countries employ weather minima to reduce the probability of aircraft encountering adverse weather, even during daylight conditions. For instance, in the United States VFR weather minima were recently introduced which prohibit daytime recreational pilots from flight in visibility of less than three statute miles. This measure reduces the risk of bad- weather encounters, and is even more effective for flights at night when bad weather is not so easily detected.
The high proportion of fatal night accidents attributable to adverse weather is in part the consequence of pilots initiating flight in weather conditions which are legally acceptable, but which deteriorate. The first indication to the night-flying pilot can be the inadvertent entry into IMC. The Board believes that, to reduce this risk, VFR flight at night should be restricted to more favourable weather conditions. Accordingly, the Board recommends that:
The Department of Transport increase VFR weather minima for night flight so as to reduce the risk of inadvertent flight into poor enroute weather conditions.
TSB-A90-71
3.2 Night Endorsement
The night endorsement qualifies the private pilot to fly during the hours of official darkness. To obtain this endorsement, the pilot undergoes a minimum of ten hours training in basic instrument flight manoeuvres. The intent is to prepare the pilot for inadvertent entry into IMC and to familiarize the pilot with aircraft control in conditions in which there is no apparent horizon. Five of the instrument training hours can be acquired in a simulator. No evaluation of competency is required prior to endorsement, nor are there re-certification requirements for the continued exercise of privileges of the endorsement.
Twenty-four studied accidents which occurred at night resulted from a loss of aircraft control, often after the apparent onset of vertigo. To understand the circumstances of such occurrences, the training, experience and skills of the accident pilots were examined. The accident pilots had seldom obtained additional instrument training after acquiring the minimum experience for night endorsement. Since instrument flying skills are perishable and require regular practice to maintain even a modicum of proficiency, the criteria for obtaining and maintaining a night endorsement apparently do not adequately reflect the skills required to cope with inadvertent entry into adverse weather. There is a higher probability of these circumstances occurring at night.
At present there is no method of ensuring that a minimum level of skill in flying on instruments has been achieved prior to receiving a night endorsement; an evaluation of a pilot's skills under the type of vertigo-inducing conditions encountered in adverse weather at night appears to be warranted. Furthermore, at present there is no method of ensuring that a minimum level of proficiency has been retained after the issue of a night endorsement; therefore, some form of recurrency training and/or testing also appears to be warranted. Such training and testing should focus on the instrument flying skills required for the safe conduct of night visual flight, skills which are considerably less complex than those required, for instance, to conduct a complete instrument approach.
In view of the disproportionate frequency of VFR-into-IMC accidents which occurred at night, the Board recommends that:
The Department of Transport revise conditions for the issue and maintenance of a night endorsement by:
Weather information can be obtained by phone, by remotely-located computer terminals, or in-person at a weather office. There are no regulations specifically requiring a weather briefing before VFR flight; yet the probability of inadvertent entry into IMC at night could be reduced if pilots had appropriate information upon which to base their decision to initiate or defer a flight. This applies to all night flights, both private and commercial, but the Board is particularly concerned about the safety of the air transportation system used by fare-paying travellers. The Board believes that the Department of Transport should encourage private pilots to obtain a weather briefing prior to conducting a flight at night, but that the requirement for operations conducted by commercial pilots should be more stringent. Therefore, the Board recommends that:
The Department of Transport require that, prior to initiating night flight under VFR from locations for which weather briefing facilities exist, pilots engaged in commercial passenger-carrying operations obtain a weather briefing.
TSB-A90-73
Accidents occurring in other than daylight conditions comprised a disproportionately large number of VFR-into-IMC accidents. Approximately 10% of all Canadian accidents occur during the hours of darkness, which parallels estimates of the general level of night flying activity (also 10%). However, VFR-into-IMC accidents occurring during the hours of darkness accounted for almost 30% of the total study accidents. Analysis pointed to three issues: night VFR weather minima; the conditions for obtaining and maintaining a night endorsement; and weather briefings.
3.1 VFR Weather Minima
The consequences of flying in reduced visibilities are exacerbated when operating at night, in light conditions which do not permit sufficient warning for the pilot to see and avoid worsening weather conditions. Inadvertent entry into IMC when the actual conditions can not be seen can be minimized by reducing the possibility of occurrence.
Other countries employ weather minima to reduce the probability of aircraft encountering adverse weather, even during daylight conditions. For instance, in the United States VFR weather minima were recently introduced which prohibit daytime recreational pilots from flight in visibility of less than three statute miles. This measure reduces the risk of bad- weather encounters, and is even more effective for flights at night when bad weather is not so easily detected.
The high proportion of fatal night accidents attributable to adverse weather is in part the consequence of pilots initiating flight in weather conditions which are legally acceptable, but which deteriorate. The first indication to the night-flying pilot can be the inadvertent entry into IMC. The Board believes that, to reduce this risk, VFR flight at night should be restricted to more favourable weather conditions. Accordingly, the Board recommends that:
The Department of Transport increase VFR weather minima for night flight so as to reduce the risk of inadvertent flight into poor enroute weather conditions.
TSB-A90-71
3.2 Night Endorsement
The night endorsement qualifies the private pilot to fly during the hours of official darkness. To obtain this endorsement, the pilot undergoes a minimum of ten hours training in basic instrument flight manoeuvres. The intent is to prepare the pilot for inadvertent entry into IMC and to familiarize the pilot with aircraft control in conditions in which there is no apparent horizon. Five of the instrument training hours can be acquired in a simulator. No evaluation of competency is required prior to endorsement, nor are there re-certification requirements for the continued exercise of privileges of the endorsement.
Twenty-four studied accidents which occurred at night resulted from a loss of aircraft control, often after the apparent onset of vertigo. To understand the circumstances of such occurrences, the training, experience and skills of the accident pilots were examined. The accident pilots had seldom obtained additional instrument training after acquiring the minimum experience for night endorsement. Since instrument flying skills are perishable and require regular practice to maintain even a modicum of proficiency, the criteria for obtaining and maintaining a night endorsement apparently do not adequately reflect the skills required to cope with inadvertent entry into adverse weather. There is a higher probability of these circumstances occurring at night.
At present there is no method of ensuring that a minimum level of skill in flying on instruments has been achieved prior to receiving a night endorsement; an evaluation of a pilot's skills under the type of vertigo-inducing conditions encountered in adverse weather at night appears to be warranted. Furthermore, at present there is no method of ensuring that a minimum level of proficiency has been retained after the issue of a night endorsement; therefore, some form of recurrency training and/or testing also appears to be warranted. Such training and testing should focus on the instrument flying skills required for the safe conduct of night visual flight, skills which are considerably less complex than those required, for instance, to conduct a complete instrument approach.
In view of the disproportionate frequency of VFR-into-IMC accidents which occurred at night, the Board recommends that:
The Department of Transport revise conditions for the issue and maintenance of a night endorsement by:
- including a practical evaluation of the pilot's skill prior to issue of the endorsement; and
- verifying continued proficiency on a recurrent basis.TSB-A90-72
Weather information can be obtained by phone, by remotely-located computer terminals, or in-person at a weather office. There are no regulations specifically requiring a weather briefing before VFR flight; yet the probability of inadvertent entry into IMC at night could be reduced if pilots had appropriate information upon which to base their decision to initiate or defer a flight. This applies to all night flights, both private and commercial, but the Board is particularly concerned about the safety of the air transportation system used by fare-paying travellers. The Board believes that the Department of Transport should encourage private pilots to obtain a weather briefing prior to conducting a flight at night, but that the requirement for operations conducted by commercial pilots should be more stringent. Therefore, the Board recommends that:
The Department of Transport require that, prior to initiating night flight under VFR from locations for which weather briefing facilities exist, pilots engaged in commercial passenger-carrying operations obtain a weather briefing.
TSB-A90-73
Okay next ATsBeaker vs TSBC research report comparison: Back in October the bureau released their report into LOSA:Loss of separation between aircraft in Australian airspace, January 2008 to June 2012
A TSBC research report (again back in 1990): REPORT ON A SPECIAL INVESTIGATION INTO AIR TRAFFIC CONTROLSERVICES IN CANADA Quote from the executive summary:
..."Following a series of losses of separation between aircraft at Lester B. Pearson International Airport in Toronto in late 1988, the Canadian Aviation Safety Board decided to conduct a special investigation of the safety aspects of the current air traffic control situation in Canada..."
Point of difference(like chalk and cheese these two): The TSBC report led to the promulgation of 48 SRs which, according to the documented evidence, have all been proactively adopted and acted on by Transport Canada since. The ATsBeaker report led to 3 SRs, which again can only best be described as wet lettuce attempts to address some fundamental safety risk issues within the ATC system.
Well there you have it, a couple of comparable research reports with similar subject matters. Those of you with the interest and the time to read can be the judge of who has the better more proactive methodology/approach in compiling research reports....hmm perhaps pass on your thoughts to the TSBC..
Part 2: Has Beaker done us all a favour??
Recently released AQONs for November '13 RRAT Supp Estimates yielded this ATsB answer to Senator Xenophon's QON 144:
b. above is worth reviewing...
"...because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety..."
I would suggest that other than the legislative framework there is very little tangible similarities in the two agencies... But perhaps the biggest point of difference is the culture within, examples are many. However the following blog piece (with vid) by the TSB Chair Wendy Tadros IMO amply demonstrates the cultural difference:
[YOUTUBE]Introducing our blog: the TSB Recorder - YouTube
Versus Beaker's blog that no one within the ATsB can contribute to and hardly anyone comments on: Beaker's blog
Full, frank & open vs mi..mi..mi..Beaker obfuscation & spin..
Another big point of difference is the TSB/ATsB claims of being totally independent...one is legitimate: Aren’t we just part of Transport Canada?...and one is no more than a charade (perfectly highlighted by the PelAir debacle)..
Finally there is the 'no blame' game contention..
TSBC:
Versus...well let's just say the word PelAir shall we??...
Yep Beaker has done us all a favour by bringing in the Canucks...
Senator Xenophon asked:
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
Answer:
a. The ATSB Commission agreed to enter into an MOU with the TSB of Canada to facilitate the review, on 24 July 2013. The MOU was executed by the ATSB Chief Commissioner and the Chair of the TSB on 29 July 2013.
b. The TSB was identified by the Chief Commissioner as well placed to conduct the review because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.
c. The review will involve the TSB conducting a comparative analysis of ATSB and TSB investigation methodologies, including a comparison against ICAO Annex 13. As part of the review, the TSB will analyse a selection of ATSB investigations, including the Pel-Air investigation, to assess how the investigation methodology was applied. The review will also assess the ATSB’s approach to the management and governance of the investigation process, the investigation reporting process and external communications.
The TSB expects to publish its report by May 2014.
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
Answer:
a. The ATSB Commission agreed to enter into an MOU with the TSB of Canada to facilitate the review, on 24 July 2013. The MOU was executed by the ATSB Chief Commissioner and the Chair of the TSB on 29 July 2013.
b. The TSB was identified by the Chief Commissioner as well placed to conduct the review because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.
c. The review will involve the TSB conducting a comparative analysis of ATSB and TSB investigation methodologies, including a comparison against ICAO Annex 13. As part of the review, the TSB will analyse a selection of ATSB investigations, including the Pel-Air investigation, to assess how the investigation methodology was applied. The review will also assess the ATSB’s approach to the management and governance of the investigation process, the investigation reporting process and external communications.
The TSB expects to publish its report by May 2014.
"...because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety..."
I would suggest that other than the legislative framework there is very little tangible similarities in the two agencies...
But perhaps the biggest point of difference is the culture within, examples are many. However the following blog piece (with vid) by the TSB Chair Wendy Tadros IMO amply demonstrates the cultural difference:
Looking back on a year of successes
February 4th, 2014
Posted by: Wendy A. Tadros
The start of a new year is filled with potential, and turning that calendar page provides a great opportunityto look forward to new challenges ahead. But it’s also a perfect time for taking stock, to look back and reflect on what has been accomplished over the previous 12 months. A little over one year ago, the Transportation Safety Board (TSB) launched this blog. We were excited, and as our social media program was still in its initial stages, we wanted to supplement our Twitter and Flickr pages with a more personal view of the TSB, one that showed what goes on behind the scenes, and offered a glimpse into the lives of the men and women whose dedication and expertise help make Canada safer. Yes, we continued to produce our investigation reports on accidents from coast to coast to coast, but we wanted this blog to take a wider view, placing the emphasis on the human interest stories—especially the ones that don’t always get told.
In other words, we wanted to give Canadians a fuller picture of who we are and what we do, to answer some of their questions, and then invite them to join the conversation.
And that‘s exactly what we’ve done. We’ve blogged about topics such as getting to accidents sites in really remote areas, a young Marine cadet’s first encounter with tragedy at sea, and even a TSB employee whose hobby is being an aviation consultant for Hollywood blockbuster movies!
But we’ve also used the blog as an opportunity to shine a spotlight on key issues and investigations—and to that end we’ve written about the recurring problem of floatplane safety, as well as what it’s like to be on site in the days following a devastating train accident.Looking ahead, 2014 is already shaping up to be a busy year. The coming months will see the release of several long-awaited TSB investigations, including into the deadly 2011 crash of a Boeing 737 in Resolute Bay, Nunavut; and the tragic 2013 derailment and fire in Lac-Mégantic, Quebec. As always, though, we won’t wait until the final release of a report to communicate safety information; if we discover risks that need to be communicated sooner, we’ll do that.
In the meantime, watch this space. We have lots of stories to tell, and plenty of TSB people who want to tell them. Because whether they’re putting together the pieces of a shattered airliner, interviewing crew members from a capsized fishing vessel, or computer modeling the deadly results of a train derailment or pipeline explosion, our people have a passion for their work—a passion they’re happy to share.
And one we think you’ll enjoy reading about.
February 4th, 2014
Posted by: Wendy A. Tadros
The start of a new year is filled with potential, and turning that calendar page provides a great opportunityto look forward to new challenges ahead. But it’s also a perfect time for taking stock, to look back and reflect on what has been accomplished over the previous 12 months. A little over one year ago, the Transportation Safety Board (TSB) launched this blog. We were excited, and as our social media program was still in its initial stages, we wanted to supplement our Twitter and Flickr pages with a more personal view of the TSB, one that showed what goes on behind the scenes, and offered a glimpse into the lives of the men and women whose dedication and expertise help make Canada safer. Yes, we continued to produce our investigation reports on accidents from coast to coast to coast, but we wanted this blog to take a wider view, placing the emphasis on the human interest stories—especially the ones that don’t always get told.
In other words, we wanted to give Canadians a fuller picture of who we are and what we do, to answer some of their questions, and then invite them to join the conversation.
And that‘s exactly what we’ve done. We’ve blogged about topics such as getting to accidents sites in really remote areas, a young Marine cadet’s first encounter with tragedy at sea, and even a TSB employee whose hobby is being an aviation consultant for Hollywood blockbuster movies!
But we’ve also used the blog as an opportunity to shine a spotlight on key issues and investigations—and to that end we’ve written about the recurring problem of floatplane safety, as well as what it’s like to be on site in the days following a devastating train accident.Looking ahead, 2014 is already shaping up to be a busy year. The coming months will see the release of several long-awaited TSB investigations, including into the deadly 2011 crash of a Boeing 737 in Resolute Bay, Nunavut; and the tragic 2013 derailment and fire in Lac-Mégantic, Quebec. As always, though, we won’t wait until the final release of a report to communicate safety information; if we discover risks that need to be communicated sooner, we’ll do that.
In the meantime, watch this space. We have lots of stories to tell, and plenty of TSB people who want to tell them. Because whether they’re putting together the pieces of a shattered airliner, interviewing crew members from a capsized fishing vessel, or computer modeling the deadly results of a train derailment or pipeline explosion, our people have a passion for their work—a passion they’re happy to share.
And one we think you’ll enjoy reading about.
Versus Beaker's blog that no one within the ATsB can contribute to and hardly anyone comments on: Beaker's blog
Full, frank & open vs mi..mi..mi..Beaker obfuscation & spin..
Another big point of difference is the TSB/ATsB claims of being totally independent...one is legitimate: Aren’t we just part of Transport Canada?...and one is no more than a charade (perfectly highlighted by the PelAir debacle)..
Finally there is the 'no blame' game contention..
TSBC:
Human factors and accident investigation: avoiding the blame game
Like many other investigators at the TSB, I often encounter those who assume “human error” is to blame for an accident. And while I understand this reaction— it’s easy, especially with hindsight, to judge a person or an organization for failing to do something— blame is a knee jerk response that does little to promote safety for the future.
Instead, the goal of a human factors specialist is to understand the actions of the people involved, thereby making informed assessments as to whether conditions will repeat themselves or an accident will reoccur.
A simple assumption
I start with a simple assumption: that the people involved didn’t wake up that morning and plan to have an accident. Thus the question shifts from “what did these people do wrong?” to “why did their actions make sense to them at that time?” Other questions soon follow, including:
1) Are other people or organizations likely to find themselves in the same situation and make the same decisions?
2) What factors in the work environment led to these actions?
3) What can be put in place to change those factors for the better?
Typically, accidents happen when actions and circumstances come together at just the right time. Many of the variables or changes can seem insignificant at the time, with people often reporting that they did little different from any other day. To get to the bottom of things, I focus on how work is supposed to be carried out (standard operating procedures, training manuals, etc). Then I compare it to how work really gets done, and again to what happened on the specific day in question.
Understanding the adaptations
Understanding these differences, or adaptations, is critical—it helps me understand the drivers for the choices people make. For instance, as adaptations are identified, we assess the extent to which they have become the “unofficial” workplace standard, and how these new (and possibly undocumented) adaptations impact the workplace. For example: are other employees aware of the changes? Is management?
The boundaries of human capacity
In any workplace, people are always juggling a variety of tasks—and with differing levels of success. Human factors investigators assess all relevant aspects of human performance: perception, attention, memory, and planning—all to determine whether the demands of the job exceed a person’s ability to perform a task reliably. We use the results from established research studies to define the boundaries of human capacity and then develop a compelling argument to explain why the event happened.
Hopefully, by identifying the factors that led to an accident (or which might increase the risk of another accident taking place), we can better understand how our complex transportation system really works. And while there is never an “ah-ha moment” in which a single cause is identified as solely responsible, our work helps shine a spotlight on the management and operational characteristics that place excessive demand on people. - See more at: Human Factors and accident investigation ? Avoiding the blame game - The TSB Recorder
Like many other investigators at the TSB, I often encounter those who assume “human error” is to blame for an accident. And while I understand this reaction— it’s easy, especially with hindsight, to judge a person or an organization for failing to do something— blame is a knee jerk response that does little to promote safety for the future.
Instead, the goal of a human factors specialist is to understand the actions of the people involved, thereby making informed assessments as to whether conditions will repeat themselves or an accident will reoccur.
A simple assumption
I start with a simple assumption: that the people involved didn’t wake up that morning and plan to have an accident. Thus the question shifts from “what did these people do wrong?” to “why did their actions make sense to them at that time?” Other questions soon follow, including:
1) Are other people or organizations likely to find themselves in the same situation and make the same decisions?
2) What factors in the work environment led to these actions?
3) What can be put in place to change those factors for the better?
Typically, accidents happen when actions and circumstances come together at just the right time. Many of the variables or changes can seem insignificant at the time, with people often reporting that they did little different from any other day. To get to the bottom of things, I focus on how work is supposed to be carried out (standard operating procedures, training manuals, etc). Then I compare it to how work really gets done, and again to what happened on the specific day in question.
Understanding the adaptations
Understanding these differences, or adaptations, is critical—it helps me understand the drivers for the choices people make. For instance, as adaptations are identified, we assess the extent to which they have become the “unofficial” workplace standard, and how these new (and possibly undocumented) adaptations impact the workplace. For example: are other employees aware of the changes? Is management?
The boundaries of human capacity
In any workplace, people are always juggling a variety of tasks—and with differing levels of success. Human factors investigators assess all relevant aspects of human performance: perception, attention, memory, and planning—all to determine whether the demands of the job exceed a person’s ability to perform a task reliably. We use the results from established research studies to define the boundaries of human capacity and then develop a compelling argument to explain why the event happened.
Hopefully, by identifying the factors that led to an accident (or which might increase the risk of another accident taking place), we can better understand how our complex transportation system really works. And while there is never an “ah-ha moment” in which a single cause is identified as solely responsible, our work helps shine a spotlight on the management and operational characteristics that place excessive demand on people. - See more at: Human Factors and accident investigation ? Avoiding the blame game - The TSB Recorder
Yep Beaker has done us all a favour by bringing in the Canucks...
So Sarcs
One of your points here I think is you believe the ATSB would be better if they all blogged about what they were doing instead of just doing it?
I think I would prefer them to just produce timely well informed reports than fill their time with updating personal internet waffle giving even more ammo to those amongst us on vendettas.
I think the NTSB investigation into the 777 is a good example of what happens when the bosses are more interested in their own careers and profiles than getting on with the job.
One of your points here I think is you believe the ATSB would be better if they all blogged about what they were doing instead of just doing it?
I think I would prefer them to just produce timely well informed reports than fill their time with updating personal internet waffle giving even more ammo to those amongst us on vendettas.
I think the NTSB investigation into the 777 is a good example of what happens when the bosses are more interested in their own careers and profiles than getting on with the job.
Different environment, different outcome, similar causal chain..final verdict??
Lessons to be learnt: Although probably too late for TSB review purposes, it is worth doing a comparison with a recently completed TSB investigation vs a bureau ongoing investigation, which appear to have some very similar causational elements...unstablised approach, SOPs, IFR to VFR visual segments etc...
This is the summary for ATsB investigation AO-2013-085
{Note:This incident was also covered by Planetalking What were they thinking on this Virgin flight? }
And this is the Findings & Safety Action statements for TSB Final report for AIR A12P0034
It will be interesting to see if we get the same standard of informative, clear & concise reporting with similar (but somewhat repetitive) safety messages when the bureau report comes out...
This is the summary for ATsB investigation AO-2013-085
On 15 May 2013, an ATR-GIE Avions de Transport Régional, ATR72‑212A aircraft, registered VH-FVR and operated by Virgin Australia Regional Airlines, was conducting a scheduled passenger service from Brisbane to Moranbah, Queensland.
At about 0715 Eastern Standard Time1 the flight crew commenced a descent from flight level (FL)2 180 and conducted a visual approach3 to runway 16 at Moranbah Airport (Figure 1).
During the approach to the downwind position of the circuit, the crew observed a band of low scattered cloud4 and fog along the flight path. The crew reported that the cloud base appeared to be about 1,500 ft above ground level (AGL), which was their planned downwind altitude for the circuit.
As the aircraft approached 1,500 ft AGL the captain, who was the pilot flying, elected to continue descending the aircraft to remain clear of the cloud. The captain reported that, as the cloud appeared to be ‘sloped’ and he had visual reference with the ground, the aircraft could be flown visually under the cloud on the downwind leg.
It became apparent during the descent that the cloud was more extensive than expected and, in order to remain visual, the captain increased the aircraft’s rate of descent to about 1,900 ft/min until levelling below the cloud at a recorded altitude of about 450 ft AGL.
Recorded data identified that, during the descent, the aircraft’s terrain alert warning system (TAWS) activated a number of terrain proximity and aircraft configuration alerts to the crew (Figure 1). The crew reported that, as they were visual, the alerts were acknowledged and flight continued below the cloud base. They also reported that the height of the cloud base was difficult to judge due to the combination of the scattered cloud and the underlying fog.
Once past the low band of cloud, the aircraft was climbed to about 950 ft AGL before the captain turned the aircraft onto the base leg of the circuit. While on base, two TAWS 'Don’t Sink' alerts, which were based on a number of parameters including the degree of altitude loss and radio altitude, were annunciated to the crew. These alerts were acknowledged by the crew and, as the aircraft’s performance appeared normal, the approach was continued and the aircraft landed on runway 16.
The investigation is continuing and will include a review of the:
•operator’s standard operating procedures and pilot training relating to the conduct of approaches
•operation and performance of the TAWS
•operator’s management of TAWS alerts.
It is anticipated that the investigation report will be released to the public no later than April 2014.
At about 0715 Eastern Standard Time1 the flight crew commenced a descent from flight level (FL)2 180 and conducted a visual approach3 to runway 16 at Moranbah Airport (Figure 1).
During the approach to the downwind position of the circuit, the crew observed a band of low scattered cloud4 and fog along the flight path. The crew reported that the cloud base appeared to be about 1,500 ft above ground level (AGL), which was their planned downwind altitude for the circuit.
As the aircraft approached 1,500 ft AGL the captain, who was the pilot flying, elected to continue descending the aircraft to remain clear of the cloud. The captain reported that, as the cloud appeared to be ‘sloped’ and he had visual reference with the ground, the aircraft could be flown visually under the cloud on the downwind leg.
It became apparent during the descent that the cloud was more extensive than expected and, in order to remain visual, the captain increased the aircraft’s rate of descent to about 1,900 ft/min until levelling below the cloud at a recorded altitude of about 450 ft AGL.
Recorded data identified that, during the descent, the aircraft’s terrain alert warning system (TAWS) activated a number of terrain proximity and aircraft configuration alerts to the crew (Figure 1). The crew reported that, as they were visual, the alerts were acknowledged and flight continued below the cloud base. They also reported that the height of the cloud base was difficult to judge due to the combination of the scattered cloud and the underlying fog.
Once past the low band of cloud, the aircraft was climbed to about 950 ft AGL before the captain turned the aircraft onto the base leg of the circuit. While on base, two TAWS 'Don’t Sink' alerts, which were based on a number of parameters including the degree of altitude loss and radio altitude, were annunciated to the crew. These alerts were acknowledged by the crew and, as the aircraft’s performance appeared normal, the approach was continued and the aircraft landed on runway 16.
The investigation is continuing and will include a review of the:
•operator’s standard operating procedures and pilot training relating to the conduct of approaches
•operation and performance of the TAWS
•operator’s management of TAWS alerts.
It is anticipated that the investigation report will be released to the public no later than April 2014.
And this is the Findings & Safety Action statements for TSB Final report for AIR A12P0034
Findings
Findings as to causes and contributing factors
1.Although the hazardous runway condition had been identified by the company's safety management system, the delay in action to mark the runway allowed this condition to persist.
2.Up-to-date weather and runway condition information was not provided to the crew, nor was it requested by the crew.
3.The pilot continued the approach below the visibility limits specified in the company's standard operating procedures.
4.Deteriorating weather, as well as the lack of approach aids and runway markings, hampered the pilot's ability to establish the aircraft onto a stable final approach prior to crossing the threshold.
5.The company's standard operating procedures for stabilized approaches were not followed, and an unstabilized approach was allowed to continue.
6.The pilot was unable to position the aircraft over the centre of the runway as it settled to land, and the left main landing gear entered the deeper snow at the runway edge, causing the aircraft to veer into the snow bank.
Findings as to risk
1.If a company's risk mitigation strategy is not implemented in a timely manner, hazards are allowed to persist, increasing the risk of an accident.
2.If company standard operating procedures do not include criteria and procedures for stabilized approaches, or they are not followed, there is an increased risk of landing accidents.
3.Operating on a snow-covered runway that does not have markings or devices to allow a pilot to easily identify the runway surface increases the risk of runway excursions.
4.If the identified risks and mitigation strategies are not communicated to the people exposed to the risks, it is possible they will deem the risk as acceptable to management and continue operations.
Safety action
Safety action taken
Transport Canada
Transport Canada indicated that further prescriptive regulations may not be the appropriate way forward, but rather that the issue of rejected approaches may be better addressed through guidance material on pilot decision making and crew resource management.
This issue will be addressed in the development of the contemporary crew resource management (CRM) and pilot decision making (PDM) training standards for 702, 703, 704, and 705 operations. These standards will include the threat and error management (TEM) model.
The regulatory development of CRM and PDM is part of the 2013/2014 priorities.
This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 18 December 2013. It was officially released on 07 Februrary 2014.
Findings as to causes and contributing factors
1.Although the hazardous runway condition had been identified by the company's safety management system, the delay in action to mark the runway allowed this condition to persist.
2.Up-to-date weather and runway condition information was not provided to the crew, nor was it requested by the crew.
3.The pilot continued the approach below the visibility limits specified in the company's standard operating procedures.
4.Deteriorating weather, as well as the lack of approach aids and runway markings, hampered the pilot's ability to establish the aircraft onto a stable final approach prior to crossing the threshold.
5.The company's standard operating procedures for stabilized approaches were not followed, and an unstabilized approach was allowed to continue.
6.The pilot was unable to position the aircraft over the centre of the runway as it settled to land, and the left main landing gear entered the deeper snow at the runway edge, causing the aircraft to veer into the snow bank.
Findings as to risk
1.If a company's risk mitigation strategy is not implemented in a timely manner, hazards are allowed to persist, increasing the risk of an accident.
2.If company standard operating procedures do not include criteria and procedures for stabilized approaches, or they are not followed, there is an increased risk of landing accidents.
3.Operating on a snow-covered runway that does not have markings or devices to allow a pilot to easily identify the runway surface increases the risk of runway excursions.
4.If the identified risks and mitigation strategies are not communicated to the people exposed to the risks, it is possible they will deem the risk as acceptable to management and continue operations.
Safety action
Safety action taken
Transport Canada
Transport Canada indicated that further prescriptive regulations may not be the appropriate way forward, but rather that the issue of rejected approaches may be better addressed through guidance material on pilot decision making and crew resource management.
This issue will be addressed in the development of the contemporary crew resource management (CRM) and pilot decision making (PDM) training standards for 702, 703, 704, and 705 operations. These standards will include the threat and error management (TEM) model.
The regulatory development of CRM and PDM is part of the 2013/2014 priorities.
This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 18 December 2013. It was officially released on 07 Februrary 2014.
