|
The latest round of short investigation bulletins are out. Some are hardly worth a mention, others more serious. The common thread is no real advice, feedback or suggestions are given by the ATSB.
Meanwhile, this one was due to be released in September, but still nothing... Investigation: AO-2012-024 - Wheels-up landing involving Fairchild SA227-AT (Metro), VH-UZA, Brisbane Airport, 15 February 2012 Word on the street this accident was handed over by the ATSB to the organisation involved to investigate themselves. The cause was determined within a day, yet over 18 months on still no mention about why we were all fecked around that morning. |
ATSB - All about juggling pots of money and mi mi mi
What folly. So 18 months after a Metro goes wheels up at Brisbane there is still no finalised report? Typical of the now incompetent ATSB. No deaths, no hull loss, yet 18 months roll by.
In comparison, just for fun, a NTSB report below. A DC-10, Dallas, almost 30 years ago, complete hull loss and 134 dead. Investigation completed in approximately 12 months! I know you can't compare apples with oranges but FFS, it is still an unbelievable difference don't you think? http://libraryonline.erau.edu/online...s/AAR86-05.pdf |
Was Whyalla catalyst for BASR??
Phearless Phelan has rehashed a classic article covering the 'other' side of the fence take on the causal chain of the Whyalla tragedy...:D: Hot Spots – Whyalla accident revisited
Now most would agree that the ATSB Whyalla investigation was (prior to 2008..:E) not one of the bureau's finest hours in AAI..:ugh: It was also probably about the time that FF began to believe they were untouchable when it came to heavyhanded enforcement action post accident/incident. It was also probably the start of their standard modus operandi of burying an unfavourable third tier operator (LCRPT/Charter)..:{ PP article quote: In a post-accident pattern of behaviour now familiar to the general aviation industry, the Civil Aviation Safety Authority (CASA) launched a series of post-accident “special audits,” interviewing various individuals including a former chief pilot (who had been dismissed six weeks earlier for alleged misconduct not related to his aviation duties); the chief pilot of another operator; and the bereaved partner of the deceased pilot. But I diverge...at the tailend of the PP article there is a link which takes you to a critique/analysis of the ATSB Whyalla report, plus a couple of more plausible scenarios for the accident itself: Pelican's Perch #57: The Whyalla Report — Junk Science? Many on here have probably read, or can vaguely remember reading..:E, this John Deakin article but for old time's sake it is well worth refreshing the memory. Needless to say (with a title like that) Deakin does not hold back in lambasting the ATSB final report...:=: In December, 2001, the ATSB (Australian Transport Safety Bureau, similar to the U.S.'s NTSB) published one of the worst accident reports I can remember reading. In my opinion, the ATSB has taken junk science, pure speculation and profound ignorance to levels seldom before seen. They have not only perpetuated "Old Wives' Tales," but they have invented a few new ones. I'm afraid we'll be hearing about "lead oxybromide deposits" for all eternity. As best I can tell, that term seems to have been INVENTED in this accident report. (Try a search on the Internet for "lead oxybromide"!) Food for thought: Hmm..maybe if they had swallowed their pride, spent some money and called in the experts we would still have a credible AAI??:ugh: |
Phelan lights another Xmas candle! Love it.
Sarcs, interesting thought provoking post, and an interesting Phelan article.
I am a bit of a fan of the old bureau days and particularly Alan Stray and Kym Bills, so out of my own general interest I might look around the chook shed to see if any light can be shed on the 'poor investigation'. There could be some valid reason (or non valid reason), a root cause even, for why an investigation pissed off the Coroner so much? As an example, although I have great respect for the NTSB, I have seen surprising reports, some quite crappy in fact, come out of investigations which one could classify as being 'sensitive', or 'political hot potatoes' := I am not alluding to anything untoward by the ATSB, but most certainly 'every action has a reaction', and if the Whyalla report was not of a standard commensurate with the bureau's normal and regular capabilities, quality and high standards then there must be a reason. Perhaps the answers are out there and a little spade work and digging from a different angle and depth is required?? Incidentally, from another thread relating to the Tiger Moth crash off beautiful Straddie, it appears mi mi mi Beaker has opened his ATSB jam jar just a fraction and is providing a few cents more than he normally would for the investigation process to be a little more 'robust'. Perhaps the well manicured bureaucrat is trying to avoid the tendentious commentary he received after the Hempel and PelAir fiasco's? Or maybe the Canucks are out here still and have been advising Beaker on how to conduct a mi mi mi investigation? |
No…..Quite simply the ATSB and for that matter CASA have virtually NIL knowledge and understanding of piston engines and their fleet operations.
I doubt this has improved since the Whyalla crash. I strongly suggest you read the George Braly evidence provided to the SA coroner. I would suggest you go see Doug Sprigg at Arkaroola re this topic. I suggest also ask why did CASA shut down a engine shop who was about to provide evidence to the coroner over a couple of paint tins in the back of a cupboard that were past their use by date? Funny, they dropped all claims after the Ada Oklahoma evidence was presented.:hmm: Funny thing CASA / ATSB could not block that.:hmm: Coincidence? Surely not. Maybe I had too many rums on board when I was educated by Mr Sprigg. But given the victim of such strange action is now a colleague and friend of mine, the dots are lining up. Smoke=Fire they say. |
Very god post Jabba :ok: See folks, it doesn't take long when looking at these matters, even briefly as I have, to see the dazzling effects of a CASA circus show!
Very interesting Jabba, interesting indeed mate. And yes, I do see a lot of 'smoke' surrounding this case. |
Study and study harder……. lost more to find.
To be fair, it was not all that hard for ATSB and CASA to bluff their way out of it. Who was there going to do the critical thinking and challenge the BS presented. Sir Doug (deserves a knighthood for this and many other things) singlehandedly exposed the can of worms. History of this would be very different had he not. I would like to write a book on it, and I best do so in the next year or three while folk remember what happened. I might sell 300 copies even. :} When I bought JD's ticket earlier this year for a trip down under we joked about a fake name….just so he could sneak into Oz undetected by ATSB/ CASA. At the first course one CASA guy was there, but fortunately he was one of the good guys :ok: We seriously joked about it……I am sure there are some that wish that article never saw the light of global aviation media day. |
Jabba #82 –"Study and study harder……. lots more to find. Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'. The industry would be placed at an increased risk level by accepting and following the 'expert' results. The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk. It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away. Strewth. I'll have a pint of whatever he's drinking; must be bloody good stuff. |
Bringing JD out here was a stroke of genius, it is difficult for the alphabet soup ATSB to deny factual evidence from internationally recognised experts no matter how hard they try to obfuscate.
|
Thanks T28D, but that was for the launch of Advanced Pilot Seminars Australia, not anything to do with ATSB.
George on the other hand did come out here about 7 years back……he must have been ducking and weaving too :} They were a team effort, George with the Dyno data, and JD with the mightier than sword pen! Great result though! And Doug Sprigg (Sir Doug ;) ) should not be left out of that either. |
Just the fact JD was here would grab their attention
|
It should, but you are smart enough to know that it might be expecting a bit much ;)
|
Leave it to the experts!
Jaba:
I strongly suggest you read the George Braly evidence provided to the SA coroner. Couple of passages from the Whyalla Coroner's report : 12.80. Mr Braly outlined his opinions about the sequence of events leading to the ditching as follows: 'The following is a short summary of the sequence of events that, based on known hard engine operating data and the known objective findings surrounding the fatal crash, is what most likely happened in connection with this fatal crash: 1) The left engine crankshaft failed. The cause appears most likely to be related to improper installation of the connecting rod on the number six cylinder. 2) The pilot feathered the left engine and increased the manifold pressure on the remaining right hand engine from a normal 30" to some larger value in the 34 to 40" MP range. The pilot most likely failed to also increase the mixture on that engine to a suitably rich mixture. 3) The indicated airspeed (IAS) of the aircraft was reduced due to the left engine being feathered and the loss of nearly 50% of the previous available cruise power. The combination of the lowered cruise speed and the increased power on the right engine left the right engine in an environment very similar to a "climb condition". That is, the engine was enjoying minimal cooling air flow due to the reduced cruise speed and suffering from higher than normal power settings, both of which are typical of operating conditions encountered during routine climbs. 4) The crucial operational error was the likely failure of the pilot fully (or adequately) to increase the mixture on the right hand engine during this engine out cruise condition. Had the pilot simply and properly increased the mixture during this critical phase of the flight, as normal training and good engine operating practices would dictate, the right engine would not have failed and the aircraft would have, more likely than not, continued to a safe landing at Whyalla. 5) Something as simple as a small excess overhang of a helicoil tang at one of the spark plugs in cylinder 6 of the right engine could have dramatically increased the susceptibility of that cylinder to pre-ignition. The photographs in the ATSB report do not detail this area of the cylinders in sufficient detail to evaluate this not uncommon cause of pre-ignition. 6) One can readily demonstrate that even a newly built or overhauled TIO-540J2B engine, in perfect mechanical condition will, under the conditions described in paragraphs 2-4 above, operate in light to medium detonation and if left unresolved, that light to medium detonation will steadily raise the cylinder head temperature to the point that pre-ignition begins. After the pre-ignition begins, the engine will suffer catastrophic failure, usually within a matter of one to five minutes, unless the pre-ignition is promptly corrected. The author of these comments invites an appropriate representative of the ATSB to visit the author’s test facility and to observe the operation of the TIO-540J2B engine in any combination of power and mixture settings desired, in order to verify each and every observation about the operation of that engine described in these comments. 7) Notes: a) The various different cruise mixture settings used by Whyalla and the other operators of these engines described in the ATSB report had no effect what so ever on this crash. At the reported normal cruise power settings, it is virtually impossible to cause one of these engines to detonate or pre-ignite, if the engine and the associated ignition system are in proper operating condition. b) The climb mixture settings used by Whyalla (as distinguished from the descriptions of the power and mixture settings used by all other operators surveyed by the ATSB) were highly improper and likely caused one or more cylinders on both engines to frequently operate in light or medium detonation during portions of each climb. c) The description of "deposits" on the pistons set forth in some detail in the report is essentially unrelated to any aspect of the cause of this crash. This extended pursuit of this subject is largely a red herring. For example, the deposits such as are described and displayed in the limited photographs in the ATSB report appear, from those photographs, in actuality, to be rather more accurately described as minimal as compared to most engines with similar operating time. In fact, they generally appear to be so minimal as to support the notion that the Whyalla engines were, in fact, frequently operating for short periods of time (probably during climbs, given the reported Whyalla engine operating technique during the climb phase of flight) in light to moderate detonation and this periodic condition actually cleaned the piston domes of some of the otherwise normal deposits. A better collection of photographs of the pistons and cylinder domes would provide still more accurate information on this subject. d) In common pilot & mechanic operating terminology, when one "leans" the mixture, one reduces the ratio of fuel to air via use of the mixture control. However, when one thus "leans" the mixture to a condition that most pilots and mechanics would routinely call a "lean" mixture, the mixture remains a stoichiometric rich mixture. (The mixture is chemically a rich mixture until the exhaust gas temperature - - as indicated by the turbine inlet temperature gage [sic] during gradual reductions in fuel flow, - - has reached a maximum value and started to decline.) The confusing terminology in this area is responsible for an enormous misunderstanding in the pilot and mechanic community of the true implications of chemically rich and lean mixtures with respect to the operation of high powered piston aircraft engines. At one point, the ATSB report on this crash attempts to accurately define these terms, but then, in other areas, fails to accurately apply the correct terminology to the operation of the engines in question, and thus, compounds the confusion for pilots and mechanics who may read the report. In its criticism of the routine use of so called "lean" mixtures, the ATSB fell into the common trap of mis-characterising stoichiometric "rich" mixtures as being "lean" mixtures. Worse, the lay press has grabbed onto this aspect of the report and has compounded the confusion in this area with published reports that completely mischaracterize the issue, blaming the crash on the use of "lean" mixtures, with an express or implied suggestion that the airline operators of this type aircraft were trying to skimp on fuel in order to save money at the expense of operating safety. (C196a, p4-6) Mr Braly's hypothesis for the causal chain from the time VH-MZK diverged right reads very similar to John Deakin's analysis article: Reference pg 140 para 12.93: 'At the point where the aeroplane diverged right on page 3 at 1847:15, I think the pilot had been wrestling with problems with the right engine since some point in the climb. I believe at about that time he decided to simply throttle the engine. He could do that, and it’s my opinion that at that point in time he had experienced an episode of pre-ignition on the right engine. Whether or not it had already put a hole in the piston is debatable, but he did not, unlike the gentleman that was shown in the recreation of the data yesterday, the benefit of that sort of instrumentation and he would not have likely been able to stop the event before it did damage to the cylinder and, as indicated yesterday, once that sort of thing starts to happen in the cylinder, even if he throttled the engine, if you later reapply power, it’s going to happen again, assuming he had a hole in the piston already. It is my opinion that the pilot decided simply to throttle the right engine and, in the process of that, the aeroplane yawed to the right slightly. In my experience teaching multi-engine pilots to fly during training, a momentary lapse in the heading control of the aircraft during major left/right power discrepancies is more common than not, even among good pilots, and I think the right-hand turn data is consistent with that, and a prompt re-correction back on course is consistent with him having done that and then retrimmed the aeroplane by use of the rudder trim control and what not to put the aeroplane back on course. At that point in time the pilot had an unknown problem with the right engine, but it was still operating, and he had a 250- or 260-hour left-hand engine, and he made the decision to continue on. In the process he would have likely pushed up the power on the left-hand engine to something approaching climb power. He may have in fact used climb power - that would be a common training scenario for a multi-engine pilot, that if you lose an engine, you put the other engine up to climb power. That’s not necessarily the most optimal training exercise, but it’s a common method of teaching multi-engine pilots. So I believe he increased the power on the left engine as he reduced the power on the right engine, and pressed on. Some time just before 1901:10 when the MAYDAY was transmitted I think the crankshaft failed on the left engine. When the aircraft hit the water the left engine was feathered - I think the left engine would have virtually auto-feathered from the oil pressure loss. The right engine was still turning and not feathered, which is consistent with the previous power reduction. I think if he had not already had a hole in the piston at the time - 1847:15 - when he throttled that engine, or when he tried to power up the right engine after the failure of the left, that he would have holed it promptly, because it would have gone back into pre-ignition. It would have been a very confusing and difficult situation for the pilot. They simply do not train for simultaneous engine failures, and they certainly do not do it at night with a full load of passengers over water.' (T3221-23) There is no doubt the Coroner's report is a truly fascinating read (if you've got the time..:rolleyes:), but the devil is always in the detail andwith most Coroner's reports that is contained in the findings and recommendations. In the case of Coroner Chivell his findings & recommendations underlined his frustration and consternation with the obvious bungling, obfuscation and disturbing shennanigans by the ATSB and to a lesser extent Fort Fumble. Perhaps this consternation is best illustrated from paragraph 15.5 (pg 181) to paragraph 15.13 (pg 183) {Note: Remembering that this was prior to the introduction of the TSI Act}. Coroner report quote paragraph 15.10: 15.10. It follows, then, that I reject any suggestion that the ATSB were constrained or limited by section 19CA of the Air Navigation Act, 1920 in this investigation. In my opinion, the remarks of the Director of the ATSB, Mr Kym Bills, to the Australian Senate on 11 February 2003 reflect this misconception: 'For many years there have, from time to time, been difficult issues in some state and territory coronial inquests. The ATSB has been seeking better mutually cooperative relationships with coroners in the context of the legislation currently before the parliament and will continue to do so. However, problems remain when the bureau is criticised at inquests for not spending more money on a particular investigation to satisfy legal queries such as those relating to future civil litigation; when the high cost of inquests redirects our resources from higher safety priorities; where a particular inquest encounters difficulties with the Commonwealth no-blame legislation; under which we operate in accordance with international agreements; or where legal certainty is sought from an investigation, whereas the evidence often does not allow this and the ATSB’s focus is on the action necessary for future safety.' The notion that ‘legal certainty’ (by which I assume Mr Bills means the finding of a fact to the requisite standard of proof) is somehow inconsistent with the ATSB’s role to ensure ‘future safety’ is not in accordance with logic. Surely an investigation must demonstrate, to an appropriate degree of certainty, that an incident has occurred in a particular way before remedial or preventative measures can be taken. IMO another (in a long line) of missed opportunities to advance our learning from a serious accident tragedy and to ultimately enhance aviation safety has been missed...:=:= As Gobbles quite often..:E..said TICK..TOCK!:{:{ |
The holes in the cheese are aligning...TICK..TOCK!
Kharon:
To me, it's not the finding as much as how the interpretation is framed. Compare the Pel Air and Whyalla "investigations" and three points shriek at you. Had it not been for industry voluntary donations of expertise, logic and analysis, the results would be still standing today. Industry exposed the truth – not the 'experts'. The industry would be placed at an increased risk level by accepting and following the 'expert' results. The 'experts' who attempted to foist this flummery, then went to extraordinary lengths to make sure 'their' risible versions (facts and circumstances) were accepted, those folk 'expert' are still out there. Posturing as 'leaders-in-the-field', preening at international events, spoon feeding hapless politicians an ever increasing load of carefully spun mystique and drawing their salaries from the toil of honest folk. It's beyond disgusting – and old Truss thinks the milk sop review, sponsored and stage managed by those who created the unholy mess is going to make this all go away. Whyalla may or may not have been the catalyst for where we find ourselves today but it is now somewhat academic. A couple of recently released bureau reports, plus Kharon's succinct post above, IMO perfectly highlight the current status quo within aviation safety regulation & accident/incident investigation in this country and add further evidence that we are fast approaching critical mass (the holes are aligning)!:ugh::ugh: First cab off the rank is the prelim report for the wx related 'Serious Incident' involving two 737s diverting into Mildura due fog at YPAD. Link to my post on the subject (incident) on ANZ&P forum: "From the sublime to the ridiculous???" In that post I put my thoughts & disgust :yuk::yuk: in fairly plain language on the ATSB downplayed prelim report...IMO truly disgusting for an incident that has enormous implications to the whole industry not just the airline sky gods!:rolleyes: Perhaps the more understated comment by wildsky (Ben's article) points to the true potential knock-on effects of the ATSB (dis)missive, prelim report and their future investigation activities into the incident. ...."I guess this “safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally” and the “research study into the unreliability of aviation meteorological forecasts” will be rolled out eventually as the Government response to: “Recommendation 24 9.106 The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.” Despite the Chief Commissioner selectively quoting the Bureau of Met’s Norfolk forecasting reliability data to disguise the real and identified risk levels, the reality was that all of the clues were presented to the ATSB and CASA that we had, and still have, a significant operational problem. Mildura, or many other mainland aerodromes, do have lower risks of forecasting errors than remote islands – but the risk still exists and the Mildura event showed just how quickly things can change from risk to actual danger to life and limb. Safety forums and research studies are what you do when you don’t really want to do anything – they are nice shows of interest but have no weight in achieving change. Makes me so glad every time I hear “safety is our number one priority”…:D:D The next report was also covered by Ben, see here: Virgin 737 cleared to fly through paratrooper drop: ATSB On the surface this report was fairly reasonable and it would appear that all DIPs have taken on-board the Bureau's concerns and are progressively addressing the significant safety issues. But again the devil is always in the detail which, as we all know, in bureau reports is (usually) contained in the Safety Issues/Actions section. This particular report has led to the bureau (surprise..surprise..;)) actually promulgating two safety issues on their Aviation safety issues and actions database, see here:AO-2012-142-SI-01 & AO-2012-142-SI-02 Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then?? I know..I know it is all about Beaker's touchy, touchy feely, feely, beyond all sensible reason methodology... But it just leaves the man at the back of the room asking.."what else are the hiding??":confused: Note: Ironically, in the case of the YMIA incident, even certain DIPs (in this case ASA) are still waiting for the ATSB to follow normal accepted practice and submit safety recommendations to frame a ASA MAP (Management Action Plan). Reference QON 161 AA 02 CHAIR Maintenance of AWIS (Sen Estimates 18/11/13).... "....Mr Hood: There are over four million aircraft movements in Australia a year, very few of which cause us significant concern. I think it is fair to say this is a concerning incident. We are cooperating fully with the ATSB. It is our hope that the ATSB will establish all of the facts and make appropriate recommendations, on which we will act...." Unless the Beaker suggestion of having a 'love in'is to be regarded as a serious SR from the bureau, it would appear that Hoody could be waiting a while...:E FFS the bureau in it's present form is a disgrace!:( More to follow...:ok: |
To be honest, Hoody should just go ask some questions of those involved, formulate a plan with those at the coal face, put it in place and move on. Waiting for the ATSB or CASA would be futile and as beneficial as holding ones breath.
I do think he would get it sorted, but if left to others lord only knows. :uhoh: |
ATSB - everybody leave your car keys in the glass bowl!
The ATSB has gone from downright lame to unimaginably pathetic. Now their solution to 'every event of a safety nature' is to have a 'love in' :mad:
So Beaker, should attendees wear name tags as well? Plenty of bowls of lollies on the table as robust tendentious discussions take place, followed by some dry humping of each other's legs, some back patting and star jumps, a game of UNO and a look at some historic Wright Brothers footage? Then it is 'party over, all go home, nothing left to see here'. I really didn't think it could get any worse (well perhaps Sunfish's smoking hole is worse), mi mi mi Beaker has lost the plot completely. Please please ICAO, FAA, Communist Party of China, AOPA, anybody really, come in and fix our Aviation system, please!!! |
The portrait of Dorian Gray.
There have been three important ATSB reports published lately; the slightly hysterical Tiger go-around at Avalon; the secretive Meat bombs v Virgin; and, the Mildura Met Muddle. Each, in it's own way significant. Once you have read and inwardly digested, just for fun, isolate the individual issues into short sentences and see what sort of picture you get and it ain't pretty. Then, if you can stomach it, line up the considered responses aimed at preventing a reoccurrence of any one of the three potentially serious incidents and time line it from start to finish. The question 'have we done enough to minimise the risks?' is nugatory. 'Have we done anything positive in a timely manner at all?, has the ascendancy: the answer being a resounding NO.
The emerging picture reminds me of the Dorian Gray story, written by Oscar Wilde. Wiki - Realizing that one day his beauty will fade, Dorian (whimsically) expresses a desire to sell his soul to ensure the portrait Basil has painted would age rather than he. Dorian's wish is fulfilled, and when he subsequently pursues a life of debauchery, the portrait serves as a reminder of the effect each act has upon his soul, with each sin displayed as a disfigurement of his form, or through a sign of aging. “Words! Mere words! How terrible they were! How clear, and vivid, and cruel! One could not escape from them. And yet what a subtle magic there was in them! They seemed to be able to give a plastic form to formless things, and to have a music of their own as sweet as that of viol or of lute. Mere words! Was there anything so real as words?”. Oscar Wilde. |
MMM - Mildura Met Muddle
K
A new form of mi, mi, mi??? |
What was slightly hysterical about the Tiger report?
What was secretive about the parachute report? Have you got anything except your secretive hysteria? |
Homework help.
Tiger’s A320 could have become a smoking hole in a suburb on this Avalon airport approach in 2011, and for CASA it was the last straw, causing it to ground the airline two days later. Sarcs # 94 – "Now my beef is that this bureau initiative is all well and good but why weren't these latent safety issues made transparent and publicly available back then?? Sandilands - ATSB Anyway OB, that's my two bob's worth; no matter how I choose to express it. |
| All times are GMT. The time now is 18:38. |
Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.