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ATSB reports
There was not the usual flood of reports at the end of July. There are now 87 outstanding reports. The oldest of which goes back to 30 June 2011 (Operational non compliance of VH-VNC near Avalon Airport). There were 10 new occurrences in July, but only 5 reports issued.
Even what look like simple reports (eg AO-2012-042 - PA34 descending below LSA at Townsville) are taking over a year. If you take the ATSB budget and divide by the number of reports (air, sea & land) the average reports costs more than $200,000. Surely even McKinsey & Co would be cheaper and faster. |
Mi Mi Mi Mi Mi Mi lost the password to the report generator.
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Maybe they haven't got the right people to generate suitable reports. Anyone can get out and kick around busted up tin and map an accident site with a bit of training, however to to follow through with a full in-depth and and accurate unbiased technical report can be a challenge for your average subject expert, ie pilot, engineer, air traffic controller, etc, if they haven't done any report writing in the past.
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers. |
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers But Sir...I haven't had any training. Use your initiative my boy and get going. But, but, Sir, how do I get to East Sale? Use your bloody initiative boy...get a Dakota or something from Fairbairn. NOW,ON YOUR WAY! It was called on the job training in those days. Not ideal but it worked most of the time. There were no FDR or CVR's. Just an experienced engineer usually and a pilot that used his initiative and flying experience to speculate how an accident happened. Mostly it was obvious. The more leisurely Court of Inquiry would have their completed report published within a month, normally. |
Maybe they haven't got the right people to generate suitable reports. 1. Randomly select any 5 past reports and I'll bet that a final year engineering student could do better and 2. Most of the reports they do are not about serous accidents. Most are like one of the oldest outstanding report where a Seneca was directed to descend below LSALT by ATC. I doubt that one takes years of experience by trained investigators. It might take years of training to create the politically correct report - but that's hardly fitting the the "without fear or favour" mantra, is it? |
Randomly select any 5 past reports and I'll bet that a final year engineering student could do better UTR |
You clearly haven't hired any graduate engineers recently. Although I might hope that a final year engineering report has the grammar corrected by a lecturer vs a graduate who is on his / her own. |
UTR...the glass half full :ok:
About all you can say though sadly. |
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.
... and (most importantly) about three "most probable" causes :ouch: :rolleyes: |
casa and atsb failure to interface with industry
Well good to see someone raising this properly.
Just don't forget PelAir and the direction from the Honourable Senators to retrieve the flight recorders and to revisit the report. Lots of problems as we all know. We have mi, mi, mi ,mi .........beaker saying to Senate - we won't answer your question until the Board meeting of 24th July 2013 [oh yeah] and this then two days ago becomes the: CANADIAN SOLUTION I would love to see the atsb brief to the Canadian TSB. Come on Mr. Beaker, you can do better than this. |
The Honourable Senators did not give a "direction" the ATSB to do anything. :=
The Honourable Senators do not have the power to direct the ATSB to do anything. The pieces of wet lettuce comprising the Senate Committee Report have been duly noted by the ATSB, and will be actioned appropriately. Why is it beyond the wit and wherewithall of posters on PPRuNe to arrange for the removal of the FDR and CVR and delivery directly to the Canadian TSB? :ugh: |
What is going on???
Got a set of togs Creamie, to give me a hand??
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TSBC & ATsBeaker differences in methodology and mandate.
If nothing else, and the terms of reference for the review of the ATsBeaker by the TSB Canada aren't expanded (as they should be), there is perhaps a lot to be learnt from the TSB in regards to its structure, true independence and its stated Mandate, not to mention the fact that the purse strings are not held by the Minister of Transport:
Mandate The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework that governs TSB activities. Our mandate is to advance transportation safety in the marine, pipeline, rail and air modes of transportation by
To instill confidence in the public regarding the transportation accident investigation process, it is essential that an investigating agency be independent and free from any conflicts of interest when investigating accidents, identifying safety deficiencies, and making safety recommendations. As such, the TSB is an independent agency, separate from other government agencies and departments, that reports to Parliament through the President of the Queen's Privy Council for Canada. Our independence enables us to be fully objective in making findings as to causes and contributing factors, and in making transportation safety recommendations. In making its findings as to the causes and contributing factors of a transportation occurrence, it is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board does not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board’s findings. No finding of the Board should be construed as assigning fault or determining civil or criminal liability. Findings of the Board are not binding on the parties to any legal, disciplinary, or other proceedings. The TSB and other organizations The TSB's mandate is distinct from those of other organizations such as Transport Canada (TC), the National Energy Board (NEB), the Royal Canadian Mounted Police (RCMP), the Canadian Coast Guard (CCG), and the Department of National Defense (DND), all of whom play a role in the transportation field. As an independent federal agency, the TSB is not associated with any of these organizations, although we do work in cooperation with them when conducting investigations and making safety recommendations. Transport Canada is concerned with developing and administering policies, regulations and services for transportation systems in Canada with respect to federally regulated marine, rail and aviation transportation modes. The National Energy Board is responsible for regulating pipelines under federal jurisdiction. This differs from the TSB's mandate of advancing transportation safety in the marine, pipeline, rail and air modes of transportation through the conduct of independent investigations, the identification of safety deficiencies, and the making of recommendations to eliminate or reduce such deficiencies. When the TSB investigates an accident, no other federal department (except the Department of National Defense and the Royal Canadian Mounted Police) may investigate for the purpose of making findings as to the causes and contributing factors of the accident. Transport Canada and the National Energy Board may investigate for any other purpose, such as regulatory infractions. Recommendations The Transportation Safety Board of Canada (TSB) is responsible for advancing transportation safety. One of the ways it does this is by making recommendations to federal departments and other organizations to eliminate or reduce safety deficiencies. Under our Act, federal ministers must formally respond to TSB recommendations and explain how they have addressed or will address the safety deficiencies. Using an Assessment Rating Guide (which includes definitions for the status of recommendations), the Board evaluates the responses and their overall effectiveness. Each response is assessed as Fully Satisfactory, Satisfactory Intent, Satisfactory in Part or Unsatisfactory. Progress made to address TSB recommendations is assessed by the Board on an ongoing basis. For recommendations and assessments made before January 1, 2005, please refer to our annual reports. |
Box diving - for fun and profit.
Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered.
Send the Navy, I'm sure the boys and girls not on 'transport duties' could do a bang up job and enjoy the outing. I expect the experience and training opportunity would/ could be of some value for money. Yeah I know, back to my knitting...:ugh: |
Beakers, non beakers, little orange boxes and comparisons!
Herr Kharon, you are correct. There are numerous legal implications for the unauthorised removal of the boxes that are currently gathering barnacles and being used to camouflage many varieties of orange reef fish. I will try to locate the specific dot points (now that the third test is finished :() . Suffice to say the 'evidence' would be classified as useless, tainted and potentially interfered with should the Styx Houseboat take up anchor, stealthily remove said boxes and whisk them away to the land of the maple leaf for a robust examination.
Also the downside is that although the boxes are at a moderate depth I don't believe they are deep enough to have been adequately preserved, such as with the AF boxes (something to do with presuure, oxygen levels, technical stuff like that). Perhaps Herr Sunfish the keen aviator, diver, and font of much knowledge could expand on this topic? Interesting and succinct research and analysis Herr Sarcs. Also of interest is the following for comparison; TSB Director, Investigations - Background as a pilot, director of flight operations and has hands on experience as an investigator. :ok: TSB Director, Operational Services - Background in HF, he has a doctorate in the subject, and also has hands on investigation experience. :ok: ATSB Commissioner Beaker - Comcare, workers comp, Ausaid and Agriculture and Fisheries, mi mi mi mi and likes playing with large pots of money. :( I just hope that when the Maples visit they don't get dragged into the whirlpool of pooh and end up taking some of the residual stained matter back to the TSB and infect some of their own people with 'beyond Reason methodology', mi mi mi, poor investigative techniques and bureaucratic bull**** 101. |
Senate Inquiry rehash/revisit for Kharon's benefit
Kharon:
Perhaps comrade Sarcs can assist – the rules in the TSI Act related to the 'evidence chain' and the process for allowing 'independent' recovery of that CVR unit. Can't be bothered to troll back through the Act again; but it seems to me there are impediments to just going and getting the wretched thing. Just can't see anyone being tempted into an endless legal wrangle with a department which clearly does not want the box recovered. 49 OBR ceasing to be an OBR under declaration of ATSB in the notice.(1) The ATSB may, by published notice, declare that a recording, or a part of a recording, identified in the notice is not to be treated as an OBR on and after a date specified in the notice. (2) If the ATSB decides not to investigate the transport safety matter to which an OBR relates, the ATSB must, by published notice, declare that the OBR is not to be treated as an OBR on and after a date specified in the notice. (3) If: (a) the ATSB decides to investigate the transport safety matter to which an OBR relates; and (b) the ATSB is satisfied that any part of the OBR is not relevant to the investigation; the ATSB must, by published notice, identify that part and declare that part is not to be treated as an OBR on and after a date specified (4) The ATSB cannot revoke or vary a notice published under this information also ceases to be OBR information.
section. (5) When an OBR, or part of an OBR, ceases to be an OBR because of a notice published under this section, then any related OBR It is also interesting to note that essentially an OBR only covers the CVR by definition and the Civil Aviation Act like-wise only places protections on the CVR. So the question there is: Would the FDR (by no protection) be also fair game if it was a stand alone unit? :confused: |
I thought '49erd'was a term use for The Skulls treatment of some of his fellow drivers at CX :hmm:
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If the recording or part of the recording on the CVR has been the subject of a Notice under s 49, the recording or the part of the recording the subject of the Notice is not treated as an OBR from the date specified in the Notice.
I can find only one s 49 Notice on the ATSB website. It does not relate to an aviation investigation. I suspect the ATSB’s (Orwellian) reasoning will be that although the ATSB didn’t think it was worth retrieving the CVR from NGA, the ATSB is not satisfied the recording is not relevant to the investigation of the ditching. Therefore, it must remain an OBR subject to the TSI Act forever …. But lots of people seems to be labouring under the misconception that because the CVR contains an OBR, no one (other than the ATSB) is allowed to touch or remove the CVR or listen to what’s on it in any circumstances. The offences in the TSI Act are for adversely affecting an investigation (s 24) and for copying OBR information or disclosing OBR information (s 53). (There are also exceptions.) If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken? If the person doesn’t copy what’s on it, or disclose to anyone what the person heard, the person hasn’t breached s 53. The person hasn’t adversely affected the ATSB’s investigation, even if the ATSB wanted to pretend it’s keen to know what’s in the OBR. Indeed, if the ATSB wanted to pretend it’s keen to know what’s in the OBR, the person could help the investigation by delivering the CVR to an independent body – surely the ATSB would have no hesitation in authorising an independent body to have access to the OBR, under s 52, so as to confirm what a great report the ATSB produced. If the person puts the CVR back in the hull, Sunfish could then dive down and remove it from the hull (with the owner’s permission) listen to what’s on it, and then put it back without copying or damaging the OBR, and without disclosing what he heard. Then Sarcs goes for a swim …. Eventually, lots of people would be able to wink knowingly at each other … ;) |
If a person retrieves the CVR from the hull (with the owner’s permission – I’m guessing that may be the insurance company) and listens to what’s on it, and then puts it back without damaging the OBR, what rule has the person broken? If the insurance company is asserting ownership over it, surely they can be forced to move it from the crown land it is presently cluttering up? (Can't complain about fuel leaks and pollution I suppose... :oh: ) |
Senator Fawcett: "Not happy Jan...err Minister!
Phelan:
Election squabbling buries air safety recommendations Liberal Senator David Fawcett says Transport Minister Anthony Albanese has failed to respond to the damning findings of the Senate Inquiry into the ATSB’s and CASA’s responses to the Norfolk Island ditching on November18 2009. ATSB today confirmed that there would now be no action on the critical recommendations until after the election. The Senate Committee’s report with 26 safety-related recommendations was released on 23 May, 2013. It highlighted serious concerns with the processes and conduct of both government agencies, and its recommendations were aimed at rectifying what it described as “the serious deficiencies that the committee had identified.” The committee’s first recommendation was that the ATSB retrieve the accident aircraft’s flight data and cockpit voice recorders “without delays.” The report said: “The committee understands that retrieval of the recorders would be particularly useful in this instance [and] that the ATSB has certain responsibilities, set out in ICAO Annex 13, when it comes to retrieval of aircraft involved in accidents. It is an assumption throughout Annex 13 that, where a FDR [flight data recorder] exists, the accident investigation body will prioritise its retrieval.” Air safety specialists believe that the aircraft’s flight data and cockpit voice recorders could be recovered with relative ease, saying they do not understand why this recommendation is being ignored, especially as further delay might damage the equipment. Also recommended were a reopening of the original investigation with a focus on organisational and systemic issues, a drastic rearrangement of the structures within which ATSB and CASA operate, the establishment of an ICAO Annex 13 independent panel to oversee ATSB investigations and reporting, and a referral to the Australian Federal Police to investigate whether CASA breached the Transport Safety Investigation act by withholding critical documents during the investigation. During estimates hearings in May this year, Senator Fawcett specifically highlighted the risk of Government inaction before the caretaker period began, causing an unacceptable delay to implementing the recommended aviation safety reforms. When asked during Estimates on May 29 if the department’s brief to the Minister would occur in sufficient time so that Mr Albanese could respond before the caretaker mode, Department Secretary Mike Mrdak replied: “We already have officers in the department – and clearly me and senior officers – who have carefully read the report now. I have had discussions with my senior officers. We envisage being in a position to provide some initial advice to the minister, I expect, certainly within the next week to 10 days in relation to it. I envisage having conversations with the Civil Aviation Safety Authority CEO and the head of the Australian Transport Safety Bureau in the coming days to ascertain their views, to enable me to provide a comprehensive view to the minister, I would hope by the end of next week.” [two months ago.] Senator Fawcett points out that the report was tabled on May 23, allowing the Minister a three month window to respond and that given its damning findings Minister Albanese should have made this his top priority, particularly given his promise that ‘nothing is as important as aviation safety.’ “Even the announcement today of an external review of the ATSB by the Canadian Transportation Safety Board (TSB) was not made by the Minister but by the agency in question, said Senator Fawcett, referring to ATSB announcement on August 2 that the transportation is safety board of Canada (TSB) will conduct an independent external review of the ATB’s investigation processes and publish the results. The review was announced jointly by TSB Chair Wendy Tadross and ATSB chief commissioner, Martin Dolan. Sen Fawcett remains unimpressed: “This raises serious concerns about the efficacy of any resulting report unless the Minister ensures that the terms of reference (ToR) and Australian management of the audit are transparent and independent.” We asked the ATSB whether a decision been made on recovery of the flight data and cockpit voice recorders of the Pel-Air aircraft, whether recovering the recorders would be an ATSB or departmental decision, and whether the investigation will be reopened as recommended in recommendation 9. We also asked if the Canadian review was a part-response to the Senate recommendations. The ATSB would not comment on the recorders or reopening the investigation, but a spokesman said: “We’ve been in discussion with the Transportation Safety Board of Canada for some time, and it’s about benchmarking and comparison of our systems of investigation. This is an initiative of the ATSB’s chief commissioner and the TSB’s Chair, and the TSB has agreed that their benchmarking review will have regard to the Senate committee’s findings, so we’ll take those into account. “In regards to your specific questions, it is the responsibility of the Government to respond to the recommendations of Senate committees. The ATSB has provided input to the preparation of a government response. The caretaker conventions that are now in place mean that a government response will not be finalised until after the federal election.“ Senator Fawcett again called on Minister Albanese to ensure that this review of the ATSB has the confidence of the aviation industry and the public by adopting Recommendation 8 of the Senate report: 8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. “While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said. “It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation orocesses as identified in the Senate report including the Canley Vale accident.” |
atsb - Flood of Reports
Here the "...flood of reports..." we did not see in July comes:
Aviation Short Investigation Bulletin - Issue 21 see the comments: @flyingoz |
Regarding Senator Fawcett’s comments quoted by Mr Phelan, the sentence that’s missing from Senator Fawcett’s comments is again the one that starts:
If elected on 7 September, a Coalition government will move immediately to …. |
Great to see that 'safety' is a non essential item that really isn't worth a pint of panther piss during periods of caretaker governments.
May I also suggest that all road enforcement rules including the operation of speed cameras, along with aviation rules also not count during 'caretaker mode', that rape and murder receive a dispensation and that tax not need to be paid during caretaker mode. Anything else? Oh yes, why not shut down the electricity and water grids along with sewerage treatment during caretaker mode?? Absolute f:mad:wits |
Dodgy ATSB final reports
The latest round of ATSB reports are a bit of a joke and don't provide any real information to improve safety. However, this one takes the cake:
Investigation: AO-2013-128 - Collision on the ground involving a Cessna 172R, VH-IMS, at Sunshine Coast Airport, Queensland on 2 August 2013 A Cessna hits a light pole while taxing and it is worthy of the ATSB to investigate? Reading the report, they much have given it to an intern to investigate. "The pilot learnt a valuable lesson" - what a crock of crap. In another report about a TCAS RA the outcome is that pilots need to maintain situational awareness - no ****e Sherlock. They knew about each other, the SA was there, how about some real recommendations. Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole? |
Well, they should submit that report for judging. A possible award for such an industry changing revelation. My congratulations to whomever approved this investigation. Rome burns but they are holding their focus like the steely eyed missile men they are. :D
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I'd be very surprised if reports weren't submitted, especially as ATC we notified of the situation (according to my source). But then again, a Q400 tail scrape must be a bigger problem for the ATSB than an in flight fire...
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The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.
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Still waiting for the final report on this one :cool:
Investigation: AO-2011-102 - Collision with terrain involving Aérospatiale helicopter, AS355F2, VH-NTV, 145 km north of Marree, near Lake Eyre, SA on 18 August 2011 |
Still waiting for the final report on this one Although the reasons for the flight path have not yet been determined, the ATSB is concerned about the conduct of visual flight rules (VFR) flights in dark night conditions – that is, conditions with minimal celestial illumination, terrestrial lighting cues or visible horizon. The ATSB is reviewing the regulatory requirements and guidance for the conduct of night VFR flights, and the training and ongoing assessment of pilot skills to conduct such flights. The ATSB is also preparing an ‘Avoidable Accidents’ educational report focussing on night VFR accidents. |
TWT - 14th November I understand, received a note from the ATSB today
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Thanks very much for that walschaert-valve !
I am amongst a lot of people that will be very glad to find out more on that one. |
FTS #24 –"Meanwhile I hear about engine shut downs and wheel fires during the last fortnight, yet there's nothing on the ATSB website. Surely they are a bigger safety concern than hitting a light pole? Looking back at coroner recommendations and ATSB reports is a tedious business, but when you do the home work a couple of things stand out. One of the most appalling (IMO) is the lack of educational information passed on to the troops. OK, there has been a fatal, not only do we need to know the what, why and how of the thing; we need to know how to prevent the thing happening again. Take CFIT for example; the FSF and other serious safety bodies have done some great work, produced invaluable material and made it freely available. Will it prevent all CFIT?, of course not; but those who take their responsibilities seriously, will have taken an hour of two, watched the video, read the material and are now aware of the risks. The light weight, compromised, technically pathetic dribble presently being served up to industry achieves nothing but an increasingly large pile of glossy 'feel good' stuff, which probably convinces the public that ATSB has it all in hand, bit like the adverts on TV. "Buy one of these and all your dreams will come true". Problem is, some mugs do believe it. The shameful travesty of Pel Air puts the current iteration of the ATSB in the class of snake oil salesmen. I hope they manage to straighten up their game before the whole sorry mess is exposed, yet again, at yet another inquiry into yet another preventable accident. Prevention has always been better, cheaper and more effective than cure. Stuff the budget, man up, do your job and regain the faith and trust of industry. "Ave, Imperator, morituri te salutant" Suetonius reports that Claudius replied "Aut non" ("or not")......Translation here....: |
The Beaker years – ‘beyond all sensible reason’ (addendum to “K” #32 )
Glad to see the mods have merged these two threads it kind of sets a background to the demise and hit to the reputation of the once proud aviation safety watchdog, the ATSB/BASI.
The bureau, much like Fort Fumble, has always had its detractors but even the critics would (once upon a time) grudgingly admit that on the whole the ATSB generally get it right and make a worthwhile contribution for the betterment of aviation safety. However IMO in the last 5 years they have seriously lost their way. The evidence of this was very much on display throughout the Senate Inquiry (hence *Recommendation 8). Also, as posters on here are noticing, through the quality of the reports being produced. The mantra now appears to be…politically correct and on budget. *R8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. Note: Beaker attempted to placate the Senators by bringing in the Canucks but Senator Fawcett rather scathingly struck back with this comment in a press release… “While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said. “It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation processes as identified in the Senate report including the Canley Vale accident.” Some would say this decline of the bureau can be tracked back to the Lockhart River investigation with the subsequent Coroner’s findings through to the Miller review. However IMO, despite all those troubling times, the bureau on the whole could still hold their heads up high till at least the middle part of 2008. Perhaps to highlight this there were two important report publications put out by the ATSB in 2008-09, one was the decade review; Australian Aviation Safety in Review: 1998 to 2007 and the other (internationally recognised) wasthe worldwide review of commercial jet aircraft runway excursions. In the foreword of the Aviation Safety Review the former and last Executive Director Kym Bills (rather proudly) had this to say: It has been an exciting and progressive year for air safety in Australia. The December 2008 release of the National Aviation Policy Green Paper established the future direction of the aviation industry, asserting the Government’s position on air safety in Australia as the number one priority. This includes the establishment of the Australian Transport Safety Bureau (ATSB) as a statutory agency with a Commission structure to enhance its independence. Legislative amendments to the Transport Safety Investigation Act 2003 to give effect to the governance changes have been passed by Parliament and the new Commission will come into place on 1 July 2009. I am delighted to release the third edition of the ATSB’s Australian Aviation Safety in Review. The format of this edition departs from that of the first two editions to provide a range of new information not previously presented. The report provides an overview of the aviation industry with a focus on safety data derived from aviation occurrences reported to the ATSB. It covers a 10-year period (1998 to 2007) and describes trends and analysis of both aviation incidents and accidents. The first chapter deals with the structure and size of Australia’s aviation sector, including the number of aircraft registered and numbers of pilots and engineers licensed, and the amount aviation activity in different sectors. The next two chapters delve into measures of aviation safety. Chapter 2 examines the trends across 10 years for the number of fatal accidents, accidents and incidents, and their rate expressed as a proportion of annual flying hours. Chapter 3 takes a closer look at the nature of aviation occurrences (incidents and accidents) in Australia through an analysis of what occurred. Chapter 4 looks at why they occurred. That is, what human actions and technical failures contributed to the occurrences. Aviation occurrence reporting requirements and procedures are described in Chapter 5, and in Chapter 6, the special topic covered is the issue of birdstrikes in airline operations. The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety. I commend the report to you. Kym Bills Executive Director Australian Transport Safety Bureau Note: I wonder on reflection whether KB would have made the same statement today?? And does he feel somewhat betrayed by the turn of events that was to occur since the end of his tenure at the ATSB?? As an example of the worth of this excellent proactive report and the knock on safety benefits, lessons learnt etc..etc our fellow Canuck comrades, the TSB Canada, have just released a final report into a Quebec runway excursion by an American Airlines 737: Aviation Investigation Report A10Q0213. Note: This excellent and very informative report is worth taking the time to read and you will find that in the web portal format is extremely easy to navigate around. You will also observe that the ICAO/FSF is listed as a reference and that the ATSB database on similar B737 incidents is referred to in appendix G. Extract from Safety Action section of this report: Safety action taken American Airlines In April 2011, as part of its pilots’ recurrent training, human-factors class, American Airlines introduced a simulation and discussion of this Boeing 737 runway excursion. This training is given to company pilots to educate them on the possibility of a runway excursion due to a nosewheel steering problem on landing roll-out after a normal approach and landing. Safety concern Despite efforts in analyzing past nose-gear steering, low-slew rate-jam events and carrying out post-event valve examinations, the cause of these uncommanded steering events remains uncertain. The safety review process completed by the manufacturer and based on a quantitative, cycle-based occurrence rate of 1 X 10-7, classified this event as an extremely remote probability, and gave it an acceptable risk level, combined with a major severity level. An occurrence rate of 1 X 10-7 meets the Federal Aviation Regulations (FARs) certification requirements. Additionally, an acceptable level of risk does not require further tracking of the hazard in the Federal Aviation Administration (FAA) Hazard Tracking System. Consequently, other than flight data analysis and valve examination, the manufacturer has not taken further action following the 11 known nose-gear steering rate-jam events that have occurred over the past 21 years. Rate of occurrence determines whether a manufacturer needs to take safety action. In order to determine the rate of occurrence, there is a need to capture as many events as possible. This capture allows identification of possible safety deficiencies, and aids in the application of risk-mitigation strategies. Since no defences have been put in place to mitigate the risk of a runway excursion following a rate jam, damage to aircraft and injury to aircraft occupants remains a possibility. The present known low rate of nose-gear steering rate jams may be explained by the fact that, directional control difficulties on take-off or landing would not often result in an excursion and/or damage or injury, and therefore would not be reported. The lack of reporting may also be due, in part, to the fact that operators, flight crew and maintenance personnel have not been made aware of the possibility of rate-jam events, nor have they been provided information on how to recognize, react or troubleshoot. The rate of occurrence would have to show a significant increase to validate corrective action, as safety action is based on FARs certification and in-service fleet following requirements. Despite technological advancements in recording devices, many Boeing aircraft do not record nosewheel steering system parameters. Boeing models affected include 707/720, 727, 737, 747 (some models), 757, 767, and 777. The cause of these low-slew, nose-gear steering rate jams over the past 21 years remains uncertain. A lack of recognition and reporting prevents adequate data collection, analysis, and implementation of risk-mitigation strategies if necessary. The Board is concerned that, in the absence of information as to the cause of uncommanded steering events due to nose-gear steering rate jams, there remains a risk for runway excursions to occur. So the question is can our bureau recover from the Beaker years and return to some of its former glory as a proactive AAI organisation at the forefront of contributing to aviation safety worldwide, or are we to continue with these politically correct, fiscally accountable, dribble of reports that have no substance or relevant safety recommendations attached?? If it is the latter then industry and taxpayers deserve a refund and our once proud safety watchdog should be disbanded! Minister it is your call but please take account of the disturbing findings in the PelAir inquiry and action a government response to the partisan Senators recommendations ASAP…:rolleyes: |
Well done boys.
2008 AART - Recommendation 1: The Minister and CASA commit to achieving completion of the development of the priority Regulatory Parts by submitting all drafting instructions to OLDP by the end of 2008 and full implementation of these Parts by 2011. 2008 Senate - Recommendation 2 The committee recommends, in accordance with the findings of the Hawke Taskforce, that CASA's Regulatory Reform Program be brought to a conclusion as quickly as possible to provide certainty to industry and to ensure CASA and industry are ready to address future safety challenges 2011 Senate – Recommendation 4 (2.281) The committee recommends that Civil Aviation Safety Regulation (CASR) Part 61 ensure that all prospective regular public transport (RPT) pilots be required to complete substantial course-based training in multi-crew operations and resource management (non-technical skills) and human factors training prior to, or in reasonable proximity to, initial endorsement training; the committee recommends that the Civil Aviation Safety Authority (CASA) expedite, and assign the highest priority to, the implementation of CASR Part 61. 2011 Senate -Recommendation 7 (2.288) The committee recommends that the Civil Aviation Authority (CASA) expedite, and assign the highest priority to, the implementation of Civil Aviation Safety Regulations (CASR) Part 141 'Flight Training Operators' and Part 142 'Training and Checking Operators'. 2011 Senate -Recommendation 10 (3.146) The committee recommends that the Minister for Infrastructure and Transport provide a report to Parliament every six months outlining the progress of the Civil Aviation Safety Authority's (CASA) regulatory reforms and specifying reform priorities, consultative processes and implementation targets for the following 12-month period. 2013 Senate - Recommendation 13 (6.58) The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. The ever more pressing need for the regulators to complete the 25 year gestation of the Australian regulations is most clearly apparent in safety recommendations from coroners, ATSB and industry, held in abeyance, dependent on the reformation. Lockhart River occurred in 2005, since then many coroner recommendations have relied on promised reforms to the pertinent regulation. Reformed regulation to minimise as far as legislatively possible, the percentage chances of accident reoccurrence. This has not transpired, despite scores of recommendations related to fatal accidents. Further, there is an almost complete lack of educational information distributed which may, from the lessons learnt, prevent a future occurrence. "K" – I have persuaded P1 to release the draft notes of one contribution made to a final report being prepared. I regret the 'Venn' report cannot be provided. I am asked to remind all that the document provided is not to be relied on legally, is only a draft of working notes, remains unedited (unaccredited) and is provided solely to promote discussion. It has been parked on Zippyshare, usual caveats. DOWNLOAD NOW button only, click once to avoid the spam etc. Working draft – Coroner inquiry. P7. a.k.a. The Old Man (TOM)....http://images.ibsrv.net/ibsrv/res/sr...lies/wink2.gif |
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could. One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around. |
"true dat".
C#35 –"One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around." |
No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers. Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review. Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports. This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k. |
Longish post warning
OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. "Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents. The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide. I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information. When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave. It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter. Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did. Senator FAWCETT: Does this report make any recommendations for improvements? Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through. Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process. |
For "K" - Klouth contribution to last two Senate Inquiries
In all the 'white noise'...mumbling and stumbling of mi..mi..mi Beaker:yuk: and the shear arrogance and blatant Sociopath behaviour of the DAS := in the AAI inquiry, you kind of forget about the worthy contributions from 3rd parties.
Geoff Klouth in representing AIPA was one of these and he gave a rather unique perspective as he is an operational Captain and a former Senior Transport Investigator with the ATSB.:D However I think GK's contribution in a 'private' capacity at the pilot training inquiry was more noteworthy. Shame:ugh: his contribution, along with many others, was white washed by Albo's Great White Elephant Paper (the GWEP)..:{ So for Kharon's benefit, & anyone who is interested, here are some links to highlight GK's contribution to the last 2 inquiries...:ok: Rural and Regional Affairs and Transport References Committee - 22/10/2012 - Aviation accident investigations – AIPA Hansard RURAL AFFAIRS AND TRANSPORT REFERENCES COMMITTEE - 15/02/2011 - Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 – Geoff Klouth Hansard Mr Geoff Klouth (PDF 51KB) Supplementary Submission(PDF 43KB) Pilot training and airline safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 – Inquiry page. |
atsb is out of touch with the Aviation Industry and so is dolan
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