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-   -   Quality of ATSB reports getting worse? (https://www.pprune.org/pacific-general-aviation-questions/598685-quality-atsb-reports-getting-worse.html)

Eddie Dean 31st Aug 2017 00:50

With only 3rd form (grade 10 I believe in the new money) I was able to read and understand the salient points of the ATSB report.
As far as I remember "they" is the correct pronoun even for singular person.
Although better educated than me here, seem to be able to conjugate verbs better than I.

Stikybeke 31st Aug 2017 01:16

Hey Eddie,

You got me thinking so I just checked with a young person, I don't know about other states but in NSW 3rd form is Grade 9....

I think I'm starting to get a headache with all this maths stuff!!!!

Stiky

advo-cate 31st Aug 2017 01:42

Question here from all the posts is the really important ones which have nagging doubts about the conclusion.

In this one, I agree - done to death and low grade. BUT - Pilots still run out of fuel. #casa is about to fix that with the new byline


"EMPTY SKIES ARE SAFE SKIES"
The really important reports that meet the doubtful criteria:


Lockhart River - New information still coming to light
PelAir - 7 1/2 years and report mark #2 just out to the DIP's - Directly Interested Parties
Mildura 737's - Took over 2 years, with poor direction as to what really happened

AND on

Eddie Dean 31st Aug 2017 01:55

Advo-cate, you must be one of those better educated than me as I completely(in my ignorance) understood both Lockhart River and Norfolk Island accident report.
Both involved JetPilot decal holders making up their own flight rules and reaping the consequences thereof.

Don't know anything about 737's so will defer to your knowledge.

Lead Balloon 31st Aug 2017 04:51

So with the Norfolk Island report, would those 'made up rules' include the ones that split the CASA FOI population about 50/50? Is there a rule that says a pilot must know when he's been misled by inaccurate and incomplete weather information?

Eddie Dean 31st Aug 2017 06:07


Originally Posted by Lead Balloon (Post 9878012)
So with the Norfolk Island report, would those 'made up rules' include the ones that split the CASA FOI population about 50/50? Is there a rule that says a pilot must know when he's been misled by inaccurate and incomplete weather information?

Wrong topic for this thread, suggest you go to the correct one for that discussion.

FGD135 31st Aug 2017 10:08


... I have noticed a continuing trend for people to attack any report emanating from the ATSB instead of discussing the incident reported on.
The message from the report is one thing, the quality of the report quite another. This thread is about the quality of the reports.

Myself, and many others are growing concerned about the quality of the written reports.

Macarthur Job would be turning in his grave. Not just at the writing, but the investigations, too. Some recent reports look like they have been written by school children, doing work experience at the ATSB. Are the investigations going the same way?

advo-cate made reference to a few recent investigations of dubious quality. There is one that I would add to his list. This was the investigation (and report) that aroused my interest in the deterioration at the ATSB. Here is the PPrune discussion on the report and investigation:

http://www.pprune.org/australia-new-...sb-report.html

thorn bird 31st Aug 2017 10:08

I would agree with you Lead. Always struck me as strange that if the pilot had broken so many rules, as alleged by so many people, why was he not charged with the offences and brought before the courts? He most certainly not the first person to be caught out by the vagrancies of Norfolk Island weather, and most probably won't be the last.

MagnumPI 31st Aug 2017 22:25


Originally Posted by Lookleft (Post 9875990)
I'm no more in favour of dumbing down writing skills than you are but I have noticed a continuing trend for people to attack any report emanating from the ATSB instead of discussing the incident reported on. Are you saying that you are confused about what happened? Do you not understand the significance of being aware of your fuel state at all times? That's the message I took from the report. If you are getting bogged down in where the full stop should be or how many times the word pilot appears then you might as well stop reading any report the ATSB publishes.

There is nothing new under the sun so if you want to learn from other people's misfortune then just re-read the ASD. Running out of fuel is nothing new.

The salient point of these reports might be obvious enough but I do believe that if there are consistent grammatical errors that this indicates a lack of thoroughness in the overall investigation. Just because these safety incidents are often repetitive in nature doesn't mean that a poorly written report is adequate.

If you submitted a report like this to an academic institution it wouldn't cut the mustard. We are expected to believe that scientific investigation has taken place, so why shouldn't there be a factually accurate and grammatically correct report?

The A330 report linked above in the other thread is most interesting as it clearly violates the impartiality standards which the ATSB are supposed to uphold. Irrespective of whether or not you think the flight crew did a good job in the circumstances (which I actually do as well), it is not the ATSB's role to use subjective statements which make it more like a narrative than a report.

Centaurus - if you are reading this, please continue posting safety investigations and reports from decades ago. They are often far more insightful than what we are seeing from the ATSB in 2017!

Old Akro 31st Aug 2017 23:43

I just had a look at the ATSB site to see what was released in the common end of the month dump.

There are currently 97 reports pending.

Over the last 6 months there has been an average of 8 new incidents per month.

Over the last 6 months the number of released reports has averaged slightly under this (something like 7.3).

Not a picture of a department on top of things.

Which puts the pedantry of this report in the spotlight. Why waste time producing such trite when there is such a backlog of real work.

Centaurus 1st Sep 2017 08:28


Centaurus - if you are reading this, please continue posting safety investigations and reports from decades ago. They are often far more insightful than what we are seeing from the ATSB in 2017!
Will do my best.

Eddie Dean 1st Sep 2017 09:17

It appears that the reports are written in the new style "simple" English.
Similar to some new Maintenance Manuals.
The reason should be obvious.

Old Akro 5th Sep 2017 09:37

I was interested to read this newly minted tome from the ATSB regarding the Chieftan that bounced a main gear on a truck on approach to Barwon Heads.

https://www.atsb.gov.au/media/577349...-040_final.pdf

I struggle to find it cohesive, let alone reaching any sort of conclusion of any value.

Not to mention the factual error that the maximum vehicle height in Victoria is 4.3m not 4.6m. Which makes a lot of the reports discussion about landing approach angles valueless. The recommended road clearance in Victoria is 4.6m to deal with vehicles up to 4.3m. If the author doesn't have the English comprehension to figure this out from published material, I weep for the future.

While there is a discussion about land zoning that seems completely spurious, any discussion about the lack of warning road signs about the airport was completely absent. I'm not sure how much difference it would have made, but the interview with the driver suggests that he was oblivious to the airport so, maybe a couple of the standard yellow warning diamonds may have done something.

Why are we paying for this?

kaz3g 5th Sep 2017 09:59


Originally Posted by MagnumPI (Post 9878956)
......

If you submitted a report like this to an academic institution it wouldn't cut the mustard. We are expected to believe that scientific investigation has taken place, so why shouldn't there be a factually accurate and grammatically correct report?

......!

No offence, but I wish that were true. At one stage in my life I had quite a bit to do with essays written by LLB students and later, with papers written by legal practitioners and social workers. I am no longer shocked by poor construction of sentences, lack of understanding of basic grammar, and inability to articulate thoughts clearly; but I am concerned that this is at least in part a consequence of the disjointed communication style now practised in social media.

Flying Binghi 5th Sep 2017 10:43


Originally Posted by MagnumPI (Post 9878956)
The salient point of these reports might be obvious enough but I do believe that if there are consistent grammatical errors that this indicates a lack of thoroughness in the overall investigation. Just because these safety incidents are often repetitive in nature doesn't mean that a poorly written report is adequate.

If you submitted a report like this to an academic institution it wouldn't cut the mustard. We are expected to believe that scientific investigation has taken place, so why shouldn't there be a factually accurate and grammatically correct report?...

Yep.

The report is the 'coal face' of all the work that happened prior. The interface between the investigators findings and we the reader. If the report reader caint understand or make use of the investigators findings then what is the point of the investigation ?

While a poorly written report might offer annoyance to the more learned around here they soon enuf see and understand the error and read on. To those like me with poor written and reading skills a poorly written report can be a confusing read that needs multiple readings to get a sense of the finer details. Whilst I'm a bit dogged and will persevere I would suspect younger pilots with the instant easy digest info mindset will simply not bother labouring though a poorly written report.






.

FGD135 5th Sep 2017 13:10

Here we go again. From a report issued today regarding a tailstrike to an A320 departing YMML:

"Good communication from the cabin crew alerted the flight crew that a tail strike may have occurred. The climb was stopped and a timely decision to return to Melbourne was taken which minimised the potential risk from damage caused by a tail strike."

"Good" communication? A "timely" decision?

These are judgements, ATSB. You are not there to make judgements. You are there to investigate and report. You just don't get it, do you?

This was my problem with their report on the Qantas A330. That report was full of glowing judgements about crew performance.

Lead Balloon 5th Sep 2017 21:23

It's a "factual" report, FGD. It's a fact that ATSB made those judgements.

First_Principal 5th Sep 2017 22:45


Originally Posted by Old Akro (Post 9882809)
I was interested to read this newly minted tome from the ATSB regarding the Chieftan that bounced a main gear on a truck on approach to Barwon Heads.

https://www.atsb.gov.au/media/577349...-040_final.pdf

I struggle to find it cohesive, let alone reaching any sort of conclusion of any value.

Apropos of my earlier post I had assumed that reports, particularly from junior investigators, would be reviewed by senior personnel.

Where I have been in this (reviewing) role I have tended to allow some leeway to authors in their telling of the story. Another person's style is not necessarily mine, and if it gets the message across, with some gentle guidance, then why should I try and impose my use of the Oxford comma, for instance?

However this report suggests to me that maybe there is, at best, a flawed review process; certain aspects of it don't reflect well on the organisation, to my mind.

To this end I wonder if anyone knows what the investigation/reporting process is within the ATSB? Is there a published set of criteria?

FP.

Lookleft 6th Sep 2017 23:24


Not to mention the factual error that the maximum vehicle height in Victoria is 4.3m not 4.6m. Which makes a lot of the reports discussion about landing approach angles valueless. The recommended road clearance in Victoria is 4.6m to deal with vehicles up to 4.3m. If the author doesn't have the English comprehension to figure this out from published material, I weep for the future.
Statements like this is why the ATSB really doesn't care what you think OA. From published material:

https://www.vicroads.vic.gov.au/busi...rance-on-roads

4.6 m is correct for certain types of vehicles.

What I find amusing is that on a pilot's forum no one is talking about the pilots attempts to fix the increased rate of descent. But then again most of the harrumphing about grammar and they and their is from journalists and other pontificating professions.

Old Akro 6th Sep 2017 23:37

Look left

If you knew me, you wouldn't question.

The Vicroads document recommends a minimum road clearance of 4.6m.

Vicroads don't get to regulate vehicle dimensions, thats the role of the RVCS section of DIRD that publishes the Australian Design Rules which are a legislative instrument. ADR 43/04 specifies a maximum height of 4.3m.

Overdimension is possible, but a completely different kettle of fish.

Eddie Dean 6th Sep 2017 23:48


What I find amusing is that on a pilot's forum no one is talking about the pilots attempts to fix the increased rate of descent. But then again most of the harrumphing about grammar and they and their is from journalists and other pontificating professions.
Em nau, yu mi wunbel

Lookleft 7th Sep 2017 01:11

Even when its in writing you won't accept it.

The Road Safety(Vehicles) Regulations 2009 allow certain types of vehicles to operate up to 4.6 metres in height.
These include:
Car carriers
Hay trucks
Livestock trucks
Vans carrying light freight (separate information bulletins detail the
operating requirements for these types of vehicles)

All vehicles likely to be on a country road passing a rural airport. Your assertion was that the investigator hadn't done their homework and therefore the whole report is wrong.


If you knew me, you wouldn't question.
All bow down:ugh:

All I know about you is what you post and from what I can tell you make statements that are incorrect. From your focus on the periphery of what happened and your lack of discussion on the actions and thought processes of the pilot I am assuming that you are not a professional pilot.

FGD135 7th Sep 2017 02:47

ATSB barking up the wrong tree
 
The ATSB's findings and "safety message" from the Barwon Heads incident suggest that they believe the pilot's non appreciation of ALA standards was the major factor.

This is WRONG. That aspect was not the major factor and I'm sure most pilots would agree with me.

The major factor was the flight path and the management thereof. This flight path was either chosen by the pilot, or was imposed on him by the circumstances, or was some combination of both.

The ATSB seem to believe that the runway threshold is the target of the flight path. This is not the case. Pilots are trained to touchdown at an "aiming point" which is some distance beyond the threshold. Passing over the threshold at 50 feet, on a descent angle of 3 degrees, for example, puts the aiming point about 300 metres beyond the threshold.

Why 50 feet over the threshold? Pilots are trained to do this because this is the optimum, according to landing performance theory. If this pilot had been conducting the approach in accordance with how he had been trained, and in accordance with his knowledge of landing performance, he would have been about 63 feet (19 metres) above the height of the threshold at the point he passed over the truck.

The aircraft was well below where it should have been. The pilot's poor management of the flight path had entirely eroded the safety margins that are provided by a normal approach.

This is the real "safety message" from this incident. Sure, ALA standards may have been a contributing factor, but only by a few centimetres.

Try again, ATSB.

Car RAMROD 7th Sep 2017 03:50


Originally Posted by FGD135 (Post 9884531)

Pilots are trained to touchdown at an "aiming point" which is some distance beyond the threshold. Passing over the threshold at 50 feet, on a descent angle of 3 degrees, for example, puts the aiming point about 300 metres beyond the threshold.

Why 50 feet over the threshold? Pilots are trained to do this because this is the optimum, according to landing performance theory.

Try that at places like Mabuiag and Darnley in the Torres Strait. Let us know how the aircraft recovery effort goes. :}

jonkster 7th Sep 2017 07:08


Originally Posted by FGD135 (Post 9884531)
Why 50 feet over the threshold? Pilots are trained to do this because this is the optimum, according to landing performance theory. If this pilot had been conducting the approach in accordance with how he had been trained, and in accordance with his knowledge of landing performance, he would have been about 63 feet (19 metres) above the height of the threshold at the point he passed over the truck.

I thought the 50' over the threshold came from very early in the history of aviation where a particular military flying school operated out of an all over field with trees up to 50 feet at one end. That is what they used as a standard procedure and when it came to making regulations it stuck.

FGD135 8th Sep 2017 01:46


Try that at places like Mabuiag and Darnley in the Torres Strait.
Sounds like you must be landing overweight, Car RAMROD. That's your choice.

This thread is not really about landing technique. More about ATSB reports. Suggest you make your comment on the Barwon Heads PA31 thread.

Car RAMROD 8th Sep 2017 04:29


Originally Posted by FGD135 (Post 9885533)
Sounds like you must be landing overweight, Car RAMROD. That's your choice.

Ahh no. Not sure how you would come to that conclusion anyway.

The strips are only 4-500m long, and in the case of Darnley, going in one of the directions is some sporty down slope. You do NOT want to be landing with your suggested aim point 300m past the threshold!

Eddie Dean 8th Sep 2017 07:00


Originally Posted by Car RAMROD (Post 9885571)
Ahh no. Not sure how you would come to that conclusion anyway.

The strips are only 4-500m long, and in the case of Darnley, going in one of the directions is some sporty down slope. You do NOT want to be landing with your suggested aim point 300m past the threshold!

And watch out for Two Dogs Rooting - will stuff up your nose wheel.:suspect:

josephfeatherweight 8th Sep 2017 08:19


Two Dogs Rooting
Seen that at Funafuti - unperturbed as we taxied past...

Lookleft 9th Sep 2017 02:12

Do you actually read what you write FGD:


This thread is not really about landing technique. More about ATSB reports. Suggest you make your comment on the Barwon Heads PA31 thread.
This is a few postings after this:


he ATSB's findings and "safety message" from the Barwon Heads incident suggest that they believe the pilot's non appreciation of ALA standards was the major factor.

This is WRONG. That aspect was not the major factor and I'm sure most pilots would agree with me.

The major factor was the flight path and the management thereof. This flight path was either chosen by the pilot, or was imposed on him by the circumstances, or was some combination of both.

The ATSB seem to believe that the runway threshold is the target of the flight path. This is not the case. Pilots are trained to touchdown at an "aiming point" which is some distance beyond the threshold. Passing over the threshold at 50 feet, on a descent angle of 3 degrees, for example, puts the aiming point about 300 metres beyond the threshold.

Why 50 feet over the threshold? Pilots are trained to do this because this is the optimum, according to landing performance theory. If this pilot had been conducting the approach in accordance with how he had been trained, and in accordance with his knowledge of landing performance, he would have been about 63 feet (19 metres) above the height of the threshold at the point he passed over the truck.

The aircraft was well below where it should have been. The pilot's poor management of the flight path had entirely eroded the safety margins that are provided by a normal approach.

This is the real "safety message" from this incident. Sure, ALA standards may have been a contributing factor, but only by a few centimetres.

Try again, ATSB.
And this just proves you have absolutely no idea about commercial GA operations:


Sounds like you must be landing overweight, Car RAMROD. That's your choice.
Those of us who have know exactly what Car RAMROD is talking about.


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