Quality of ATSB reports getting worse?
 

I read ATSB reports habitually. As a low time pilot that struggles to fly as often as I'd like I find it helps to keep my head in the game.

However, I have to wonder if lately they've been getting work experience kids to write them? This gem being an example:

http://www.atsb.gov.au/media/5773259...-020-final.pdf

Were they always this bad?

The BOM strikes again... :}

Its just nonsense. If they can't do better, why not save the money and not investigate it at all.

Old Akro, your post makes me wonder something that no-one I know has been able to answer.

At my home airfield there have been two serious accidents in the past couple of years. Both were non-fatal but the aircraft (both VH registered) were destroyed. The authorities were informed and I believe attended to interview people, but reports were never published.

So, what criteria has to be addressed for an investigation to happen and a report to follow?

Why is someone landing nosewheel first in a 182 at Bathurst considered worthy of a report but two near-fatal accidents not?

Short answer? Resources. So they pick and choose based on criteria available on the ATSB website. This extract was before BASI was amalgamated within the ATSB.

‘In recent years, the Bureau has adopted a policy of selective investigation, similar to many of our equivalent organisations in other countries. The traditional approach in Australia had been to investigate everything, no matter how minor. However, many categories of air safety occurrence are repetitive in nature, such as ground loops involving aircraft with tailwheel undercarriages, and no new prevention knowledge is gained by continuing to investigate such events. However, the law requires that all accidents and incidents must be reported. Because BASI receives all these reports, it retains the ability to monitor trends, and can initiate an investigation into safety issues raised – for example, by a number of relatively minor occurrences. While these events individually would not warrant full investigation, considered as a group they may be indicative of broader systemic safety deficiencies – a topic which will be addressed later in this paper.
In practice the Bureau does not distinguish operationally between accidents and incidents – they are all ‘safety occurrences’. The objective of selective investigation is to concentrate the Bureau’s resources on in-depth investigations, which offer the greatest potential to enhance air safety. BASI has developed and refined various criteria to decide which events will be looked at most closely – one of these is a primary emphasis on the safety of fare-paying passengers in any category of operation – high capacity regular public transport (RPT), low capacity RPT and charter, and other commercial operations involving fare paying passengers.
AVIA5022 The Purpose of Investigation – Edition 4. 11

In addition, in part enabled by the redeployment of resources as a result of the selective investigation policy, BASI is placing a much stronger emphasis on applied systems safety studies. This is aimed at identifying and rectifying underlying factors within the aviation system which can impact upon safety at the ‘sharp end’ – that is, in the cockpit, cabin, control tower, maintenance workshop, or on the ramp.’
Lee R. (circa. 1997) New Directions in Air Safety

The issue I have with the report is the lack of investigation into the Right Hand fuel tank indication of being half full but the actual fuel found to be only 25 L. (total).

Read this:

https://www.avweb.com/news/maint/182907-1.html

HZE was produced in 1985 so some of that information is irrelevant but the filling of the tanks - very!

A little bit of research added to the ATSB report would have provided valuable knowledge to the readers.

And that would help keep your head in the game.........

And forget anything useful on piston engines......the lack of anyone who knows them is startling. Of course some think they do but they would fail an APS fun test. Many posters on here could do better.

And maybe every now and then they do a half-ars*d job of knocking out a few easy ones to help improve their KPI's.

Short term profit and greed is why we cant have anything nice in Australia anymore. The profit & cost margin.

How do we as a society accept this? How can we accept undermanned authorities when we bring in taxi drivers on working visas.

Its messed up.

It takes a well lead, hard working, forward thinking committed society to make sacrifices to have good infrastructure, beautiful and liveable cities and well run authorities that are not tied at the wrists.

Anything worthwhile, long lasting and first-world takes sacrifice and commitment and and we in Australia no longer have the willingness nor guts to do it. We are selling out to the lowest bidder, for the least cost and greatest profit. In my lifetime we have started to become third world.

Our authorities are run at bare bones, our once beautiful city buildings, parks and skylines are being mined by property developers, our infrastucture is selling to private hands.

There is nothing nice for the long term for the general citizens of our country in this.

The classic example; Airport Security and Border Control - security and CBP queues doubled out the entrance doors but fewer than half the lanes active because of understaffing.

Public transport: Sydney about $3 to get from Sydney to the last stop on the train line beforre Sydney airport. Another $12 on the fare if you take the next stop to the airport - MacQuarie Bank owns Sydney Airport.

Melbourne: no public transport link at all!

I want a government that can govern, cities that belong to the people.

Next thing you'll be telling us that public infrastructure should be returned to public ownership!

Back when airports and ground transport infrastructure were owned and run by public institutions, how many millionaires were making their millions out of that infrastructure? None! See how inefficient that is?

Now there are plenty of millionaires making their millions milking these assets. That's efficient!

Utopia is a documentary.

While you're all busy criticising the delivery, how about thinking of the message and the audience?

If a major job of such a report is to inform, then it's told a fair story - particularly to newer recruits to GA. Unsubtly we can see from this:

(1) What can happen when the juice runs out
(2) That Cessna's and other craft with similar fuel systems can effectively cross feed between tanks when not level
(3) That the end result of (2) can mean you end up with far less fuel than you originally thought
(4) That some tank and filler siting mean that you may never fill a tank properly if the craft is not level
(5) Before taxiing out on a longer jaunt check you should check your fuel levels with a dipstick (on a level surface!)


Personally I've often wondered when reading of similar issues why more people don't do (5)?

As to the quality of the report, well we can all do better, and if I wasn't being the devil's advocate I might have a negative comment or two, but in the end it's the same old story that's only been told hundreds of time before in hundreds of such reports so perhaps they've just run out ways of saying the same thing :ugh:

FP.

Wouldn't the report have been better if it had stated the short points in your post?

Or even the Avweb article points

I would have to agree that that was a fairly poorly written report, seemed like they were waffling on to get the word count up.

Haven't flown a C210 for a long time, but the fuel selector from memory was left tank, off and right tank, but no position for feeding from both tanks as mentioned in the ATSB report?

After '82 (21064536 and up) the fuel selector was left-both-right with a seperate on/off fuel valve.

75L/hr ?????

Well that is probably appropriately ROP. It should have been a lot less.

If you think the reporting is shoddy there, try reading some of the ATSB rail incident reports. I have been personally involved with more that one fatal incident and others as well which where damning on the employer but not a single f was given by either the ATSB or the prosecutors.

Certainly not being an apologist here but, as is the way these days, the report is effectively anonymised as it issued by an organisation. However it will have most likely been written by an individual and (hopefully) reviewed by another...

Individuals are not born with the ability to write concise, accurate, and informative reports - these things take time and experience. Additionally in a world such as we have today where everyone's sensibilities need to be taken into account, writing public reports is not made any easier than it was, to my mind the converse is true.

Perhaps then this could have been a 'first report' by someone? Certainly if I were allocating lead investigatory and reporting roles to someone who had not had such a role before then this would be the type of accident I'd choose - non-fatal, and to a certain extent not that uncommon.

Regardless I think it still told sufficient a story to get the points out of it I earlier elucidated. Yes you could shorten it and make it more succinct, but then I'm sure you'd all complain there wasn't enough background or something :rolleyes:

FP.

Thanks gassed budgie, only ever flown the C210M and N models.

Re C210 fuel, 60 litres per hour was a good ball park figure, no don't know how get 75litres per hour.

Maybe based upon flying with mixture in rich the whole time?

If the aircraft was being run full rich all the time, that's a dangerous practice that should have been highlighted as such by the ATSB.

I don't see what's wrong with the report - what's missing?

I don't see what's wrong with the report - what's missing?
 

You really don't get it, do you!

Fuel gauge indicating 50% in Right Hand tank = 25% fuel available and the noise stops..... and you don't want to know why.

The planned fuel consumption, the electronic gadgetry and the fuel indication were probably in close alignment with the expected endurance remaining - which is how we operate aeroplanes.

Over different terrain, this could have been a fatal accident.


full rich all the time, that's a dangerous practice - What?!

I think people should take another look at First Principals post because it is the most sensible I have read. The 75ltr/min figure was what the pilot planned on, there is no mention of what the inflight figure was. From my point of view the report is all about being aware of how much fuel you actually have before departure and being aware at all times how much is left. Who in their right mind relies on the fuel gauges of light aircraft anyway?

All of that points to the fact that the assumptions made were obviously incorrect. Unless there was a fuel leak somewhere, if the pilot overestimated how much fuel was on board then all the other assumptions are incorrect. The electronic wizardy is only as ggod as the information put into it. It applies to airliners as much as light aircraft.

This attitude is part of the problem - pilots hear this dribble often enough and they don't look at the gauges.

If the gauges are not reliable, the aircraft is unairworthy. Write them up and get them fixed, whether or not the aircraft is 'light'.

scavenger, try reading CAAP 234 para 12 and 13.

While I applaud the sentiment it's not necessarily correct. The MEL for many aircraft may not include operating gauges, particularly if alternative methods of calculating the fuel quantities are available.

One of the more well known is Air Canada 143, aka the Gimli Glider. As I recall this new 767 had a fault with all of the fuel gauges but was still able to operate if the fuel quantities were calculated as sufficient for the proposed flight. While in this instance the ensuing miscalculations resulted in a major incident the point first of all is that 'light' or not, gauges are not necessarily required, nor are they infallible.

This is why I return to my earlier comment - dipping the tanks prior to a flight, particularly of any duration, is a no-brainer. It costs a couple of minutes of time perhaps, but could save an awful lot of grief. And if there's any lingering question, do it en route if/when you land - something else that could be taken from this report if you'd care to, the data is there...

FP.

I could not agree more. Light aircraft fuel contents gauges are often unreliable for many reasons. Yet, when leaving the factory floor, they don't start off that way. Same with parking brakes. The problem then arises where general aviation instructors and pilots accept these type of defects as normal GA and then quietly sneak off and leave the decision to write up the snag to the next unsuspecting pilot who flies that aircraft. Yeah,:ok: right:ugh:

Aircraft owners have the moral responsibility to do their bit and supply fuel tank dip sticks. After all, it is in their financial interest to keep the fuel gauges serviceable and thus lessen the chance of someone running out of fuel due to a defective fuel gauge. Having said that, if dip sticks are part of the aircraft equipment it would be good airmanship (Non technical Skills, if you prefer that buzz-word) for pilots to use them.

That's what I said. Book endurance figures only work if the engine is leaned for cruise in accordance with whatever assumptions were made by the book writers about cruise engine settings.

Ironically in this case, the actual hourly fuel consumption was probably higher than the (very rich-for-cruise) 75 litres per hour assumed for planning. By my count, there were 5 take offs and a number of very short legs. During all of those take-offs and climbs I'm assuming it was 'balls to the wall', in which case the engine was gobbling in the order of 100 litres per hour (unless the pilot was using the target EGT leaning during climb technique, but even then the fuel consumption would have been much higher than 75 litres per hour during take off and climb.

For example, I'm pretty confident that during the 30 minute flight from Katalpa to Pine View Station the aircraft consumed more (a lot more) than 37.5 litres.

Fuel consumption for a 4.5 hour trip with one take off and landing is vastly different than a 4.5 hour trip with 5 take-offs and landings (including manoeuvring in the circuit and taxiing at each).

CASA in its wisdom reintroduced regular fuel tank calibration. Gigantic waste of money and a retrograde step in my view. There is no reason why the fuel gauges should no be reasonably accurate.

Furthermore, the thinking owner / pilot will be doing periodic cross checks of refuel quantities with gauge readings.

I have tabled every fuel tank calibration that out Seneca has had in its life and there is very little variation. In fact I would suggest that the major variotiin is caused by LAME's who don't know how to do it properly.

Then of course there is the $2 piece of wood Dowling that every aircraft should have as a calibrated dipstick. Once again, it probably only takes 6-10 refuels to draw a calibration line.

Gee - maybe it would be a safety enhancement if the ATSB published some tips about this??

No, they were not. It appears that, these days, the writer is just not of the quality he was in the old days.

A few examples from that report linked to by MagnumPI:

Clunky and overly wordy. The words, "the pilot" appear far too often. The first sentence is entirely irrelevant. This entire passage could thus have been written more simply and concisely:

Approaching Mildura, and with the AWIS now indicated a cloud base varying between 1,000 ft and 3,000 ft, the decision was made to observe the conditions from overhead the aerodrome.

Note that this simpler form has avoided the dreadful "the pilot" altogether.

Yes, the ATSB are politically correct too, and will go to whatever lengths it takes to avoid divulging genders, but this attitude has been taken to ridiculous lengths in this report. The phrase "the pilot" appears 31 times in this short report. The gender-neutral "they" also appears an excessive number of times, and on many of these occasions, the usage is wrong. Wrong because "they" means "more than one".

Examples:
It is most likely that this refuelling was done by a single person, which means that "they" cannot be used.

We know that at this stage of proceedings, the pilot was the only occupant, so again, "they" cannot be used. In their zeal to be politically correct, they are subverting the language!

A poorly written report. Makes one long for the Macarthur Job days. Now don't get me started on the quality of their investigations.

Cannot? We know writer can, because the writer did; "... should not be used", surely? :p

FP.

Thank goodness someone commented on the grammar. Very poor.
Fuel gauges could not be trusted in my day. I bet not much has changed.

I have had only one inaccurate fuel gauge indication, on one flight, in 32 years of flying GA aircraft.

And did you rely on the other fuel gauges to determine how much fuel you considered was remaining in the tanks?

The ATSB reports are not written for pilots but for the "man on the Clapham omnibus" Literacy skills are not that good in society genarally so the report serves its purpose. Even newspapers are written for the reading ability of a 12 year old. If the message of the report was to inform Joe average that pilots should be certain of how much fuel is in the fuel tanks instead of assuming how much there is, then job done from what I can tell. All the other discussion on the number of times the word pilot appears is just intellectual pontificating!

Parts don't even make sense:

"...the pilot conducted numerous turns with both fuel tanks were selected." (sic)

Didn't have to. I was in the circuit and about to land. The gauge for one tank suddenly dropped from the reading that coincided with the calculated consumption to a reading of zero, because of (what turned out to be) a wiring problem. I knew that the tank had not suddenly lost a quarter of its contents and I wasn't running on that tank anyway. If everything dropped to zero and it turned out those indications were accurate, my only option would have been to ..... do what I was already doing.

As to whether the report serves its purpose, unnecessary waffle distracts and therefore detracts from the effectiveness of safety messages.

So you're in favour of allowing the dumbing down of our writing skills, Lookleft?

It appears that, since the days of the Macarthur Job and the Aviation Safety Digest there has already been considerable dumbing down in the area of ATSB reports and investigations.

The problem with dumbing down is that there is no end to it. You either accept a standard, and work to maintain that standard, or allow the open-ended dumbing down, resulting in wordy reports that fail to convey the message effectively.

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.