Bravo - Finally, some sense from two Prune posters.

11. Feb, 2015

All very Hi tech and the elves are going nuts.  So, while we wait:-At long last, after 3181 posts, sweet logic, pragmatic professional thinking and cool sense prevail; finally.  Halle-bloody-lujah...🙂.. 


Ian W – Pprune - At one stage in my 'career' I qualified as an ISO-9000 auditor. One of the things that was expressed to me during the training was that procedures were not required for everything, only where it was really essential the procedures were not varied. Or to put it another way one of the more experienced QA instructors said:

"You go to audit some companies and they have several tables all covered with procedure manuals 2 or 3 deep. You go into others and they hand you a single slim folder. You know immediately which company actually follows their procedures.

I think that this has application in the aviation world. Less by rote procedures and more capable personnel will make a better more professional airline which in the long term will be safer and more profitable.

Unfortunately, that message has not percolated through to 'management' and tickboxes and inhibition of original thought are seen as the way to do it. That inevitably leads to the:

'if there isn't a procedure for it - you are not allowed to do it'; and, 

'I have learned all the procedures in the manual and the boxes have all been ticked, so I don't need to know anything else.'


 

 Q0283 @ Pprune 1nvestigative approach taken by the KNKT/NTSC ?


What I would like to understand is the huge difference between how the AirAsia and the latest TransAsia accidents are treated by the respective national authorities (both acting under ICAO Rules). 

In the AirAsia case the (investigation) authorities have published few preliminary facts (radar, FDR and CVR data). But have published some short ‘final opinion’ conclusions( {we know what happened} “ we have the ‘key‘ “ – and – “it was not a suicide”). 
In the TransAsia case the (investigation) authorities have already published many preliminary facts (radar, FDR and CVR data). And have published a ‘preliminary factual’ conclusion (one engine out and the second good one shut down too). 

From a professional personal point of view you learn much much more from getting the preliminary facts yourself, struggle with them to find probable cause and contributing factors, and then compare these when preliminary, interim and final reports are published. The main learning moments being where the professional official report either confirms or rejects your professional personal conclusions.

From that professional viewpoint you can only be very very happy with the approach taken by the Taiwanese ASC. And at the same time negatively surprised by the approach taken by the Indonesian KNKT/NTSC.

In context, the Taiwanese ‘political’ risks appeared to be much greater than the Indonesian ones. Declaring the pilot a hero ( while keeping the ‘from hero to villain pilot’ case after rolling the 747 in mind ). Possibly shutting down the good engine too (keeping the UK 737 case in mind). And the mainland Chinese passengers (keeping general politics and MH370 emotions in mind).

In the Indonesian case no-one, not a single mention on PPRuNe I think, suggested a suicide. And no-one expects an investigation team to have the ‘key’ in an early stage. There is a lot of information that can be published without having any political overtones. Publishing the MH370 take-off fuel weight for instance would also have harmed no one, on the contrary one could even say.

Is there a PPRuNe member who has an informed opinion on this. And can give us a better understanding of how the Indonesian investigation might view its own QZ8501 approach.

Nice to see the 'real deal' at work, always a pleasure; thank you gentlemen....👍.....

Toot - toot....😀.....

9. Feb, 2015

Quote:


"Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air."


 

Good point; and, in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion. For sake of argument lets 'assume' (we may, safely take a small risk) that the ATSB investigators were competent and they followed the well trodden path a 'bog-standard' accident investigation should take. The report even allowing for the 'theoretical' should have got us to within a bulls roar of the why, how and wherefore; it may have even provided some peripheral causal reasons which assisted in defining the desired end result – risk mitigation. There were several valid, not overly theoretical issues which did make it into the final report; RVSM, flight and fuel planning, lack of operational support, fatigue, lack of 20.11 training, etc, (don't ever forget, CP responsible for all) from which a reasonable operator could make adjustments to SOP, in an effort to mitigate the risk of reoccurrence. I don't have too many problems with the notion of 'theoretical', provided it can be translated, by the operator into practical fixes. So far the ATSB investigators are free and clear, reputation intact.

It's what happened next that got me cranky (just a bit): Sarcs at # 2653 has gone to some trouble to point out the direction a perfectly serviceable accident 'report' was being driven and IMO, in deference to the law, he has treated the 'aftermath' with kid gloves. For the thinking man, joining up the remaining dots to form the final picture is a piece of cake. The Senate inquiry surely got there.

It has been a long, slow difficult process since then: the Senators didn't waste too much time, their report was out in a timely manner; but since then, purgatory. Forsyth, then TSBC, then miniscule response, at the end we get (headline) "Pel-Air to be reinvestigated". 

The academics and theory of 'how' to investigate an incident which happened, what ? five years and a bit ago have not changed and have had precious little to do with what transpired after the IIC report was 'edited' and produced. It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far. 

The comment below followed an article published by Australian Flying re the re Pel-Air MKII. 

Quote:


Sceptical • 10 days ago

Head of Aviation Investigations at the time of the report? Ian Sangston. 

Told of factual errors prior to release of the report? Ian Sangston. 

Head of Aviation Investigations for the new report? Ian Sangston. 

Conflict of interest?


 

Just about says it all. The background noise? Oh, that's the playroom clock; tick, tock, tick, tock.

8. Feb, 2015

👍From Planetalking blogpiece:- It looks like TransAsia is in really big trouble over crash


Ben Sandilands

Posted February 7, 2015 at 1:53 pm | Permalink

An experienced pilot who doesn’t wish to comment in his own name or using an alias has offered the following perspective, which I think makes some persuasive observations:

When I did my multi engine rating, my instructor strongly emphasised that the actions after engine failure must be done quickly. I’ve had discussions with other multi engine rated pilots who all sing from the same songsheet & there’s almost a macho mentality that says ‘if you can’t do it quickly you shouldn’t be flying one’.

They’re wrong. It’s stupid. People die as a result.

Agreed that pilots ought to, on an ongoing basis, practise & be familiar with engine out procedures.
Agreed that pilots ought to think about what they will do in the unlikely event of an engine failure after takeoff, before every takeoff.

But, the training mentality that pilots must accomplish the engine out procedures with haste is the problem.

After engine failure, the first & main priority is to control the aircraft. The TransAsia pilots appear to have not done this.
The subsequent actions, identifying the engine which has failed, ought to be done carefully. The TransAsia pilots appear to have not done this.
An engine failure after takeoff is stressful. That’s even more reason why pilots should be trained to take a pause before identifying the failed engine.

While I acknowledge that engine failures are practised in a simulator, there’s a huge mental difference between being in a sim & knowing that you’re physically safe, compared to being in a plane with big scary objects outside and knowing you might die.

If the ATR engine auto feathers, then it’s almost idiot proof. Almost.
You would just have to maintain control of the aircraft on the single working engine, pretty much without any additional actions.
If you were basically competent in hand flying an aircraft [a topic for another day] then you’d be looking every bit the hero.
But throw in a rushed engine failure check in a stress situation & you’d have the perfect ingredients for a crash.

As you’d know from crash reports, this is not the first of this type of accident & certainly won’t be the last.

As a passenger, I’m always a little nervous until there’s a goodly amount of height between me & the ground. I know how pilots are trained!


MTF...P2

 

7. Feb, 2015

The new web site – HERE - is a Work in Progress – Comments are open for the published posts...Patience required, more to follow...😎...

We note the unspeakable Pprune web site continues it's mindless descent into becoming a bland, politically correct, edited, moderated and censored mouthpiece for the 'vested interest' society.  At least on the Australian forums; populated by resident Trolls who have only one agenda – continue the party line.  There is so much hidden and so many heads stuffed in the trough which must be protected that any semblance of truth, or vestige of criticism must be snuffed out.  Of course no one dare say you are upsetting 'the powers that be' with accurate reporting and explanation of what is going on; no, far too gutless for that sort of thing. 

The thing the PAIN association finds most concerning is the total apathy of the Australian aviation industry, reflected on the UPP.  Whether this ennui has developed after years and years of frustration; or, fear of retaliation or from any of the many other subliminal reactions should be a cause for government concern; the almost total lack of investors willing to support a once thriving industry is slowly killing a potential source of employment and taxable revenue. 

Lack of political will to affect change has been a feature for the past three decades.  There have been some 20 odd investigations, inquiries and 'reports' made.  All serious, expensive and damning of the way the regulator has performed.  The three most recent have generated almost 70 serious recommendations clearly indicating that the regulator has made an absolute shambles of a 23 year, 250 million project to modify the regulations.  The reports also indicate a serious, deep rift between regulator and regulated, which will need more than a band aid and a kiss from Mum to heal.  So what has happened after the last go around?– well, nothing really.  A little window dressing, a little rhetoric, but apart from that, SFA.  The new director is embroiled in a battle with his 2IC who has not only refused to resign, but is determined to continue the McComic madness, actively and openly rallying support within the Golden West Mafia (GWM).  Gods help us, for the Minuscule will not: and; industry sits on it's arse, desperately avoiding being the one who spoke out of turn, lest they be next.  Pathetic.

But it's not just the complete absence of political and industry will; Australia has a user pays system and if you want to use the system then you must pay.  The Baksheesh is not of the open, honest kind, but the thrilling clandestine type; where you must join the secret society of Mutual Back Scratchers (MBS).  Like any high powered criminal network, once your in, there is no out.  Not, mind you that many want out; No, the grass is too green, the water too sweet and the thrill of being 'in' are all far too alluring. 

And so, the grist to the mill keeps flowing: high profile complaint is seduced with sweet offers and membership pleasing deals, too good to be refused.  The riff-raff may be ignored with impunity or hammered down by the sheer power of the Iron Ring, which may be used to decimate political will, influence a government and pervert the result of any honest report which clearly defines that there is, indeed, 'something rotten in Denmark'.  Lucky country – #Bollocks.

Aye well, at least here I can have my say, I can even 'moderate' fools and trolls off the site.  Can't wait..🤪... Toot-toot.,,,👍,

6. Feb, 2015

Beware world – the ex director and author of the great Australian aviation tragedy McComic  is vying for a seat at ICAO.  First Australia, then world domination by a man who created the infamous Cathay Pacific 49' ers saga, engineered the great Pel-Air duck up, compromised the industry complaints commissioner, emasculated the Australian aviation industry and is under investigation for breaches of the sacred Transport Safety Act (TSI) and other 'matters', such as lying through his teeth, under oath to Parliament.


Steve Creedy – "AUSTRALIA’S licensed aircraft maintenance engineers (LAME) lobbying hard in Canberra to reverse rule changes they say are illegal and unsafe have been backed in an opinion by high-profile lawyer Bret Walker."


Now, of all the stultifying, mind numbing, self immolating things anyone can do, reading the aviation regulations of your own country ranks up there with cooking shows; but to read those of another country ranks number one in the self harm games.  But; if there are people out there in Tweep land who can bear to delve into the mysterious world of Australian aviation regulation, they will get quite a shock.  Here is a primer:-

The USA and NZ manage to deal with pilot licensing (Part 61) in about 60 pages of sane, practical regulation written in language as close to plain English as it is possible to get.  Australian part 61 boasts some 1600 pages to cover the same topic, this supported by a 'Manual of Standards' (MOS) of similar, titanic proportions; these manuals are based in the most confused, tortured legalese possible, filled with blood curdling threats of criminal prosecution and all offences are strict liability.  Strict liability places a reverse onus, the burden of proving oneself innocent, firmly on the head of the accused.  But wait, there's more; the rule set is totally bloody useless, unworkable and has horse and cart sized holes in the very fabric. 

The same philosophy is applicable to all the CASA regulations which revel in criminal prosecution and sheer volume.  The heartbreak is from a battered industry which has tried to rein in the behemoth of the McComic era rule makers and thus far, not only failed to do so, but has become terrified of it's own shadow, under the repressive autocracy of McComic and his happy band of catamites.

Think hard Dear World, very hard for if the McComic era lands and takes root in Montreal, not even your daughters gold fillings will be saved in the rapine and pillage of a McComic inspired ICAO slaughterhouse.

Selah.