ACCIDENT INVESTIGATIONS - ATSB and Recreational Aviation Australia

[turboplanner]

This is the link to Transport Safety Investigation Act 2003

It explains the Structure of ATSB, powers etc.

http://classic.austlii.edu.au/au/legis/cth/consol_act/tsia2003374/

 

 

SAOs need to avoid conflict with the processes of ATSB, Police and Coroners Courts, which they have done in the past. 

However:

• there are still opportunities for monthly reports of incidents; these need to be writted by a suitably skilled person
• Self Administering Organisations can publish Coroners Reports which often provide an insight which helps us avoid a similar incident. There can be a lag of years in publishing the report, but the present situation is that reports are going to waste because nobody gets them.

[Yenn]

Finding the suitably skilled person is the problem.

Write your own report in clear English and RAAus will amend it to mean something different.

[turboplanner]

2 minutes ago, Yenn said:

Finding the suitably skilled person is the problem.

Write your own report in clear English and RAAus will amend it to mean something different.

Before the Limited Company was formed, members would have raised that with their Committee member.

[Flying_higher]

3 hours ago, turboplanner said:

Before the Limited Company was formed, members would have raised that with their Committee member.

I'm not sure what the forming of a company has to do with it. Can't you just write to the Chair / Board member / CEO now as well? I've certainly done this and had good success.

[turboplanner]

8 minutes ago, Flying_higher said:

I'm not sure what the forming of a company has to do with it. Can't you just write to the Chair / Board member / CEO now as well? I've certainly done this and had good success.

What are your thoughts on RAA's recent policy of reducing its involvement in accident investigation?

[old man emu]

1 hour ago, turboplanner said:

What are your thoughts on RAA's recent policy of reducing its involvement in accident investigation?

Absolutely foolish. 

[turboplanner]

1 minute ago, old man emu said:

Absolutely foolish. 

I agree; there are definitely grids of government responsibility to stay away from, e.g. Police, Coroner, ATSB limitations.

However the benefits of examining the simpler cases are self benefiting. 

Ultimately Self Administering bodies need to minimise their casualties regardless of the sport, or they risk running out of PL insurance capacity, or are shut down. Setting up compliance and enforcement and a natiral justice protocol are relatively simple.

[old man emu]

12 hours ago, turboplanner said:

there are definitely grids of government responsibility to stay away from

 

Actually my comment was not in relation to that. The Coroner, aided by the police investigation on the Coroner's behalf, welcomes any reliable information when conducting an Inquest. The Coroner is seeking factual information and if it comes from experienced sources, all the better.

 

My comment harkens way back to the fundamentals of Management Systems which can be identified in this simple diagram:

An organisation creates a plan or procedure aimed at attaining a result. Then it does (implements) that plan or procedure. After implementation the results are monitored (checked) to see if they match the expectations, and decisions made to keep the status quo, or to modify the plan or procedure and go around the cycle again, again and again until there no more reasonable improvement can be made,or the goal of the plan is reached . Does that sound like Harvard School of Business mumbo-jumbo? Hardley. You did exactly that when you made your cuppa this morning.

 

Failure to be involved in the investigation of incidents breaks the cycle and precludes any further improvement on the one hand, and on the other opens the door to declining standards.

[turboplanner]

10 minutes ago, old man emu said:

 

Actually my comment was not in relation to that. The Coroner, aided by the police investigation on the Coroner's behalf, welcomes any reliable information when conducting an Inquest. The Coroner is seeking factual information and if it comes from experienced sources, all the better.

 

My comment harkens way back to the fundamentals of Management Systems which can be identified in this simple diagram:

An organisation creates a plan or procedure aimed at attaining a result. Then it does (implements) that plan or procedure. After implementation the results are monitored (checked) to see if they match the expectations, and decisions made to keep the status quo, or to modify the plan or procedure and go around the cycle again, again and again until there no more reasonable improvement can be made,or the goal of the plan is reached . Does that sound like Harvard School of Business mumbo-jumbo? Hardley. You did exactly that when you made your cuppa this morning.

 

Failure to be involved in the investigation of incidents breaks the cycle and precludes any further improvement on the one hand, and on the other opens the door to declining standards.

Yes, I agree with your cycle.

 

I agree that anyone or an organization can provide information to Police, Coroner and ATSB.

 

And Police have been calling in RAA for assistance at sites. (Not sure if this will continue under the new RAA intent)

 

However the grids I was referring to were a person or organization going into a crash scene and doing their own thing, so just the legal grids or boundaries.

[old man emu]

14 minutes ago, turboplanner said:

However the grids I was referring to were a person or organization going into a crash scene and doing their own thing, so just the legal grids or boundaries.

Got ya. Apart from the immediate rescue of SURVIVORS, or the control of fire, no one should enter, or remain in the site of an incident if they have no investigative duties.

 

A big problem I found with traffic accident investigation was the overzealous use of fire extinguishing materials by both the Fire Brigade and RFS. That earned then the name "Evidence Eradication Team". Firies can only go into action to quell an existing fire, but not do anything against the possibility of fire except to prepare and watch. However, I have no objection to members of the public recording the site before the arrival of investigators. Often those recordings save evidence that is otherwise lost.

[Flying_higher]

1 hour ago, old man emu said:

 

Actually my comment was not in relation to that. The Coroner, aided by the police investigation on the Coroner's behalf, welcomes any reliable information when conducting an Inquest. The Coroner is seeking factual information and if it comes from experienced sources, all the better.

 

My comment harkens way back to the fundamentals of Management Systems which can be identified in this simple diagram:

An organisation creates a plan or procedure aimed at attaining a result. Then it does (implements) that plan or procedure. After implementation the results are monitored (checked) to see if they match the expectations, and decisions made to keep the status quo, or to modify the plan or procedure and go around the cycle again, again and again until there no more reasonable improvement can be made,or the goal of the plan is reached . Does that sound like Harvard School of Business mumbo-jumbo? Hardley. You did exactly that when you made your cuppa this morning.

 

Failure to be involved in the investigation of incidents breaks the cycle and precludes any further improvement on the one hand, and on the other opens the door to declining standards.

From what RAA said at their AGM, they will continue to help Police where they can. I don't think their aim is to be obstructionist but just make sure they aren't trying to be the ATSB. They also said they'll always analyse what they can with the info they can through their SMS and that CASA were ok with this.

 

I actually think its odd that the Government (via CASA) issue all these regulations but because the ATSB won't do their job, they (CASA/Govt) have no idea whether the risks they say they're supposedly controlling with the regs work, because the investigation part of the cycle is missing. Does this mean we should ignore the regs too? From my perspective you either do the whole cycle or you don't do any of it!

 

 

 

[facthunter]

It's another disconnect from the reality of flying small aeroplanes. Incident  and accident investigation is an essential part of keeping flying safe(r). Nev

[turboplanner]

1 hour ago, Flying_higher said:

From what RAA said at their AGM, they will continue to help Police where they can. I don't think their aim is to be obstructionist but just make sure they aren't trying to be the ATSB. They also said they'll always analyse what they can with the info they can through their SMS and that CASA were ok with this.

 

I actually think its odd that the Government (via CASA) issue all these regulations but because the ATSB won't do their job, they (CASA/Govt) have no idea whether the risks they say they're supposedly controlling with the regs work, because the investigation part of the cycle is missing. Does this mean we should ignore the regs too? From my perspective you either do the whole cycle or you don't do any of it!

Be careful going down that path.

ATSB are there for VH registered aircraft; they will if the issue is important, step in and investigate an RA aircraft.

 

RA aircraft fly because RAA is a self administering organisation; it's up to RAA to manage the organisations risks.

Where it gets a bit confusing is that the minute you enter a runway at your local airfield,  CASA, Airservices and ATSB rules also kick in, but I certainly wouldn't be saying ATSB won't do their job.

[old man emu]

Half the reason that ATSB investigations take so long is that, as with so many occupations based on the Trades, there are not enough qualified personnel. And Heaven help the aviation industry if they seduced AMEs from the workshop floor. There aren't enough of them to keep the aeroplanes in the air anyway.

 

From my experience as the Coroner's representative investigating a fatal aviation incident, the involvement of ATSB caused a pain in the butt. They seemed to think that their work was Secret Squirrel stuff and would not forward reports to me as the person responsible for putting the report together. They reckoned that their reports were for the Coroner's eyes only. 

 

The only lead I got from them was that there was no sign of spilled fuel, nor smell of fuel around the aeroplane. At least I could investigate the fulling of the aircraft and propose  fuel exhaustion as a primary cause.  

[Flying_higher]

The only reason ATSB are there for VH- registered aircraft is because they wrote the rules (TSI Act) around what their capacity (funding) is. I just can't see why the life of one Australian is more important than another depending upon whether you have numbers or letters on the aircraft. Surely this is about improving aviation safety?

 

If you look at the midair at Gympie, it could have very easily have been a VH- registered aircraft and therefore ATSB would have investigated and looked at airspace risk. We all operate in the same sky regardless of the licence we hold or the registration of the aircraft. Now, I don't disagree that the self administration allows for aircraft that don't meet airworthiness and design standards but same applies in the VH- experimental world and ATSB still investigate those..... MY mind just boggles with this stuff, it really does, because I just cannot see why they wouldn't investigate.

 

As far as be careful what you wish for, again, I don't disagree with you, but at least it'll be a consistent approach! And perhaps if the ATSB did have the funding it needs the resultant reports would be done in a more timely manner and be more useful.

 

Anyway, just my take on it, FWIW.

[turboplanner]

3 minutes ago, Flying_higher said:

The only reason ATSB are there for VH- registered aircraft is because they wrote the rules (TSI Act) around what their capacity (funding) is. I just can't see why the life of one Australian is more important than another depending upon whether you have numbers or letters on the aircraft. Surely this is about improving aviation safety?

RA flyers wanted to build their own, use specifications below the safety minimums of GA aircraft, do their own maintenance, do their own training and qualifying to a lower standard and make up safety ground by setting a very low stall speed. There might be more, but enough to demonstrate what RA was established for, so you can't have your cake and eat it too. RAA has to decide what level it's going to place on a life.

 

RAA through it's predecsssor took RA aircraft from the limitations of paddocks away from airfields and below 300' to flying out of regional airports. The current safety system is based on that scenario. I understand the dot you are drawing, but the present RAA system doen't have a bad bad name for interfering with GA.

[Flying_higher]

I think you're right turbo. But I would add that if the government is interested enough to place lots of regulation on RAA, surely they should do this with open eyes and understand if the regulations do good or not. In otherwords, the government can't have its cake and eat it too. And like I said earlier, I'm pretty sure ATSB treat VH- experimental the same as a type certified aircraft operation. This is only because there is a part 61 licence holder at the helm. 

 

It's all just splitting hairs to me. 

[turboplanner]

3 minutes ago, Flying_higher said:

I think you're right turbo. But I would add that if the government is interested enough to place lots of regulation on RAA, surely they should do this with open eyes and understand if the regulations do good or not. In otherwords, the government can't have its cake and eat it too. And like I said earlier, I'm pretty sure ATSB treat VH- experimental the same as a type certified aircraft operation. This is only because there is a part 61 licence holder at the helm. 

 

It's all just splitting hairs to me. 

You're looking at it back to front; the government gave RAA and exemption to fly and gave them the freedom to set their own rules (Self Administering Organisation.

 

Experimental flies under GA rules.

 

If you start to pick and choose parts of RA, parts of GA, parts of US regulations or European regulations or NZ regulations they all started from different beginnings, different people and different pilots changed them along the way and here we are nearly a hundred years later each with their own rules. RA was never meant to fly interstate let alone nationally, so better to pick one and live within its rules.

[Yenn]

What is specified inRAAus rules and regs, I thought they were responsible for safety and I fail to see how they can be responsible without investigating accidents.

[Flying_higher]

Surely that’s like saying Qantas has to do it’s own fatal (hopefully not) accidents because they have an SMS that requires them to analyse all safety reports. 

[turboplanner]

11 minutes ago, Flying_higher said:

Surely that’s like saying Qantas has to do it’s own fatal (hopefully not) accidents because they have an SMS that requires them to analyse all safety reports. 

No, you can't run every rabbit to its burrow, there are boundaries.

[turboplanner]

31 minutes ago, Yenn said:

What is specified inRAAus rules and regs, I thought they were responsible for safety and I fail to see how they can be responsible without investigating accidents.

Well first priority is their duty of car to eliminate reasonably forseeable risks.

Then comes investigating accidents becaise that an inform future rules and actions.

[facthunter]

What about the PRIME reason for investigating accidents? To inform other pilots engineers operator's so  they won't be caught in the same trap.

[old man emu]

14 minutes ago, facthunter said:

What about the PRIME reason for investigating accidents? To inform other pilots engineers operator's so  they won't be caught in the same trap.

An the other thing is to identify unforeseen failures in structures that lead to incidents.

[facthunter]

That's for the above . ALL Airlines get documents and advice of inspections required or Parts replaced or retraining . Any Airline worthy of the name has a operational flight safety department. IF THEY do the appropriate thing , The Authority leaves them alone which the Companies prefer, naturally so often they impose a greater penalty than the Authority would have.  Nev