Australian Transport Safety Bureau Occurrence: Importance Of Safety Management In Aviation Industry

Outlining the issues associated to the case

Discuss About The Australian Transport Safety Bureau Occurrence.

This report depicts the role of proper safety measurements in the engineering aviation industry to give secured fly to the consumers. Due to lack of proper security and risk management measures a major collision occurred in aircraft VH-PFT that has been reported by the Australian Transport Safety Bureau (ATSB).  The ATSB reported this fatal risk in the year of 2016, 21^st July. The transport bureau found the reasons behind the accident based on that two different hypothesis were also presented accordingly (Islam et al. 2016). According to the advisers of the flights, the flight has been ceased for the low level flights. It is the responsibility of the operators to take necessary safety management measures to avoid the accident but they failed to.  

It was the responsibility of the engineers assigned to the project to take proper risk management measures to avoid the accidents. On 29^th December 172S aircraft at the 1748 Australian Eastern Daylight saving time the Cessna aircraft (172S) departed from the Cambridge Airport was registered under VH-PFT faced this vital accident (Fontaine, Martinettib and Michaelides-Mateouc 2016). The passengers flying from Tasmania to a photograph yachts for participating in Sydney Hobart race. Due to improper design components after flying to the height of 50 ft the aircraft entered within a vertical climbing turn. The upper wing of the aircraft turned around 180 degree and that the nose of the aircraft was pitched down vertically.

After analyzing the details of the aircraft design and architecture it is identified that the safety management processes undertook by the operators were not sufficient for facilitating the key operational risks with low level fly which was conducted on “Sydney Hobart race yachts”.

The Australian transport safety bureau was formed in the year of 1999 by the Australian government and it defines the necessary safety measures those are required to be measured by the aviation industry to avoid fatal accidents of the aircrafts. It has different safety unite which operates worldwide to scatter safety awareness among the people. The safety measures are generated by the civil engineers. The employees’ work for the bureau are around and the executive of the aviation industry is the chief commissioner.

The ICAO document implies the details of the safety manuals necessary to be followed in the aviation industry for the flight fly. The actual concept of safety and the way through which the safety measures can be evaluated are developed in this document. In order to avoid the accidents advanced operational and functional actions are needed to be undertaken by the authority of the industry (Sabatini et al. 2016). It also implies that the safety if the aviation industry in divided into three different areas such as technical era, human factors and organizational factors.

Main idea or hypothesis generated from the case background

According to the detail of the CAAP CASA it has been found that, it is the role of the person who is associated to the aircraft project to do all necessary role play for a successful implementation of the results. The other chemical components present in te jet should be analyzed to avoid chemical blast and other accidents.

In order to adopt the holistic integrated approach necessary business benefits and the accounts for the human variability are also elaborated in this document (Branch 2016). The cultural concepts are also illustrated in this communication to encourage the system in a timely manner organizational influence etc. According to the international 

According to the Civil Aviation Advisory Publication (CAAP) are applied to the holders of the air operator certificates those are perfectly subjected to the civil aviation conditions. Under the CAAP, the ICA has developed certain mandatory occupations in terms of cabin crew, flight crew, flight operational officer etc. All the other operations operated by the occupations include different safety related works such as technical skills, no technical skills, decision making, fatigue awareness program, stress management, decision making etc. However, the occupations are not at all covered under the CAAP (Wijnands et al. 2016). The role of the crew resource manager and the joint aviator authorities are also mandatory to managed. There are many benefits that may rise with both the technical and non technical training.

The CASA low level flying regulation implies the general competency rules in terms of application of the operating level limitation. A proper weight and balance between the requirements are needed to keep for operating the navigation of the aircrafts and other pertain system as well.

The airlines hazard as well as risk management procedure deals with the bird strike analysis, personnel injury, poor materials, damage in the airline path, lack of training amng the pilots who are operating the aircrafts.

It was defined that there were many key operational risks associated to the low level fly if the aircraft which was conducted by the “Hobart race yachts” in Sydney. It was done using the airline risk management framework model developed by CASA. An enterprise based wide range risk management approach was developed by CASA to identify, analyze and resolve the risks associated to the aviation industry (Lin et al. 2016). With the help of these measures the operators will be able to create high valued well informed evidence and vision from the safe sky also.

Australian transport safety bureau aviation occurrence investigation

The specific range of practices those are included in the risk management approach developed by the CASA are entry level control, surveillance, enforcement procedure, standard development, finance management approach, project management, procurement, human factors, airspace administration etc. It is necessary for the aircraft engineers to analyze and evaluate these factors individually to avoid any accident or fall of a fly. The risk assessment rife developed by CASA is all adopted by the aviation industry.

 At the aircraft design phase, the engineers should give serious concentration on the raw materials those are to be supplied by the suppliers. Many risks may rise due to low level raw materials. It is the role of the project head to identify all common risks that may occur in aircrafts and relevant risks management strategies are also needed to be developed at the very initiation phase. A safety risk management approach was conducted by ‘”Hobart race yachts” but that was not enough to save it from a fatal fall (Poulos et al. 2015). The CAAP outlined guidance on risk management process that was developed o for this particular case. The steps are as follows:

It is necessary for the aviation team to apply necessary logical as well as systematic methods for establishing the context to identify analysis and treat the risks accordingly. At the operational and strategic level the engineers should evolve all necessary functions and activities so that the risk areas and the factors all can be mitigated from the root.

The risks those are identified in the initial stage should be analyzed perfectly so that proper safety measures can be identified for that. It is the role of the project manager and resource managers to give serious concentration on the risk factors in aviation industry. Implementation of a risk management process is referred to as an important part of risk analysis. Up to date both internal and external reporting is required to be done by the project managers to identify and analyze the risk. Based on the risks a risk register should be prepared to analyze the risks from the root. Certain tools and techniques are there those are to be used for developing the risk management process of the case study (Littell and Stimson 2016). The cause of the risk and their potential consequences are also identified in the risk management process based on standard ISO 2009. With an accurate risk analysis approach, the outcomes those may gain include hazard and occurrence reporting, trend analysis, employment and risk management process, monitoring normal operation, risk scenario development and information exchange etc.

ICAO document 9859 3rd Edition

The risk evaluation approach for the aircraft VH-PFT must be developed combining both the risk identification and analysis details. The family of the photographer Tim Jones and the pilot Sam Langford were killed in the fatal accident that was going to take part in the “Hobart race yachts”. Due to the air crash, the family of the photographers was killed. Against the plane operators the family of the photographer filed case and launched court action (Stimson et al. 2017). They were appointed to cover the “Hobart race yachts” when the fatal accident took place in storm Bay. According to the reporters this took place due to wrong acts and negligence and default from the operators end.

According to a report of Cessna 172 stated that it needs to fly at the height not more than 120m for recovering. The flight was already running below beyond permission. According to the Tasmania aircraft fly regulations the aircrafts are only allowed to fly above 45 m above the identified obstacles (Landry 2017). However, in order to capture aerial picture without permission it started flying below 45m. It was a serious fault from the operators end.

After analyzing all these aspects it was quite clear that the safety management process adopted by aircraft VH-PFT was very weak and insufficient from the aircraft operators end. In order to minimize the risks according to the current safety management strategies the Tasmania aircraft has stopped low fly for photography (Washington Clothier and Silva 2018). This extensive change was needed to evolve by the airlines to avoid this kind of fatal accidents. From the case analysis it is found that the main issues were lack of training of the pilots regarding the low level fly and negligence in safety permissions.

Training: Professional level training on fly should be arranged by the Tasmanian aircrafts pilot so that they can recover such risky situations properly.

Awareness program: An awareness program should be arranged by the aviation industry to make sure that the pilots are maintaining all aspects properly. Up to date information are required to be released by the government to increase the awareness among the pilots and other aircrafts members.

The report from the Australian safety bureau was released in the year of 2016.  It has been found that after a steep climbing turn the aircraft entered to a spin and this was the main reason for which the pilot failed to control the plane as he was not trained for that action or situation (Naweed, O’Keeffe and Tuckey 2016).  For the stalling of the aircraft the fatal accident took place in aircraft VH-PFT. After the turn the aircraft nosedived vertically into the sea east for Cape Raoul on Peninsula Tasmania. After the vertical nosedive it sank approximately 90 m over the floor of the ocean. At the height of 15 m above the ocean level it captured and finished the photo shot on “Hobart race yachts”. However, there was a minimum distance that has to be always maintained by the airlines in this kind of shoots which is around 45 m. 

CASA CAAP SMS-1(0)

After communicating with the consultant it has been found that, the height was absolutely insufficient for the pilot for the aircraft recovery. The pilots were not professionally trained for the low level flights. According to the Cessna, if any C172 enters to a spin or stall then it become very difficult for the pilots to recover the fly from that minimum height or low level fly (Ismail 2016). The Australian safety bureau implies that, proper operational risk measures are required to be obtained and considered by the aircrafts to avoid this kind of fatal accidents.

There are many factors that contribute to the accident are as follows:

• Error from the pilot end
• Machine level failure
• Weather or natural disaster
• Sabotage
• Other errors such as manmade error

After analyzing the details of the aircraft VH-PFT, it has been found that the aircraft is facing serious or fatal accidental risks on 2014 due to lack of experience of the pilots in lower fly and operational risk the Tasmania aircraft faced serious issues accordingly. Though, the pilot was aware of the staling features of C172 and aware of the stall warning but still the faced serious level accident. In a fly test the pilot was demonstrated ability for recovering the stall with a 100 ft altitude loss (Fontaine, Martinettib and Michaelides-Mateouc 2016). The low level flight training was enough from the aircraft end. The pilot was not trained and aware of the backpressure application. In order to take the maximum lift to the flight pitch adjustment was very much necessary to be considered by the pilots. However, it was not yet given for the pilots. Due to smaller gap the pilot was unable to recover the turn as a result the accident location took place in the ocean surface. After inspecting the wreckage and different video footage it has been found that the leading edge of the wings has are completely forced to a relatively flat location on the front wings spars.

On the other hand the nose of the aircraft was dive absolutely vertically. After the accident the windshield of the aircraft was also destroyed through the outer structure of the aircraft was found intact in nature. The issues of the flight control approaches were not still accurately identified. The elevator trim of the flight was in a neutral position. Due to this reason the flap actuator positioned showed that, it was in between the 10 degree to 20 degree of the selectable location. The frame of the engine mount of the aircraft was broken for the accident. Though, with a control cable the engine was still found attached to the fuselage. In the preliminary stage no such issues were identified. The structural integrity was completely maintained within the cabin area (Branch 2016). The stall warning system of the aircraft was damaged due to the chemical reaction with the water. Thus, the system service ability was not determined according to the service level requirement. After accident some of the data cards were recovered those were in good condition. For recovering data those cards were sent to the Tasmania forensic department.

CASA CAAP SMS-2(0)

 It has been found that in order to avoid this kind of fatal accidents the aviation industry should follow the rules of safety policy, objectives and procedures. The key safety of the personnel and the other safety commitments are also needed to be considered by the aviation industry. In order to conduct the risk management strategy for the fatal aircraft accidents the five different risks those are identified include: controlled flight into the terrain, turbulence hazards, low level engine and other parts of the aircrafts, bird hazards etc. However for this particular case the main issues that have been identified include lack of training for low level fly for the pilots and lack of proper operational activity consideration to avoid accidental risks. Both the internal and external recordings are also needed to keep the safety of the system. Safety policy procedures, security measures and other low level flying are also needed to be considered for the successful fly of the aircraft with no such accidents.

In the risk management approach different risks are identified those are required to be mitigated from the operational activities. Certain recommendations are also given in accordance with the identified risks of aircraft VH-PFT. It is expected that with the help of proper recommendations the issues will be completed mitigated and managed accordingly. The recommendations are as follows:

Proper training: The pilots were not trained for the low level flies. Thus, for sudden turnover they were unable to recover the situation. Professional training and development program should be arranged by the Australian Aircraft industry for their pilots.

Operational activities: The operation management department of the aviation industry should consider all necessary operational activities so that the operation level issues associated to the aircraft VH-PFT can be mitigated completely. Negligence of all necessary acts and adoption of wrongful acts were the main reasons for which the accident occurred. 

Conclusion

From the overall discussion it can be concluded that, the Tasmania aircraft VH-PFT, faced a fatal accident due to negligence of the pilot and his training lag. It was the responsibility of the operation team to include proper operational programs and training for the pilots so that they can get the ability to cope up with risky environmental situations. Sydney arranged a “Hobart race”. The people who participated in the race were allowed to shot from the upper side by aircraft VH-PFT. The minimum distance that was to be maintained by the pilot was around 45m but the pilot did not maintained it and decrease the distance gap in 15m. Due to low level fly the upper wing of the flight turn about 180 degree and the nosedive vertically and over the ocean surface and run for about 90m. This accident was one of the most fatal cases indentified on that particular time zone.

CASA CAAP SMS-3(1)

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