01 DDAAFS overview and introduction to aviation accident inv

  1. 
  2. DDAAFS overview &
    introduction to aviation accident investigation
  3. AVMO Course 01-2016
  4. Squadron Leader Ben Abrahams
    Safety Investigation – Engineering 2
  5. Lieutenant Commander Denes Illyes
    • Safety Investigation – Operations 2
    • Assessment Criteria
  6. • 5.4 Introduction to AAI and DDAAFS
    • – Outline the role of the Directorate of Defence Aviation Air
    • Force Safety in aircraft accident investigation.
    • – Refer to relevant ADF policies and sources of information specific to aircraft accidents and incidents.
    • – Describe the role of the Aircraft Accident Investigation
    • Team (AAIT).
    • – Outline ADF policies that relate to the initial response to and investigation of aircraft accidents and incidents.
  7. – Apply relevant ADF policies and procedures to the initial response to and investigation of aircraft accidents and incidents.
  8. -
  9. DDAAFS overview
    DDAAFS Purpose
  10. Enabling Defence aviation capability through effective and integrated safety programs.
    DDAAFS Mission
  11. To provide independent specialist advice to those
    who influence Air Force and Aviation safety in the promotion and maintenance of safety standards that support capability.
  12. To improve Air Force and aviation safety to enhance capability through positively influencing safety behaviour by fostering and promoting a generative safety culture.
    Location
  13. Defence Establishment Fairbairn, ACT
    • Building F4 / Level 1
    • Organisational Structure
  14. D!RCCTORATC Of
    Defence Aviation and Air force Safety
  15. ,•.-...·_-I I-'M-
    - �·
  16. -·•
    • Plf1 -
    • :!..".:" ..
    • ,
    • ··-·•
  17. ·1··-·, •E..l. e
    • -··-•
    • =----··
  18. ....·.-.....-_...,-._..
    • .-·.·---•--·
    • ----
  19. LIIIM
    • :."-=..-
    • ;
    • suu-.c,,......,..c..o11<>•t
  20. :..=-
    • ga:-:,-:
    • ··--
    • -..-- _
    • --·-
    • ,.-I...-....,.-. M
    • i.-.-�-·
    • -=··-==·
    • P-·--f-f·
    • U-U-iLL· W
    • --· -·
    • Pi'W
    • i-·i-l - --
    • -·•
    • ·· .i'M---·•'-•
    • ·- --·
    • =-=-
    • .-. ·- _
    • --··----· •
    • ·-:-::•:.-""-···
    • '
    • .u ...
    • -··
    • � ...' .
    • J;l==-
    • -·- -_
    • -- _
    • ....'.
  21. •., II' IM
    • -··
    • -· •---
  22. • -...-.. -
    • ·� ... =·--".....
    • ·"-I::'.:-' -·
    • I-'·I-i ·I M
  23. -..-.-......·..·-·
    -..-·-- _
  24. ::.::... M
  25. :-·.-.":"·"-·"'
    • -·----,-.,_ •
    • i-i I -
    • .. ·-- - ·
  26. .. ·---··-- ·-·-- ..._.....,.
    • Roles & Responsibilities
    • (Aviation Safety)
  27. • Principal representative/adviser to Defence Aviation Authority (Chief of Air
    Force) on Defence aviation safety management
  28. • Aviation safety policy formulation
  29. • Monitor effectiveness of the Defence Aviation Safety Management System
  30. • Advice and tools to services on implementation and management of their
    ASMS
  31. • Aviation safety education and training
  32. • Develop strategies and programs to enhance Defence aviation safety
  33. • Investigate all Defence aviation accidents.
    • Roles & Responsibilities
    • (Air Force Safety)
  34. • Assist the CAF with safety governance through due diligence (WHS Act)
  35. • Support WHS regulator (Comcare) interventions
  36. – Provide advice to commanders
  37. • Develop and improve Air Force WHS Management System
  38. – RAAFSafe including policy, training, assurance, risk management and WHS
  39. investigation capability
  40. • Prescribe WHS standards and provide advice to CAF and safety network as required
  41. • Air Force WHS policy development and maintenance.
    Products/capabilities
  42. • AAP 6734.001 ‐ Defence Aviation Safety Manual (DASM)
  43. • AAP 6730.002 ‐ Aviation Accident WHS Manual (AAWHSM)
  44. • AAP 6730.001 ‐ Air Force Safety Manual (AFSM)
  45. • Defence Aviation Hazard Reporting & Tracking System (DAHRTS)
  46. • DDAAFS Snapshot Survey
  47. – safety culture (aviation safety & WHS).
    Products/capabilities
  48. • Safety Communication
  49. – active promotion of safety throughout the Air Force and ADF aviation environments
  50. • Applied Human Factors Specialist Support
  51. – implementation and continuance of Human Factors training and
  52. education for Aircrew/Maintenance Human Factors, and culture/leadership programs.
    Products/capabilities
  53. • Aviation Safety Education and Training
  54. – responsible for the development and management of aviation safety‐related training
  55. • Safety Data Analysis and Exchange
  56. – management of the DAHRTS database, ASOR
  57. monitoring and statistical analysis.
    Products/capabilities
  58. Safety Investigation
  59. • provide independent and dedicated investigation capability for aviation system accidents
    – all Australian Defence aviation system accidents
  60. – assisting / participating in investigations of foreign military accidents involving ADF personnel (subject to approval)
  61. – assisting investigation of foreign military accidents in Australian territory
  62. – major civil accident ‐ mutual national transport safety investigation capability (ATSB‐DDAAFS MoU).
    Want further information?
  63. • DDAAFS Webpage:
  64. – Latest POC info
  65. – Access to DAHRTS and AAPs
  66. – Links to other guidance material/tools
  67. – Training Schedule
  68. • DDAAFS SharePoint:
  69. – ASOR SuperSet Data
  70. – Safety presentations
  71. • DDAAFS group e‐mail:
  72. – ddaafs@defence.gov.au
  73. Introduction to aviation
    accident investigation
  74. Defence
    • accident history
    • Defence Aviation Accidents (fatalities & hull losses) 1980-2015
  75. 10 Investigation
  76. Operator error focus Organisational issues focus
    ..... - - - - - - - - - - - - - - - · 1 · - - - - - - - - - - - - - - - - - - - - -�
  77. 9
    -
  78. SAFETY CULTURE?
  79. 8 AIRWORTHINESS BOAROS
  80. Pl.Hornet,
    • PllalUS Ponef,
    • 7 PC-9,8707,
    • Nomad
  81. 6 OPERATIONAL REGULATIONS
    • 4 .1
    • • •
    • r,•
    • ••
    • • •
    • ••
    • 3 ••
  82. Sea King
    Ill�
  83. 2 F-111G
    • (Pulau Aur)
    • • ••
    • (Nlas)
    • 0
  84. --0
  85. 1
  86. N.... .... .....
    l.l."..I
  87. • Non-fatal • Fatal
    • 0 0 0 0
    • ....... r,i N N
  88. 83 Deaths • = Number k . led
    • 89 Aircraft il
    • Safety information feedback loops: outer ; inner
  89. ORGANISATION organisational deficiencies: latent conditions
  90. MANAGEMENT DECISIONS AND
    • ORGANISATIONAL PROCESSES
    • WORKPLACE
    • local conditions
  91. ERROR- PRODUCING CONDITIONS
  92. VIOLATION- PRODUCING CONDITIONS
    • PERSON
    • group/team
  93. ERRORS VIOLATIONS
  94. TECHNICAL FAILURES
    DEFENCES BARRIERS
  95. ACCIDENTS
    & SERIOUS INCIDENTS
  96. TASKING
    OPERATIONS
  97. LATENT CONDITIONS
  98. The Reason Model of Systems Safety
    – more than just Swiss Cheese
  99. Limited coping resources can get nibbled away
  100. Accumulat ion of minor event s. N ot so much
    • holes as st eady
    • at t r it ion
    • (Reason, 2000)
    • ADF Investigation requirement
  101. • Aviation safety occurrence
  102. – Any occurrence which adversely affects, or could adversely affect, the safety or airworthiness of an Aviation System, or safety of third parties.
  103. • Four classification levels:
  104. – Accident (DDAAFS to investigate)
  105. – Serious Incident (investigator must be independent of the incident unit, e.g. DDAAFS, WASO/FASO/RASO)
    – Incident (incident unit to investigate)
  106. – Event (not investigated).
    ADF policies relating to initial response to and investigation of aviation accident and incidents
  107. • DI(G) OPS 02‐2 – Defence Aviation Safety Program
  108. – Authority for AAP 6734.001 ‐ Defence Aviation Safety Manual (DASM)
  109. • AAP 6734.001 – Defence Aviation Safety Manual
  110. – Outlines Defence ASMS (12 elements)
  111. – AL3 (Jan 15) introduced new Section 4 – key content from ADFP 731 – Medical
  112. Guide to Aircraft Accident/Incident Investigation
  113. – Two key ASMS elements for initial response:
  114. • Element 9 Investigation
  115. • Element 10 Emergency response.
    ADF policies and sources of information
  116. • AAP 6730.002 – Aviation Accident Work Health & Safety Manual:
  117. – Key source of information to assist with hazard identification and associated risk management on an accident site
  118. • Other DDAAFS publications and guide books:
  119. – Hazards at aircraft accident sites – Guidance for police and emergency personnel (Edition 6 January 2014) – ATSB/DDAAFS
    – Aviation Accident Checklist Edition 6 January 2014) – ATSB/DDAAFS
  120. – ADF Aviation Safety Occurrence Investigation – Quick Reference Guide AL 4.
    ADF policies and sources of information
  121. • PM 184 – Medical Report on an Aircraft Incident or Accident (Web Forms)
    – Aircrew/passenger medical report – 72 hour history, injuries/causes, survivability aspects
  122. – Medical and rescue services assessment
  123. • PM 185 – Medical Officer’s Incident/Accident
    Check List (hard copy only)
  124. – Provides further guidance on completing PM184 forms.
    DDAAFS role in accident investigation
  125. • Not part of initial response / rescue
  126. • Only ADF agency for aviation accident investigation
  127. • DDAAFS will form an Aviation Accident Investigation Team
  128. (AAIT) , which will deploy as soon as possible
  129. • Take‐over of site control from Incident Site Commander once emergency services actions complete / survivors rescued / fatalities removed
  130. • Not responsible for recovery of aircraft or site restitution
  131. • Produce Aviation Accident Investigation Report.
    DDAAFS role in accident investigation
  132. • DDAAFS is able to support two concurrent accident investigations:
  133. – trained Aviation Safety Investigators (ASI) across aircrew, engineering and maintenance
  134. – each team will typically have five DDAAFS ASIs
  135. – Each team supplemented by other agencies as required
    (next slide)
  136. – heightened readiness & short notice to move.
  137. (02) 6144 9199
    Investigation Team composition
  138. 1. Officer in Charge (management oversight – conduit btwn AA & AAIT)
  139. 2. Investigator in Charge (Project manager / senior investigator)
  140. 3. Lead operations investigator (aircrew, planning, execution, weather, ATC)
  141. 4. Lead technical investigator (wreckage examination, maintenance aspects)
  142. 5. Operations investigator
  143. 6. Technical investigator
  144. 7. Crash Data Recorder (CDR) specialist (investigative support – crash kits, PPE, CDR recovery)
  145. 8. Human Factors specialist (support to Ops/Tech investigators during interviews)
  146. 9. External support – platform specialist (Ops/Tech and OEMs), SAVMO, evidence documentation
    • (ADFIS), accident engineering forensics (DST Group), Site Safety (ENVHO, EODF).
    • Investigation support and liaison
    • ,..-------+
    • '
    • +------- '
    • ·-•'
  147. AFHQ
    ---+ '4--,
  148. lnveslll)a.toon ' "'""""'•"II--
    '
  149. -·--•
    • --·
    • 18 ,--+
    • ADF,S ' '
    • ' -··
    • 'I I
    • '-""""
    • O.O.M.,FS 'I ....... I
    • ''
    • ....
    • -·•··
    • '
    • ' 'I
    • Pubic:Atlan
    • {separate to I
  150. '"'"""""' ''
    • ,t_•!I OSRG. I
    • �)
    • I
    • lw<-(Q•
    • """"'
    • ' '
    • '' '
    • ,'... ---..s.i..11:e'idiuilO...,.----- ''
    • -r.. _-.,
    • .... - -cii,u...;;.,.- - ....
    • ' -- '
    • I <:::��- '(
    • -... .............
    • Al.i:honll85.
    • lnddertl.lrlit•
    • Op,,
    • Mainie,,ence.
    • .......... r=
    • 1 --. I
    • I -·-- !'
    • '
    • • OAAA &
    • O,,\R
    • level
    • Affeeled Parti.
    • ·OM& TMleYel
    • -ASR-
  151. -·•
  152. ln:eiviews
  153. -
    • O"O""M"fS'
    • ����Si!ie Su�ppor/t -
    • 'I
    • v:I I:
  154. Al.S·I-.MU,hA0SG
  155. OIC MIT/Alff
  156. I l -Sh I
    • Site Support I :
    • ADI' C.,Vu di
    • �,�������=�Liaison
    • :'I
    • :'l
    • t
    • I
  157. l'r
    • t.6.SCENG. ARDU).
    • fODl,(GWBI
    • MUl.9). Jfl.A. DOS
    • DGTA·AOI'
    • (ASI, ES!,
    • sssc.
    • NOT&CL!
    • 11C AAITIAIIT
    • I I F�R
    • .. I
    • '-------' I'
    • ,.._-1,.....,_. 'r
  158. Primary DutiH
    ·O-ps L�ead & SSuupportt
  159. lnvestlgatora
    • ..,..,
    • -- System SMEs Site Safety
  160. .1o,,_eo..a1 I
    • • - Mroto{"'"''-) I
    • · r
    • I
    • T eeh Lead & Support
  161. ATC
    • �Safety
    • HF/Psyd,
  162. SecoodNy Out.In;
    • St:e Safety OITicef
    • Sile s«ur11y Lllison Qfl',oer
    • Ml*' aod Logistics Lilllson Offloer
    • DDAAFS Aviation DSTO PlatbmSME
    • CT-I (Ops/Tech)
  163. OOMfS- Al/MED �SME
    • F�SI.Es (SAVMO) (AE:O'OEM)
    • ATS6 ..
    • EOOF
  164. """"""""'
    • ADFIS
    • ,-AO-FI�S ''
    • 'I
    • '
    • Site RIIIXMWY LlalSoo CXftcer
    • '°""'"""'
    • �� ..,._ ;..--",:---'\ """""
    • '
    • ' - - - - - Mlt/l"JT��tlii..-.ili,ii...-�:-liil"Csii•.1alit1, f'wlio�Mi,iigi"IM""lj" - - - - .... '
    • �lrp ,r.�-Lliliot,l, "J ../
    • Safety Investigation equipment
  165. • AAIT will use a variety of specialised equipment and Personal Protective Equipment:
  166. – Individual Go‐Bags (Macpacs)
  167. – Crash kits (x2), GPS site mapping kit, photographic kit, PPE kits, sampling kits, hand tools, GoPro
  168. – Specific training and regular familiarity training to maintain competence in their use.
    • Crash Data Recorder download & analysis
    • Crash Data Recorder download & analysis
    • examples
    • .... �-- . .
    • : .::����������- -���,
    • � \l
    • ,0 �L Jl
    • •l''i
    • l'l;.
    • .:,. �
    • -
  169. - . .. .
  170. FLIGHT PHASE
  171. ,. ..
  172. " "
    • •"
    • '"
  173. • Investigation
    • Role of the AAIT
    • – Managed as a ‘project’
    • – Responsible for safety of all personnel once site handover has occurred
    • – Reports directly to Appointing Authority (accident  Service
    • Chief)
    • – Recommend safety action (if required) at any time
  174. • Key phases:
    • – Notification
    • – Pre‐deployment
    • – Field phase (evidence collection)
    • – Analysis and Report Writing
    • – BOI/COI (expert witness).
    • Case Study – PC9/A Accident
    • A23‐039, 18 May 11
  175. Initial phase of investigation
    Pilatus PC9/A information
  176. • Two seat advanced trainer
  177. – MB Mk 11 ejection seats
  178. • P&W PT6A‐062 turboprop
  179. • MTOW 2710kg
  180. • Ceiling 25 000 ft
  181. • Range 1850km
  182. • Operated by CFS, 2FTS,
    • 4SQN, ARDU
    • Accident background
  183. • Student instructor flying
    (Rear Seat)
  184. • Intercepted outbound leg
    (220 radial), climbing
  185. • Approx 3600 ft, 3.0nm from
    RWY 04 threshold
  186. • Loss of power experienced
  187. • QFI assumed control, turned to nearest RWY (04)
    Accident Background
  188. RWY04 threshold
  189. Impact Site
    • • Student commenced checklist
    • items
    • • QFI established aircraft in glide
    • • QFI declared MAYDAY to ESL
    • approach
    • • QFI commenced ‘Mechanical
    • Failure’ checklist
    • • When apparent A23‐039 would not make runway, QFI directed ejection
    • • Student initiated command ejection
    • Site Investigation
  190. Impact Site
  191. • A23‐039 impacted approx 0.5 nm SW of RWY 04 threshold
    • – Came to rest on RAAF ESL boundary fence
    • – Initial impact approx 15 – 20m prior to resting point
    • • Aircraft destroyed in impact
    • – Fuselage/wing effectively separated
    • – Nose significantly damaged
    • – Front cockpit disrupted
    • – Fuel tank rupture and fuel spill
    • – Propeller destroyed
    • Site Investigation
    • Site Investigation
  192. • 19 May 11
    • – AAIT personnel on site
    • – FDR/CVR recovered
    • • 20 May 11
    • – Engine recovered and sent to Pratt & Whitney
    • Canada Australasia (Brisbane) for teardown
    • – Fuel system, cockpit components recovered
    • • 21‐22 May 11 (weekend)
    • – Site survey, additional components recovered
    • – Documentation review
    • • 23 May 11
    • – Wreck moved to secure hangar, site handover
    • – Engine examination commenced (Brisbane)
    • Site Investigation
  193. • Aircraft impacted wings‐
    • level, slight nose‐down
    • • Wholly intact prior to impact
    • – Excepting ejection debris
  194. • Control surface integrity assessed as serviceable prior to impact
  195. • Fuel present in aircraft
  196. • Oil present in engine
    • • Hydraulic fluid present in hyd system lines
    • Investigation process
  197. 1. Initial response
  198. 2. Initial notification
  199. 3. Pre‐deployment – planning/preparation
  200. 4. Deployment – field phase
  201. 5. Redeployment – analysis, report writing
  202. 6. AAIR issue
  203. 7. BOI/CDF COI
    Summary
  204. • DDAAFS overview:
  205. – Manages ASMS and WHSMS policy (outlined in the
    DASM and AFSM)
  206. – Investigation is only one of many roles
  207. – DDAAFS is the lead ADF organisation for all accident investigations (+ other occurrences if necessary), but is supported by other agencies
    Summary
  208. • Intro to accident investigation:
  209. – 4 levels of ASOR classification – event, incident, serious incident, accident
  210. – Safety investigations only ‐ Why it happened  prevent recurrence +
    improve safety
  211. • No blame or liability apportionment
  212. – Investigation report (with safety recommendations)
  213. – BOI / CDF COI – expert witness (to explain circumstances of the accident)
  214. – Initial response is by bases/units, not DDAAFS
  215. – Key policy document outlining investigation and emergency response is the DASM
    • However there is a number of supporting documents
  216. 1999 F-111 Palau Aur
  217. QUESTIONS
  218. 2005 Sea King Nias
    • 2006 Black Hawk HMAS Kanimbla
    • 2012 Chinook MEAO
Author
david_hughm
ID
328907
Card Set
01 DDAAFS overview and introduction to aviation accident inv
Description
01 DDAAFS overview and introduction to aviation accident inv.txt
Updated