01 DDAAFS overview and introduction to aviation accident inv



DDAAFS overview &

AVMO Course 01-2016

Squadron Leader Ben Abrahams

Lieutenant Commander Denes Illyes

• 5.4 Introduction to AAI and DDAAFS

– Apply relevant ADF policies and procedures to the initial response to and investigation of aircraft accidents and incidents.

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DDAAFS overview

Enabling Defence aviation capability through effective and integrated safety programs.

To provide independent specialist advice to those

To improve Air Force and aviation safety to enhance capability through positively influencing safety behaviour by fostering and promoting a generative safety culture.

Defence Establishment Fairbairn, ACT

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• Principal representative/adviser to Defence Aviation Authority (Chief of Air

• Aviation safety policy formulation

• Monitor effectiveness of the Defence Aviation Safety Management System

• Advice and tools to services on implementation and management of their

• Aviation safety education and training

• Develop strategies and programs to enhance Defence aviation safety

• Investigate all Defence aviation accidents.

• Assist the CAF with safety governance through due diligence (WHS Act)

• Support WHS regulator (Comcare) interventions

– Provide advice to commanders

• Develop and improve Air Force WHS Management System

– RAAFSafe including policy, training, assurance, risk management and WHS

investigation capability

• Prescribe WHS standards and provide advice to CAF and safety network as required

• Air Force WHS policy development and maintenance.

• AAP 6734.001 ‐ Defence Aviation Safety Manual (DASM)

• AAP 6730.002 ‐ Aviation Accident WHS Manual (AAWHSM)

• AAP 6730.001 ‐ Air Force Safety Manual (AFSM)

• Defence Aviation Hazard Reporting & Tracking System (DAHRTS)

• DDAAFS Snapshot Survey

– safety culture (aviation safety & WHS).

• Safety Communication

– active promotion of safety throughout the Air Force and ADF aviation environments

• Applied Human Factors Specialist Support

– implementation and continuance of Human Factors training and

education for Aircrew/Maintenance Human Factors, and culture/leadership programs.

• Aviation Safety Education and Training

– responsible for the development and management of aviation safety‐related training

• Safety Data Analysis and Exchange

– management of the DAHRTS database, ASOR

monitoring and statistical analysis.

Safety Investigation

• provide independent and dedicated investigation capability for aviation system accidents

– assisting / participating in investigations of foreign military accidents involving ADF personnel (subject to approval)

– assisting investigation of foreign military accidents in Australian territory

– major civil accident ‐ mutual national transport safety investigation capability (ATSB‐DDAAFS MoU).

• DDAAFS Webpage:

– Latest POC info

– Access to DAHRTS and AAPs

– Links to other guidance material/tools

– Training Schedule

• DDAAFS SharePoint:

– ASOR SuperSet Data

– Safety presentations

• DDAAFS group e‐mail:

– ddaafs@defence.gov.au

Introduction to aviation

Defence

10 Investigation

Operator error focus Organisational issues focus

9

SAFETY CULTURE?

8 AIRWORTHINESS BOAROS

Pl.Hornet,

6 OPERATIONAL REGULATIONS

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Sea King

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• Non-fatal • Fatal

83 Deaths • = Number k . led

ORGANISATION organisational deficiencies: latent conditions

MANAGEMENT DECISIONS AND

ERROR- PRODUCING CONDITIONS

VIOLATION- PRODUCING CONDITIONS

ERRORS VIOLATIONS

TECHNICAL FAILURES

ACCIDENTS

TASKING

LATENT CONDITIONS

The Reason Model of Systems Safety

Limited coping resources can get nibbled away

Accumulat ion of minor event s. N ot so much

• Aviation safety occurrence

– Any occurrence which adversely affects, or could adversely affect, the safety or airworthiness of an Aviation System, or safety of third parties.

• Four classification levels:

– Accident (DDAAFS to investigate)

– Serious Incident (investigator must be independent of the incident unit, e.g. DDAAFS, WASO/FASO/RASO)

– Event (not investigated).

• DI(G) OPS 02‐2 – Defence Aviation Safety Program

– Authority for AAP 6734.001 ‐ Defence Aviation Safety Manual (DASM)

• AAP 6734.001 – Defence Aviation Safety Manual

– Outlines Defence ASMS (12 elements)

– AL3 (Jan 15) introduced new Section 4 – key content from ADFP 731 – Medical

Guide to Aircraft Accident/Incident Investigation

– Two key ASMS elements for initial response:

• Element 9 Investigation

• Element 10 Emergency response.

• AAP 6730.002 – Aviation Accident Work Health & Safety Manual:

– Key source of information to assist with hazard identification and associated risk management on an accident site

• Other DDAAFS publications and guide books:

– Hazards at aircraft accident sites – Guidance for police and emergency personnel (Edition 6 January 2014) – ATSB/DDAAFS

– ADF Aviation Safety Occurrence Investigation – Quick Reference Guide AL 4.

• PM 184 – Medical Report on an Aircraft Incident or Accident (Web Forms)

– Medical and rescue services assessment

• PM 185 – Medical Officer’s Incident/Accident

– Provides further guidance on completing PM184 forms.

• Not part of initial response / rescue

• Only ADF agency for aviation accident investigation

• DDAAFS will form an Aviation Accident Investigation Team

(AAIT) , which will deploy as soon as possible

• Take‐over of site control from Incident Site Commander once emergency services actions complete / survivors rescued / fatalities removed

• Not responsible for recovery of aircraft or site restitution

• Produce Aviation Accident Investigation Report.

• DDAAFS is able to support two concurrent accident investigations:

– trained Aviation Safety Investigators (ASI) across aircrew, engineering and maintenance

– each team will typically have five DDAAFS ASIs

– Each team supplemented by other agencies as required

– heightened readiness & short notice to move.

(02) 6144 9199

1. Officer in Charge (management oversight – conduit btwn AA & AAIT)

2. Investigator in Charge (Project manager / senior investigator)

3. Lead operations investigator (aircrew, planning, execution, weather, ATC)

4. Lead technical investigator (wreckage examination, maintenance aspects)

5. Operations investigator

6. Technical investigator

7. Crash Data Recorder (CDR) specialist (investigative support – crash kits, PPE, CDR recovery)

8. Human Factors specialist (support to Ops/Tech investigators during interviews)

9. External support – platform specialist (Ops/Tech and OEMs), SAVMO, evidence documentation

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• AAIT will use a variety of specialised equipment and Personal Protective Equipment:

– Individual Go‐Bags (Macpacs)

– Crash kits (x2), GPS site mapping kit, photographic kit, PPE kits, sampling kits, hand tools, GoPro

– Specific training and regular familiarity training to maintain competence in their use.

- . .. .

FLIGHT PHASE

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• Investigation

• Key phases:

Initial phase of investigation

• Two seat advanced trainer

– MB Mk 11 ejection seats

• P&W PT6A‐062 turboprop

• MTOW 2710kg

• Ceiling 25 000 ft

• Range 1850km

• Operated by CFS, 2FTS,

• Student instructor flying

• Intercepted outbound leg

• Approx 3600 ft, 3.0nm from

• Loss of power experienced

• QFI assumed control, turned to nearest RWY (04)

RWY04 threshold

Impact Site

Impact Site

• A23‐039 impacted approx 0.5 nm SW of RWY 04 threshold

• 19 May 11

• Aircraft impacted wings‐

• Control surface integrity assessed as serviceable prior to impact

• Fuel present in aircraft

• Oil present in engine

1. Initial response

2. Initial notification

3. Pre‐deployment – planning/preparation

4. Deployment – field phase

5. Redeployment – analysis, report writing

6. AAIR issue

7. BOI/CDF COI

• DDAAFS overview:

– Manages ASMS and WHSMS policy (outlined in the

– Investigation is only one of many roles

– DDAAFS is the lead ADF organisation for all accident investigations (+ other occurrences if necessary), but is supported by other agencies

• Intro to accident investigation:

– 4 levels of ASOR classification – event, incident, serious incident, accident

– Safety investigations only ‐ Why it happened  prevent recurrence +

• No blame or liability apportionment

– Investigation report (with safety recommendations)

– BOI / CDF COI – expert witness (to explain circumstances of the accident)

– Initial response is by bases/units, not DDAAFS

– Key policy document outlining investigation and emergency response is the DASM

1999 F-111 Palau Aur

QUESTIONS

2005 Sea King Nias