Updated: CASA has applied addition oversights and a condition on ATR operators.
The ATSB has issued an alarming interim report into a set of incidents involving a Virgin Australia ATR 72 turbo-prop in 2014 saying a fault in the design had not been taken into account when it was certified as safe to fly.
The report also makes it clear that the inability of Virgin Australia to properly identify the unsafe condition of the airliner which continued to fly 13 sectors over five days after the incident remains under investigation.
The first incident happened on February 20, 2014, as the Virgin flight sustained a pitch disconnect crisis while on descent into Sydney. The pitch disconnect occurred while the crew were attempting to prevent the airspeed from exceeding the maximum permitted airspeed (VMO). The aircraft was significantly damaged during the occurrence.
In its first interim report issued last year the ATSB found to put it in blunter language that the two pilots broke the structure of the T-tail by forcing the controls in opposite direction.
In this report it finds that:
During the continued investigation of the occurrence, the ATSB has obtained an increased understanding of the factors behind this previously identified safety issue. This increased understanding has identified that there are transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads that could exceed the strength of the aircraft structure.
The ATSB also found that these transient elevator deflections were not identified, and therefore not considered in the engineering justification documents completed during the aircraft type’s original certification process. The ATSB considers that the potential consequences are sufficiently important to release a further interim report prior to completion of the final investigation report.
ATR isn’t represented in Australia, but Plane Talking understands that the maker, based in Toulouse, and partly owned by Airbus, is well aware of the contents of the second interim report and will respond in due course.
The separate issue of the disclosure standards from Virgin Australia, the quality of its oversight of the regional turbo-prop division, and prima facie evidence of an unsatisfactory culture outcome in the cockpit of the flight on descent into Sydney remains extremely important.
It was dealt with in Plane Talking at that time but largely ignored by the PR obedient general media in this post.
The core elements of the ATSB report show that Virgin Australia’s engineering contractor and the airline failed to identify and understand serious damage done to this aircraft in the turbulence event.
The aircraft was then allowed to carry passengers for thirteen sectors in that state before an in-flight crisis five days later approaching Albury from Sydney where it was grounded after landing, and remains to this day, pending repairs if indeed it can be repaired.
These are scandalous disclosures. No one in the general flying public in this country expects that a contract maintenance organisation could be so bad at its job that it failed to understand and identify the grave safety of flight issues apparent on the Virgin turbo-prop on 20 February.
It is after all, what the maintenance provider is paid by Virgin to do, rather than scratch their heads and release the aircraft back into service.
It’s Virgin’s inescapable legal obligation to ensure that all aircraft are safe before flying. It didn’t ensure the safety of these 13 flights. It’s CASA’s role to enforce and maintain a safe level of oversight on airline operations and ensure that those who carry out aircraft maintenance are competent and effective.
This is a 68 passenger airliner. The situation with the turbo-prop which remained grounded at Albury for months, was one that could have ended, at any time during the five days Virgin Australia had no obvious idea what was going on, in a pile of wreckage and bodies.
Learning, as the industry does today, there was also a blind spot in the certification of the turbo-prop as safe doesn’t build confidence in either the airliner nor the operator in this situation.
The public communication of the seriousness of the ongoing situation in February 2014 was non-existent, and for those media that did make inquiries, totally unsatisfactory.
More recently Virgin Australia has further rolled back its involvement with regional turbo prop services to keep a token force of six of the aircraft operating across parts of it network, once its Queensland ATR base is closed down. Canberra will remain a focus of ATR operations, contradicting the emphasis on E-190 jet flights that prevailed in recent years.
The airline has often said that safety is its first priority and that the ATR operations are safe. Well, they weren’t safe for five days in 2014, the airline was clueless as to what was going on, and the issues with this aircraft appear to be of sufficient concern for the ATSB to issue a global notification to other ATR operators.
Virgin Australia said:
Safety is Virgin Australia’s number one priority, and we continue to liaise closely with the relevant regulatory bodies and the aircraft manufacturer in relation to the Australian Transport Safety Bureau’s ongoing investigation into the ATR’s pitch disconnect mechanism. Virgin Australia has taken a number of risk mitigation measures and is confident the aircraft remains suitable for operations.
CASA continues to audit ATR aircraft operators to ensure appropriate actions have been taken to reduce the likelihood of the aircraft being mishandled in a manner similar to the incident flight. Flight procedures and pilot refresher training for the ATR aircraft operated in Australia have been amended since the event occurred.
CASA concurs with the European Aviation Safety Agency (EASA), the State of Design, that the aircraft is safe when operated in accordance with documented operating procedures.
CASA will look carefully at the findings of the aircraft manufacturer’s engineering analysis of the issues associated with a pitch disconnect when this work is completed.
If this analysis raises any ongoing safety issues CASA will take appropriate action. CASA will take into account any measures taken by EASA.
CASA is requiring monthly reports from the air operators of ATR aircraft to make sure the actions that have been implemented continue to be effective.