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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 26th Nov 2012, 10:32
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What gobbles said!

ps gobbles see you still have to pussyfoot around the Senate thread...hmm Mr GG and friends in high places, its just not cricket

Update to Ben's latest on this topic:
Further evidence of the disquiet the ATSB Pel-Air report is causing here and abroad.



A highly experienced industry figure has written as follows concerning the ATSB Pel-Air report problems in response to today’s earlier post:


To answer your question, “Has Australia been dragged back toward the dark ages in air accident investigations in order to cover up gross deficiencies in the performance and professional integrity of CASA, the air safety regulator?” the short answer is an emphatic “Yes.”

Let us deal with the core finding of the ATSB report of pilot error as the principle cause of the Pel-Air accident. This type of finding is indeed from the dark ages and was put to rest by Hon. Peter Mahon in his Royal Commission into the Air New Zealand DC10 accident at Erebus in 1979 and Justice Virgil Moshansky in his Commission of Inquiry into the Dryden accident in Canada in 1989. Since those inquiries there has been a greater focus latent system failures, local conditions, local triggers, active failures (including pilot error/violation) and most significantly organisational factors in aviation accident investigations.

An organisational factor includes not only factors within the operator but the regulator as well and it is these organisational factors that get up the nose of operators and regulators. The CASA special (secret) audit revealed very clearly some of the operator organisation factors that resulted in this accident and the organisation factors of the faults within CASA that also resulted in the accident.

Was the Pel-Air pilot flying in accordance with CASA regulations and Pel-Air standards approved by CASA? I believe so. If it was not for the local triggers i.e. the Norfolk weather conditions there would not have been an accident (no pilot error) however all the other condition would have remained present just waiting for a trigger.

CASA would not have conducted their special audit and the organisational factors would not have been addressed due to CASA’s lack of oversight.

The Bureau of Air Safety Investigation (BASI) was the world leader in accident investigation and their expertise under Dr Rob Lee was sought from similar aviation accident investigation organisations worldwide as well as ICAO. Mr Dolan’s response concerning Professor Reason’s model is a disgrace and demonstrates a complete lack of understanding as the factors that cause accidents outside of the pilot making an error or committing a violation. The aviation safety system, including the role of the regulator, should be such that these pilot errors or violation are trapped thus preventing the accident. Much has been written on this subject but the bible is “Managing the Risks of Organisational Accidents” by Professor Reason. I recommend it to Mr Dolan.

Two good studies of aircraft accidents that involved organisation factors are the BASI investigation report into the Ansett B747 accident at Sydney in 1994 (Investigation Report 9403038) and the ATSB report onto the Qantas B747 accident at Bangkok in 1999 (Investigation Report 199904538). Both investigations taking place before the unannounced ATSB policy change.

What has caused the ATSB policy change? It was not too long ago that the ATSB did not hesitate to address factors within CASA and making appropriate recommendations for corrective action in their investigation reports. This fearless and appropriate response in ATSB investigations strained their relationship with CASA that resulted in the ‘Miller Report’. Did this report result in the ATSB becoming a subservient organisation to CASA instead of remaining an independent investigator?

The last point to be addressed concerns the last paragraph of your blog where you mention ‘enforcement’ by CASA. This is the problem, CASA do not do enforcement. They are not the ‘Policeman on the Beat’ giving out tickets, all they do is audit and recommend corrective action. Their special audit of Pel-Air demonstrates this lack of enforcement that is essential as one part of ensuring a national system of safety. They should not hide behind the ‘Just Culture’ principles, even Professor Reason espouses that violators need to be tackled.



Pel-Air: Industry identity critiques ATSB safety retreat | Plane Talking

Last edited by Sarcs; 26th Nov 2012 at 11:25.
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Old 27th Nov 2012, 07:47
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So who is the industry identity?
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Old 28th Nov 2012, 11:35
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Dolan Briefs AAvPA

Apparently Beaker briefed the Australian Aviation Psychological Association last week with a paper called "Beyond Reason". Was anyone there to hear it? I hear more waffle, but importantly a footprint for the future of the ATSB.
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Old 28th Nov 2012, 18:19
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"Beyond Reason". At least he got the bloody title right – it is beyond all reason. I'm surprised he dare show his face in public let alone stand up and talk at it. Elephanthideitus.

I reckon next time he speaks we should get a bus load together, turn up and heckle the bejasus out of him.
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Old 28th Nov 2012, 21:35
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Oh the shame

Apparently Beaker briefed the Australian Aviation Psychological Association last week with a paper called "Beyond Reason". Was anyone there to hear it? I hear more waffle, but importantly a footprint for the future of the ATSB.
Now that is funny! Perhaps he was seeking tautological help from the Association for his cuurent emotional state?
As for "Beyond Reason" I am very surprised to see him mention anything James Reason, isn't "Reason" a banned word in his vocabulary?

Then again he is a Muppet so maybe he was briefing these blokes:
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Old 28th Nov 2012, 23:34
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Beyond Reason.
Consider Sid Dekker and Prof Erik Hollnagel.
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Old 29th Nov 2012, 03:39
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Professor Hollnagel does makes some interesting observations. All of the bolding is mine:
Even though accident investigations ostensibly aim to find the “root cause”, the determination of a cause reflects the interests of the stakeholders as much as what actually happened.

Finding a cause is thus a case of expediency as much as of logic
. There are always practical constraints that limit the search in terms of, e.g., material resources or time. Any analysis must stop at some time, and the criterion is in many cases set by interests that are quite remote from the accident investigation itself. [A] cause is always a judgement made in hindsight and therefore benefits from the common malaise of besserwissen [German for ‘know-it-alls’]. More precisely, a cause – or rather, an acceptable “cause” – usually has the following characteristics:

- It can unequivocally be associated with a system structure or system function (people, components, procedures, etc.).

- It is possible to do something to reduce or eliminate the cause within accepted limits of cost and time. This follows partly from the first characteristic, which in a sense is a necessary condition for the second.

- It conforms to the current “norms” for explanations. This in particular means that the cause corresponds to the most popular theory at the time. For instance, before the 1960s it was uncommon to use “human error” as a cause, while it practically became de rigueur during the 1970s and 1980s. Later on, in the 1990s, the notion of organisational accidents became accepted, and the norm for explanations changed once more.
In the article from which the above quote is extracted, Professor Hollnagel also refers to a study undertaken as part of the second phase of the Human Error in Air Traffic Management project, carried out by Dedale SA for Eurocontrol. After that discussion, he states:
The issue here is, of course, not so much whether the subjects acted correctly but rather that the observers often would classify actions wrongly because they could not see the situation from the subject’s point of view. The lesson to be learned is that an action should not be classified as an “error” only based on how it appears to an observer.
And as part of the concluding discussion:
The conclusion is that the term “human error” should be used carefully and sparingly – if it is to be used at all. In the long term it may be prudent to refrain from considering actions as being either correct or incorrect, firstly because these distinctions rarely apply to the action in itself but rather to the outcome, and secondly because they imply a differentiation that is hard to make in practice. The alternative is to acknowledge that human performance (as well as the performance of technological systems) is always variable.

The consequence of acknowledging the existence of this variability is that many so-called “human errors” can be seen as the outcome of successful performance adjustments, which include ways of saving attention, managing workload, making decisions based on heuristics (in the sense of naturalistic decision making), etc. As long as these adjustments meet the socio-technical expectations to acceptable results, they are seen as being goal-oriented, effective, and reflecting the intelligence of human beings. Moreover, “errors” or “poor decision-making” resulting from such intentionally sub-optimal actions are often detected and recovered in time. Because these adjustments usually are successful they become the norm, and are therefore also used when the conditions – in retrospect – are unfavourable. It is thus only when the detection and/or recovery for some reason fails, that they become “human errors”.
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Old 30th Nov 2012, 01:46
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Fuel calculations.

Interesting weekend reading for the fuel planning conscious.

Download – ATSB response to Davies.

Download – Davies response to ATSB.
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Old 30th Nov 2012, 21:04
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Another well-argued submission by Mr Davies.

(And who’d have thought that “tergiversation” was a real word!)
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Old 30th Nov 2012, 22:36
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Nice work by Richard Davies. How many ATSB jobs could be eliminated by subcontracting the work to him?
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Old 30th Nov 2012, 23:12
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atsb and the validity of reports

From Richard Davies supplementary submission:



and:



and:



Well atsb - please explain why you have not brought to casa's attention this serious discrepancy.

It is another failure by casa to properly surveil.

Last edited by Up-into-the-air; 30th Nov 2012 at 23:45. Reason: more stuff
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Old 30th Nov 2012, 23:18
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PAIN,
very interesting reading these two submissions make.
They could perhaps lead into a whole enquiry into CASA's
interference with manufactuers recommended Data and procedures.
The requirement to produce an alternative Flight manual,
variously known as part B of the operations manual or
FCOM or CTS, and the influence various FOI's opinions
of how a particular aircraft should be operated reflected in these manuals,
is a very vexing conundrum for chief pilots and perhaps explains the staggering costs involved in placing an aircraft on an AOC.
Until the manual is produced and submitted there is no real idea
of exactly what it must contain other than vast amounts of data
cut and pasted from the certified Flight manual. A lot of chief pilots will
just go with the flow, anything for a quiet life, and include anything
an FOI wants, regardless of whether he agrees with it or not, who can blame him with a CEO breathing down his neck because he wants revenue and an FOI who will brook no dissent ("Not a fit and proper person" threat) or "lets see if I can top the record bill for service"
The sad thing is there can be five different operators in Australia operating the same aircraft type five different ways, thats supposed to be "Safe"

Last edited by thorn bird; 30th Nov 2012 at 23:20.
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Old 3rd Dec 2012, 23:50
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ATSB sup submission 2(1) Appendix B deals with the change of philosophy/methodology of ATSB 'safety actions' and the once obligatory 'safety recommendation'.

"Managing safety issues and actions

Traditionally, accident investigation agencies produce final reports and issue safety recommendations to other organisations or individuals, to encourage change in order to prevent a recurrence of an accident.

Comment: What is wrong with tradition and a tried, accepted and justified methodology that means pertinent safety issues discovered in the course of an accident/incident investigation are disseminated and transparent to aviation stakeholders worldwide?

Further, performance targets are often associated with the number of recommendations issued by investigation authorities. The focus of an ATSB investigation is on achieving safety outcomes; that is through the identification of the factors that increased risk, particularly those associated with ongoing/future risk (safety issues), such that action can be taken by relevant organisations to address the identified 'safety issue'.

This does not in itself require the issuing of safety recommendations, although that is an option. Noting that safety recommendations are not enforceable (Perhaps they should be??), the issuing of a safety recommendation in itself may not achieve any tangible safety benefit, if the target organisation elects not to accept and react to the recommendation. Maybe the organisation shouldn't have any choice?

In this regard, the ATSB prefers to encourage proactive safety actions that address the 'safety issues' identified in its reports. Other benefits of this approach are that the stakeholders are generally best placed to determine the most effective way to address any 'safety issues' and the publication of the safety actions that address an issue proactively should be viewed as a positive step that provides for timely safety action prior to the release of the report and a level of completeness (Beaker always the 'tidy freak') when the final report is published. This approach is reflected in the difference that Australia has filed with respect to Annex 13 para 6.8.

The response to a safety recommendation is most often unlikely to be any different to the safety action reported by an organisation in response to an identified safety issue, but the latter is likely to be more proactive and timely (Based on whose assessment?). That is specifically the case with respect to the Norfolk Island investigation, where the responses to any formal safety recommendations to CASA and Pel-Air related to the two identified safety issues, are likely to be as per the safety action detailed in the report.

Reference 'Safety Actions' pages 45-49 of the ATSB report: http://www.atsb.gov.au/media/3970107...-072_Final.pdf

The ATSB is in the process of redeveloping its website to be 'safety issue' focused rather than 'recommendation' focussed. The point of importance is that the safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation.

This statement does show a proactive approach to tracking and disseminating the safety action/issue information. So why then change the methodology and on what evidence/research has this new policy/approach to safety actions/issues based?

However, experience has been that this is rarely required. Would that be the experience of the last four years since Beaker took over?

The ATSB's Safety Investigation Information Management System (SliMS) provides tools for investigators to record and track safety issues and actions, including through the setting up of alerts to prompt periodic follow-up of progress with safety action where a safety issue is open and the safety actions are being monitored (the same process applies if a recommendation were issued). In addition, a standing agenda item is included in the quarterly Commission meetings to review safety issues and actions during the previous quarter, with particular focus on those that remain open.

The ATSB's Annual Plan and part of the ATSB's Key Performance Indicators
specifically relate to a measurement of safety action taken in response to safety issues; in the case of 'critical' safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for 'significant' safety issues, the target is 70%.

For the FY11 /12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed."

Definitely more questions to be asked in regards to the demise of the 'Safety Recommendation' in Oz??

The Beaker spin in this sup submission highlights that the ATSB can no longer be regarded as independent and left to carry out an essential service without fear nor favour. The ATSB is now a neutered, ineffective agency that is more interested in not upsetting various 'stakeholders'.

The 'Beaker policy' (and by default Albo's policy) is totally flawed and if allowed to continue will see the total demise and reputation of the ATSB go down the plughole. Hopefully the Senators can see these issues and are not deterred by the Beaker spin!
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Old 4th Dec 2012, 00:29
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ATSB urrgently in need of a Beakerectomy...

A succint sarcs strikes again, superb commentary.You have identified the overarching ATSB issues with your robust assessment. You have highlighted the issues that underpin ATSB's fall from grace. Your examination is fresh, non-tautological and is of absolute 'best practise'. You're in line for the "2012 Robust Medal'. Good work.

The Beaker spin in this sup submission highlights that the ATSB can no longer be regarded as independent and left to carry out an essential service without fear nor favour. The ATSB is now a neutered, ineffective agency that is more interested in not upsetting various 'stakeholders'.
Absolutely. A neutered entity that has also had its spine removed.
- An 'independant' body that that has it's strings pulled by Team Albaswisscheesie.
- A neutered independant body to scared to report because it may upset airline heirachy or create adverse publicity by reporting fact and truth.
- A neutered body that is prepared to take advice from, of all people, Fort Fumble!
- A neutered body that has lost it's direction and is governed by spin and mimimimimimi waffling bureaucrats.
- Yes, a neutered body that is drowning in it's own dribblings. It is neutered, spineless and has not a hint of testicular fortitude left.

The 'Beaker policy' (and by default Albo's policy) is totally flawed and if allowed to continue will see the total demise and reputation of the ATSB go down the plughole. Hopefully the Senators can see these issues and are not deterred by the Beaker spin!

- It's direction has floundered. It's direction is lost.
- It's authority is now questionable.
- It's ability to report tacit facts has been decimated.
- It's fuctionality is lost. It's current path is untennable.

One could question, in a tautological manner, what relevance the ATSB even has currently? Maybe they have morphed in with the rest of 'the ills of society'?

Last edited by Valley of Hinnom; 4th Dec 2012 at 00:35.
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Old 4th Dec 2012, 02:35
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Here's an interesting exercise to compare/assess how far the ATSB has come (or not) compared to the old BASI.

Some would say that the PIC of the DC3 that ditched into Botany Bay was also made a scapegoat by the authorities. However it is still worth comparing the two final reports as they both dealt with a controlled ditching where all POB survived. This may perhaps highlight the differences in the current Beaker regime 'final report' to a BASI compiled 'final report'.

Botany Bay ditching:
http://www.atsb.gov.au/media/24341/a...401043_001.pdf

Norfolk ditching:
http://www.atsb.gov.au/media/3970107...-072_Final.pdf

Perhaps the most revealing is the synopsis or in the ATSB report the 'Safety Summary'.

SYNOPSIS

On Sunday 24 April 1994, at about 0910 EST, Douglas DC-3 aircraft VH-EDC took off from runway 16 at Sydney (Kingsford-Smith) Airport. The crew reported an engine malfunction during the initial climb and subsequently ditched the aircraft into Botany Bay. The DC-3 was on a charter flight to convey a group of college students and their band equipment from Sydney to Norfolk Island and return as part of Anzac Day celebrations on the island. All 25 occupants, including the four crew, successfully evacuated the aircraft before it sank.

The investigation found that the circumstances of the accident were consistent with the left engine having suffered a substantial power loss when an inlet valve stuck in the open position. The inability of the handling pilot (co-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and
organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non-adherence to operating procedures and lack of skill of the handling pilot.

Organisational factors relating to the company included:
• inadequate communications between South Pacific Airmotive Pty Ltd who owned and operated the DC-3 and were based at Camden, NSW and the AOC holder, Groupair, who were based at Moorabbin, Vic.;
• inadequate maintenance management;
• poor operational procedures; and
• inadequate training.

Organisational factors relating to the regulator included:
• inadequate communications between Civil Aviation Authority offices, and between the Civil Aviation Authority and Groupair/South Pacific Airmotive;
• poor operational and airworthiness control procedures;
• inadequate control and monitoring of South Pacific Airmotive;
• inadequate regulation; and
• poor training of staff.

During the investigation, a number of interim safety recommendations were issued by the Bureau.These recommendations, and the CAA’s responses to them, are included in this report.
And the Norfolk version:
SAFETY SUMMARY

What happened

On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger.

On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft’s fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.

What the ATSB found

The requirement to ditch resulted from incomplete pre-flight and en route planning and the flight crew not assessing before it was too late to divert that a safe landing could not be assured. The crew’s assessment of their fuel situation, the worsening weather at Norfolk Island and the achievability of alternate destinations led to their decision to continue, rather than divert to a suitable alternate.

The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not minimise the risks associated with aeromedical operations to remote islands. In addition, clearer guidance on the in-flight management of previously unforecast, but deteriorating, destination weather might have assisted the crew to consider and plan their diversion options earlier.

The occupants’ exit from the immersed aircraft was facilitated by their prior wet drill and helicopter underwater escape training. Their subsequent rescue was made difficult by lack of information about the ditching location and there was a substantial risk that it might not have had a positive outcome.

What has been done to fix it

As a result of this accident, the aircraft operator changed its guidance in respect of the in-flight management of previously unforecast, deteriorating destination weather. Satellite communication has been provided to crews to allow more reliable remote communications, and its flight crew oversight systems and procedures have been enhanced. In addition, the Civil Aviation Safety Authority is developing a number of Civil Aviation Safety Regulations covering fuel planning and in-flight management, the selection of alternates and extended diversion time operations.

Safety message

This accident reinforces the need for thorough pre- and en route flight planning, particularly in the case of flights to remote airfields. In addition, the investigation confirmed the benefit of clear in-flight weather decision making guidance and its timely application by pilots in command.
Which kind of speaks for itself, however it is also very interesting to compare the two 'Safety Actions' sections of the report as this more than highlights the previous 'ballsy', big cohuna attitude of BASI compared to the neutered, lapdog, Beaker version of the ATSB!
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Old 4th Dec 2012, 04:47
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Managing safety issues and actions

Traditionally, accident investigation agencies produce final reports and issue safety recommendations to other organisations or individuals, to encourage change in order to prevent a recurrence of an accident.
Further, performance targets are often associated with the number of recommendations issued by investigation authorities. The focus of an ATSB investigation is on achieving safety outcomes; that is through the identification of the factors that increased risk, particularly those associated with ongoing/future risk (safety issues), such that action can be taken by relevant organisations to address the identified 'safety issue'.
This does not in itself require the issuing of safety recommendations, although that is an option. Noting that safety recommendations are not enforceable, the issuing of a safety recommendation in itself may not achieve any tangible safety benefit, if the target organisation elects not to accept and react to the recommendation.

In this regard, the ATSB prefers to encourage proactive safety actions that address the 'safety issues' identified in its reports. Other benefits of this approach are that the stakeholders are generally best placed to determine the most effective way to address any 'safety issues' and the publication of the safety actions that address an issue proactively should be viewed as a positive step that provides for timely safety action prior to the release of the report and a level of completeness when the final report is published. This approach is reflected in the difference that Australia has filed with respect to Annex 13 para 6.8.

The response to a safety recommendation is most often unlikely to be any different to the safety action reported by an organisation in response to an identified safety issue, but the latter is likely to be more proactive and timely. That is specifically the case with respect to the Norfolk Island investigation, where the responses to any formal safety recommendations to CASA and Pel-Air related to the two identified safety issues, are likely to be as per the safety action detailed in the report.
A false dichotomy, mere speculation and conflating causation and correlation.

The false dichotomy is the implication that the ATSB should either issue safety recommendations or encourage proactive safety actions that address the ‘safety issues’.

Both can happen, and both should happen, in the course and conclusion of an investigation.

If the ‘target organisation’ is prepared to accept and react to a safety recommendation, it is free to do that ‘proactively’ when the ‘safety issue’ is identified earlier in the investigation. Nobody suffers if a corresponding safety recommendation is subsequently made and closed.

If a ‘target organisation’ is not going to accept and react to a safety recommendation, the ‘target organisation’ is not going to take proactive action to address the ‘safety issue’ that would have led to the recommendation. But putting the recommendation on the public record has important consequences if it is ignored or rejected.

Certainly it’s preferable that the ‘target organisation’ take action when the ‘safety issue’ is identified rather than wait for the report, if the ATSB is going to take 1000 days to produce a report. But that’s no reason to exclude safety recommendations from the report.

The speculation is that issuing a safety recommendation in itself may not achieve any tangible safety benefit; stakeholders are generally best placed to determine the most effective way; the latter is likely to be more proactive and timely. Let me speculate as well: Perhaps the prospect of a safety recommendation being made is one of the factors that may prompt the proactive action to address the ‘safety issue’?

I am disturbed to note that the ATSB seems not to understand the difference between causation and correlation. The ATSB seems to believe that Pel-Air’s and CASA’s actions after the ditching were caused by the safety issues identified by the ATSB.

Pel-Air’s actions were caused by a very, very cold chill after a hull loss that was a coin toss away from lives lost, and the matters revealed by the CASA audit (and probably some quiet words from Pel-Air’s insurers). CASA isn’t doing anything now that it wasn’t claiming to be doing prior to the incident. The actions of Pel-Air and CASA in this case therefore provide no support to the ATSB’s approach to safety recommendations. And what if the actions of Pel-Air and CASA don’t turn out to be “as per the safety action detailed in the report”, despite ATSB’s speculation that it is “likely” to turn out that way?

And remind me: who’s taking the proactive and effective action in relation to the adequacy of the life vests and the procedure for deployment of the life raft?
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Old 4th Dec 2012, 04:50
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Sarcs, other than both ended in the ocean, there are not many similarities to compare the two reports.
Dodgy maintenance versus none dodgy maintenance
Aircraft in wrong operational category versus correct category
CAA versus CASA
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Old 4th Dec 2012, 06:29
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Trolling again Blackie.

Kharon - "Trolls rarely add anything of value to the conversation"
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Old 4th Dec 2012, 08:57
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@denzledude - you do know what ironic means?
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Old 4th Dec 2012, 10:33
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Isn't that Big Iron?
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