Norfolk Island Ditching ATSB Report - ?
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Safety Recommendations
This is from the NTSB web-site:
Why on earth is the ATSB drifting off from the rest of the world? Imagine if there was ever a large fatal here (touch wood), these clowns wouldn't have a clue.
Safety Recommendations
Safety recommendations are the most important part of the Safety Board's mandate. The Board must address safety deficiencies immediately, and therefore often issues recommendations before the completion of investigations. Recommendations are based on findings of the investigation, and may address deficiencies that do not pertain directly to what is ultimately determined to be the cause of the accident.
For example, in the course of its investigation of the crash of TWA flight 800, once it was determined that an explosion in the center fuel tank caused the breakup of the aircraft, the Board issued an urgent safety recommendation and three other recommendations in 1996, four years before completion of its investigation, that were aimed at eliminating explosive fuel/air vapors in airliner fuel tanks. The Board issued an additional recommendation in 1997 regarding the detection of explosives and six recommendations in 1998 to improve fuel quantity indication systems. When the Board issued its final report on the TWA 800 accident in 2000, four additional safety recommendations were issued that focused on the aircraft wiring systems.
Safety recommendations are the most important part of the Safety Board's mandate. The Board must address safety deficiencies immediately, and therefore often issues recommendations before the completion of investigations. Recommendations are based on findings of the investigation, and may address deficiencies that do not pertain directly to what is ultimately determined to be the cause of the accident.
For example, in the course of its investigation of the crash of TWA flight 800, once it was determined that an explosion in the center fuel tank caused the breakup of the aircraft, the Board issued an urgent safety recommendation and three other recommendations in 1996, four years before completion of its investigation, that were aimed at eliminating explosive fuel/air vapors in airliner fuel tanks. The Board issued an additional recommendation in 1997 regarding the detection of explosives and six recommendations in 1998 to improve fuel quantity indication systems. When the Board issued its final report on the TWA 800 accident in 2000, four additional safety recommendations were issued that focused on the aircraft wiring systems.
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Why on earth is the ATSB drifting off from the rest of the world? Imagine if there was ever a large fatal here (touch wood), these clowns wouldn't have a clue.
And you are correct, the clowns/muppets/nupty's wouldn't have a clue what to do if a 'smoker' occurs. But then again, the fronline ATSB lads/ladettes are still capable of doing what they have to do, for now. Give it 5 years and Beaker will have Investigation Graduates from Asia on cheap wages doing the job so he can make budget and bonus.
Last edited by gobbledock; 6th Dec 2012 at 06:05.
That "tendentious blogger" fires another shot at the FF lapdog Beaker and his cronies...
Australian safety agency contradicts itself over ...safety | Plane Talking
Oh just a bit more 'tautological rubbish' for FF to wade through...good job Ben!
ATSB says it supports safety management systems it ignored in Pel-Air crash inquiry
An ATSB review of the effectiveness of safety management systems in Australia completely contradicts the position in took its its much criticised final report into the crash of a Pel-Air medical flight near Norfolk Island in 2009.
The ATSB this morning published a review of the effectiveness of the safety management systems that it insisted were irrelevant considerations in framing a final report into crash of a Pel-Air Careflight air ambulance jet into the sea near Norfolk Island on 18 November 2009.
The crash report is the subject of an unfinished Senate inquiry which is itself due to report by the end of February. It is controversial because of evidence that alleges that the ATSB conspired with CASA, to frame all of the cause of the crash on the pilot to the exclusion of substantial failures by the air safety regulator to properly audit the operator Pel-Air and meet its obligations to exercise oversight of the carrier, and its pilots, among other matters.
This is what the ‘independent’ safety authority, the ATSB says as to why it commissioned “a systemic review of the effectiveness of safety management systems”.
Why have we done this report?
Australian aviation, marine and rail industries have all recently incorporated safety management systems into regulations and operations as a required way of managing safety. Safety management systems (SMS) refer to organisations having a systematic approach to managing safety, including organisational structures, accountabilities, policies and procedures. They generally include several common elements such as explicit management commitment to safety, appointment of key safety personnel, hazard identification and risk mitigation, safety investigations and audit, and safety performance monitoring. Although Australia’s transport industries’ SMS approach is following world’s-best practice, little empirical research evidence has been presented to determine the impact on safety of a structured SMS. The objective of this research investigation was to examine the published research literature into the efficacy of safety management systems, safety programs and related management processes that is applicable to high-reliability transport operations. The examination also aimed to identify which characteristics of these systems, and/or other organisational characteristics or external influences, are most related to the quality of an organisation’s safety management.
The outcome of this review may help organisations and regulators prioritise their efforts on those areas most likely to improve safety performance, and provide guidance for reviewing, auditing or investigating an organisation’s safety management processes.
This is the ‘safety message’ at the end of the summary.
Safety message
Incorporating safety management systems into normal business operations does appear to reduce accidents and improve safety in high-risk industries. At present, there have only been a small number of quality empirical evaluations of SMSs and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety over other elements, although management commitment and appropriate safety communications do affect attitudes to safety. Transport organisations that provide an appropriate investment and commitment to a safety management system should receive a positive return on safety.
The fact is that nowhere in the controversial and abruptly rewritten final version of the ATSB report into the accident is the the term SMS or safety management system used, never mind discussed or examined in relation to the operations of Pel-Air, which were found widely unsafe in a CASA audit the safety regulator had suppressed at the time, and which was not referenced anywhere by the ATSB document eventually released on 30 August this year.
The Pel-Air report raises extremely serious issues about the administration of air safety in Australia, and has seen CASA and the ATSB take positions completely at odds with the standards and expectations of the international air safety community, as represented by ICAO.
An ATSB review of the effectiveness of safety management systems in Australia completely contradicts the position in took its its much criticised final report into the crash of a Pel-Air medical flight near Norfolk Island in 2009.
The ATSB this morning published a review of the effectiveness of the safety management systems that it insisted were irrelevant considerations in framing a final report into crash of a Pel-Air Careflight air ambulance jet into the sea near Norfolk Island on 18 November 2009.
The crash report is the subject of an unfinished Senate inquiry which is itself due to report by the end of February. It is controversial because of evidence that alleges that the ATSB conspired with CASA, to frame all of the cause of the crash on the pilot to the exclusion of substantial failures by the air safety regulator to properly audit the operator Pel-Air and meet its obligations to exercise oversight of the carrier, and its pilots, among other matters.
This is what the ‘independent’ safety authority, the ATSB says as to why it commissioned “a systemic review of the effectiveness of safety management systems”.
Why have we done this report?
Australian aviation, marine and rail industries have all recently incorporated safety management systems into regulations and operations as a required way of managing safety. Safety management systems (SMS) refer to organisations having a systematic approach to managing safety, including organisational structures, accountabilities, policies and procedures. They generally include several common elements such as explicit management commitment to safety, appointment of key safety personnel, hazard identification and risk mitigation, safety investigations and audit, and safety performance monitoring. Although Australia’s transport industries’ SMS approach is following world’s-best practice, little empirical research evidence has been presented to determine the impact on safety of a structured SMS. The objective of this research investigation was to examine the published research literature into the efficacy of safety management systems, safety programs and related management processes that is applicable to high-reliability transport operations. The examination also aimed to identify which characteristics of these systems, and/or other organisational characteristics or external influences, are most related to the quality of an organisation’s safety management.
The outcome of this review may help organisations and regulators prioritise their efforts on those areas most likely to improve safety performance, and provide guidance for reviewing, auditing or investigating an organisation’s safety management processes.
This is the ‘safety message’ at the end of the summary.
Safety message
Incorporating safety management systems into normal business operations does appear to reduce accidents and improve safety in high-risk industries. At present, there have only been a small number of quality empirical evaluations of SMSs and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety over other elements, although management commitment and appropriate safety communications do affect attitudes to safety. Transport organisations that provide an appropriate investment and commitment to a safety management system should receive a positive return on safety.
The fact is that nowhere in the controversial and abruptly rewritten final version of the ATSB report into the accident is the the term SMS or safety management system used, never mind discussed or examined in relation to the operations of Pel-Air, which were found widely unsafe in a CASA audit the safety regulator had suppressed at the time, and which was not referenced anywhere by the ATSB document eventually released on 30 August this year.
The Pel-Air report raises extremely serious issues about the administration of air safety in Australia, and has seen CASA and the ATSB take positions completely at odds with the standards and expectations of the international air safety community, as represented by ICAO.
Oh just a bit more 'tautological rubbish' for FF to wade through...good job Ben!
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SMS, Xmas and the gift that keeps on giving
Sarcs, the problem with serial liars is that they eventually lose track of the lies and consequently shoot themselves in the foot. In cometh thy Beaker. Before all the excitement of the past few months, Herr Beakers only understanding of SMS was the text messages that Albo sent him to advise him that his bonus was ready!
And as you succinctly and robustly pointed out Sarcs, the ATSB has become totally contradictory. They are acting like some kind of hybrid aviation hermaphrodite, confused about it's gender and position in life! Switching here and there, dabbling with this and massaging that. Here a mimi, there a mimi, everywhere a mimimimimi.
The real kicker is this. ICAO promulgate SMS, CASA as the state then in turn promulgate SMS. However we have the CASA not factoring in the elements of SMS into their investigation of Pelair, and neither does Team Beaker! Poor old SMS, it is being treated like a $2 crack whore. Everybody promoted it, used it, pounded it for all it's worth (while they demanded larger organisation budgets to accommodate the almighty SMS and it's introduction). But now, it is no longer needed. It rates no mention in the Pelair fiasco, WTF???
The mad scramble taking place at the ATSB, ASA and CASA is funnier to watch than Albo drinking a few bottles of Chteau La Mondotte Saint-Emilion 1996, eating matsutake mushrooms, Almas caviar and Italian white alba truffles, while trying to articulate aviation policy to his entourage of batty boys and not spilling a drop on his silk tie!
Many folks new years resolution is to see the Senators chop down the Xmas tree's that be known as ATSB and CASA, cut off it's baubles and burn them to cinders. Who knows, that wily old bearded gift giver (no, not the Voodoo Witchdoctor) might even have a new ASA, ATSB and CASA tucked away in his robust sack! The gift that keeps on giving! And all us kiddies would love to play with those new toys.
P.S
Dear Santa: This Xmas, please, no tautological presents. We want something new (written above). We have been good, we promise!
P.S.S No gifts for Flyingfiend this year. He has been very naughty!
And as you succinctly and robustly pointed out Sarcs, the ATSB has become totally contradictory. They are acting like some kind of hybrid aviation hermaphrodite, confused about it's gender and position in life! Switching here and there, dabbling with this and massaging that. Here a mimi, there a mimi, everywhere a mimimimimi.
The real kicker is this. ICAO promulgate SMS, CASA as the state then in turn promulgate SMS. However we have the CASA not factoring in the elements of SMS into their investigation of Pelair, and neither does Team Beaker! Poor old SMS, it is being treated like a $2 crack whore. Everybody promoted it, used it, pounded it for all it's worth (while they demanded larger organisation budgets to accommodate the almighty SMS and it's introduction). But now, it is no longer needed. It rates no mention in the Pelair fiasco, WTF???
The mad scramble taking place at the ATSB, ASA and CASA is funnier to watch than Albo drinking a few bottles of Chteau La Mondotte Saint-Emilion 1996, eating matsutake mushrooms, Almas caviar and Italian white alba truffles, while trying to articulate aviation policy to his entourage of batty boys and not spilling a drop on his silk tie!
Many folks new years resolution is to see the Senators chop down the Xmas tree's that be known as ATSB and CASA, cut off it's baubles and burn them to cinders. Who knows, that wily old bearded gift giver (no, not the Voodoo Witchdoctor) might even have a new ASA, ATSB and CASA tucked away in his robust sack! The gift that keeps on giving! And all us kiddies would love to play with those new toys.
P.S
Dear Santa: This Xmas, please, no tautological presents. We want something new (written above). We have been good, we promise!
P.S.S No gifts for Flyingfiend this year. He has been very naughty!
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atsb and attitude to accidents
The following from Ben Sandilands is instructive:
My bolding
Surely, the reliance on these systems, by atsb's own admission does not have full justification - How can a move to this as a basis for safety, give us a long term safety outcome.
Well??? Mr. atsb
At present, there have only been a small number of quality empirical evaluations of SMSs and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety over other elements, although management commitment and appropriate safety communications do affect attitudes to safety.
Surely, the reliance on these systems, by atsb's own admission does not have full justification - How can a move to this as a basis for safety, give us a long term safety outcome.
Well??? Mr. atsb
When you live....
ATSB’s Chief Commissioner, Martin Dolan, has just posted his latest blog post on no-blame investigations.
In the post, Martin discusses how the no-blame approach to investigating has major benefits for improving transport safety. Martin also touches on the ATSB’s strong commitment to the no-blame philosophy.
In the post, Martin discusses how the no-blame approach to investigating has major benefits for improving transport safety. Martin also touches on the ATSB’s strong commitment to the no-blame philosophy.
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atsb and attitude to accidents
The dolan blog is here for those readers among us:
Blog - Investigating human error
and:
Blog - 'No-blame' investigations
The interesting note to this is the casa - atsb relationship being probed in the current senate inquiry.
At one point, on questioning from Senator Fawcett [25th October 2012]:
The following comment says it all:
Blog - Investigating human error
and:
Blog - 'No-blame' investigations
The interesting note to this is the casa - atsb relationship being probed in the current senate inquiry.
At one point, on questioning from Senator Fawcett [25th October 2012]:
Senator FAWCETT: Going back in part to the issues Senator Xenophon was pursuing about the information that is passed on to CASA, given that the general aviation community to date has not been aware, broadly, of that level of disclosure of enough information that CASA knows the name of the pilot, now that they are aware of what is going on, do you anticipate that that may lead to a drop-off in the number of people who are reporting incidents?
Mr Dolan: We have certainly had that risk drawn to our attention as part of our consultation about potential new arrangements. We have paid serious attention to that, and in the light of those comments we are reviewing the proposal we put out for consultation. The existing reporting form makes it clear that information that is reported to us through the current system will be shared with CASA, so it is not operating in a vacuum. I think it is a fair comment that not everyone who is notifying us would be aware of all the details of how that information is shared. And, yes, there is a risk that that will lead over time to some reduction in the extent and the detail of the reporting we receive.
CHAIR: Mr Dolan, who made the decision not to recover the black box?
Mr Dolan: I did, Senator.
Mr Dolan: We have certainly had that risk drawn to our attention as part of our consultation about potential new arrangements. We have paid serious attention to that, and in the light of those comments we are reviewing the proposal we put out for consultation. The existing reporting form makes it clear that information that is reported to us through the current system will be shared with CASA, so it is not operating in a vacuum. I think it is a fair comment that not everyone who is notifying us would be aware of all the details of how that information is shared. And, yes, there is a risk that that will lead over time to some reduction in the extent and the detail of the reporting we receive.
CHAIR: Mr Dolan, who made the decision not to recover the black box?
Mr Dolan: I did, Senator.
Tony Taggart said...
If CASA gets its way and forces identification of people involved in all incidents and occurrences that are now reported in the happy knowledge that anonymity is assured, then let me tell you that, the reporting culture will evaporate faster than a jet burns fuel. That CASA action is the most dangerous in the history of aviation in this country.
DECEMBER 5, 2012 04:11
If CASA gets its way and forces identification of people involved in all incidents and occurrences that are now reported in the happy knowledge that anonymity is assured, then let me tell you that, the reporting culture will evaporate faster than a jet burns fuel. That CASA action is the most dangerous in the history of aviation in this country.
DECEMBER 5, 2012 04:11
Last edited by Up-into-the-air; 17th Dec 2012 at 02:29. Reason: more stuff
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Being a bit selective
What I got from the report done for the ATSB was that it was based on available research into SMSs and that the majority of the research done on OH&S systems with very little done on low probability/high consequence industries such as aviation. I would put about as much value on that report as I would put on the ATSB report into the Norfolk Island ditching.....bugger all.
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Couldn't agree more Spike! Falls from heights and coffee spills are a great danger to our industry. Safe coffee Beaker! What a joke. Wait till the FAA come back and speak to Beaker! We are doomed!
Beaker’s new paradigm for the ATSB
Jinglie said: Why on earth is the ATSB drifting off from the rest of the world? Imagine if there was ever a large fatal here (touch wood), these clowns wouldn't have a clue.
flying-spike said: What I got from the report done for the ATSB was that it was based on available research into SMSs and that the majority of the research done on OH&S systems with very little done on low probability/high consequence industries such as aviation. I would put about as much value on that report as I would put on the ATSB report into the Norfolk Island ditching.....bugger all.
Hence the ATSB final report fell under public scrutiny, 4 corners got hold of it and the good Senator X (Saint Nick) and Senator Fawcett ultimately pushed for a ‘please explain’ which has led to where we are now.
If you refer to Attachment B of ATSB supplementary submission 2[1] headed ‘Managing safety issues and actions’ you will see get an insight into Beaker’s grand vision for the future.
Senate Committees – Parliament of Australia
In summary this is where the Beaker defends his new methodology into the management of safety issues and actions picked up in the course of an ATSB transport safety accident/incident investigation. The questions that need to be asked, is it working? Does it promote the dissemination and free flow of safety critical information to industry participant’s worldwide?
Attachment B paragraph 4 reads:
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
Here’s a short exercise that perhaps highlights the deficiencies and flaws in the Beaker vision of managing safety issues and actions. The following are extracts from the changed (Beakerised) Safety Issues and Actions ATSB database for all sections of the ATSB remit i.e. not just Aviation:
Safety issues and actions
We then put in 'critical' in the 'original risk' section.
Safety issues and actions
You’ll see that it comes up with one entry only, which is probably because this is the new Beaker method of recording safety actions and recommendations and therefore the system is yet to ‘catch up’ with the new methodology.
Ok for sh*ts and giggles lets open up the one entry that deals with those RR engines mounted on the A380:
Recommendation AO-2010-089-SR-012
So this SR was generated because of the uncontained engine explosion on the Qantas A380 VH-OQA out of Singapore in 2010. However what this one example shows is that normally a ‘critical safety issue’, like most of the world, should automatically generate a Safety Recommendation.
Now we’ll go to the next level down i.e. ‘Significant safety issues’:
Safety issues and actions
We now have a total of 11 entries depicted and of those 2 are SRs. One Marine SR that occurred on 30 July 2012 and one Aviation SR that occurred on 13 December 2010, which deals with a standby power deficiency in the B747-400 QRH.
Although the new methodology means there aren’t many entries so far it is still possible to see that even a significant safety issue can lead to the ATSB generating a SR. It is also interesting to note that all 11 entries are listed under the “Type:” column as either recommendations or ‘safety advisory notices’ and that significant safety issues (at least) are now starting to be listed, example: AO-2009-012-SI-001. So I wonder if the same thing is happening for minor safety issues?
Safety issues and actions
And that would be a yes! Ok so is the Pel-Air ‘critical safety issue,’ that has only recently been downgraded to ‘minor’, in there?..Err it would appear not, nor is any of the other ‘minor’ safety issues published in the Pel-Air final report! So although under the Beaker system all safety issues will now be supposedly published in the ATSB database, the Pel-Air (and god knows how many others) minor safety issues are yet to be included….just another cloak of invisibility!
Such a convoluted system! Too bad if you are operating in a remote base with dodgy internet coverage and you don’t know where to look on the ATSB site for that significant safety issue that happens to be relevant to the aircraft you’re operating…I mean WTF??
The biggest issue from this Beakerised system in regards to the ATSB investigation into the Norfolk ditching is perhaps best highlighted by this quote from the ‘Safety Action’ section of the preliminary report issued 13 January 2010:
The remainder of the investigation is likely to take some months. However, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues.
This was prior to the ATSB bringing to the attention their now infamous CSI to the regulator. Under the old system that CSI would have automatically triggered a SR that would have had to be addressed in a timely matter as per the TSI Act. Instead we ended up with the ridiculous situation where a CSI that was well supported by an excellent documented investigative review by the ATSB investigation team, gets left in limbo for over 29 months before finally being downgraded to a minor safety issue!
Perhaps this farce is best summed up by Jinglie’s last:
Wait till the FAA come back and speak to Beaker! We are doomed!
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I'm over here
Some can't handle the truth it seems.
Endless postings on the other thread full of unmitigated childish rantings.
Go whinging to the teacher when someone calls you on your mendatious ravings.
Non aviation people reading your bulsh1t have asked me for assurance that you don't actually fly the aircraft they travel in.
For over five years you have been praying for a major aircraft accident to "prove" the regulator is inefficient - hasn't happened you knobs.
Endless postings on the other thread full of unmitigated childish rantings.
Go whinging to the teacher when someone calls you on your mendatious ravings.
Non aviation people reading your bulsh1t have asked me for assurance that you don't actually fly the aircraft they travel in.
For over five years you have been praying for a major aircraft accident to "prove" the regulator is inefficient - hasn't happened you knobs.
From ABC News
A Senate Committee has raised serious concerns about the competency of the bodies overseeing Australia's aviation industry.
The committee has investigated the official reviews into a Pel-Air plane ditching into the ocean off Norfolk Island in 2009.
The service had been flying a patient from Samoa to Melbourne for treatment on behalf of CareFlight.
All six people on board survived but only the pilot, Dominic James, escaped without injury.
The committee has found the Civil Aviation Safety body withheld critical documents from the Australian Transport Safety Bureau and that many in the industry are reticent to speak out because of a fear of retribution, especially from CASA.
Independent Senator Nick Xenophon says of particular concern was the evidence of the head of the ATSB, Martin Dolan.
"In respect of his credibility as a witness," Senator Xenophon said.
He says the report highlights serious concerns about the oversight of the industry.
"My confidence in our aviation safety regulators and accident investigation body CASA, the Civil Aviation Safety body and the ATSB have been shaken to the core," he said.
Karen Casey was injured in the crash and says the report must be acted on.
"The truth has finally been revealed," she said.
The report has been referred to the Director of Public Prosecutions.
A Senate Committee has raised serious concerns about the competency of the bodies overseeing Australia's aviation industry.
The committee has investigated the official reviews into a Pel-Air plane ditching into the ocean off Norfolk Island in 2009.
The service had been flying a patient from Samoa to Melbourne for treatment on behalf of CareFlight.
All six people on board survived but only the pilot, Dominic James, escaped without injury.
The committee has found the Civil Aviation Safety body withheld critical documents from the Australian Transport Safety Bureau and that many in the industry are reticent to speak out because of a fear of retribution, especially from CASA.
Independent Senator Nick Xenophon says of particular concern was the evidence of the head of the ATSB, Martin Dolan.
"In respect of his credibility as a witness," Senator Xenophon said.
He says the report highlights serious concerns about the oversight of the industry.
"My confidence in our aviation safety regulators and accident investigation body CASA, the Civil Aviation Safety body and the ATSB have been shaken to the core," he said.
Karen Casey was injured in the crash and says the report must be acted on.
"The truth has finally been revealed," she said.
The report has been referred to the Director of Public Prosecutions.
Oh dear
Aunty does not know the difference between a WWII and a Learjet.
Maybe they could request, on PPRuNe, input from an ex-corporate pilot.
Aunty does not know the difference between a WWII and a Learjet. Maybe they could request, on PPRuNe, input from an ex-corporate pilot.
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Air safety agencies have 'full backing' despite report on Norfolk Island crash
This is what it has come to. Complete incompetence backed up by more complete incompetence
Cookies must be enabled. | The Australian
Cookies must be enabled. | The Australian
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Updating thread with latest from AvWeb:
Australian Senate: Norfolk Island Crash Investigation Could Lead To Criminal Probe
In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia's Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air's operation that directly contributed to the accident. CASA's action, says the Senate report, may have violated Australia's Transport Safety Investigations Act. "It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation," said Sen. David Fawcett.
The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island en route from Samoa with a critical but stable patient. The Westwind's ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight's captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. En route, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB's accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.
Following the ATSB's findings, James challenged some of the investigator's findings but his queries were dismissed by the ATSB. The Australian Senate took up James' case last year and its probe revealed widespread flaws in the ATSB's investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that "unequivocally concluded … that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies." Yet no mention of this report appeared in the ATSB's findings blaming the pilot. "In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies," the Senate report said.
Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. "This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That's why I think we need an inspector general of aviation," Sen. Nick Xenophone told Australia's ABC News. "This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB," he added.
The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB's chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. "CASA's internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses' evidence that they did not think surveillance was adequate, when CASA's own internal investigations indicate that CASA's oversight was inadequate," the report said.
In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia's Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air's operation that directly contributed to the accident. CASA's action, says the Senate report, may have violated Australia's Transport Safety Investigations Act. "It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation," said Sen. David Fawcett.
The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island en route from Samoa with a critical but stable patient. The Westwind's ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight's captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. En route, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB's accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.
Following the ATSB's findings, James challenged some of the investigator's findings but his queries were dismissed by the ATSB. The Australian Senate took up James' case last year and its probe revealed widespread flaws in the ATSB's investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that "unequivocally concluded … that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies." Yet no mention of this report appeared in the ATSB's findings blaming the pilot. "In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies," the Senate report said.
Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. "This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That's why I think we need an inspector general of aviation," Sen. Nick Xenophone told Australia's ABC News. "This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB," he added.
The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB's chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. "CASA's internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses' evidence that they did not think surveillance was adequate, when CASA's own internal investigations indicate that CASA's oversight was inadequate," the report said.
Australian Safety Regulator and investigator down in flames
While there is a significant thread already running in the Pacific sector, it seems to me that this news item has wider implications.
A recent Australian senate review has found that both the Regulator (CASA) and the Safety Investigator (ATSB) have significant issues to address. The inquiry, into the handling of information by CASA and the ATSB and reporting by ATSB of a ditching off Norfolk Island of a Pel-Air Westwind on a medevac flight, as well as the way in which senior bureaucrats handled themselves appears at:
Senate Committees ? Parliament of Australia
While the Pilot was deemed at fault for running out of fuel by both ATSB and CASA, the Senate report makes a big issue of the fact that both CASA and ATSB sought to blame ONLY the pilot, ignoring systemic organisational failures in the their own agencies.
It makes interesting reading, particularly for those that think that mishandling a cover-up only compounds the origininal stuff up.
A recent Australian senate review has found that both the Regulator (CASA) and the Safety Investigator (ATSB) have significant issues to address. The inquiry, into the handling of information by CASA and the ATSB and reporting by ATSB of a ditching off Norfolk Island of a Pel-Air Westwind on a medevac flight, as well as the way in which senior bureaucrats handled themselves appears at:
Senate Committees ? Parliament of Australia
While the Pilot was deemed at fault for running out of fuel by both ATSB and CASA, the Senate report makes a big issue of the fact that both CASA and ATSB sought to blame ONLY the pilot, ignoring systemic organisational failures in the their own agencies.
It makes interesting reading, particularly for those that think that mishandling a cover-up only compounds the origininal stuff up.
Last edited by Seabreeze; 31st May 2013 at 02:40.
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casa anyone?? what is their obligation?? in this
This is the latest at the Senate estimates on 18th November 2013 :
PelAir Ditching:
Senator XENOPHON: Mr McCormick, today marks four years to the day since the ditching of the VH-NGA off Norfolk Island and nearly seven months since the references committee issued its report on aviation accident investigations. Has CASA formulated a response to the recommendations in the report?
Mr McCormick: The part that we had to do has been completed. The documents are no longer with CASA.
Senator XENOPHON: But there were various recommendations and you have given your views as to those recommendations to the department?
Mr McCormick: Yes, we have.
Senator XENOPHON: When did you do that?
Mr McCormick: I would have to take the exact date on notice. It was before the election.
Senator XENOPHON: It seems so long ago, Mr McCormick. I take it that it was at least 2½ months ago.
Mr McCormick: Certainly we formulated our inputs—of course, they are the minister's responses when the report is tabled—for the previous government and we have prepared our inputs for this government.
Senator XENOPHON: Are you able to tell us which of the recommendations of the committee CASA thought ought to be implemented?
Mr McCormick: I would prefer to leave that to the minister to reply.
Senator XENOPHON: But you do have a role to provide advice independently to government about aviation safety. Is that correct?
Mr McCormick: That is correct. We have provided our input to the present government on 26 September.
Senator XENOPHON: Just after the election? But do you have a view about some of the recommendations made by the Senate committee in relation to the ditching of the VH-NGA?
Mr McCormick: As I think I have said before, CASA is a learning organisation. We take on board any input that is given to us. We are certainly not the same organisation that we were leading up to that particular ditching in 2009. We considered in particular the Chambers report recommendations that we have implemented and, as I said, I had best wait for the minister to reply to the formal tabling of the report.
Senator XENOPHON: I am not asking the minister. I am hopeful that I will get an opportunity to speak to the minister later this week in person. Do you concede that the Senate report was useful in highlighting aspects of the investigation that could have been done much better?
Mr McCormick: I think any report is useful, Senator
Senator XENOPHON: For what?
Mr McCormick: Useful as an informative document for a learning organisation.
Senator XENOPHON: You do not concede that CASA could have done things a lot better in relation to the Pel Air ditching?
Mr McCormick: You are talking about what we might have done better outside of the report. We can always do better, as I said right at the start and during the Pel Air hearings themselves.
Senator XENOPHON: So, I have to wait to see what the minister says. Will you at least acknowledge that you actively advised the minister not to support some of the recommendations of the committee?
Mr McCormick: We do not formulate the recommendations to the minister, Senator.
Senator XENOPHON: So, what did you do?
Mr McCormick: We provided technical input to the department which formulated the responses to the minister.
Senator XENOPHON: Did that technical input lead to a particular conclusion about the Senate's recommendations?
Mr McCormick: There were 22 recommendations from memory and then there were some additional comments from yourself.
Senator XENOPHON: Twenty-six.
Mr McCormick: As I say we do not formulate those recommendations.
Senator XENOPHON: But did CASA have a view as to whether it thought any of the recommendations were worth implementing or not? Did you have a view that, say, this recommendation is nonsense or this recommendation is worthy of further consideration by the department?
Mr McCormick: From our point of view we were not dismissing anything out of hand. All we can give is our opinion of what we think of the recommendations.
Senator XENOPHON: So, please answer my question. Did you make specific recommendations or give advice to the department about whether any of the 26 recommendations ought to be supported or rejected by the department?
Mr McCormick: I am trying to answer your question, but I personally do not know what we said as far as the answers go, compared to what answers came out there. I am not comparing both. Our concern was what the recommendation meant to us. We did not form a view for the government or whether the government would accept or reject it. That was not our role.
Senator XENOPHON: Let's go back a step. I do not want to labour this. If you did provide a response—saying this is a recommendation of the Senate committee; this is what the recommendation would mean to us—presumably some of those responses would have been 'This is unworkable' or 'This is something that could be implemented'. Presumably, by framing your answer in terms of what it would mean to CASA would be a de facto acceptance or rejection of the committee's recommendation. Is that a fair summary?
Mr McCormick: I do not know if anyone was more actively involved in this than myself, but we would say what that recommendation meant as to where we are today and its effect on us. But whether it is accepted or rejected is not something we recommend.
CHAIR: It is most unlike you, Mr McCormick, that you did not have a strong view. You are the brains trust and if you wanted to tell them to tell the committee to go to hell, I would not be offended.
Mr McCormick: I would not dream of it, Senator.
Senator XENOPHON: Dream of what?
Mr McCormick: Making a recommendation to accept or reject a recommendation.
Senator XENOPHON: Perhaps I should ask the minister or the secretary this. What difficulty would there be in CASA providing material to the department about the Senate inquiry on Pel Air.
Mr McCormick: Again, Senator, I will have to take that on notice. I am not sure what the protocols are around that.
Senator XENOPHON: Perhaps I will ask the secretary. Given the communication that was sent from CASA to the department what difficulty would there be for the department and CASA to provide us with a copy of CASA's response
Mr Mrdak: The minister is currently finalising his consideration of a response to the Senate inquiry. I will take that on notice. I do not think there is an issue in principle but I would need to take that on notice and come back to you.
Senator XENOPHON: For instance,—I am not saying this would be the case—if the majority of this committee was minded to ask for that response at some stage, whether it waits for the minister's response to the Senate inquiry with recommendations, you do not see any particular difficulty with that as a matter of principle?
Mr Mrdak: Without pre-empting the minister's consideration of the matter, we have put an extensive amount of material and a draft response to successive ministers. Without prejudicing that process I will take that on notice.
Senator XENOPHON: Let us not talk at cross purposes here. I am saying that CASA gave a considered response presumably to the Senate inquiry, to the minister, to consider. That itself would not be a draft, it would be a document from CASA to the department. What harm would there be for that document eventually seeing the light of day?
Mr Mrdak: Again, without recalling the exact details of the document, I do not have an issue in principle, but I need to take it on notice.
Senator XENOPHON: At the end of the day you would not have an issue in principle with that being released, would you, Mr McCormick?
Mr McCormick: Again, I will take it on notice. I personally do not, but I am not sure what the protocols are. Perhaps Dr Aleck might have something to say.
Dr Aleck: I will concur with what has gone before and to add that CASA made a number of submissions to that inquiry. To the extent that the recommendations dealt with the same issues that were covered by the submissions I suspect there would be some alignment with our submissions.
Senator XENOPHON: Mr McCormick, today marks four years to the day since the ditching of the VH-NGA off Norfolk Island and nearly seven months since the references committee issued its report on aviation accident investigations. Has CASA formulated a response to the recommendations in the report?
Mr McCormick: The part that we had to do has been completed. The documents are no longer with CASA.
Senator XENOPHON: But there were various recommendations and you have given your views as to those recommendations to the department?
Mr McCormick: Yes, we have.
Senator XENOPHON: When did you do that?
Mr McCormick: I would have to take the exact date on notice. It was before the election.
Senator XENOPHON: It seems so long ago, Mr McCormick. I take it that it was at least 2½ months ago.
Mr McCormick: Certainly we formulated our inputs—of course, they are the minister's responses when the report is tabled—for the previous government and we have prepared our inputs for this government.
Senator XENOPHON: Are you able to tell us which of the recommendations of the committee CASA thought ought to be implemented?
Mr McCormick: I would prefer to leave that to the minister to reply.
Senator XENOPHON: But you do have a role to provide advice independently to government about aviation safety. Is that correct?
Mr McCormick: That is correct. We have provided our input to the present government on 26 September.
Senator XENOPHON: Just after the election? But do you have a view about some of the recommendations made by the Senate committee in relation to the ditching of the VH-NGA?
Mr McCormick: As I think I have said before, CASA is a learning organisation. We take on board any input that is given to us. We are certainly not the same organisation that we were leading up to that particular ditching in 2009. We considered in particular the Chambers report recommendations that we have implemented and, as I said, I had best wait for the minister to reply to the formal tabling of the report.
Senator XENOPHON: I am not asking the minister. I am hopeful that I will get an opportunity to speak to the minister later this week in person. Do you concede that the Senate report was useful in highlighting aspects of the investigation that could have been done much better?
Mr McCormick: I think any report is useful, Senator
Senator XENOPHON: For what?
Mr McCormick: Useful as an informative document for a learning organisation.
Senator XENOPHON: You do not concede that CASA could have done things a lot better in relation to the Pel Air ditching?
Mr McCormick: You are talking about what we might have done better outside of the report. We can always do better, as I said right at the start and during the Pel Air hearings themselves.
Senator XENOPHON: So, I have to wait to see what the minister says. Will you at least acknowledge that you actively advised the minister not to support some of the recommendations of the committee?
Mr McCormick: We do not formulate the recommendations to the minister, Senator.
Senator XENOPHON: So, what did you do?
Mr McCormick: We provided technical input to the department which formulated the responses to the minister.
Senator XENOPHON: Did that technical input lead to a particular conclusion about the Senate's recommendations?
Mr McCormick: There were 22 recommendations from memory and then there were some additional comments from yourself.
Senator XENOPHON: Twenty-six.
Mr McCormick: As I say we do not formulate those recommendations.
Senator XENOPHON: But did CASA have a view as to whether it thought any of the recommendations were worth implementing or not? Did you have a view that, say, this recommendation is nonsense or this recommendation is worthy of further consideration by the department?
Mr McCormick: From our point of view we were not dismissing anything out of hand. All we can give is our opinion of what we think of the recommendations.
Senator XENOPHON: So, please answer my question. Did you make specific recommendations or give advice to the department about whether any of the 26 recommendations ought to be supported or rejected by the department?
Mr McCormick: I am trying to answer your question, but I personally do not know what we said as far as the answers go, compared to what answers came out there. I am not comparing both. Our concern was what the recommendation meant to us. We did not form a view for the government or whether the government would accept or reject it. That was not our role.
Senator XENOPHON: Let's go back a step. I do not want to labour this. If you did provide a response—saying this is a recommendation of the Senate committee; this is what the recommendation would mean to us—presumably some of those responses would have been 'This is unworkable' or 'This is something that could be implemented'. Presumably, by framing your answer in terms of what it would mean to CASA would be a de facto acceptance or rejection of the committee's recommendation. Is that a fair summary?
Mr McCormick: I do not know if anyone was more actively involved in this than myself, but we would say what that recommendation meant as to where we are today and its effect on us. But whether it is accepted or rejected is not something we recommend.
CHAIR: It is most unlike you, Mr McCormick, that you did not have a strong view. You are the brains trust and if you wanted to tell them to tell the committee to go to hell, I would not be offended.
Mr McCormick: I would not dream of it, Senator.
Senator XENOPHON: Dream of what?
Mr McCormick: Making a recommendation to accept or reject a recommendation.
Senator XENOPHON: Perhaps I should ask the minister or the secretary this. What difficulty would there be in CASA providing material to the department about the Senate inquiry on Pel Air.
Mr McCormick: Again, Senator, I will have to take that on notice. I am not sure what the protocols are around that.
Senator XENOPHON: Perhaps I will ask the secretary. Given the communication that was sent from CASA to the department what difficulty would there be for the department and CASA to provide us with a copy of CASA's response
Mr Mrdak: The minister is currently finalising his consideration of a response to the Senate inquiry. I will take that on notice. I do not think there is an issue in principle but I would need to take that on notice and come back to you.
Senator XENOPHON: For instance,—I am not saying this would be the case—if the majority of this committee was minded to ask for that response at some stage, whether it waits for the minister's response to the Senate inquiry with recommendations, you do not see any particular difficulty with that as a matter of principle?
Mr Mrdak: Without pre-empting the minister's consideration of the matter, we have put an extensive amount of material and a draft response to successive ministers. Without prejudicing that process I will take that on notice.
Senator XENOPHON: Let us not talk at cross purposes here. I am saying that CASA gave a considered response presumably to the Senate inquiry, to the minister, to consider. That itself would not be a draft, it would be a document from CASA to the department. What harm would there be for that document eventually seeing the light of day?
Mr Mrdak: Again, without recalling the exact details of the document, I do not have an issue in principle, but I need to take it on notice.
Senator XENOPHON: At the end of the day you would not have an issue in principle with that being released, would you, Mr McCormick?
Mr McCormick: Again, I will take it on notice. I personally do not, but I am not sure what the protocols are. Perhaps Dr Aleck might have something to say.
Dr Aleck: I will concur with what has gone before and to add that CASA made a number of submissions to that inquiry. To the extent that the recommendations dealt with the same issues that were covered by the submissions I suspect there would be some alignment with our submissions.
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UITA, good work. What a hilarious three stooges act between the Doc, Boyd and Captain Angry!! Naughty naughty Senators, how dare they ask for the DAS opinion! Does CAsA really know how utterly ridiculous they look? Why not answer the questions? Why not 'grow a set' and give an opinion? Spineless weak little men. Desperately clinging to their empire.
Dear Senators,
Although the CAsA are happy to try and 'call you out', obsfucate, massage words, not give yes or no answers and generally treat you with contempt by their actions, the IOS supports your work and appreciates your efforts to pull these dimwits into line
I loved Xenophons line of questions, I wonder what little parcel of information he is sitting on??
Fort Fumble at yesterday's senate sitting?
Dear Senators,
Although the CAsA are happy to try and 'call you out', obsfucate, massage words, not give yes or no answers and generally treat you with contempt by their actions, the IOS supports your work and appreciates your efforts to pull these dimwits into line
I loved Xenophons line of questions, I wonder what little parcel of information he is sitting on??
Fort Fumble at yesterday's senate sitting?