There is nothing in the report that suggests the Reason model of accident causation was even remotely considered. That model should develop a schematic interaction between individual error and factors such as faulty top level management decisions. Instead, there's nothing of the sort.''
A 60-page draft of that report has been circulated for discussion but sources say it has been so ''dumbed down'' the recommendations do not address regulatory problems highlighted by the ditching. ''Word in the industry is that a political fix is in so nobody would be offended,'' one aviation figure said.
It is understandable that the ATSB would consult with the parties to an inquiry in relation to the final version of a report, but there does come a time when it begins to resemble a negotiation as to how much of the truth, and how bluntly what is left of the truth, can be released to the public.
The reason for the delay is that the ATSB is unwilling thus far to use its power to publish a final report without waiting an eternity for affected parties to approve the rewriting it has already undertaken to dumb down the document to a level where it is totally inoffensive to anyone except perhaps those who were injured or exposed to mortal peril by the flight.
17 August 2007 Lockhart River Coroner Barnes.
In my view, this attack on the methodology used by the ATSB is without substance. I do not accept that by requiring its investigators to always consider whether organisational influences may have contributed to an incident, the professional judgement of those investigators is likely to be overborne.
CASA contends that the ATSB had a conflict of interest that should have led to its actions being identified as one of the organisational influences that may have contributed to the crash. Further, CASA asserted that the ATSB should have refrained from investigating the incident on account of it having such a conflict.
CASA had senior, expert legal representation who I’m sure would not have made such a sustained attack on the integrity of the ATSB investigation report without explicit instructions. In my view, these protestations are symptomatic of serious, ongoing animosity between the two organisations that needs redressing.
The press, though muzzled can smell the pony pooh. Coroner Barnes, could see, smell and touch the same, a Judge in WA almost stood in it. The Senators, with stronger stomachs feast on it when it's served up in neat white paper packages.
It's almost 7 years (May 2005) since LHR. The crash was tragic enough, but to find, almost a decade later that the CASA has gained complete control of a crippled, blind emasculated investigatory body is perhaps the greatest tragedy (or comedy if you like) of all.
Are the Senators – ignored ?, Judges treated with contempt ?, Coroners led to foregone conclusions ?, the industry terrorised and the public still in grave danger from potted policy. ??.
Perhaps honest answers would embarrass the Minister responsible. Albo signed off on the LHR pantomime and the latest Senate 'white paper' fiasco. And yes, it's all Bollocks.
What amazes me with LHR is that ASA (and by default CASA) kept the RW12 GNSS RNAV approach in service for another 4 years after the crash!
You'd think a 'proactive' regulator would just pull it, until it was proven to be safe, me thinks maybe they were playing the 'statutory limitation' card (3 years) meanwhile.......the ATSB were getting more indicators that it was a dangerous approach! See here:
The Lockhart River crash and the Norfolk Ditching are not just isolated examples of the regulator's obfuscation and the ATSB's powerlessness to act in the interests of safety. Here is a quote from a WA Coroner's report into the 2003 Cessna 404 accident at Jandakot:
“In submissions counsel assisting made the following observations in respect of CASA’s performance” –
“In the context of this case and the matters considered during the course of the inquest bearing upon and relating to the crash of VH-ANV it would be difficult to imagine a more supine and reactive safety regulator than CASA”.
“In the context of general aviation and in the circumstances relating to the present case, it is difficult to disagree with this description.
" The lunatics are very much in charge of the asylum"....
Sarcs - The Lockhart River crash and the Norfolk Ditching are not just isolated examples of the regulator's obfuscation and the ATSB powerlessness to act in the interests of safety.
During the LHR 'thing' the ATSB seemed to be on the attack, the Coroner certainly seemed to want to back their position. Reading Barnes, you get the distinct impression that once again the regulator was denying any or all responsibility. Did LHR 'break' the ATSB independent spirit?; or, has it just been a gradual spiral downward since then?. Hard to know.
But, something has changed; I suspect that crock which is now being paraded through courtrooms as a new 'catch all' defence has an effect – must be tough to beat the publicaly stated attitude:-
AA_Phelan. It’s also true that Federal Court Justice Kenny struck out the claim against CASA and its Deputy Director Terry Farquharson (and others) on the basis, in broad terms, that CASA and its officers owe no duty of care to the public in the performance of their duties. (My bold)
It's hard to know if the ATSB have just rolled over for a peaceful life, or if the current management is operating in public service mode (ass covering principal); or if the "fix" is in, to ensure that CASA and the Minister thing always shine bright; aye it's a puzzle. It's no puzzle to work out the ATSB is hamstrung by lack of resources a submission to the Senate states:-
In 2009 – 10 the ATSB received approximately 15 100 notifications through its mandatory accident and incident reporting system (8 393 were classified as safety occurrences). During that period the ATSB had the resources to commence 70 new investigations. Ten safety research and analysis reports were released in this period. (My bold).
Long version - https://senate.aph.gov.au/submissions/comittees/viewdocument.aspx Sorry, I can't get the link to the down load to work.
The release of the Norfolk ditching incident and others to be released shortly will decide whether or not the industry places the ATSB firmly in the ranks of CASA apologists or with the angels.
Selah. All my bold.
Last edited by Kharon; 1st Apr 2012 at 21:46.
Reason: The usual suspects. Bloody link
Yet there is the typical (buried) 'get out of jail free card', subpara 2.5 reads...
2.5 The ATSB and CASA will seek to uphold the values of this MoU and fulfill their respective commitments. However, both organizations acknowledge that this MoU is not legally binding and that nothing in this MoU can legally restrict the statutory duties, discretions and powers of
either organization under relevant legislation.
So you can see the internal memo....." To all operational staff, if you see a copy of the MoU between the ATSB and CASA in the vicinity of the Ops department offices, please use and dispose of in the 'Authority' approved manner...ps please use the bottom floor toilet block as we have had some issues with the plumbing"....
Sarcs - " To all operational staff, if you see a copy of the MoU between the ATSB and CASA in the vicinity of the Ops department offices, please use and dispose of in the 'Authority' approved manner...ps please use the bottom floor toilet block as we have had some issues with the plumbing"...
Nah, that's an old memo, from back when documents used to 'vanish' mysteriously, the new budget has helped the situation with nice soft , fluffy bog rolls; problem is the blighters keep nodding off to sleep during the mandatory meditation break with heads against the roll.
No mate, the new problem is the electronic leaks; seems when the rats desert the sinking ship, some of the electronic cheese sticks to their furry little arse' s. Thus providing future security and a star in the Willyleaks Hall of Fame. Interesting web site that one.
Sotto voce “Sarcs, is it just me or is it too damn quiet in here ?; I know they're out there, I can hear 'em breathing”.