Back at post# 327 Kharon alluded to a report that had been forwarded to him, that report was generated by a number of PAIN editors. The passage that Kharon quoted was;
Many areas of 'operational' and legal significance have not, in our opinion been satisfactorily addressed or presented. These important, directly related elements, whilst technical are relatively straight forward; and, may be readily comprehended by 'the man in the street'. We believe that this information properly presented could have greatly assisted the Coroner formulate a decision with greater clarity.
From an industry point of view, it appears that the inquiry was ruthlessly driven to an almost forgone conclusion. Primarily by the omission of what is believed to be important information for the Coroner to consider; the inability of the court to interview essential witnesses and examine that testimony. Some of the Coroners remarks seem to reflect this.
One shortcoming, in our view of the ATSB is, that, unlike the USA National Transport Safety Bureau (NTSB), ATSB does not find a “most probable cause” of an accident, or present 'ranked' contributory causes.
Little Bighorn and Sarcs guessed correctly and so the story goes on and on...
However the PAIN editors have now agreed to release some more relevant quotes from that document (and maybe some others which we have produced). Hopefully this may give motivation to concerned professionals and industry stakeholders to get involved in the upcoming Senate Inquiry. By the way recent intel would seem to indicate that the Senators feel that this inquiry is just the beginning!
As recent posts seem to hinge around the pilot experience, lack of good training and operational support, please find the following quote from our Lockhart River report;
It is not the writers intention to defend or speculate on the reasons why a particular pilot behaves in one way; or, acts in a particular manner during a critical phase of flight. It is acceptable for the aircrew behaviour to measured against accepted 'industry standards'.
In the normal course of events, the industry not the Authority, has a system for identifying, dealing with and, where necessary isolating most of the unstable, dangerous or, inherently rogue elements. Unsuitable people may pass through a flight school phase, qualify, acquire a first job quite easily. Further down the career road to enter an 'airline' environment there are some serious barriers raised which fairly effectively 'weed out' those not suitable. Should the rogue candidate avoid or slip through this system, the safety net of the company Training and Checking System (TCS) provides an effective last line of defence.
In the 'smaller' airline operations the early safety nets may be bypassed, but this is usually more than balanced by the TCS as the TCS pilots are flying 'on line' almost everyday and intimately know and understand their charges. So the balance is maintained.
Not so in this case; there is anecdotal, hearsay information that the pilot was prone to some of the more undesirable traits which, under reasonable circumstances would have been 'hammered out' by the TCS system or, the pilot's employment would have been terminated. This aircrew was not, on the available data, provided with either proper guidance, discipline, training or management. In short, there was a normalised deficiency, produced by a failed, CASA approved and monitored, internal TCS.
It goes on to say;
The pilot in command was clearly undisciplined, incorrectly trained, neither qualified or competent to operate a passenger service into a relatively high risk port.
The co pilot was clearly undisciplined, incorrectly trained, neither qualified or competent to operate a passenger service into a relatively high risk port.
The above comments on the aircrew are not, nor can they be considered the sole fault of the aircrew, essentially they are abandoned by the Training and Checking System, the company and the CASA to fend for themselves, unsupported, as best they may in what was a hostile, subsequently fatal environment.
The lack of training and guidance material precluded a less confident pilot acquiring, through research into the company manuals, the knowledge to safely operate a Regular Public Transport passenger service to this port.
That sounds very similar to this accident scenario, the only differences being that this operation was airwork and didn't involve any fatalities!
PAIN Editors