Hey blackie while your banging on about the pilot here's a very impressive, factual 19 point appraisal that perfectly summarises the truth behind this whole farcical, sordid, abomination.
The most amazing thing is it is part of a submission from a complete layman (by his own admission). He was also an eyewitness to not only the ditching but all the lies, obfuscation and maladministration displayed by our esteemed Federal aviation safety agencies.
Yet here you are a self professed aviation maintenance expert and consultant that continues to bag the pilot and defends the indefenceable in what can only be for your own self interests, well read this and weep:
I believe a number of factors are pertinent to the investigation and the circumstances surrounding the crash.
1. This was the third crash of a Pel Air aircraft, the other two in 1985 and 1995 each causing fatalities. It could be expected that such a record would require stricter supervision by the regulator but there is no evidence of this.
2. Audits of Pel Air by CASA prior to this crash found no evidence of problems. This reflects extremely poorly on the performance of CASA a point that is confirmed by an audit of CASA conducted by the international regulator, ICAO and the American regulator, the FAA. (see point12.)
3. A special audit of Pel Air by CASA, conducted immediately after the crash, found 31 safety and regulatory breaches. These included systemic issues with flight planning, fuelling, fatigue management and training.
4. The details of the special audit report were to be kept from the public. A point apparently designed to maintain the commercial interests of Pel Air, at that time vying for a lucrative Air Ambulance contract. It would be difficult to imagine any organisation inviting such tenders would even consider Pel Air if these failures were known. Pel Air was subsequently awarded the Air Ambulance contract in Victoria, on Christmas Eve, only 6 weeks after a near fatal crash.
5. Pel Air was allowed to rectify their defects without public scrutiny. The public has a right to make informed decisions about their travel arrangements. Had I been aware of the poor safety record of Pel Air and of the risk involved in taking that flight given the poor state of the regulatory framework, then it is possible that I would have selected a safer option.
6. At least one of the defects uncovered was found by the ATSB to be a “critical safety issue,” that carried an intolerable risk to safety. This involved poor regulatory guidance by CASA and, in a video conference between representatives of the two bodies, CASA appears to have agreed, at that time, that this was indeed a critical issue.
7. The ATSB’s final report downgraded the significance of this critical issue to one of only minor importance with the Chief Commissioner of the ATSB, Martin Dolan, claiming that the issue was immaterial to the cause of the crash.
8. The ATSB did not properly report the findings of the special audit. It is simply incomprehensible that a publicly funded body such as the ATSB, charged with investigating the most serious of accidents, would almost totally ignore the results of a special audit conducted immediately after the loss of a jet aircraft.
9. The ATSB did not believe that the 31 identified regulatory and safety breaches contributed in any way to the crash. This is the most damning reflection on the performance of the ATSB and of Martin Dolan in particular. I believe it would be almost impossible to find any impartial observer who would accept that none of the defects found with Pel Air’s or CASA’s regulations, policies or procedures had any impact upon the circumstances of that flight. Martin Dolan repeated this ad nauseum on the 4 Corners video interview and could offer no satisfactory, rational explanation.
10. CASA too could not accept the findings of their own special audit, ignoring their own identified inadequacies and preferring to blame the pilot. John McCormick, the Director of Safety at CASA could find no problem with the poor state of Pel Air’s flight planning procedures and the fact that each pilot performed the complex fuel calculations in a different way.
Instead, he claimed that as a pilot himself with 40 years experience a pilot is solely responsible for this. His own auditors took an opposing view, and reported that non-standardised flight planning is deficient and issued a Request for Corrective Action.
11. CASA approved the Operations Manual of Pel Air, issuing an Airworthiness Certificate. This is an implicit acceptance of the flaws with flight and fuel planning subsequently found by the special audit and illustrates the systemic problems at CASA.
12. ICAO found numerous problems with the operation of CASA in the months leading up to the crash. This was confirmed by the FAA in an audit of CASA conducted just weeks after the crash.
13 The public was informed of neither of these important findings.
14. As pointed out on the 4 Corners program the ATSB’s final report was flawed, causing it to be quietly withdrawn some 24 hours after publication. The report was then reissued with no form of version control. I now have two versions of the final report and do not know which to believe.
15. The report omitted crucial information on the issue of Reduced Vertical Separation Minima (RVSM). This issue, together with apparent deficiencies of the Operations Manual severely limited the pilot’s ability to plan the flight effectively. This apparently deliberate omission ensured that the blame for poor flight and fuel planning was pinned on the pilot despite the constraints that each of the above placed upon him.
16. There is no attempt by the ATSB to undertake root cause analysis of the issues raised in their final report. This was exemplified by the issue of Threat and Error Management (TEM), a procedure to improve flight safety by identifying potential threats and errors. According to the report ICAO regulations require training in TEM, though not for this category of flight.
CASA regulations however do not require training in TEM. The logical outcome of these points would be to analyse the reasons why there is no such training requirement in Australia and why this flight was in this particular category. If such training is required, or does help prevent accidents and the flight was found to be in an inappropriate category for this type of operation then CASA could be held accountable for this. Instead, the report simply omitted analysis of these issues.
17. Despite the requirement in the Operations Manual neither of the crew had undertaken training in Crew Resource Management (or in TEM). The ATSB’s investigation went further; in a survey of both trainee and experienced pilots the report found inconsistencies in their approach to the legal requirement to divert to an alternate because this is not part of the syllabus for a trainee pilot. Despite these findings the ATSB declined to offer any recommendations that may improve this clearly unsatisfactory situation.
18. Despite all of these findings no adverse comment was made about the lack of CASA regulation regarding training and nomination of an appropriate flight category. No recommendations regarding flight crew training were made neither was there any mention of corrective action in the form of regular audits of Pel Air to ensure that such oversights are not repeated.
19. We were invited by the ATSB to make submissions regarding the draft final report before publication. I made suggestions regarding the wearing of lifejackets during over water operations, the adequacy of emergency locator beacons and the use of audits to ensure compliance. Most of these were ignored and gave the impression that the ATSB was committed to its own agenda and was unwilling to consider simple improvements to practices that would have a tangible impact upon survivability.
Bloody well done Mr Currall my hat's off to you, couldn't of summed it up better myself and may you recieve justice and retribution for all the hurt you and your wife have endured and continue to endure!
