The ATSB has lost the plot!
It’s official the ATSB are in total denial and firmly sticking to their befuddled and totally flawed script. The bigger question is why?
Kharon said: If, and it's a big if the enquiry can join the dots between Lockhart and Pel Air, the wheels will come off. Not just the present bunch will be for the ministerial high jump. The ICAO and every other responsible NAA will simply refuse to allow Australian aircraft anywhere near their airspace. Just the fact that they failed to issue a caution on the survivability, life vest and life raft debacle is enough. It would have been very nice to send a neatly worded report out.
Kharon the ATSB standard line of defence for the points that you make (from ATSB Answers to QON):
11. HANSARD, PG 64
Senator NASH: So at no stage did you ask them, 'Did the prescribed safety procedures work?' You are the Australian Transport Safety Bureau and at no stage did you ask the prescribed safety requirements work?
Mr Sangston: I do not know precisely what was asked in the interview.
CHAIR: Could we have a record of the interviews?
Mr Dolan: We can draw it to your attention. It should be amongst the material we have already supplied. We will find it for you.
ATSB response:
The survival aspects of the accident were reported on pp 20 to 24 of the investigation report.
In light of other issues raised during the course of the inquiry, the following is additional information that the ATSB obtained in the course of the investigation but did not include in the report on the basis that it did not indicate broader safety issues:
- As indicated on p 21 of the investigation report, the liferafts were reported removed from their normal storage position and placed in the aircraft's central aisle ready for deployment after the ditching. There are advantages and disadvantages associated with this action. Access to the liferafts may be more readily available from a position in the central aisle; however, in anything but a low energy impact with the water, it could be expected a life raft might move/dislodge from that position.
- As indicated on pp 19 and 21 of the investigation report, the reported two or three large impacts with the water were sufficient in this case to fracture the fuselage immediately forward of the main wing spar. The fractured fuselage was reported to have remained aligned for a few seconds before the aircraft's nose and tail partially sank with the passenger cabin/cockpit section adopting a nose-down attitude.
- The copilot indicated that a quantity of equipment and baggage descended or rolled down the fuselage as it filled with water - this could be expected to have included the life rafts (p 22 of the investigation report refers).
- Given the insecure equipment and baggage in the darkened cabin/cockpit area, the difficulty experienced with the aircraft's main door, the requirement to assist the patient from the stretcher and then the aircraft and the increasing ingress of water, the priority given by the remaining aircraft occupants to exiting the aircraft over recovering and deploying the liferafts is understandable. Whether in that context their recovery and deployment would have been more likely from their stowed position is debatable.
- In interview with the ATSB, the PIC indicated that he was not wearing a life jacket and reported that the light on the nurse's life jacket was not working (although it is possible that the light was obscured by the patient she was supporting – see the nurse’s interview notes below). The PIC also recalled that he may have inadvertently slightly deflated one of the survivors' life jackets in the water at some time but it was too dark to tell, and that the whistle lanyard on one of the three jackets was too short and could not be used. It was not possible to determine whether or not this was due to tangling or snagging of the lanyard.
- The passenger indicated at interview on 24 November 2009 that his life jacket rode up on him and he found that this pushed his head forward. In addition, the passenger reported that the whistles were not available on two of the jackets and that he only activated one inflation 'toggle'. Another of the survivors activated the second toggle on the passenger's life jacket.
- The copilot was interviewed on 2 December 2009. In this interview the copilot indicated that she did not wear a life jacket and that she initially attempted to open the aircraft's main door before the fuselage tipped down. This compelled the copilot to seek an emergency exit. The copilot reported that, once on the surface, the doctor helped her to remain afloat.
- The doctor was interviewed on 4 December 2009. The doctor confirmed that only three of the aircraft occupants had life jackets but that all three jackets worked satisfactorily. He reported that one life jacket light failed and that only one whistle was located. He indicated that, once near rescue, he wasn't sure that a whistle would have helped. He reported that at evacuation, the priority was assisting the patient from the aircraft, rather than deploying the life rafts.
- An interview with the patient on 10 December 2009 determined that the patient was not wearing a life jacket. This is consistent with the report from the doctor that he did not put a life jacket on the patient due to concerns about a jacket hindering the already difficult task of releasing the patient's restraints after the ditching (pp 20 and 21 of the investigation report refer).
- The flight nurse was interviewed on 10 December 2009. The nurse recalled that only half of her life jacket had inflated but that was all right. The nurse reported assisting the patient to stay afloat and that after one hour it was difficult to maintain the patient afloat. The flight nurse stated that two life jacket lights were working, but that hers was generally underneath the patient, who was being held afloat.
Is it just me or did the ATSB totally miss the premise of the question asked?? Reading that answer you’d have to ask… “have you (the ATSB) totally lost the plot?”
Oh but (god forbid) there’s more much more, take a look at the following quote from the Answers to QON PDF in regards to the decimation of the ‘safety recommendation’
in Oz:
Further, with respect to the inclusion of ‘Recommendations’, it is important to note the difference filed by Australia in relation to Annex 13 Para 6.8 noted above.
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.
This philosophy is neat and doesn’t upset the relevant parties to an accident/incident allowing organisations to address safety issues highlighted by the final report without fear or prejudice (natural justice). However what it effectively means is that if you don’t read the report and take note of the proactive safety actions carried out by interested parties those actions and the subsequent lessons learnt become invisible to the worldwide aviation industry.
The NTSB had come to the conclusion, some 40 odd years ago, that the obligatory ‘safety recommendation’ signified the cornerstone of their existence, that is why they have devoted a whole electronic database to SRs so that the valuable lessons learnt can be disseminated worldwide. The NTSB isn’t alone in their recognition of the importance of issuing the obligatory safety recommendation..NZ, UK, EASA all deploy SRs and maintain a database.
If this adopted mentality (above) and the standard displayed in this report by the ATSB is allowed to continue then one would have to ask why have the ATSB??