PPRuNe Forums - View Single Post - Senate Inquiry, Hearing Program 4th Nov 2011
Old 23rd Nov 2012, 20:01
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Kharon
 
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Catch 22?

Operationally, the whole thing of 'that' METAR from Nadi is not too critical; most crew would have a "6000'? WTF" moment. If it were not for the almost immediate follow up report from Nadi, (the carefully spelled out SPECI), then no doubt questions would be asked and clarification requested. But the next report, hard on it's heels would nullify (or make nugatory as we must now say) the previous, probably erroneous report. Some crews may have privately questioned the previous 6000' call, but most would just join the dots and discard it as 'an error', the 'latest' revised SPECI makes much more sense. I could be tempted to bet a bag of sweeties the TAF for Nadi had a similar cloud base and visibility. Face was saved, and perhaps as a courtesy to Fiji, that tiny bit was left out of Mr. Dolan's available evidence.

Thing puzzles me is why it came be omitted from the CASA and ATSB report. It is easily explained; e.g. "our investigation revealed that the ATC in Nadi had inadvertently read 6000 not 600 due to a typographical error, we have addressed this with the Fijian authority"; and endit, off the hook, no foul, no penalty. It is the omissions which now raise the awkward questions.

Mr Dolan: I will try and add some information to that. As we tried to make clear, there was an initial assessment of the evidence we had available to us, which was essentially about decision-making en route and what informed us and everything else—whether the guidance that was available was reliable. – Hansard.
The 6000' cloud base element was not 'initially' provided; nor was it provided during the two year head scratching period and was only 'discovered' during the 4Corners report.

Why did the ATSB not 'discover' and address the 6000' report error during their research?

Was the omission by CASA of the reported cloud @ 0801 the reason the ATSB failed to mention the erroneous details of 'that' METAR?

FACT : the first version of the Final Report, after the 4Corners revelation, was corrected by the ATSB.

FACT : CASA Accident Investigation Report 09/3 page 7 fails to mention the 6000' CB version @ 0801.

Was the information initially provided to the ATSB deliberately misleading or, is the report a joint effort cobbled together by the ‘parallel’ investigation team under the MOU?

If you put the two reports alongside they almost exactly mirror each other with the exception of 'that' METAR, lately included and not addressed. The CASA report, concluded two years prior included a summary and basic conclusion of the CASA Special Audit Report, which directly conflicts the final audit conclusions/findings, not sighted until 'earlier' this year.

Could this all indicate that during the compilation of the report there was an edict issued prescribing how the conclusions/findings should be written? Was this the work of one pair of hands operating under instructions or a joint effort attempting to brush the incident off as a once in a lifetime non safety related event?

Was the TSI act 'breached' by the CASA manager 'producing' the ATSB briefing? Page 33 of the Transport Safety Investigation Act 2003, part 24 makes the results of nobbling an investigation pretty clear. Then the MOU 4.1 also spells out why this is naughty.

This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof.

Taxi Minister?

Last edited by Kharon; 23rd Nov 2012 at 20:09.
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