Jinglie perhaps BH was a secret co-author of that infamous hidden report (CASA Accident Investigation Report 09/3) that PAIN found at the tail end of attachment 4 of the FF submission??
Pg 28 of the transcript:
Mr Dolan: We see our job as a different job from CASA's. The special audit was in relation to CASA's views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB's final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason's model, would be viewed as violation; and that is principally the responsibility of the regulator.
If the ATSB remit is.."
focus of our investigations is on error and understanding error" it is beyond belief that the ATSB "scope" of the investigation shouldn't include the following areas (borrowed from Jinglie's post on Norfolk thread
):
Simply put, in an accident like this, how can:
ATC
Weather forecasting
Comms
Crash Survivability
ORG issues
Regulatory issues
CRM
Fatigue Risk Management
Aircraft performance
not be adequately covered in the ATSB analysis?
Very good question Jinglie but there is also another factor in all this. If we accept Beaker's simplified philosophy (i.e. ATSB deals with error and CASA deals with 'violation'). And we also accept that the bureau's 'standards of investigation' must meet the requirements of both the TSI Act and ICAO Annex 13. What standard does the regulator's (slightly skewed) parallel investigation have to meet in order to possibly be presented as part of a brief to the CDPP, or AAT, or other enforcement action? The bigger question is does it meet that standard?