Jinglie said: Why on earth is the ATSB drifting off from the rest of the world? Imagine if there was ever a large fatal here (touch wood), these clowns wouldn't have a clue.
Why indeed?
flying-spike said: What I got from the report done for the ATSB was that it was based on available research into SMSs and that the majority of the research done on OH&S systems with very little done on low probability/high consequence industries such as aviation. I would put about as much value on that report as I would put on the ATSB report into the Norfolk Island ditching.....bugger all.
Spike I would add that the Norfolk final report isn’t a one off aberration in the Beakerised recent years, it is just the one accident that caught mainstream media attention and hence public interest. Which, due to the pilot surviving, created an awkward situation for the relevant authorities that they couldn’t automatically default to the normal line of defence..“nothing to see here it was all the pilot’s fault!”
Hence the ATSB final report fell under public scrutiny, 4 corners got hold of it and the good Senator X (Saint Nick) and Senator Fawcett ultimately pushed for a ‘please explain’ which has led to where we are now.
If you refer to Attachment B of ATSB supplementary submission 2[1] headed ‘Managing safety issues and actions’ you will see get an insight into Beaker’s grand vision for the future.
Senate Committees – Parliament of Australia
In summary this is where the Beaker defends his new methodology into the management of safety issues and actions picked up in the course of an ATSB transport safety accident/incident investigation. The questions that need to be asked, is it working? Does it promote the dissemination and free flow of safety critical information to industry participant’s worldwide?
Attachment B paragraph 4 reads:
The ATSB is in the process of redeveloping its website to be 'safety issue' focused rather than 'recommendation' focussed. The point of importance is that the safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation
Here’s a short exercise that perhaps highlights the deficiencies and flaws in the Beaker vision of managing safety issues and actions. The following are extracts from the changed (Beakerised) Safety Issues and Actions ATSB database for all sections of the ATSB remit i.e. not just Aviation:
Safety issues and actions
We then put in 'critical' in the 'original risk' section.
Safety issues and actions
You’ll see that it comes up with one entry only, which is probably because this is the new Beaker method of recording safety actions and recommendations and therefore the system is yet to ‘catch up’ with the new methodology.
Ok for sh*ts and giggles lets open up the one entry that deals with those RR engines mounted on the A380:
Recommendation AO-2010-089-SR-012
So this SR was generated because of the uncontained engine explosion on the Qantas A380 VH-OQA out of Singapore in 2010. However what this one example shows is that normally a ‘critical safety issue’, like most of the world, should automatically generate a Safety Recommendation.
Now we’ll go to the next level down i.e. ‘Significant safety issues’:
Safety issues and actions
We now have a total of 11 entries depicted and of those 2 are SRs. One Marine SR that occurred on 30 July 2012 and one Aviation SR that occurred on 13 December 2010, which deals with a standby power deficiency in the B747-400 QRH.
Although the new methodology means there aren’t many entries so far it is still possible to see that even a significant safety issue can lead to the ATSB generating a SR. It is also interesting to note that all 11 entries are listed under the “Type:” column as either recommendations or ‘safety advisory notices’ and that significant safety issues (at least) are now starting to be listed, example: AO-2009-012-SI-001. So I wonder if the same thing is happening for minor safety issues?
Safety issues and actions
And that would be a yes! Ok so is the Pel-Air ‘critical safety issue,’ that has only recently been downgraded to ‘minor’, in there?..Err it would appear not, nor is any of the other ‘minor’ safety issues published in the Pel-Air final report! So although under the Beaker system all safety issues will now be supposedly published in the ATSB database, the Pel-Air (and god knows how many others) minor safety issues are yet to be included….just another cloak of invisibility!
Such a convoluted system! Too bad if you are operating in a remote base with dodgy internet coverage and you don’t know where to look on the ATSB site for that significant safety issue that happens to be relevant to the aircraft you’re operating…I mean WTF??
The biggest issue from this Beakerised system in regards to the ATSB investigation into the Norfolk ditching is perhaps best highlighted by this quote from the ‘Safety Action’ section of the preliminary report issued 13 January 2010:
The remainder of the investigation is likely to take some months. However, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues.
This was prior to the ATSB bringing to the attention their now infamous CSI to the regulator. Under the old system that CSI would have automatically triggered a SR that would have had to be addressed in a timely matter as per the TSI Act. Instead we ended up with the ridiculous situation where a CSI that was well supported by an excellent documented investigative review by the ATSB investigation team, gets left in limbo for over 29 months before finally being downgraded to a minor safety issue!
Perhaps this farce is best summed up by Jinglie’s last:
Wait till the FAA come back and speak to Beaker! We are doomed!
