Having dutifully ploughed through the 228 page response, AQON 211112 and identified several howlers, contradictions and plain, old fashioned 'porkpies'; I can report that as a definitive study of corporate spin, it is a masterpiece. The tabled data is the work of master craftsman. Clearly history is repetitive:-
AQON 211112_PDF page # 48.
ATSB response to the question ‘Is this new methodology internationally recognised?’:
The first significant investigation undertaken using the new analysis methodology was the ATSB’s investigation of the fatal Metro 23 accident near Lockhart River, Queensland on 7 May 2005 (ATSB investigation 200501977). Following the completion of this investigation, there was some criticism of aspects of the ATSB’s methodology by the Civil Aviation Safety Authority regarding the ATSB’s use of a Reason-type model and the ATSB’s definition of ‘contributing safety factor’, and the Queensland State Coroner had concerns regarding the description of the standard of proof associated with the ATSB’s definition of ‘contributing safety factor’.
Norfolk - Sub03_Currall.
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 As pointed out on the 4 Corners program the ATSB’s final report was flawed, causing it to be quietly withdrawn some 24 hours after publication.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.
Lockhart River - Urquhart – Coroner Barnes. 20 Aug, 2007.
" Evidence clearly provided to the inquest both by CASA witnesses and others, showed how CASA has not really changed anything in the way it operates and its serious disregard for promoting safety within the Regional Airline Industry. This is supported by reams of information and statements I have read over a long period of time. Does CASA not have some duty of care in an industry where safety is paramount and should there not be serious consequences imposed on individuals and the organisation for breaches of this? " etc.