UITA said (without yelling
): The Australian Story about Lockhart River should be re-visited by us all to remember the impact that poor regulatory surveillance has and some of the happenings when the ABC Australian Story looked at this tragedy in light of the current Senate hearing into PelAir.
Australian Story - A Call From Lockhart River - Transcript
The
parallels should be examined.
Good find on the thread UITA although I'm with Oleo and would suggest that the chances of Beaker instigating an inquiry into FF are about zilch...FF seem to have some kind of hypnotic hold on him..
Skull: "
Watch the Albo trough invite going left to right...watch the Albo.."
Beaker: "
mi..mi..mi..you..you..you"
Skull: "
Now you are under FF control...I want you to ignore the organisational issues in the Pel-Air investigation.."
However UITA you are right in suggesting that there are parallels to LHR but the parallels are going in reverse when it comes to the ATSB, here is an excerpt from the LHR Coroners report that shows exactly what I mean.
Coroner Barnes said (my bold):
In 2004, the ATSB took advantage of a redesign of its occurrence database to examine other aspects of its activities with a view to utilising advances in information technology to enhance the quality of its investigation processes by modernising its record keeping, documents and exhibit management, analysis of the evidence, project management and report workflow. The Bureau is to be commended for attempting to adopt a scientific approach to what has been, in many instances treated as an art form. However, there is, I would suggest, some basis for concern about aspects of the project’s outcome. In view of its recency and importance to future investigations I consider it worthwhile to record some concerns about how it will be applied.
The analysis framework that was developed as part of that project is said to “improve the rigor, consistency, and defendability of investigation analysis activities and to improve the ability of investigators to detect safety issues in the transportations system.”
A key component of the new system, including the analysis framework, is the use of standardised terminology. A significant term, a “contributing safety factor,” is defined as an event or condition that increases safety risk and which, if it had not occurred or existed, the occurrence under investigation or another contributing safety factor would “probably” not have occurred or would “probably” not have had such serious consequences. The Bureau settled on a 66% probability as a sufficient causal connection.
CASA, in its submissions to this inquest suggested that this was too low a threshold; that it raises serious doubts as to whether the findings in the ATSB report regarding contributing safety factors can be relied upon. In my view, the validity of such a benchmark can be challenged from at least two other perspectives. Firstly, to suggest that the accuracy of deductive reasoning or even speculative assessments to which the approach will be applied can be gauged with such precision is, in my view, misconceived. A calibration that may be ideally suited to measuring tangible items or the outcomes of chemical or physical processes may have no application to the vagaries of human behaviour.
Further, there seems no good basis for requiring the same level of certainty in relation to all possible contributing causes in all cases and seeking it solely from within the evidence gathered during an investigation. Lawyers apply what is referred to as the Briginshaw principle whereby the level of persuasion or conviction required and the evidence necessary to establish it may vary, having regard to the seriousness of the issue under consideration; the gravity of its consequences and inherent likelihood of it occurring. The ATSB should perhaps heed the warning of Justice Dixon (as he then was) who, when discussing the level of persuasion necessary to find a fact proven said ”It can not be found as a result of a mere mechanical comparison of probabilities independently of any belief in its reality.”
A number of other aspects of the ATSB’s methodology also concerned CASA. The first was that the report did not disclose that this was the first investigation that had been managed under the new model which was untested. This seems of little substance: the investigation processes and the reports findings are open for scrutiny and CASA has actively participated in that in various fora. If the methodology is flawed, whether on its first application or its fiftieth, that should be exposed and this inquest should be part of that scrutiny.
Of more concern is CASA’s suggestion that in its efforts to look beyond the immediate physical cause of an incident, the ATSB has created a framework that is biased towards a conclusion that organisational factors contributed to the crash (NB Well FF have well and truly negated that now). The ATSB claims to have built on seminal work by Professor James Reason whose root cause analysis model has been applied in numerous multi-factorial incident investigation contexts. The Bureau says it extended the range of factors to be considered when analysing the various possible contributions to an incident that go beyond the actions of the individuals directly involved (well the bureau under Beaker have done a complete 180 on that methodology).
The lead investigator, Mr Madden, acknowledged that the model assumed that there will never be an incident that can adequately be explained by either the occurrence event and some individual actions but he did not say, as the CASA submission asserts, that there will always be organisational influences which could, if in place, have prevented the problems that resulted in the incident.
In fact, he said when cross examined by CASA’s counsel that the model requires investigators at the outset to always consider the possibility of such indirect contributions “to ensure that we don’t missing(sic) anything” but that if “during the course of the investigation we find that , in the organisational influences area that it is indeed not the case, well, there won’t be any prominence given that in the accident report and it may indeed cease at around the risk control area.”
This misconstruing of the investigation model is in my view significant. It leads CASA to assert that the systemic bias creates an unwitting focus on organisations such as CASA and encourage speculative attempts to link it to the cause of the accident. This tendency can is said to be counter-productive in terms of aviation safety because:-
it leads to a loss of focus on the “real” cause of the accident;
false safety issues are created and are unlikely to be respected;
the force of “legitimate” findings against CASA “in any other such report is at least diminished”...
In my view, this attack on the methodology used by the ATSB is without substance. I do not accept that by requiring its investigators to always consider whether organisational influences may have contributed to an incident, the professional judgement of those investigators is likely to be overborne.
Coroner Barnes found (unfortunately) that this conflict between the bureau and FF wasn't healthy and warranted a recommendation:
Interaction between the ATSB and CASA
Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.
Recommendation 4 – Ministerial assessment of interagency relations
Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted.
Which led to the infamous Miller review and that gentleman's recommendation 17:
Recommendation 17 – MOU
The agencies should negotiate a new MOU and include matters such as:
(a) a means of encouraging more day-to-day interaction between the agencies when serious accidents and incidents occur;
(b) a review as to whether the current time periods for CASA responses to ATSB reports and safety recommendations should be more flexible, taking account of the need for timely investigation outcomes;
(c) ways of enabling CASA personnel to obtain greater value from participation in ATSB investigations;
(d) a mechanism for developing common safety messages in cases where the agencies have come to different expert views on the causes of the accident or incident;
(e) provision for regular seminars involving the ATSB and CASA staff at the operational level to consider agreed aviation safety issues, including the presentation of research outcomes;
(f) exchanges of personnel between the ATSB and CASA with the main objective being that officers from both agencies obtain the benefit of the training and experience the other agency can offer;
(g) improved co-ordination of research initiatives and education programs on matters relating to aviation safety;
(h) the information that CASA can expect to have disclosed to it the ATSB's confidential voluntary reporting scheme (REPCON);
(i) guidance on the circumstances in which the Executive Director might be expected to provide information to CASA under the TSI Act and a mechanism for that to occur;
(j) reviews of information holdings of both agencies to see whether greater sharing of data would be beneficial and feasible;
(k) a review of the principles applied by the ATSB in seeking information from CASA (including a reduction in the number of requests for information under section 32 of the TSI Act);
(l) discussion of legislative proposals in areas of interest to both agencies; and
(m) provision for annual reviews of the MOU.
And then ultimately the MOU of 2010 and as they say the rest is history...FF turns the tables and becomes the bureau's puppetmasters!!
Oh and Albo ensures bureau compliance by hiring mi..mi..mi..Beaker!!
