Ditching to ditching..
Oh well after that brief interlude...
As I stated in this post; http://www.pprune.org/7725153-post7.html ….all roads lead back to LHR and it is extraordinary how many similarities there are between the PA ditching investigation, flawed ‘Final Report’, FF surveillance/oversight (or lack there of!) and the LHR accident. The major difference is that the ‘safety watchdog’ under Beaker have now cashed in their chips and are no longer in the game….god help us!
From the ‘Chambers Report’, the ‘FRMS Special Audit Report’ and indeed the ‘SAR’ it would now appear that Fort Fumble has not addressed any of the highlighted deficiencies of its adopted ‘systems based auditing’ and ‘risk based surveillance program’ that were publically documented in the ATSB LHR ‘Final Report’ and in the Coroner’s report.
The angst, animosity and total open warfare between the bureau and FF was first made public knowledge in the course of the LHR Coroner’s inquest. However I believe there was several instances where the bureau had been critical of the new surveillance procedures adopted by FF at the turn of the century.
The one that stands out is the ditching fatal accident of PA-32-300 VH-MAR and the subsequent safety recommendation R20040042 that was generated from that investigation; which read…“The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review their Safety Trend Indicator process, including with a view to developing a methodology to assist in objectively assessing potential at-risk organisations. That should include formal ‘triggers’ that enable the consistent prediction of the requirement for additional surveillance until Civil Aviation Safety Regulations Part 119 takes full effect”…
Recommendation R20040042
If you read the response text you will see that FF got particularly defensive of their new fandangle surveillance system.
After Hamilton Island there was the Toowoomba C90 EFATO SRs (R20040064-R20040069) that were further critical of FF’s surveillance procedures…then there was Lockhart…
Reference pg 44 Coroner’s report (my bold and comments):
As detailed earlier, CASA became aware of a number of deficiencies in the operations of Transair in about 1998 and 1999. Those deficiencies gave rise to a concern that Mr Wright, as CEO, Chief Pilot, Head of Checking and Training and line pilot was “stretched a bit thin”.
Steps were then taken in early 2000 to address those concerns by requiring Transair to appoint a maintenance controller, safety manager and re-organise the structure of Transair’s organisation. I have highlighted earlier the considerable delay that occurred before these organisational deficiencies were addressed and the suboptimal manner in which some key positions were filled. CASA sought to “keep the pressure on” so to speak, by refusing to at first accept the nominee for deputy chief pilot. It was not so assiduous with the equally important role of safety manager.
Thereafter, CASA conducted various scheduled audits and ramp checks in accordance with its Surveillance Procedures Manual. None of the audits identified any problems associated with the duration or quality of endorsement training, frequency of proficiency checks or whether appropriately authorised pilots were conducting such checks. * (pel-air similarity)
It may be suggested that having regard to the concerns that CASA raised with Transair in 2000 concerning the work load of the Chief Pilot as the head of the check and training organisation of Transair, inadequacy of Transair’s “systems of corporate management control and communications” and the need for “a comprehensive safety system within the organisation”, CASA should have been minded to ensure that Transair was strictly complying with its own operations manual and had an effective program of recurrent training in place.
The extent of CASA’s assessment of Transair is well documented and highlights a number of inconsistencies between CASA’s oversight of Transair and its regulatory policies and surveillance guidelines. It seems CASA’s surveillance did not detect that some of the line and base checks had been undertaken by pilots not approved to do this, and that training stipulated in Transair’s operations manual had not been delivered. *(pel-air similarity) It is also apparent that audits of other operations run by Transair, notably the Big Sky Express, did not detect breaches of various aspects of the AOC. Nor did there seem to be much continuity of effort from one audit to the next, and some audits were done with very few resources (often only one inspector) and very little time spent. * (so what has changed??)
CASA’s task was made more difficult by its inability to develop an adequate risk assessment tool for targeting its audit and surveillance activities. When the agency switched to systems auditing in about 2000 an advance that apparently marks it as a leader in aviation safety and warranting commendation it attempted to apply a safety trend indicator system that failed and was abandoned * (but was it abandoned?). Because systems auditing was so new, the guidance the agency could give to its inspectors was minimal. *(comes back to the ATSB’s previous criticisms of the system auditing and risk based surveillance system)
Further, I accept the ATSB’s conclusion that even if CASA had fully met its own requirements, there is insufficient evidence to conclude that it would have detected and corrected the fundamental problems with Transair’s operations. *(again the similarity to Pel-Air is embarrassing!)
Another area of concern relates to CASA’s processes for assessing risks associated with applications by air operators to vary their AOC to add new routes. Such applications required CASA field officers to apply the guidelines and provisions of a particular manual of air operator’s certification. In the case of Transair this involved considering the operator’s request, in 2001, to add Bamaga as its first mainland Australia regular public transport route (from Cairns), and subsequently in 2004 to seek the addition of Lockhart River.
In neither case did CASA require the operator to conduct a comprehensive or structured risk assessment of the proposed change. In particular, no such assessment was required in relation to Transair’s operating procedures, pilot experience or level of training, the rostering practices of Transair in relation to pilots who would be flying the routes involved and the pilot resources available to Transair. In short, it was not part of CASA’s processes to require Transair to undertake a formal risk assessment or make out a safety case for the inclusion of Lockhart River as a new port although it did require Transair to revise performance charts. *(again the similarities to PA are embarrassing i.e. CASA BK weren’t aware of many of the routes that PA was flying internationally)
I find that senior CASA management failed to provide sufficient guidance to its staff to enable them to fully and effectively evaluate risk management issues associated with Transair’s application to add Lockhart River to its air operator’s certificate as an interim port on the Cairns – Bamaga route. That guidance may have been as straight forward as requiring Transair to engage an independent specialist to conduct an assessment of, and provide a report on, all safety issues that were pertinent to the operation proposed. *(good job Barnesy pity he dropped the ball..but that man Harvey wouldn't have helped!)
Hmm..food for thought: Q/ Given what has (so far) been revealed in the Senate inquiry and if god forbid there had of been a fatality, the question that should be asked is whether Coroner Barnes’ summation would look out of place in the subsequent Coroner’s report into the Norfolk ditching??
NB A bit sharp to react there blackie..err No Hoper..err Owen corrected..and I will ignore the RPT vs Airwork comment because it is only relevant to the 'scoping' and risk matrix of an individual AOC or were you saying that Barnesy got it right with LHR??? Now back to the naughty corner...
Last edited by Sarcs; 6th Mar 2013 at 03:47.