Old 21st Mar 2013, 01:09
  #1296 (permalink)  
Sarcs
 
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
UITA all good stuff but para d) onwards was even better and summarises and suggests to where the Senators should be shining the spotlight on in the context of this inquiry, I also disagree with your assertions in regards to compromised investigations that go beyond 2008 (Beaker's reign).

This inquiry is dealing with an obviously severely flawed and compromised ATSB investigation and final report that is here and now, may I suggest that it is way too early to test the veracity of your assertions beyond 2008.

From para d) onwards of the Aherne submission was so good that I couldn't do justice to it by summarising, so here is the complete version:
d) Breach of International Conventions

Australia is a signatory to article 37 of the Chicago Convention, ICAO, Part IV International Standards and Recommended Practices.

As such, three International Standards (International Standards are defined as 'shall', International conventions intend to foster standardisation, consistency and efficiency and when it comes to safety- shared learning) under Annex 13 have not been complied with, namely Annex 13, 5.4 which states:

"The accident investigation authority SHALL have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of Annex 13" Annex 13, 5.6 states:

"The investigator in charge shall have unhampered access to the wreckage and all relevant material, including flight recorders and ATS records, and shall have unrestricted control over it to ensure that a detailed examination can be made without delay by authorised personnel participating in the investigation".
However:

1) The Investigator in Charge was not given unhampered access to the relevant material of the "Chambers Report", the "UK CAA FRMS Study of the pilot" and the internal CASA survey results of its "Flying Operations Inspectors Survey" and the complete "FRMS" report by CASA officers.

2) The aircraft wreckage (evidence) was not recovered which meant that:

a) Crashworthiness data was not gathered. (Data as to how the impact forces were distributed, which load paths were critical, how energy was dissipated remain unknown and would have been useful information for future aircraft design.
b) Reasons for the survivability of the accident could not be determined. Seatbelt function, seat design, floor attachment points; cabin design; emergency exit design, stretcher design and placement.

3) The Flight Data Recorders and Cockpit Voice Recorders were not made available to the
Investigator in Charge because of budget, not safety considerations. As a result the following
data (evidence) is missing:

a) How much fuel was on board the aircraft? What were the fuel flow rates?
b) What were the actual winds and temperatures?
c) What was the navigation instrument accuracy? How accurately were the instrument
approaches flown?
d) What altimeter settings were used by the crew? How accurate were the altimeters?
e) Which systems were operable / degraded /inoperable?
f) What decision making process was used by the crew?
g) What discussions were had regarding the viability of continuing the flight to Melbourne
following a diversion to Noumea-this centres around flight and duty limitations.
h) What discussions were had regarding the costs of a diversion (fuel , navigation charges,
landing charges, hotel and transport for passengers and crew)?
i) To what extent were the crew fatigued?
j) To what extent did the nature of the operation (EMS) influence the crews’ decision making?
k) To what extent did the lack of operational support by the Operator (contactability, landing
permissions, fuel availability, flight following) influence the crews’ decisions?
l) What was the quality of the radio transmissions being received by the crew?
m) To what extent did CRM influence the accident sequence?
n) To what extent did the first officer perform her function?
o) How did the flight crew successfully ditch an aircraft at night.(Data on the aircraft pitch
attitude, speed, configuration, rate of descent and orientation with respect to wind and
wave would have been invaluable )

Annex 13, 5.13 states:
"If, after the investigation has been closed, new and significant evidence becomes available, the State which conducted the investigation SHALL re-open it. "

However: Despite new evidence being brought to the attention of the ATSB this has not yet happened.

Australia is obliged under International Convention to re-open the investigation.

4. Conclusion

In light of the "Chambers Report", the "UK CAA Fatigue study of the pilot" and the "Flying Operations Inspectorate Survey", as a signatory to article 37 of the Chicago Convention, Australia must withdraw the ATSB publicly released Final Report into the ditching of NGA on 18 November 2009, and re-open the investigation.

5. Recommendation

Recover the Flight Data Recorder and Cockpit Voice Recorder from the aircraft.
Kind of backs up what many on here have been saying and questioning on here since this inquiry first started.
Sarcs is offline