Hey Princester to add to Kharon’s advice the CVR/FDR was a combined unit…..“The aircraft was equipped with a model FA2100 solid-state cockpit voice recorder (CVR) and a flight data recorder (FDR). Both units were installed in the aircraft’s tailcone” (from the final report).
Although it was generally accepted that the longer the recorders sat on the ocean floor the greater the probability of recorder degradation, however essentially the recorded information could still be retrieved (especially from the FDR as it is digitally recorded).
On the matter of what useful information could be extracted, perhaps Mr Brian Aherne’s supp submission (Sub_10_Aherne_Supplementary3[1].pdf) that deals with “Prejudice, Outcome Bias and Coercion” at paragraph 3 best summarises your query and also highlights how all the evidence was handled by the ATSB (CVR/FDR info highlighted in red):
3. Evidence:
a) Outcome Bias.
Email from Martin Dolan to ATSB Investigator and General Manager Investigations written 10 February 2010:
Thanks very much for this. My discussion yesterday with John McCormick gave me some confidence that CASA was looking for systemic answers and amenable to our approach. Since then CASA has changed its rhetoric and seems to be hardening its view that there has been a regulatory breach that needs to be addressed.
I think it would be helpful if you and other addresses could meet with me so that we agree the best way to manage our relationship with CASA in the course of this investigation.
Analysis:
It is very clear that the ATSB had decided on a systemic investigation approach but that simply because CASA changed its rhetoric the ATSB did too. This is evidence of a weak State safety investigator that allowed itself to be influenced by the regulator whose shortcomings may have been exposed in any systemic investigation.
b) Prejudice and Outcome Bias
Email: Wednesday 18 August 2010 From CASA Officer to Director of Aviation Safety and Deputy Director of Aviation Safety
Re: ALIU Accident report Norfolk Island ditching VH-NGA
The above referenced report is now complete………….I have discussed the report with the ATSB and there are no differences in the key areas which will eventually be published by them in their report. I have aligned the report with the submission made by …our Westwind FOI Subject matter expert in yesterday’s AAT meeting.
Analysis: For CASA to have confidence that there would be no differences from the key findings (made by CASA) in an ATSB report which was still two years away from being complete is strongly suggestive that a meeting of the minds had occurred and an outcome agreed. This is evidence of prejudice and outcome bias.
c) Lack of independence of the ATSB and its investigators
Email: 6 August 2012. ATSB officer to General Manager Investigations
…Many of my arguments that have been rejected have been ones where I have applied safety management methods and tolls and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead….To make useful comments on these matters relies on a belief in and use of contemporary safety management theories and methods. To me this was particularly evident when CASA’s Norfolk Island audit report came into our hands and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA’s findings not mine! When I have to rely on CASA’s opinion to persuade the ATSB how can I claim that the ATSB is independent when it investigates CASA?
Analysis: This shows that the ATSB undermined the independence of its investigator. It also shows that the ATSB is unduly influenced by CASA or it shows a crisis of confidence at the ATSB. Either way the ATSB is clearly not independent of CASA.
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?
PNM said:
Given that this outfit appears to have run in a familiar West Texas style of operations (minus most of the beef), what chance was there that anyone even cared about the serviceability state of the recorders? I also have little doubt that the minimum required standard of recorders is probably useless.
Good point Princester however surely that fact alone (the serviceability of the CVR/FDR) was worth knowing, much like the u/s CVR in the Lockhart River Metro. At the least it would have meant more scrutiny would have occurred on the P/A maintenance organisation with a couple more RCAs etc chucked into the mix.
Anyway PNM hope that helps…now back to the ‘Chambers Report’ crucifixion!
