Oleo said:
But the ATSBeakers actions (or should I say budget guided non actions) and the way it conducted its investigation is a separate issue, but one which of course highlights the fact that it is another piece of our safety oversight capacity that is completely buggered beyond belief!
Some people say 'why retrieve the boxes' we know what happened. Bull**** to that I bellow. The boxes could shed additional light on the accident, they would provide technical data as well as voice transcript and of which a totally accurate and comprehensive overview of the accident is obtained. Roll that into a 'lessons learned' package and suddenly you have a value benefit to industry. But no, King Beaker and his mighty budget, his bureaucratic background and all his so-intellectual mi mi mi-ing couldn't see the potential in this. Which proves their stupidity and inability.
Although the level of obfuscation and cover-ups instigated by Fort Fumble and revealed by this inquiry is mind bogglingly staggering, it is probably something that industry stakeholders are not overly surprised by. These shenanigans have being going on behind the scene for the best part of 3 decades (as Oleo continuously reminds us). Note: Although there is no doubt that it is only getting worse, much worse!
However the true travesty, again as Oleo points out (above and in posts
#1746 and
#1755), is the decimation of the ATSB’s once proud reputation in only five short years (i.e. Beaker’s reign). Beaker’s ‘beyond all rational reason’ methodology has been shown up to be the furphy that it is in the many threads that have pointed out defective, spurious and neutered ‘Final Reports’ that are really beyond the pale for the quality and content that we once all expected from the bureau prior to 2008.
Beaker’s methodology would also seem to be in direct conflict with ICAO, here’s a quote from page 31 of the proposed Annex 19 SMM:
Apart from establishing findings and root causes to accidents/incidents , most investigation exercises also result in the uncovering of hazards/ threats. An effective and comprehensive investigation process includes the identification and discrimination between an ultimate consequence, an unsafe event and hazards/ threats that contribute to the accident/incident.
This may include any systemic, latent or organizational factors within the entire aviation system framework. In today‘s proactive safety management environment, there is an important and necessary integration between an accident/incident investigation process and an organization‘s hazard reporting/ identification process.
Investigation reporting forms should have a clear provision to document hazards/ threats uncovered during the investigation process that would require separate follow up action by the organization‘s hazard identification and risk mitigation process.
It is common for some investigation reports to limit their ―Conclusion and ―Action Taken/ Recommend to immediate or direct cause(s) only. Thus, any secondary or indirect hazards/ threats could tend to be overlooked , unless this gap can be bridged by linking the accident/incident investigation and hazard identification processes.
We could excuse Beaker and his cohorts for adopting a flawed methodology; after all we are only human and subject to making mistakes. However what I personally cannot excuse is Beaker making the once obligatory Safety Recommendations (that one would expect to be generated from any serious accident/incident investigation) almost totally obsolete. The safety actions section is now no more than a summary of political correctness and will be summarily dismissed to the dustbin of history while the bureau continue to pussyfoot around the sensitivity of various ‘directly interested parties’.
This decimation of the SR would appear to be in contrast to nearly all effective and reputable aviation accident investigative bodies throughout the world, and is also in direct contravention with the ICAO principles on the subject.
To highlight the integral part the SR plays in the accident investigation process (in most parts of the world) here is a quick comparison of Final Reports into some significant ditching accidents…lets start with the Hudson River US Airways Flight 1549:
http://www.ntsb.gov/doclib/reports/2010/aar1003.pdf
The NTSB generated no less than 34 Safety recommendations (refer page 124 and the NTSB SR page)
Then there was the 1971 ditching of a ONA DC9 near St Croix, Virgin Islands which generated 18 safety recommendations (pg 16). These recommendations are still faithfully recorded on the NTSB database today:
http://www.airdisaster.com/reports/ntsb/AAR71-08.pdf
Even the third world country of Ethiopia was able to generate a Final report on Ethiopian Airlines B767 ditching (the Federal Islamic Republic of the Comoros November 23, 1996) which included SRs, page 34 and in the appendices:
http://www.fss.aero/accident-reports/dvdfiles/ET/1996-11-23-ET.pdf
So if nothing else is learnt (besides the ugly cover-ups and revelations of a cancerous regime we are now all acutely aware of), or if no proactive change comes from the Senate Inquiry, let us please..please as an industry push to reclaim our bureau (call it the ‘save our bureau campaign’), let us snatch it back from the bureaucrats and untangle it from the tentacles of the axis of evil prevalent at Fort Fumble.
The deconstruction of Fort Fumble will be a long drawn out process and is reliant on ‘political will’ but saving the bureau is achievable now with industry pressure as well as input from industry experts e.g. Bryan Aherne, Ben Cook, Alan Stray..etc..etc.
“Save our Bureau” or ‘sob’
when it no longer exists and is swallowed up by Fort Fumble!
ps Besides perhaps we would then see the revival of the paperback version of the classic crash comic
...hmm doin a Kelpie!