Lefty believe it or not I too have read and analysed the LHR report and Coroner's report several times. I totally agree with you about the LHR ATSB report being full and comprehensive, as it should have been considering the over 20 million dollars of taxpayers money it took to complete. I also agree the report does not hold back in it's criticism of CAsA's oversight of Transair, however the passages you quote also highlight what was the primary focus of the investigative team in regards to reviewing the Transair/CAsA relationship/management of the AOC i.e. the audit process and surveillance.
There is, as you point out Lefty, one example of the ATsB questioning an AOC variation approval process, where an AWI refused to approve the Brisbane to Inverell route approval on the grounds of inadequate (in his opinion) Company Maintenance Control (PDF page 154-156 of
ef-121779 pdf). {Note: IMO this example was probably highlighted because it is the only instance (that I can see) in all the variations where an AWI or FOI has voiced a concern about the applied for variation/addition to the AOC}
But the one really crucial AOC variation, in light of the accident, that should have been heavily scrutinised was the port approval for LHR...so why wasn't it?
Was it maybe because the LHR port approval wasn't redflagged by a AWI or FOI (like the example above) and so didn't draw the attention of the ATSB investigators?
Or was it because the ATSB primary focus was on the CAsA audit/surveillance processes of Transair and not so much the AOC variations/additions?
Anyway enough of the thread drift here is a TSB you tube video that perhaps highlights their priorities in regards to OBRs (be it for trains):[YOUTUBE]
And in regards to accident/incident investigation methodology and subsequent safety actions/recommendations, perhaps the recently released report into a Beaver amphib crash (with additional links) highlights how the Canucks go about it
:
AVIATION INVESTIGATION REPORT
A12P0070 CONTROLLED
Watchlist issue identified in May 2012 floatplane accident near Peachland, British Columbia
Aviation Recommendation A12-01
Aviation Recommendation A12-02
As I said earlier there is a lot we could learn from the TSB Canada!