OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa.
It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).
"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.
The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.
I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.
When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.
It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.
The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..
Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned,
we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur?
We would be concerned if it did.
Senator FAWCETT: Does this report make any recommendations for improvements?
Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system.
But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.
Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet,
so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.
I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions....