Sarcs # 118 –" [&] subsequent knock on effect of Monarch crash, and I'm afraid to say I'm with Lefty on this one.
Not only with LL, but with CAA this time. Some of the BASI IR are bumptious and have the potential to create more red tape with little increased safety value. Was there (from memory) some fairly heavy political heat surrounding this event?, can't remember – anyone?.
Seems the BASI boys back then at least remembered what accident investigation meant, can't see the Monarch investigators leaving an aircraft in the ocean of not recovering the CVR/FDR equipment.
Australia is a signatory to the Convention on International Civil Aviation (Chicago 1944), which established the International Civil Aviation Organisation. Article 26 of the Chicago Convention obligates the governments of countries that are signatories to the Convention to conduct investigations into aircraft accidents in their territories which involve specific aircraft from other countries which are signatories to the Convention. Article 37 (k) of the Convention recommends that, as far as the law of individual countries permit, member countries should adopt uniform international standards and practices for aircraft accident investigation. The international standards and practices for aircraft accident investigation are described in Annex 13 to the Convention.
Australia has given domestic legal effect to its international obligations under the Convention by incorporating the articles of the Convention within the Air Navigation Act of 1920. Part XVI of the Air Navigation Regulations (ANRs) of that Act provides the legal authority for the Secretary of the Commonwealth Department of Transport to require the investigation of aircraft accidents and incidents occurring within Australia. The authority to conduct aircraft accident and incident investigations is delegated by the Secretary to the Director and other designated officers of the Bureau of Air Safety Investigation.
Australia has by historical practice applied the standards and practices of Annex 13 to all aircraft accident and incident investigations. In doing so, the fundamental objective of the investigation is the prevention of aircraft accidents and incidents.
In accordance with the principles of Annex 13, it is not the purpose of this activity to apportion blame or liability. The sole purpose of the Bureau’s operations is the maintenance and enhancement of flight safety.
It seems to me the 1993 statement below has a repetitive sound: May 7, 2005 qualified and prompted the renamed ATSB to finaly produce their CFIT report. The Monarch CFIT occurred in 1993
The investigation found that the circumstances of the accident were consistent with controlled flight into terrain. Descent below the minimum circling altitude without adequate visual reference was the culminating factor in a combination of local contributing factors and organisational failures. The local contributing factors included poor weather conditions, equipment deficiencies, inadequate procedures, inaccurate visual perception, and possible skill fatigue. Organisational failures were identified relating to the management of the airline by the company, and the regulation and licensing of its operations by the Civil Aviation Authority.
Pages 27 to 28 provide the FOI statement which are worth reading and some consideration.
He said at no stage was he aware that VH-NDU was being operated with the RMI and HSI inoperative. If he had known he would have stopped the operation.
To my mind, if the FOI would have known and stopped the operation, then CP who did know all about the equipment situation should not have authorised the flight.
In fairness, I can't see what CAA or BASI could have done more than they did; the FOI statement seems to be 'fair and reasonable'. The CAA response seems to be plausible, if anything for my two bob's worth, the BASI seem to be playing the CAA bashing game just a little too loudly if anything. There is a lot of post event 'posturing' and bum covering going on, but page 30 gives you the clues.
A letter to cancel the approval of the Chief Pilot was subsequently prepared but not sent, as he resigned from that position on 17 May 1993. A new Chief Pilot was approved on the same day.
Memories faded now, but it seems to me this CP eventually ended up working for CASA and has aspired to some 'senior' position, but don't bet the house on that; it was a long time ago.
The chronology starting at page 31 is worth half a coffee and, for me more clearly defines the issues; but here again, the retrospective analysis shows what should have been done before hand; but there are few 'cures' initiated to reduce the probability of this reoccurring again, 10+ years later, in 2005 at Lockhart River. Bad response all around – Yes; poor BASI report – No.
Check paragraphs 1.19.4 (p 36) and 1.19.8 (p 40) valuable in 1993 priceless in 2004. In fact, when you get down to 1.20 (p 41) there is some very good informative data. No, (IMO) we need to remove Monarch from the list of poor investigation.