Sundy QASAtation: BASR & APOD
Definition: APOD – A point of difference.
Word is the miniscule was presented with the WLR report on Friday, which he will make public on Tuesday and the TSBC review report will now be delayed till the end of June...
OK ‘what will be will be?’
While we continue to contemplate our navels let us reflect on the poohtube vid that Jinglie refers…“I just watched Dolan mumbling to Senator Fawcett about the Commissioners and Safety Recommendations. Top job to get paid a bucket load when the actually don't make any Safety Recommendations...”
Apparently, for the sole purpose of austerity (i.e. limited resources), we now seem to be the only signatory state to ICAO that has significant notified (BASR – Beyond all sensible Reason) differences to both Annex 13 & 19.
From Annex 13: Safety recommendation. A proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident. In addition to safety recommendations arising from accident and incident investigations, safety recommendations may result from diverse sources, including safety studies.
And Australia’s ND to that definition (my bold): Safety Recommendation - Essence of definition adopted in legislation and in policy and procedures documents. However, Australia reserves the term safety recommendation for making formal recommendations which are used as a last resort.
Beaker has argued the point (verbatim) that a SR (BASR) will only ever be issued as a last resort if identified safety issues are not proactively addressed by the addressee. This BASR approach is in direct contradiction to the practices/methodology of every other 1st world country and tier one signatories (which includes some resource limited 3rd world countries) to ICAO.
One of those countries that strongly adhere to the, ICAO endorsed, SR methodology is Canada (see here). To reinforce their commitment to upholding the (i.e. Annex 13 ‘spirit and intent’) SR methodology, the Canucks also take the additional step to reissue SRs when outstanding SRs have not been adequately addressed:
Reassessing outstanding safety recommendations to ensure accountability
Gatineau, Quebec, 30 May 2014 - Urging industry and regulators to take action on a number of outstanding safety recommendations, the Transportation Safety Board of Canada (TSB) today released its annual reassessment of responses to Board recommendations. The reassessments show that progress has been slow especially in Aviation where only 61% of the Board's recommendations have been implemented.
Again this year, the aviation sector has seen limited movement on recommendations. While 5 recommendations have received the TSB’s highest rating of “fully satisfactory”, another 32 remain unresolved. Indeed, 6 of the 32 have been classed as “dormant” as the TSB foresees no action on the part of the regulator. The TSB remains committed to the Watchlist goal of reducing landing accidents and runway overruns where there are a number of outstanding recommendations including calls on Transport Canada (TC) for longer runway safety end areas or a means of stopping aircraft that provides an equivalent level of safety.
The SR/safety issue is very much an APOD with the TSBC and the ATsBeaker investigative methodology, and therefore very much falls within the ToR of the TSBC peer review. Hopefully the Canucks will point out this discrepancy and include a recommendation with some instructional guidance on how best to administer a proper transparent and effective SR/safety issue system.
IMO Beaker’s politically correct BASR is absolute BOLLOCKs…
APOD ICAO (Safety Recommendation system in practice) vs ATsBeaker (politically correct) BASR system – In the ATsB final report of the investigation into the ditching of VH-NGA under the heading Organisational and management information the bureau made the following cursory summary of CAsA’s oversight of PelAir…
“…The regulatory requirements affecting the flight were administered by CASA and established a number of risk controls for the operation that were promulgated in the Civil Aviation Regulations (CAR) and CAOs. Those controls related to the operator, the pilot in command (PIC) and the conduct of the flight. Surveillance was carried out by CASA of operators’ procedures and operations to ensure that such flights were conducted in accordance with those approvals and the relevant regulations and orders…”
…but after the findings of the Senate AAI inquiry and on CAsA’s own admissions (& the Chamberpot report), there were many obvious deficiencies in the regulator’s oversight of the PelAir Operation that were contributory to the ditching.
However in the ATsB’s blinkered view these safety issues were not significant enough to issue either a significant safety issue or SR to the regulator and the rest is history.
The NTSB have recently issued two SRs to the FAA (one of these SRs was listed as URGENT) in regards to concerns for the regulatory oversight of one of the largest Air Carrier (Part 135, Part 121) operators in the State of Alaska. The following is the background synopsis for those SRs…
“…Since 2012, the NTSB has investigated six accidents and one incident related to operators owned by HoTH, Inc. On September 5, 2012, about 1100 Alaska daylight time (AKDT), Era Aviation (dba Era Alaska) flight 874, a Bombardier DHC-8-103, N886EA, experienced an uncommanded left roll consistent with a stall and uncontrolled descent during climb about 12,000 ft mean sea level (msl) near Soldotna, Alaska.2 The flight crew regained control of the airplane about 7,000 ft msl, and the flight returned to Ted Stevens Anchorage International Airport (ANC), Anchorage, Alaska. The 12 passengers and 3 crew members were not injured, and the airplane was not damaged. The airplane was being operated under the provisions of 14Code of Federal Regulations(CFR) Part 121 as a regularly scheduled passenger flight between ANC and Homer Airport (HOM), Homer, Alaska. Day instrument meteorological conditions (IMC) prevailed at the time of the incident. This incident is currently under investigation…”
And these are the SRs:
Conduct a comprehensive audit of the regulatory compliance and operational safety programs in place at operators owned by HoTH, Inc., to include an assessment of their flight operations, training, maintenance and inspection, and safety management programs, and ensure that permanent corrective action is implemented for all adverse findings. This audit should be conducted by a team of inspectors from outside Alaska. (A-14-22) (Urgent)
Conduct a comprehensive audit of the Federal Aviation Administration (FAA) oversight of 14 Code of Federal Regulations Part 135 and Part 121 certificates held by operators owned by HoTH, Inc., and ensure that permanent corrective action is implemented for all adverse findings. This audit should be conducted by a team of inspectors from outside Alaska and should include a review of inspector qualifications, turnover, working relationships between the FAA and operators owned by HoTH, Inc., and workload to determine whether staffing is sufficient. (A-14-23)
Which is followed by…
“…The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate receiving a response from you within 30days regarding A-14-22 (Urgent) and 90 days regarding A-14-23 detailing the actions you have taken or intend to take to implement them…”
Through the user friendly NTSB SR system, it is also possible to actively monitor the outcomes of these SRs:
Rec #: A-14-022 (Click for link)
NTSB Status: Open - Await Response
Issue date: 5/1/2014
Accident Date: 9/5/2012
Source Event:
Location: Soldotna Alaska
Mode: Aviation
Most Wanted List: No
Closed date:
Report Number:
Accident ID: DCA12IA141
View Status by Addressee
View NTSB Recommendation Letter [PDF]
Rec #: A-14-023 (Click for link)
NTSB Status: Open - Await Response
Issue date: 5/1/2014
Accident Date: 9/5/2012
Source Event:
Location: Soldotna Alaska
Mode: Aviation
Most Wanted List: No
Closed date:
Report Number:
Accident ID: DCA12IA141
View Status by Addressee
View NTSB Recommendation Letter [PDF]
Certainly is
a lot to like about the NTSB/TSBC board system and it is obvious that they are truly operating independently and unencumbered by the regulator.
From the last Estimates it was revealed that the ATsB is beholden to the same budgetary efficiencies ($60 million savings to industry) as the rest of the Dept, IMO this further stresses the Annex 19 requirement that the ‘State maintains the independence of the accident and incident investigation organization from other State aviation organizations’.
Maybe part of the problem with the bureau is that they fall under the Dept and consideration should be put to oversight and funding for the bureau to come (like the TSBC & NTSB) directly from the parliament, food for thought! 
Last edited by Sarcs; 1st Jun 2014 at 02:48.