Kharon:
Working out the odds the determination of TSBC to protect a solid reputation must be factored in; then there's the integrity of the investigating panel to consider; the current 'mood' of the minister and Senators to weigh in. The IOS entries in the race cannot be discounted, nor can the 'treatment' the WLR had prescribed for the DAS and ATSB bi ignored.
And there's the rub do we truly expect the good investigators at the TSBC, who make their living out of solving (on the face of it) what went wrong across the broad spectrum of a causal chain (Reason Model) and in compliance with Annex 13 Chapter 5, to just rubberstamp their review??
{Comment: Despite the ToR I would suggest that the natural curiosity of the Canuck AAI investigators will have them flicking through the Senate PelAir report and viewing the 4 Corners program both of which are readily accessible off the internet.}
so the TSB Scoping doesn't really seem appropriate if it was intending to look at recommendations, does it?
Totally agree SIUYA it does seem limited in scope. However what does give me some hope are the very lines that you quoted...
"...Was the report review conducted in a thorough manner and was it effective? Is the analysis contained in the report complete and thorough? Are the findings and recommendations well supported by facts and robust analysis? Were the comments received from directly involved parties adequately considered and was the disposition of these comments full communicated?..."
The TSBC adhere strictly (no notified differences) to Annex 13 Chapter 5. Chapter 5 refers you to the ICAO Manual of Aircraft Accident and Incident Investigation, this manual is very much Reason oriented (reference Ch 3 para 3.2), & provides guidance on ICAO accepted practice/methodology of accident/incident investigation.
Chapter 3 ORGANIZATIONAL INVESTIGATION, Paragraph 3.5 METHODOLOGY (my bold):
3.5.1 The application of the Reason Model to accident and incident investigation
The organizational investigator will often rely on other groups to identify active failures, local factors and failed or absent defenses. As this information becomes available, the organizational investigator will be in a position to consider the underlying organizational and systemic factors which enabled the situation to develop.
In the event of a major investigation, there may be daily briefings which will enable the organizational investigator to become aware of the progress of other groups. It may be appropriate, however, for the organizational investigator to arrange for a member of each group to act as a contact and report information which may have a bearing on organizational issues.
In the early stages of the investigation, the organizational investigator may need to attend or review key interviews conducted by other groups such as ATC or Operations. This will ensure that potential organizational issues are not being neglected during the interview. As the investigation progresses there may be a need to conduct interviews specifically directed at organizational issues.
In addition to relying on information from sources such as interviews, and documents, the organizational investigator may choose to collect information via additional means such as structured survey interviews, or questionnaires.
The organizational investigator should develop a listing of the organizations that played a role in creating potential local or systemic factors. For example, if the accident is remote from the organization headquarters, there may be an intermediate level of supervision involved. Similarly, when outsourcing is used for example for aircraft maintenance, there may be several contractual relationships established involving multiple organizations. In this case, the relationship between each organization should be well understood to identify breakdowns in the management oversight and communications. Finally, as the investigator comes to understand the organization’s structure, there must be consideration of the government relationship with the organizations related to the issuing and continued oversight of the operations and/or maintenance certificates.
Potential organizational weaknesses may become apparent during the investigation. Yet these organizational weaknesses may have had no role in the development of the accident. If no evidence subsequently emerges to link these weaknesses with the active failures, local factors and defenses of the accident scenario, the organizational investigator should not list these weaknesses among the accident factors. Such findings should however be included in the accident report and if applicable they should be a subject of a safety recommendation. It might be appropriated to place such findings under additional information in the accident report.
We are all now fully aware that the ATsB pretty much scoped out of their report all organisational issues (including CAsA oversight of PelAir) as not being contributory to the ditching. However, according to the above methodology, the TSBC may have an entirely different view on this and the OI's most definitely falls within the remit of the TSBC ToR…
“…Would we have done things differently? This review will identify any best practices and any issues or gaps in the investigation report review process…”
The TSBC ToR…
2 — Review of the Investigation Methodology
The TSB will collect information and conduct a comparative analysis of the ATSB and TSB investigation methodologies, including the approach for the risk assessment of safety issues. The analysis will also include a comparison the two methodologies to the relevant provisions of Annex 13 to the Chicago Convention. This benchmarking analysis will identify the strengths (best practices) and the weaknesses (gaps) of each methodology.
…also means that the Canucks, especially in light of the Senate inquiry findings, will have to consider as part of their ‘comparative analysis’ and in light of the FRMS special audit report & the Chambers Report…
“…Reopening of investigation
5.13 If, after the investigation has been closed, new and significant evidence becomes available, the State which conducted the investigation shall reopen it…”
…to see whether they would have, under their methodology, have come to the same conclusion as Beaker & his fellow Commissioners.
{Note: The ToR also, by design, should encompass both the initially notified and intended Critical Safety Issue & ATSB Prelim Report (Jan-Feb 2010) and the subsequent about face that the bureau took at the time.}
IMO the ToR are definitely not a tick-a-box routine and there is certainly sufficient scope for the TSBC to make some fairly constructive recommendations to the ATsB.
Also as "K" said
..."Working out the odds the determination of TSBC to protect a solid reputation must be factored in..." is particularly relevant when the eyes of the international aviation community and the travelling public are focussed on our neck of the woods in respect of the MH370 search & investigation..
