Kharon:
Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB 'sovereignty' during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from 'Serious' to 'Minor'? In short, have the Pel Air books been 'cooked'?
Bugger “K” stole my thunder…
…oh well relegated to gap filler yet again…
Ok before we start working through the ‘timeline of embuggerance’ (TOE) an update on the MoP Stakes from the Senate: Possible imposition of a penalty on a witness before the Rural and Regional Affairs and Transport References Committee or a person providing information to the committee
{Note the Committee Senators (Stewards) membership includes one loud, outspoken BIG MACK}
Kharon:
In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF 'White hats' grab the spell book and start weaving - preparing a proper response. All good until it was realised CASA were going to have 'egg on their face', had the ATSB not backed down. Perhaps that 'GWM report' was prepared to riposte the ATSB brick bat. "We're on top of this" says Sleepy Hollow.
In the eyes of the TSBC: It would first be prudent to refer to what we know they have been scoped to review in regards to PelAir. From ATSB AQON 4 Senate Estimates (24/02/14) RED said:
The Transportation Safety Board of Canada (TSB) has agreed to review the ATSB’s investigation methodologies and processes. Specifically, the review is examining the ATSB’s:
• Investigation methodology and its application
• Management and governance in relation to investigations
• Process for compiling an investigation report
• Approach to communicating with persons and organisations external to the ATSB in relation to an investigation
As part of the review, the TSB has undertaken to examine the application of the ATSB methodologies to the Norfolk Island investigation and two others.
The review was instigated in response to Senate References Committee criticisms that the ATSB investigation of the Norfolk Island accident did not comply with the requirements of ICAO Annex 13 or the ATSB’s written standards. The review is also intended as part of the ATSB response to Inquiry recommendations concerning the adequacy of the ATSB’s investigation policies, procedures and training.
The exercise is not a reinvestigation of the occurrence, and hence the TSB has not sought to reinterview involved parties. Howevers part of eviewing the ATSB’s investigations, the statements and other evidence of involved parties have been available to the review team.
Therefore it would be safe to assume that the TSBC would be reviewing most, if not all, the published under privilege documentation from the Senate AAI inquiry, which would include the following 2 documents:
1. Correspondence from the ATSB to CASA regarding a critical safety issue, received 22 October 2012;(PDF 2663KB)
2. Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)
As RED indicates the TSBC will review the PelAir report against the recognised international standards for AAI (as outlined in ICAO Annex 13) and not on any domestic arrangements i.e. the MoU.
On the subject of safety issues identified, in the course of an investigation, by the AAI as needing prompt action and a SR promulgated Annex 13 states:
Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.
6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.
RESPONSIBILITY OF A STATE RECEIVING
SAFETY RECOMMENDATIONS
Action on safety recommendations
6.10 A State that receives safety recommendations shall inform the proposing State of the preventive action taken or under consideration, or the reasons why no action will be taken.
Note — Nothing in this Standard is intended to preclude the State conducting the investigation from making proposals for preventive action other than safety recommendations.
The ATsB intent to compliance with the Annex is outlined in s25A of the TSI Act.
So in terms of 1. (Attachment one above) the TSBC would give the ATsB its 1st tick i.e. the investigators have identified a CSI and have basically
written a DRAFT of the soon to be notified SR. However it would probably be seen as passing strange, not normal practice, that the ATsB are essentially giving the intended SR addressee a ‘heads up’.
I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect ofthe lack of regulation or guidance for pilots when exposed to previously unforecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.
But maybe this is a good initiative because the letter does goes on to say…
“….In later telephone calls to me, you suggested that the receipt of this letter would allow you to 'kick-start' CASA's consideration of, and response to the issue.
Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB's initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA's commitment to address the safety issue is appreciated…”
And indeed the ‘White Hats’ (as “K” calls them) stepped into action and started proactively addressing what they assumed would soon be a published ATsB SR, published an update to OS 09/13 (see 4.4 of CAIR 09/3) and started writing NPRM 1003 OS.
So maybe the TSBC would have given the ATsB leeway and understood that in the interests of better relations (as this was seen as a test case for the newly just minted MoU), that this little divergence from SOP could be advantageous.
However on reading the internal email at 2. this acceptance of diverging from SOP IMO would have come to a resounding conclusion (crash)
:
We were discussing the potential to reflect the intent of our new MoU that describes the 2 agencies as 'independent but complementary'. We discussed the hole that CASA might have got itself into by its interventions since the ditching, and how you might have identified an optimum path that will maximise the safety outcome without either agency planting egg on the other agency's face.
Right now, I suspect that CASA is entrenching itself into a position that would be hard to support. If we were to contemplate an exit strategy, or an 'out', then CASA would need to recognise that it is 'in' something in the first place. This is my take of how I see their position at the moment.
When the aircraft ditched, both the flight crew and the operator stopped their Westwind Aeromedical operations.
CASA coached and guided the operator very well as they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pei-Air are now operating again. The same thing hasn't happened to the flight crew. While they may not have been the 'Aces of the base', they were following the relevant procedure provided by both CASA and their operator. This is an opportunity for CASA to follow the same approach with the flight crew as they have done with the operator.
As a systemic investigator, we see 3 separate slices of 'Reason cheese' with aligned holes ( flight crew, operator & rule-maker), and we want to seal all those holes. The operator has now been realigned, and I think CASA has done a very good job in helping them. For the flight crew, they do need realigning to ensure they now meet the updated Ops manual requirements. For the rule-maker, I would be extremely satisfied if they then proactively realigned everybody's understanding of this operational risk, and how it can be managed in the future.
As we discussed yesterday, following the ditching, everything went (metaphorically) 'up in the air'. CASA has done a good job in realigning Pei-Air while it was still in the air so that it returned to earth with a much better take on how to manage this risk.
Unfortunately, they took action on the flight crew without first contemplating their end-game. If they reframe their pre-emptive action with the flight crew to show that they had managed all the levels of safety management by simply putting the pilots' permissions to fly on hold until they had found the problem and remedied it, then they would look far better than if they tried to prosecute the probably indefensible and hardly relevant.
We will be telling this story in our final report, if not earlier, so why not make the most of this opportunity for both agencies to publicly work harmoniously, in a parallel direction?
IMO any good TSBC investigator could well relate and be most disturbed by the angst that this fellow investigator was feeling at this point in time. The massive conflict of interest is beyond obvious and directly in contravention of the spirit & intent of Annex 13.
Hmm…think I’m going to have to have more parts to this as I’ve just discovered a couple more errant dots and I’m yet to look through the eyes of the other investigator…
MTF…