Part two - Of lessons learnt but not heeded.
The Kharon post here linked to Ben’s article - Is the Pel-Air cover-up going to drag on forever? Which indeed is a good question, much like the RRP will the obfuscation, embuggerance, pineappling & victimisation of minor IOS players, continue unabated until the inevitable extinction of the GA industry or smoking black hole finally grabs the attention of the travelling public and the MSM??
Ben makes the point:
Much depends on candid and fearless disclosure of the truth about the botched Pel-Air inquiry. For the Minister, for his department, for CASA, the ATSB, and the TSB of Canada, and not least, for those injured and damaged by this avoidable accident.
Before I launch into - Part two- it is worth reflecting on a section of MQ’s testimony in the 22 October 2012 Senate AAI inquiry hearing…
"...Yes. It got very personal. I use the term 'pendulum'; the pendulum has now swung from one of adverse tension that was not producing the sort of outcomes that the aviation safety industry wants to completely the opposite way, where I believe those two organisations are basically acting as one....It is a professional thing and it is a big part of the aviation industry that there be transparency and that these two organisations have very specific roles under their acts, and that seems to have diminished...”
Ok the next example starts with this recently released report AO-2013-010. Again the report seems to have taken an inordinate amount of time (over 18 months) to complete given the relative (transparent) complexities involved?? However unlike the previous report this one does go to the trouble of highlighting a 'safety issue'; and eventually (22 August 2014) the bureau published this SI on their website..
: AO-2013-010-SI-01
Although one does wonder if this only happened because CAsA, for some bizarre reason, decided to put in their 2 bob's worth into a 'safety issue', that for all intents & purposes, had been resolved:
Although not in response to this occurrence, on 28 March 2013 the Civil Aviation Safety Authority (CASA) released revised fatigue management and flight and duty time requirements in Civil Aviation Order (CAO) 48.1 Instrument 2013. These requirements were to take effect for existing operators on 30 April 2016.
The revised CAO 48.1 stated that, for air transport operations, an operator had to comply with a set of limits and requirements (dependent on the type of operation) or operate to a fatigue risk management system (FRMS), if that FRMS was approved by CASA.
If an operator was not using a CASA-approved FRMS, CAO 48.1 stated that a flight crew member (FCM) must not be assigned or commence a flight duty period at home base unless, within the 12 hours immediately before commencing the duty period, they had at least 8 hours consecutive sleep opportunity. For a duty period commencing away from home base, the 8-hours sleep opportunity must be provided within the previous 10 hours. Sleep opportunity was defined as:
a period of time during an off-duty period when an FCM:
(a) is not meeting the reasonable requirements of bodily functioning such as eating, drinking, toileting, washing and dressing; and
(b) has access to suitable sleeping accommodation without, under normal circumstances, being interrupted by any requirement of the AOC [Air Operator’s Certificate] holder.
Compared to the previous standard industry exemption to CAO 48, the revised CAO 48.1 also provided more restrictions regarding the length of duty periods associated with early starts.
As we all know the introduction of CAO 48.1 has been the subject of much contention by Senator X (& some major pilot unions); it should also not be forgotten that 48.1 is effectively a wedge in the RRP, which hopefully will be resolved beyond yet another legislative instrument sometime in the next two decades...
Now for the parallels with the PelAir debacle, to begin remember this??
Senator Fawcett: “…With all due respect, Mr McCormick that complete answer had no relevance to the point that I raised. Everything you have said is quite possibly correct, but it has no relevance to the point that your own internal investigation indicated that CASA's oversight of the Fatigue Risk Management System at Pel-Air was inadequate…”
Some 21 months before the Pel-Air Norfolk Is ditching CAsA conducted a ‘Special Audit’ of Pel-Air’s CAR 217, for that audit report see here. In the course of conducting that audit CAsA discovered a serious non-compliance in regards to the training required for the company’s FRMS, this NCN led to the issuance of a ‘Safety Alert’:
CAR 217 Training and Checking Organisation - Fatigue Risk Management System(FRMS)
The company's Fatigue Risk Management System (FRMS) was approved by CASA on the
30th April2007. Operations conducted under this FRMS require training for all flight crewsprior to them being rostered for operational duty. The audit of the CAR 217 organisation'sflight crew training records revealed that while flight crews had been operating under theFRMS for 11 months, the FRMS training required had not been conducted. This noncompliancewas considered to represent an immediate threat to the safety of operations andCASA issued a 'Safety Alert' on the 12th March 2008 which required operations conductedunder the FRMS to cease and operations to be conducted in accordance with CA048.
Apparently the company responded proactively…
“…The company accepted CASA's decision and advised CASA on the 17th March 2008 that the required training had been completed. CASA responded on the 18th March 2008 by issuing approval for the company to resume operations in accordance with the FRMS…”
The audit report concluded with this recommendation (page 5):
Given the fact that the company provide training and checking for 70 pilots it is important in the interest of operational safety for PEL management to resolve the issues stated in this report and establish more effective and frequent internal audit of the conduct and recording of the training and checking of flight crew. Given the number of pilots currently employed and the company's proposed expansion into the SAAB 340 aircraft, a review of the current workload of the Chief Pilot and Head of Training and Checking's should also be considered.
{Note: The CAsA evaluation on page 6-7 is also worth reading, especially in light of the findings in the AAI inquiry}
Eventually the company CAR 217 (& FRMS) was given a reasonable bill of health (a tick & flick) with the addition of a CAsA caveat that they would be ‘closely monitoring’…
“..The Safety Alert was lifted flight crew were trained and they are currently operating under their FRMS. Management have been cooperative and the REX Board have launched an internal inquiry to ensuring a breach does not occur again. SYD Region is satisfied and are closely monitoring the operation…”
But then we had the ditching of VH-NGA and another ‘Special Audit’ with further damning findings highlighted in Ben Cook’s FRMS SAR.
Ahh…but don’t worry the company put in place and actioned a MAP that CAsA again ‘closely monitored’ and all is well again…
One word BOLLOCKS!
Until such time that we see positive proof that the ATsB has retreated from its current BASR approach and is prepared to (when required) hand out the proverbial pineapple; then the IOS will continue to ‘closely monitor’ all reports and propaganda being published by the bureau and CAsA with a suspicious eye…
MTF…
{Note for Beaker: Pineapples are not meant to be served as wedges decorating the sides of frosted cocktail glasses at some politically correct ‘love in’, organised by ATsBeaker…}