Spot on "K" the person who paraphrased "Closing the loop" was indeed Senator Fawcett long before the PelAir cover-up inquiry came on the radar...
:From
Budget Estimates ATSB Hansard 23/05/12
Senator FAWCETT:When there is an aircraft accident and there is a fatality and the coroner becomes involved, can you describe the relationship between ATSB and the coroner?
Mr Dolan: The legislation, the Transport Safety Investigation Act, requires us to cooperate with coronial processes. Therefore, coroners have, if you like, a special relationship with us. There is a range of information and support that we are required to give to coroners that we do not give to other legal processes. We try, as far as possible, to ensure that our reports are reliable and comprehensive and therefore can be used by coroners to form their views, which are largely no blame and in parallel with what we are trying to establish.
We recognise that there are areas where coroners will investigate and we do not. We are trying to deal with that carefully. We do that mostly by making sure we are in close contact with the police who are working with the coroner so that there is clarity from the beginning as to whether we are going to be playing to any significant extent. We are always happy to explain our reports to coronial processes. In addition, we have been offering accident fundamentals training, the basics of how we approach our job, to a range of police officers across the jurisdictions who are likely to be assisting coroners in carrying out their duties.
Senator FAWCETT:Do coroners ever face the situation where they have to
choose between your advice and that of another aviation expert?
Mr Dolan: Quite often. It used to be more common than I think I have noticed in the last year or two that alternative views were put to coroners—
Senator FAWCETT:Who would those other stakeholders be?
Mr Dolan: Our experience has been that counsel assisting, in trying to do a comprehensive job in support of a coroner, sought other lines of information and brought it to bear in the process. Other parties, all of whom have their own interests in a coronial process, often find it necessary to test a range of alternative hypotheses. Sometimes the weight comes down to a different place than we placed it. That is just part of the relationship. If there is a coronial finding that is inconsistent with what we found or more information comes to light in the course of an inquest that is relevant to our investigation, we will reopen the investigation and make sure that is properly weighed up in our processes.
Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?
Mr Dolan: We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.
Senator FAWCETT:Who should have that role then?
Mr Dolan: I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.
Senator FAWCETT:Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?
Mr Dolan: I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.
Senator FAWCETT:Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we,
as a nation, close this loophole to make our air environment safer?
Mr Mrdak: I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.
Senator FAWCETT:You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?
Mr Mrdak: We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.
Senator FAWCETT:Thank you.
Unfortunately for DF, who was still relatively new to the game, his question to M&M was not officially recognised as a QON and therefore was totally ignored until Supp Estimates a week before the PelAir Cover-up inquiry was to begin:
Senator FAWCETT:Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.
Mr Mrdak: It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.
Senator FAWCETT:Do you have a time frame on when you might be able to report back to the committee?
Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.
Senator FAWCETT:If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.
Mr Mrdak: Yes.
Senator FAWCETT:Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.
Mr Mrdak: We will come back to you on that.
This time the good Senator's line of inquiry was listed as a QON...
However presumably due to the sensitivities in the PelAir cover-up M&M handballed the answering of the QON to Beaker...
Who in typical Beaker fashion obfuscated the QON with these weasel words...
:
Answer:
One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.
The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.
Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.
The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed, not addressed, no longer relevant or withdrawn.
A safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required.
The ATSB policies and procedures for identifying and promoting safety issues, including through the issuance of a formal recommendation, is outlined in its submission to the Senate References Committee Inquiry into Aviation Accident Investigations.
The ATSB’s Annual Plan and part of the ATSB’s Key Performance Indicators specifically relate to a measurement of safety action taken in response to safety issues; in the case of ‘critical’ safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.
As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for following up on recommendations and safety issues identified by the ATSB, as provided for in the Memorandum of Understanding between the agencies. Aviation safety agency heads will continue to monitor the present arrangements to provide an adequate system for addressing issues identified through ATSB investigations.
As we now all know this was where it was revealed that Beaker (BASR) had taken the bureau to beyond Reason in AAI investigative methodology -i.e. Beyond All Sensible Reason...
Now although Senator Fawcett's QON was officially obfuscated by Beaker this did not deter the Senator and
closing the loop was subsequently incorporated into the PelAir cover-up report at R17-R21:
Recommendation 17 - The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.
Recommendation 18 - The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.
Recommendation 19 - The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.
Recommendation 20 - The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.
Recommendation 21 - The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
The miniscule's response to these recommendations would appear to have again obfuscated Senator Fawcett's original
closing the loop concern with further weasel words that presumably were authored by M&M and Beaker...
Example R17...
"...Response
The Government supports this recommendation.
The ATSB publishes on its website a list of all safety issues and actions highlighted in
its investigation reports, including recommendations. The status of these issues and
actions is updated quarterly.
The ATSB Annual Report to Parliament also provides details of safety issues and
advices published in the ATSB investigation reports and advice on the status of
recommendations..."
The response at R18 is interesting because apparently the bureau action/inaction is contingent on the final report from the TSBC..
Response
The Government supports this recommendation in-principle.
ATSB policies and procedure$ require that the details of actions taken in response to
safety issues identified as part of an investigation are included in the investigation
report. The ATSB website provides an ongoing status report on the action undertaken
in response. The ATSB reviews and updates this information quarterly.
The ATSB will review its policy on the use of recommendations, including in relation to
international best practice and having regard to the final report of the Canadian
Transportation Safety Board peer review.
However the response to R21 is the most disturbing and highlights that there never was any intention for the government, department or bureau to
close the loop..:
Response
The Government notes this recommendation.
All recipients of recommendations are required to respond with details of intended
action (if any) within 90 days and this response is published by the ATSB. This
arrangement provides for oversight of implementation and the identification of related
factors or processes impacting the timeframe for implementation of specific
recommendations.
The implementation of safety actions, including the time needed and the resources
involved, may vary on a case by case basis. Further, the implementation of some
safety actions may be tied to the implementation of others, or other regulatory
initiatives, meaning that implementation needs to be accommodated within broader
aviation safety regulatory processes.
Ministerial intervention in safety actions by its independent safety agencies is not
necessary and could undermine the proper independence of our statutory agencies in
acting in accordance with their legislative mandates.
Hmm...so I guess '
Ops Normal' &
'nothing to see here' but I do wonder if the international community will be quite so naïve when the final outcome of the MH370 search & investigation comes to its ultimate conclusion....
MTF...
