I must apologise forthwith to the Canucks..
Still reading through the report but the extreme effort of adhering to the restrictive ToR...
"The terms of reference and the scope of the TSB Review excluded re-investigating the Norfolk Island ditching; rather, the Review was to focus on how the investigation was conducted."
...has not diluted any of the professionalism of which the reviewers have displayed in taking to the task.
There are some deep messages that need to be learnt from if the ATsB is to recover any of their once respected reputation on the world stage of AAI and once again be an effective air safety watchdog.
What is truly evident is that the involvement of CAsA in a parallel investigation - for what would have to be said as being for devious reasons - has had a profound impact in the conduct and performance from the investigative team up to middle and executive management at the bureau...
This conflict of interest was very carefully crafted & outlined in sub-paragraph 3.7.3.1
3.7.3.1 Misunderstanding of the roles of ATSB and CASA
Independence is critical to the work of an accident investigation body whose sole mandate is to improve safety. Parallel investigations by other agencies to fulfill their respective mandates should have no bearing on the actions of an independent safety investigation. In the Norfolk Island investigation, there was no real barrier to prevent any avenue of investigation or examination of the regulatory process itself. However, there was a misunderstanding that affected the quantity and quality of the data available for analysis.
The Norfolk Island ditching occurred four months after structural changes made the ATSB fully independent: on 01 July 2009, the ATSB had ceased being a division within the Department of Infrastructure, Transport, Regional Development and Local Government, and became a separate statutory agency. These changes should have had the effect of reducing the likelihood of any influence by CASA on an ATSB investigation.
However, at a December 2009 progress briefing to ATSB management, one of the risks to the investigation discussed was the CASA parallel accident investigation. Afterward, perceptions of how this issue had been resolved differed. The IIC believed he had been instructed not to cover the same areas as CASA, since the regulator was conducting a parallel investigation.
Meanwhile, the Commission and ATSB managers believed it was well understood that the investigations were fully independent and that there were no barriers to the ATSB investigation.
In addition, there were several communications between the IIC and the Chief Commissioner on the issue of regulatory action planned by CASA against the pilot. These communications did not clarify the independence of the ATSB investigation, and the IIC continued to believe that he had been instructed to avoid duplicating CASA's efforts.
The IIC's misunderstanding of the roles of CASA and the ATSB was never resolved. It resulted in information not being collected from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence prevailed in the company in general.
To be fair to the bureau they were only trying to adhere to the spirit and intent of the newly minted MoU, unfortunately the other side was not playing by the Queensberry rules and systematically set about undermining and unsettling the IIC into distraction...
And the rest as they say would have been history but for a 4 Corners program a nosey independent Senator and the non-partisan Senate Committee...
So again apologies TSBC..
Just a pity about the time delay and the fact you were hamstrung by the ToR - as I fear your excellent report (so far) may well be lost in the 'Bankstown Chronicles'...
MTF...much more..
Ps Well done Ben...
{Comment: Dear TSBC I will not - at this stage - retract my 'BOLLOCKS' for the Canleyvale review as I believe you have been severely misled...}
Addendum: AA online - Canada’s TSB publishes critical review of ATSB