Merged: Senate Inquiry

[Sarcs]

A word from our (WWIOS) resident TBA members

TBA - Tendentious Bloggers Association...

Beaker...

"...At the simplest level, the answers to the Senator's questions are straightforward - and a fair amount of the information is publicly available.

We are prepared to answer them in whatever forum they arise (with the exception of anonymous rumour sites and some tendentious bloggers)..."

First from Proaviation (Phearless Phelan)...:

Canadian study identifies flawed processes and policies

An independent review of the ATSB’s investigation processes and methodologies delivered its report on schedule this week. But it won’t bring much comfort to industry, nor to a travelling public already uneasy over the revelations of the Aviation Safety Regulation Review; and last week’s grilling of Airservices Australia executives in Senate Estimates over top-level management conflict, concerns over possible whistle-blower abuses and the non-resolution of long-standing operational safety issues.

ATSB had commissioned a “peer review” by its Canadian counterpart, the Transportation Safety Bureau of Canada, in the wake of a series of adverse findings by a Senate committee and widespread media coverage centred on the ATSB’s investigation into the ditching of a Pel-Air Aeromedical Westwind jet at Norfolk Island in November 2009.

The TSB’s terms of reference were to conduct a new and independent objective review of ATSB’s investigation methodologies and processes, working independently of any other person or organisation.. The reviewers were not asked to revisit the Norfolk Island findings, but to review the way the investigation was conducted, and also to review two other investigations – an Augusta helicopter winching accident in December 2011 at Kangaroo Valley, and a Piper Chieftain crash at Canley Vale near Bankstown airport in June 2010.

That meant that at least for now, the deeply flawed Norfolk Island investigation report would remain on the public record indefinitely, presumably as a standing reminder of how not to go about meeting the ATSB’s and CASA’s obligations.

The other two accidents were added to the assignment “in order to provide a useful comparison” of ATSB’s procedures over a wider spread of events.
Perhaps also to identify whether the Norfolk investigation was a random aberration, or par for the course. ProAviation is in contact with several parties who have been equally injured by the arrogance and overconfidence of both organisations.

On the Norfolk Island investigation, the TSBC commented:
The TSB Review of the Norfolk Island investigation revealed lapses in the application of the ATSB methodology with respect to the collection of factual information, and a lack of an iterative approach to analysis. The review also identified potential shortcomings in ATSB processes, whereby errors and flawed analysis stemming from the poor application of existing processes were not mitigated.
Problems identified by the Canadians included “misunderstandings” about the respective responsibilities of CASA and the ATSB, leading to the ATSB collecting insufficient information from the operator, which in turn also hampered the analysis of specific safety issues; weaknesses in the application of the ATSB analysis framework, lapses from normal accident investigation procedure; and the re-categorisation of a ‘critical’ safety issue to ‘minor’, which shifted the focus away from the issue itself – and the potential for its mitigation.

In contrast, the TSB was less critical of the Kangaroo Valley and Canley Vale investigations, despite considerable industry disquiet with their findings.

The TSB Review made 14 recommendations to the ATSB in four main areas:

• “Ensuring the consistent application of existing methodologies and processes;
• “Improving investigation methodologies and processes where they were found to have deficiencies,’
• “Improving the oversight and governance of investigations , and
• “Managing communications challenges more effectively.”

Findings from the TSB review of the Norfolk Island investigation were:
1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analysed.
5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
9. At the ATSB, the Commission does not formally review some reports until after the DIP [directly interested parties] process is complete. This increases the risk that issues with the scope of the investigation and the quality of the report will be identified too late in the process to be resolved.
10. The lack of a robustly documented feedback process after the Commission review increases the risk that issues with the scope of the investigation and the quality of the report will not be addressed.
11. Ultimately, the lack of a process for the Commission to review the DIP responses, ensure the DIP comments were addressed, and provide DIPs feedback reduced the effectiveness of the DIP process in improving the quality of the Norfolk Island report.
12. Although senior managers were aware of the possibility that the report would generate some controversy, communications staff were not consulted and no communications plan was developed.
13. Once the investigation became the subject of an external inquiry, the ATSB could no longer comment publicly on the report, which hampered the Bureau’s ability to defend its reputation.

The report’s recommendations offer comprehensive fixes to identified problem areas as well as throwing further light on the deliberations of the Canadian team.

The review reported on, but did not criticise the ATSB’s controversial decision not to spend $200,000 on recovering the cockpit voice and flight data recorders, notwithstanding that there were several unique lessons to be learned from a successful night ditching of a light jet in a remote area which was survived by all six occupants.

To be fair to PP that review of the TSBC report was before this mornings revelation that the Miniscule wants Beaker and his fellow commissioners to consider (i.e. DO) re-opening the PelAir investigation.

However if he were to know I don't believe he would have quite put it the way Ben did in this evening's contribution from Planetalking...:

Call for ATSB chief’s removal over Pel-Air report fiasco

Ben Sandilands | Dec 03, 2014 6:40PM | EMAIL | PRINT

Senior mandarins in aviation tried to lock their Minister, Warren Truss, into a position he no longer wants to be in. A very bad career move

Senator Nick Xenophon calling for Dolan's removal from ATSB


The scope for major changes in Australia’s air safety investigator, the ATSB, its aviation regulator, CASA, and their administrator the department of Infrastructure and Regional Development looms large following the Minister’s abrupt call for a fresh look at the Pel-Air crash inquiry report.

A great deal of political and administrative capital was invested in producing and defending the vindictive, unfair and inadequate final report that the ATSB issued, and subsequently defended, concerning the Pel-Air crash of a Westwind corporate jet doing a medical charter into the sea near Norfolk Island on 18 November, 2009.

In what might prove a critical development in the public administration of air safety in this country, that report, released after many delays on 30 August 2012, seems set to be undone, or redone.

As might prove to be the case for Martin Dolan, the discredited ATSB chief commissioner whose testimony before a Senate hearing into the investigator’s botched processes over its Pel-Air findings was rejected by an all party committee.

Independent SA Senator, Nick Xenophon, lost no time in calling for Dolan’s removal “and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and CASA.”

The human suffering aspect of what at first glance seems like a minor hull loss in the middle of the night is difficult to discuss for legal reasons at present. However it was anything but minor for the six people onboard when it was ditched in the sea because it had reached its intended refueling stop at Norfolk Island, on its way from Apia to Melbourne, when it discovered the weather advice it had received was wrong, it was unable to land, and it no reserves to reach an alternate.

Pel-Air, the operator was a mess. It grounded its surviving Westwinds voluntarily after the crash. Its deputy chairman and former coalition aviation minister John Sharp, even gave a media interview in which he admitted there ‘was no plan B’. The operator didn’t even have a written oceanic fueling policy. It was an appalling state of affairs, all seemingly brushed under the carpet by two safety authorities and a federal department.

One of those people on the flight was quite seriously injured, yet more than five years later, she is being appallingly treated, even gloated over by some parties on the basis that Australia’s air regulations in respect of such accidents were so lax/ or non-existent, that anyone using them had no legal protection whatsoever. (Which may not prove to be the case, of course.)

That regulatory vacuum persists to this day, despite lies from CASA under previous management as to how promptly it was going to fix the situation, and an apparent paralysis of that organization under a recently departed head of safety when it came to actually reforming or performing any of its obligations to aviation stakeholders and the public.

However the testimony of Dolan to the Senate, and the tale of administrative incompetence and lack of clear management on his watch during the bungled Pel-Air inquiry that is set out by the TSBC peer review ought to have him out of the door on skates.

The identification of the secretary for Infrastructure and Regional Development, Mike Mrdak with the Dolan, ATSB and CASA positions on the Pel-Air inquiry places him in a difficult position. Mr Mrdak took his Minister, Mr Truss, to a place where the Minister no longer wants to be, which is always in hindsight, a bad, bad move.

It was Mrdak’s department that told Truss to reject earlier calls, including from the Senate committee inquiring into the ATSB, to recover the flight data recorder from the Pel-Air wreckage and redo the findings, which were essentially a lazy and incomplete scapegoating of the pilot in charge of the Westwind.

The privileged Hansard records of the testimony of Dolan, the then director of air safety for CASA, John McCormick, and Mrdak are substantially incompatible with the findings of the TSBC.

It was Mrdak’s department that wrote the original position taken by Minister Truss that there was no point in retrieving the flight data recorder or correcting the accident report. It will be interesting to see if Mrdak can perform the necessary U-turn, and repudiate his previous words, while remaining on top in Infrastructure.

When Minister Truss’s Air Safety Regulation Review panel, chaired by David Forsyth, reported at the end of May this year it anticipated that the TSBC report would be both critical and released in the near future.

It was however, repeatedly delayed, to the point where some feared it mightn’t even see the light of day, given reported resistance to its contents within the ATSB.

The report released on Monday was written in a manner likely to put a casual reader into a coma. But for those who read the full document, it proved highly critical of the ATSB, setting out comprehensive failings in terms of collecting and assessing information.

There was dissent within the investigating team, to the point where a ‘coach’ appointed to assist in the inquiry, sought, eventually successfully, to be relieved of his role.

The TSBC dealt deeply with the disruption caused in the investigation by uncertainty over the appropriate relationship with CASA, which conducted parallel inquiries, including an audit that was withheld from the ATSB, into the Pel-Air Westwind operation subsequent to the crash.

As reported earlier in Plane Talking and examined by a Senate committee into the ATSB’s procedures in relation to Pel-Air, CASA suppressed an audit that found that the crash could have been prevented had the regulator carried out its own duties of oversight over the Westwind operation.

The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report, in which the committee took that rare if not unprecedented step of giving a section of their findings to their lack of confidence in the testimony and conduct of the chief commissioner of the ATSB, Martin Dolan.

Today’s decision to have ‘another look’, which to be clear, is a direction not a suggestion, reflects poorly on Truss’s Labor predecessor Anthony Albanese.

Mr Albanese broke several commitments to deal with the adverse Senate findings into the ATSB, and was ineffectual or unwilling in relation to the Pel-Air issues, which first arose on his watch with ample opportunity for ministerial direction or intervention.

Mr Truss has not escaped criticism in this portfolio either, and not just from Plane Talking. But something has changed, this damaging and disgraceful report will be ‘fixed’ in its procedural or methodological shortcomings, there is already a new Director of Air Safety at CASA, and there may well be further changes for the better in the administration of air safety.

Priceless... I think it is fair to say that Ben fair and squarely hit the nail on the head of probably close to the last nail in Beaker's coffin...

Come on Miniscule you know you want to...

MTF...