Sarcs - {Comment: Dear TSBC I will not - at this stage - retract my 'BOLLOCKS' for the Canleyvale review as I believe you have been severely mislead}".
Sarcs – I'm not sure that the Pprune management would tolerate the publication of the Canely Vale chapter from the Bankstown Chronicles; so after much 'consultation' with the BRB and P7, I hope a potted twiddle will suffice.
There exists a document which, for wont of better, we shall call the "Cheese" document, it has quite a history. The final draft was quite short, five pages in all, the initial draft, shorter again, three pages. Draft 1 was provided to the CEO, GM, three Chief Pilots, two CASA FOI, their 'acting team leader', and to two independent 'safety experts'. Although Draft 1 was short, it was pretty much to the point and designed to have an immediate effect on what was identified as a rapidly developing, operationally 'unhealthy' situation; there was no doubt in the authors mind that inevitably, there would be a major accident if the matters mentioned were not addressed quickly and correctly. This was stated in Draft 1 and supported by anecdotal, peer reviewed evidence. The conclusions of that review were supported by no less than four, independent, active chief pilots and two independent safety analysts. Fully aware that the potential for a fatal accident was at an elevated level; the matter was entered into the company Safety Management System (SMS) and 'flagged' urgent for a full SMS meeting.
It was the following day that two CASA FOI arrived 'on site', their manner was noted as angry, impatient, dismissive, one being particularly aggressive. I will not labour the point – in short, the CPO and HOTAC were 'told'. Told to remove the matter from the SMS, not to interfere outside of their own remit and, for their own good, it was better to let CASA sort out the issues, in house and informally. No further action was ever taken by CASA regarding the matter.
Over the next two month period, it was observed and noted by senior pilots that 'things' were deteriorating, rapidly. Another report was prepared. Draft 2 was blunt – it warned that a fatal accident was probable, a time bomb. If immediate changes to training, supervision and operational practices were not made; as a matter of urgency it was no longer no longer a matter of if, simply when.. It was agreed, by all that after the last caning from CASA that the matter should simply be referred to and dealt with by the CEO and SMS management.
To the credit of management a company wide SMS accord was initiated and a review of all 'operating' protocols and policy was commissioned, to define the 'problem' areas and identify changes required. All company divisions and the CEO embraced the concept and wholeheartedly became involved; all except one. The division which employed Andy Wilson and had created the urgent need for 'control'.
After the fatal crash the aforementioned CASA FOI conducted an 'audit' and found that the 'paperwork' was all in order, and that there were no 'operational' aberrations. Which is hardly surprising as they weren't looking for them, tick and flick worked just fine, when it suited their masters purpose.
ATSB were informed of the company concerns, they even subpoenaed the 'Cheese' report which had forecast the accident almost 12 months (to the day) previously. And did nothing. Not even interview the eight senior, qualified individuals, to determine if any of the itemised topics could have contributed. For example, from 'Cheese':- (abridged and slightly edited to protect the innocent).
a) Senior pilots report being personally informed, on several occasions of pilots being 'instructed' to perform operations in a manner which defies most of the sensible and legitimate tenets of sound practice, Wilson repeatedly being the recipient of several of these 'tirades'. The most recent was a serious dressing down, delivered post flight to one of the most sensible, intelligent pilots on staff. The pilot requested a private meeting to explain the event and to seek guidance.
b) In short; the pilot was tasked to Lismore NSW, after a second attempt at the approach, the aircraft was visual at the minima, but, on top of a very low deck of Stratus (lifting fog) which obscured the aerodrome and prevented a landing. The aircraft was diverted to Ballina.
c) This individual later responded to a general question related to the days operation with a sketch of the days events. He was then taken aside and 'briefed' (instructed) on how it should be done and berated for not doing the job in the 'approved' manner. Not to labour the issue the essential points where:-
(i) Slow the aircraft (PA 31-350) to less than 120 knots,
(ii) Stooge about until you identify a roadway which leads toward the aerodrome,
(iii) Get below the cloud and follow the road through the hills until the runway is sighted.
An independent analysis of the Canley Vale accident, from a holistic perspective was provided, in confidence, to both the Pel-Air and Forsyth inquiries. Clearly the Canadian TSB were never provided the information, even the analysis of the flight path was grossly flawed and that fell squarely with the TSBC remit..
If the Pel-Air investigation is to be reopened; then both the Botany Bay and Canely Vale accidents need to be examined in depth. If there is any doubt remaining that Pel Air was a 'reverse' fit up, then an open, impartial, honest inquiry into the death of young Andy Wilson and Cathy Shepard will confirm, beyond a shadow of doubt any lingering notion that CASA and the ATSB have acted less than honourably, in another hidden display of routine normalised deviance.
This is not the time to take your foot off the gas pedal.
Selah.