A most disturbing commentary Mr Ferryman and one that I gather that is held under parliamentary privilege and therefore can be freshly referred to by those that matter.
It is also yet another example of how the ATsB is in non-compliance with its charter to be fully independent:
The independence of the ATSB is integral to the Bureau's safety role. Investigations that are independent of the parties involved in an accident, as well as transport regulators and government policy makers, are better positioned to avoid conflicts of interest and external interference. Being able to investigate without external direction provides an assurance that the findings will be determined and fully reported on without bias.
This is also in contravention to its obligations under ICAO Annex 13
5.4 The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of this Annex.
It should also be noted that now under Annex 19 it is the responsibility of the State to ensure the independence of the State AAI.
If there is one fundamental lesson that should have been learnt from the Senate inquiry into the PelAir cover-up this is it. From all recent evidence - in bureau investigations/prelim & final reports - this is not a lesson that either the department or it's aviation agencies has learnt.
Now we finally get the TSBC peer review report where again the credibility of the ATSB being independent is questioned and made the subject of a TSBC recommendation:
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Kharon -
"...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..."
From a recently released REPCON it would appear that Kharon is not on his own in his concerns about the now proven to be incestual relationship between the bureau and CAsA:
Reporter's concern
The reporter expressed a safety concern regarding the number of Australian Transport Safety Bureau investigations which have indicated in their report that the Civil Aviation Safety Authority (CASA) have detected issues during their audits but have not taken the appropriate action to fix the issues. However, these reports have then not indicated that this was a contributing safety factor in the accident.
The investigations include but are not limited to
AO-2011-102,
AO-2011-033 and
AO-2009-072.
Operator's response (Operator 1)
In order to respond to this REPCON, it is of benefit to understand the different outcomes likely when comparing a regulatory surveillance activity with the conduct of a safety investigation:
- Regulatory oversight. Routine regulatory surveillance cannot examine all aspects of an operator on a frequent basis, and it cannot identify all the issues with an operator (or similar organisation) or their operation. More specifically, unless other intelligence or specific concerns have been identified previously to indicate otherwise, such activities generally examine a relatively broad range of aspects of an operation or operator at limited depth.
The frequency and depth of this ‘routine’ surveillance could be expected to be based on factors such as the type or classification of operation and size of the operator or operation.
In general, less surveillance might be expected for smaller operators, for non-passenger-carrying activities and for operators using smaller aircraft.
- Safety investigations. Safety investigations conducted after an accident or serious incident are often able to identify problems or safety issues that may not be easily detected during a regulator’s routine surveillance activities. More specifically, a safety investigation conducted after an accident/serious incident usually has a more targeted scope as a result of the evidence already gained from other sources, and generally has more time to identify potential safety issues than in the case of a routine audit. Finally, whereas surveillance activities traditionally focus on regulatory compliance, safety issues identified as a result of safety investigations are not restricted to compliance with regulatory requirements.
- Safety investigation and ‘contribution’. Given their limited resources and many potential occurrences to investigate, safety investigation agencies carefully scope their work to maximise the efficiency of their investigations and the potential for safety enhancement.
Before the ATSB includes a detailed examination of the effectiveness of a regulator’s surveillance activities as part of an investigation’s scope, it would generally need to establish that:
- There are significant problems (in terms of number and/or level of risk) with the relevant operator’s risk controls and/or safety management processes, which are related to the investigated occurrence.
- Given factors such as the severity of these safety issues, the length of time they existed, the size of the operator and the nature of its operations, it is reasonable to expect that a regulator’s oversight activities probably should or could have identified these safety issues.
Ultimately, to conclude that any potential problems with regulatory oversight processes were a contributing factor to an accident/serious incident would require the investigation to have, in the first instance, concluded that problems with the operator’s occurrence-specific risk controls and/or safety management processes contributed to the accident/serious incident. In addition, a problem with the design, implementation or other aspect of the regulator’s surveillance processes would need to have been shown (‘existence’) and the conclusion reached that the surveillance problem(s) could have realistically prevented or significantly reduced the likelihood or magnitude of one or more of the operator’s safety issues (‘influence’).
Given this understanding, the following discussion explains why no safety issues associated with regulatory surveillance were identified as contributing factors in the ATSB investigations highlighted by the REPCON reporter:
- AO-2011-033. This investigation involved a small operator conducting primarily freight charter operations in light, twin-engine aircraft. In terms of the scope of the investigation, the ATSB did not consider a detailed review of the regulator’s oversight activities was warranted. The ATSB report noted that CASA found several problems with the operator after the accident, but these problems were not directly related to the circumstances of the accident and safety issue relating to the operator identified by the investigation.
- AO-2011-102. This occurrence involved a small operator conducting primarily aerial work and some charter operations with film crew as passengers and, as part of the scope of the investigation, the ATSB obtained CASA regulatory surveillance documentation. The ATSB did not consider that the nature of the safety issue it identified with the operator would reasonably have been identified by CASA during its routine surveillance activities. However, the ATSB did conclude in its report that there were problems with relevant regulatory requirements and a safety recommendation was issued to CASA in that regard. The ATSB continues to monitor CASA’s action in response to this safety issue.
- AO-2009-072. This investigation involved an aerial work operation and, as part of the scope of the investigation, regulatory surveillance documentation was obtained from CASA and examined. In respect of the safety issue that was identified with the operator, the ATSB considered that it was not an issue that would or should necessarily have been identified as a result of routine surveillance activities. However, problems were found with the general nature of the available regulatory guidance on fuel planning and on seeking and applying en route weather updates, which increased the risk of inconsistent in-flight fuel management and decisions to divert. As indicated in the investigation report, safety action was taken by the operator and CASA in response to these safety issues in an effort to prevent a recurrence of the accident.
Regulator's response (Regulator 1)
CASA has reviewed the REPCON and concurs with the response provided by the ATSB.
Anyone care to add to the list of investigations that question the veracity of the claim that the ATsB is fully independent...
I strongly suspect the Mildura fog incident and the Albury ATR birdstrike incident are candidates for external embuggerance of the ATsB ongoing investigations, but as the reporter (above) indicates there are probably many more...
This is not the time to take your foot off the gas pedal.
Totally agree Ferryman this is by no means over...
Addendum - Performance of ASA 28/11/14 Hansardis finally out not sure what the delay was but maybe this bit had something to do with it...
:
Senator XENOPHON: I think it would be good if we could see any minutes in respect of that. Isn't it in the context of Senator Gallacher raising concerns about compliance or noncompliance—I am not saying there was any noncompliance—in respect of certain public works? And then, as a result of a line of questioning from Senator Gallacher, you raise the issue of the AFP being brought in in respect of leaks. It is not an unreasonable proposition, as Senator Gallacher put forward, that there appears to be a correlation between some legitimate concerns being raised in the context of this parliamentary process and calling in the AFP. Indeed, I wonder—and I will seek advice from the Clerk of the Senate—whether it raises issues of privilege.
MTF...
