Addendum to Part 1: Before we move onto part 2 it is worth noting that just prior to the Doc's insightful spiel on the 2010 MoU etc. - Senator Fawcett had this to say in regards to the 'passing strange' dichotomy that was facing the Senate Committee...
:
Senator FAWCETT:I accept the fact that the detail, if you like, of some of the issues that were found with the operator ended up in the reports.
The issue here, as you correctly point out in most of your written and oral evidence, is that the pilot is the last line of defence and is a key part. The operator is another one. As you correctly point out, many of those things made their way into the report. But the oversight by the regulator is a third tier and that is what is missing from the ATSB report.
It is clear that CASA had in its possession, through these reports—and this is where the Chambers report differs from the special audit. The Chambers report is CASA's own assessment of how it performed its oversight role, which is why, to use your term, it appears 'passing strange' to the committee that there should be such strong rebuttal against witnesses who say we do not think the surveillance was adequate. There was very strong rebuttal, in a public space, saying 'CASA rejects that', when you know your own internal investigations by senior managers are saying that your oversight was inadequate.
We are happy that you are taking steps to correct it. Surely it is in the public interest, rather than us having to drag it out through a committee process like this. There were inadequate processes. The ATSB should be provided with that information so the public have confidence that you recognise there are problems internal that contributed to our culture, environment and practices by pilots that led to an error and an accident. The public should have confidence that, regarding the organisational characteristics and culture as such, (a) you are learning—and yes, that is good and (b) that you are also transparent and will say 'ATSB: yes, we were making mistakes in the past and we are addressing it, but here is a report of our own assessment.' For you to say in things like this rebuttal, in quite strong language and with absolutely no hint of compromise, that you reject any assertion that your oversight may have been inadequate when your own internal reports are damning in that area, is surely not in the public interest, nor does it inspire public confidence.
Then there was this in response to Dr Aleck's statement:
Senator FAWCETT: I have a comment as opposed to a question. Dr Aleck, you made the point about internal reports not being made public. I just wish to make the comment that if CASA had made this report available to ATSB in an open and transparent manner, as required by the MOU, the report would not have been made public. ATSB probably would have included some facts that CASA had recognised that they were deficient in some areas—and the report does, despite your comments, recognise that areas of the oversight were in fact deficient, not just undesirable. That would not necessarily have been made public, but it would have informed the report in terms of an approach to aviation safety that would give us a good basis going forward.
The second point, Mr McCormick, is that you pleaded the case that CASA cannot do everything; you cannot police every corner. I accept that. I understand that departments are resource constrained. But there are two issues. First, part of the purpose of a safety investigation is to ask, 'Is the resourcing adequate?'—and, if it is not, for the government to then be required to respond to a recommendation out of an ATSB report that perhaps more resources are required in an area. So, to just not disclose that is not actually an adequate answer. Second, in terms of things like FRMS, the work had already been done by CASA—two officers of CASA had done the work. My understanding from the documents is that you had peer review and comment from organisations such as the CAA, which gave a very clear indication that in using a more advanced fatigue management system the flight that was undertaken would not have been approved under an FAA-endorsed fatigue management system.
Now, that requires no additional effort, minimal additional resources on behalf of CASA—except perhaps an email to advise the ATSB that fatigue was probably a causal factor in why the error was made by the pilot. Yet that was not disclosed, as the MOU clearly indicates it should have been.
Which IMO gives further weight to the BRB Xmas hypothesis i.e. GMP(2).
For now though let us move on to the once hidden, infamous CAIR 09/3 and the established connection with the 2010 MoU.
Perhaps this relationship was best described in a post I made back in July of this year -
Third MoP sponsor: The case of the shrinking Attachment B??:
It can be seen that besides the addition of para 9.3 the two MoUs basically remain in effect for the same period of time, with the same conditions for varying, extending or terminating. From that one has to question how it was possible for the PelAir parallel investigation to have been conducted under the guidance of the 2010 MoU, when it was yet to be officially executed. Maybe there had been an ‘exchange of letters’ between Beaker & McComic which had terminated the ’04 MoU. However that would have meant that such agreement between parties would have necessitated bringing forward the official execution of the ’10 MoU and we know that didn’t happen. We also now know that FF were at least operating to the DRAFT version of the ’10 MoU in conducting their PelAir parallel investigation...
From the infamous (previously hidden) CAIR 09/3 report:
Synopsis
The Accident was notified to the Australian Transport Safety Bureau {ATSB) who in turn notified the Civil Aviation Safety Authority (CASA) on Wednesday 18 November. The ATSB decided to conduct an investigation. The CASA Manager Accident Liaison and Investigation Unit (ALIU) was tasked with conducting a parallel investigation for CASA purposes. An investigation into the circumstances of the accident was commenced the next day. CASA informed the ATSB of the investigation in accordance with sub section 4.1.2 of the joint MOU...
And then further down:
...Now I know that there is ample political/legal wriggle room in all this and that the MoUs are not in fact legally binding, but it does bring me to my déjà vu moment i.e. the mysterious 3rd
MoP.
Here is the original FF PelAir submission attachment (B, C & D): Original
Which you can see had 102 pages & contained the 1996, 2001, 2004, 2010 MoUs & the infamous CAIR 09/3 report.
Now here is what is supposed to be the same document that continues to be readily available off the Senate PelAir inquiry webpage: Current (B, C & D i.e. Attachment 5). Except the attachment has shrunk and is now only 82 pages?? Some may think that this is merely the RRAT committee Secretariat cleaning up the files (i.e. getting rid of blank pages or double ups). However I seriously don’t think that any officer of the Secretariat, no matter how OCD they may be, would even contemplate altering a published & protected under Parliamentary privilege document, it would be akin to career suicide.
So what pages are now missing??
Ok page one still lists the contents of attachment B – CHECK
Then we have the 1996 MoU till page 20 – CHECK
However then the ‘current’ doc jumps to attachment C, completely omitting the 2001 & 2004 MoU...
So there you go, has a person or persons unknown (& for reasons unknown) deliberately altered a Parliamentary document ?(i.e. a possible third MoP??)...
Q/ The next question is why?? After all the MoU is not a legally binding document.
Q/ Does it matter?? Probably not but considering the timeframe for this deliberate act (between the dates 15 February ‘13 to 01 March ‘13) and some of the references contained within the FF sup submission, I have some strong suspicions on motive…
Now if the average person at the back of the room put those questions I posed back then to the BRB Xmas hypothesis well I'd say the fat lady is now singing the chorus...
However if your still unsure take a look at the following references from the 2010 MoU, keeping in mind that apparently (according to the TSBC records) there never was a CASA observer delegated to the ATsB investigation:
4.1 Parallel investigations:
4.1.1 The ATSB may undertake 'no-blame' safety investigations in accordance with the TSI Act and CASA may separately undertake investigations with a view to possible safety-related action pursuant to its functions under
Section 9 and/or Part IliA of the Civil Aviation Act.
4.1.2 As soon as reasonably practicable after either the ATSB decides to conduct an investigation, or CASA decides to conduct an investigation in relation to a matter that would be a reportable matter to the ATSB, each organisation will notify the other organisation.
4.1.3 If either organisation considers an investigation conducted by the other organisation is creating an unreasonable impediment to the performance of their functions, they will raise the matter with the other organisation.
4.1.4 With respect to its own investigation, each organisation will seek to gather evidence from original sources in the first instance and then, where practicable, on the basis of information provided by the other organisation.
ATTACHMENT A- Participation in investigations
1. Participation in investigations will be co-ordinated through the Manager ALIU, CASA and the Director Aviation Safety Investigations, ATSB.
2. The Organisations may agree that a CASA officer may act as an observer or an external investigator for the purposes of an ATSB safety investigation under the direction of the Investigator In Charge (IIC). The CASA Officer will be required to sign an agreement acknowledging his or her obligations and duties, appropriate to the level of their involvement in a transport safety investigation.
3. The CASA Officer will be given access to evidence to the extent necessary to enable the IIC to effectively complete the investigation.
4. The ATSB will not normally seek to participate in CASA regulatory investigations, but may request participation in, or information from, any investigation undertaken by CASA. ATSB Officers who participate in a CASA investigation must comply with any lawful direction given to them by the CASA Officer-in-charge of the investigation.
So join your own bloody dots but the BRB Xmas hypothesis gets my tick of approval...
I'll be back...