Merged: Senate Inquiry

[Sarcs]

Wow! New Year..new page now let's clean out the dross.

And a happy New Year to you Mr Ferryman would you like a dollop of cream on your donuts??

Love it "K" first choccy frog for '15 perhaps...

Now, that's not corrupt, no Sir, it's just the spirit of cooperation shining through to ensure that business as usual is not disturbed. Smooth as silk.

& the quote from Creamy is top shelf...

CP -Prepare for a masterclass in using the infinite flexibility of language to choose any approach you like from time-to-time to justify anything you like from time-to-time time::::

Just re-winding a couple of weeks before we move on and down the new page...remember this from Ben - Reopened Pel-Air inquiry could be on slippery slope to ruin??

Nevertheless, the Minister acted, and on 6 December, based on very, very good advice, Plane Talking reported that a replacement for the chief commissioner of the ATSB, Martin Dolan, would be announced, and some serious work on the matters identified in the TSBC report would occur.

That appointment hasn’t yet occurred, and the report in Plane Talking is either wrong or premature. Since then Plane Talking has seen correspondence which would suggest to a reasonable reader that a determined effort to frustrate what might be the Minister’s best intentions (or not) is underway.

It seems like the iron clad rule of life in public administration in Australia, that it takes precedence over the elected executive branch, and will run right over the top of injured or damaged parties without any concern other than keeping Ministers compliant, and administrative decisions untouched, is being pursued with determination.

But not necessarily success. The Pel-Air genie is out of the bottle, and Australia is in the humiliating position of attempting to maintain the validity of a nasty second rate accident report that by world’s best practice is a joke.

Mr Truss could emulate his Labor predecessor, Anthony Albanese, and run away from accountability for the quality of the report, and the woeful lack of progress in reforming and administering the air safety regulations of this country. It might however be very wrong to assume he is that weak, and no such assumption is being entertained here for the immediate future.

The problem for Mr Truss, and the ATSB and CASA is that the work done by his own coalition colleagues, Senators Bill Heffernan and David Fawcett, Labor’s Glenn Sterle, and independent Nick Xenophon, is notably and in copious detail, damning of the conduct of Martin Dolan, and the former director of air safety for CASA, John McCormick, and uncovered matters relating to the conduct of CASA and the ATSB that are in Hansard for everyone to find and digest.

Make no mistake, that conduct in relation specifically to the Pel-Air matters, as well as some necessarily broader issues, was second rate, prejudicial to damaged or injured parties, sub-standard by world’s best practice and inherently contrary to the safety interests of airlines and their passengers flying within or to and from this country.

Pel-Air, in the TSBC, and in the Senate committees that have probed those matters, is a small plane crash indicating much bigger questions need to be asked about the conduct of both authorities, as well as the now discredited position taken by the secretary of the department of Infrastructure, Mike Mrdak, that there was no safety benefit to be had in re-opening the crash inquiry.

The senators named above have no intention of letting this matter go through to the keeper. They will keep hammering away at this until the matters are cleared up, and Mr Dolan removed from his role at the ATSB, in the process of dealing with more serious safety administration issues.

Which IMO deserves a bucket of choccy frogs but there you go.

Well since the Miniscule's fateful speech to the Parliament & apparently one passing strange, brief MH370 telephone interview with Bloomfield (Dolan on MH370 - "Ad libitum"?? ) it would appear that Beaker has gone MIA which I suppose is normal practice for most Public Servants over the Xmas hols:

Christmas closure

The ATSB’s offices will be closed for normal business from Thursday 25 December 2014 to Friday 2 January 2015, with only priority services available.

Immediately reportable Incidents and accidents can be reported to the notifications line on 1800 011 034.
Written aviation notifications can be reported online.
Confidential safety concerns (REPCON) can be reported either online or a phone message left on 1800 020 505. These will be processed from 5 January 2015.
General enquiries can be made on 1800 020 616.
Requests for flight crew licence checks during this period will be processed from 5 January 2015.
The Commissioners and staff of the ATSB would like to wish everyone a safe and happy Christmas and New Year. Please take care if you are travelling during the holidays.

& this from the JACC in charge of the MH370 search in the SIO - MH370 Operational Search Update—
23 December 2014:

The Australian Government remains committed to the MH370 search. While search operations will continue uninterrupted over the Christmas period, there will be no MH370 Operational Search Update on Wednesday, 31 December 2014.

However Beaker seems to have this infatuation (if it is Beaker..) with talking to the international media, here he was again talking to the New York Times on Monday our time - In Shadow of New Search, a Long Aviation Mystery Remains Unsolved:

“We remain confident that we will find the missing aircraft in that search area, but obviously because it is about probability, we can’t give an absolute guarantee,” Martin Dolan, the chief commissioner of the Australian Transport Safety Bureau, said Monday morning in a telephone interview.

Hmm...think someone needs to get a muzzle on the Beaker...

Addendum last post for 2014:

From the Sanga missive which refers to the TSBC peer review report it would seem that the new fall guy (other than DJ of course) will be the IIC, example:

CASA had conducted a special audit of Pel-Air from 26 November to 16 December 2009, after the ditching. The IIC was concerned that reviewing the special audit report might bias the ATSB investigation, and so did not request a copy. The ATSB received a copy of the CASA special audit report in July 2012, during the DIP process.

Which is partly true for indeed the IIC did drop the ball, cave in to pressure and subsequently going all insular with the carriage of the PelAir investigation:

3.7.2.1.3 Company and regulatory oversight

In this investigation, very little of the data collected documented the actions taken by the regulator to oversee Pel-Air's operations or the actions taken by Pel-Air itself. Data collection at Pel-Air consisted of interviews with the occurrence crew and the Westwind fleet manager and a review of documents Pel-Air had provided. Investigators had not interviewed additional Pel-Air crews to determine the extent to which the flight planning and fuel monitoring deficiencies observed in the occurrence existed throughout the company, and only one management interview had been conducted over the course of the investigation.

Similarly, no interviews were held with CASA operations inspectors who were familiar with the operation and oversight of Pel-Air, and several key documents, including the CASA special audit of Pel-Air, were not obtained until very late in the investigation.

The lack of data in these areas was felt throughout the investigation. Two examples of this are the removal of a finding with respect to Pel-Air's oversight of its aeromedical operations,Footnote 20 and the lack of any analysis of CASA's oversight of Pel-Air.

The reasons for inadequate data collection in these areas will be discussed below in the section on governance of the investigation.

But that doesn't mean that the Team Leader(s), GM Sanga, Chief Commissioner Beaker & co get off Scott free... Let us take a look at the section mentioned above and ID where the above mentioned cop some flak (in red):

3.7.3 Management and governance of the investigation

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 (1) believed it was well understood that the investigations were fully independent and that there were no barriers to the ATSB investigation. {(1) After the Senate AAI report you gotta laugh at that one..}

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.
Oversight of investigation

Accident investigation bodies are entrusted with conducting comprehensive, impartial investigations into transportation occurrences in order to improve safety; staff complete the investigation work on behalf of the agency. There should be several layers of oversight and multiple processes to ensure that the output of the investigation is rigorous and defensible.

At the ATSB, the levels of oversight above the IIC are the team leader, the GM and the Commission. Quality-control processes, in addition to regular supervision by the team leader, included analysis coaching, critical investigation reviews, and peer reviews.

Although the processes in place provided multiple opportunities to address problems with the data quality and analysis, as described above, the lack of effective communication and weaknesses in the follow-up meant that certain issues remained unaddressed throughout the investigation:

• Critical reviews were conducted periodically during the investigation but did not identify specific shortcomings in the data collection or analysis. The TSB Review team repeatedly heard that the critical review process was a valuable opportunity to discuss how to manage investigation risks, but that it was high level and unlikely to identify shortcomings related to data sufficiency or analytical rigour.
• The GM and the team leader relied upon the expertise and judgment of the IIC when communicating the “critical” safety issue to CASA, and did not review the underlying analysis.
• The breakdown in the analysis coaching did not prompt any action on the part of the team leader to explore the reasons for it, or to address weakness in the quality of data or analysis.
• Multiple peer reviews were commissioned over the course of the investigation. The IIC appears to have been unaware of the latter two peer reviews until they were complete, indicating ineffective communication between the IIC, the team leader and the GM. Although the IIC responded to each peer review, he was working in isolation, and it was left to him to accept or reject the peer reviewers' input. In the end, a number of critical points raised by the reviewers were not addressed and did not result in additional data collection or analysis.
• The report passed the team leader's review, but the GM found it to be analytically weak. Rather than returning it to the team leader or IIC, the GM personally edited the report so that the analysis was supported by the available information. WTF??

Attempts to address problems with the quality of the analysis relied on peer-centred processes rather than on direct intervention by the team leader. In addition, few steps were taken to ensure that these attempts resulted in adequate analytical support for the report findings. This approach was evident at all levels, as indicated by the GM's decision to revise the report himself. Ultimately, ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.

A number of factors underlying this indirect approach were identified to the TSB Review team.

• There was a change of team leader, and some of the critical events, such as the breakdown of the analysis coaching, took place in the transition period.
• During the Norfolk Island investigation, the ATSB was undertaking an atypical number of high-profile level-2 investigations that were consuming significant resources and attention. For example, the second team leader was deployed to a major investigation outside the country as the IIC was completing the initial draft of the Norfolk Island investigation.
• There was a backlog of investigation reports, and the GM was trying to deal with it by editing reports himself, while at the same time as addressing the issues of analysis and team oversight.

Yep no doubt about it t'was very, very ugly...

I'll be back!