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Old 9th Jan 2015, 01:08
  #2606 (permalink)  
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
Pel-Air MKII & the bollocks factor??

The spot on Sceptical comment followed the Anderson comment;...
...A very dark day in ATSB history was when that farcical report was released.
ATSB credibility in the aviation sector (and undoubtedly the others as well) - Gone!.

Martin Dolan must now be removed from his post as head of the ATSB - the report and the circumstances surrounding it left no doubt the ATSB was happy to have CASA dictate the content of reports and direct inquiries.
The words 'collusion' and 'deceit' come to mind

ATSB independence, impartiality and integrity - None!...
...both comments perfectly highlight what should have happened once the Pel-Air MKII was formally announced but due to the morally bankrupt individuals involved didn't...
It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far.
Totally and utterly agree... But to support the Sceptical & Anderson opinionated commentary let us take perhaps one final look at the now recorded evidence (some hearsay, some factual) presented in the TSBC peer review report and the Senate AAI inquiry.

Quotes from TSBC report supporting Sanga COI:
The GM was making these revisions himself, and he did the same for the draft Norfolk Island report. It was in the course of this work that the GM concluded that the available data did not substantiate classifying the safety issue on guidance for en-route weather-related decision making as significant, and modified the report to recast it as a minor safety issue.
From under the section 3.7.3 Management and governance of the investigation:

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:
  • ...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...
  • ...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...
...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 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...
All of which IMO proves beyond doubt why the current GM of aviation investigations should not be anywhere near the Pel-Air MKII re-investigation; which includes sending vomitus missives to the DIPs...
Next - quotes from TSBC report in regards to Beaker:
When the Commission reviewed the report in June and July 2012, the commissioners expressed concern that there was insufficient factual information and analysis in the report to support a finding related to oversight of aeromedical operations by Pel-Air. The Commission was also concerned that the CASA special audit of Pel-Air was not relied upon more extensively.
Communications among commissioners indicated that there was concern with the lack of analysis of the adequacy of company and regulatory oversight, especially in light of the CASA special audit report. However, this concern did not result in changes to the report.
Passing strange that both those quotes would appear to be in direct conflict with Dolan's evidence given in the AAI public hearings...

1st Hansard quote 22/10/12:
Senator XENOPHON: How do you reconcile the ideals set out in your submission with the fact that the CASA special audit does not make it into your report? There is no mention of it. Serious organisational issues with respect to Pel-Air do not make it into your report—how can that be?

Mr Dolan : We do not explicitly refer to the CASA audit report in our investigation report. We provided the committee, which probably has not had a chance to consider it yet, with our assessment —

Senator XENOPHON: Sorry, have you not had a chance to consider the CASA special audit?

Mr Dolan : No, we have reviewed it carefully, and we have reviewed it carefully in the light of our report.
There were a range of factors that were highlighted in the CASA special audit that we believed we had already addressed, particularly in the factual basis of our report.

Senator XENOPHON: But why didn't you mention the CASA special audit in your report? It goes to systemic issues, it goes to organisational issues, it identified a number of deficiencies in relation to Pel-Air's operations, yet not one mention of it is made in the ATSB report about an incident involving a Pel-Air aircraft.
2nd Hansard quote 15/02/13:
Senator XENOPHON: When did you ask for the CASA special audit conducted on Pel-Air?

CHAIR: It was a short while before you concluded your report, as I recall.

Mr Dolan : It was at a late stage in the process, yes. We can get you the exact date.

Senator XENOPHON: It was at a late stage in the process. Can I suggest to you the only reason you asked for that CASA special audit, which was not provided to you by CASA, was that Mr James's lawyers had contacted you, Mr Sangston, saying, 'We understand there's a special audit and we'd like to get a copy of it.'

Mr Sangston : Sorry, Senator; I was just looking up that date.

Senator XENOPHON: My understanding is that it took Mr James's lawyers until as late as 3 July 2012 to write to you saying, 'We understand there's a special audit; we'd like to get a copy of that special audit,' and that until that time you had no awareness of the existence of that special audit.

Mr Dolan : No, I do not think that is true. Mr Sangston may wish to disagree with me.

Senator XENOPHON: Or was it that you thought it was not relevant to provide to Mr James as a directly interested party?

CHAIR: As I understand it, there was a press release in 2009 from CASA saying that they were going to have the audit, so the world knew about it.

Mr Dolan : We were aware that CASA was undertaking a special audit.

Senator XENOPHON: When did you get a copy of that?

Mr Dolan : As I say, Senator, it was very late in the process.

Senator XENOPHON: After 3 July 2012?

Mr Dolan : Yes, Senator, I believe it was in late July or early August.

Senator XENOPHON: You are aware that CASA had conducted a special audit, but you did not think it was relevant to your investigations to get a copy of that special audit into Pel-Air?

Mr Dolan : We were happy that our investigations were covering the territory we needed to cover in understanding the facts.

Senator XENOPHON: Sorry, could you say that again, I could not hear you?

Mr Dolan : We were happy that our investigation was covering the relevant territory. On analysing the special audit report—and I believe we supplied a table reflecting this to the committee—we satisfied ourselves that the major lines of inquiry that had been undertaken through the special audit were ones that we had also turned our minds to.

Senator XENOPHON: But how do you know without seeing the document? How would you know that? How would you know that you are satisfied with a particular line of inquiry when you have not even seen the report? You were aware of the report but you did not bother to ask for it?

Mr Dolan : We do not as a matter of routine seek special audits. Special audits are for the purpose of CASA's regulatory activities. We try and keep our investigations, as much as we can, separate from what CASA has to do. It is not as a matter of default that we would see and try to rely on CASA regulatory investigations as a basis for our work.

Senator XENOPHON: But in the context of the memorandum of understanding about the exchange of information between the two agencies, in the context of this investigation, in the context of Mr McCormick expressing his views that they were changing their rhetoric and hardening their view and concerns within your organisation about egg on ATSB's face and CASA's face, you did not think it relevant at all to obtain a copy of a CASA special audit into Pel-Air, the very airline that was involved in this incident? I just do not get it. How can you explain it to—to use Senator Heffernan's terminology—the reasonable man, the reasonable person at the back of the room? What has gone wrong here that you did not get the CASA special audit?

Mr Dolan : As I said, Senator, we do not as a matter of routine seek special audits. CASA undertakes special audits for their purposes; we undertake investigations for our purposes. There are times when it may be helpful to us to take a look at what CASA has been doing but it is not something we would consider as a matter of default.

Senator XENOPHON: What a terribly glib answer, Mr Dolan. You are investigating an accident where six people could have died. You did not see the relevance of getting the special audit? This is not a routine matter. You are actually in the midst of an investigation and you deliver a report nearly three years after the event that cannot, on any reasonable standard, comply with ICAO annex 13. There are reports from Nigeria and Lebanon, from countries that could be seen as developing countries, that comply with ICAO annex 13. Do you consider you have complied with ICAO annex 13 with this report?

Mr Dolan : Yes, Senator.

Senator FAWCETT: Bearing in mind time, I note that we have just come to that issue of annex 13. I note in your submission you highlight that you have requested a number of exemptions or notified departures from that in a number of areas. My comment would be that I think, if those departures have resulted in this report, then they should be re-examined because they are clearly, in terms of the information flow from CASA to yourselves around the role of the regulator and operator as well as the individual, and all the other issues like fatigue that roll into that, there were clearly a number of contributing factors that were not considered in any thorough way in the report. I think those exemptions should, perhaps, be revisited because they do not meet the test, as Senator Heffernan would say, of the reasonable man at the back of the room.

Mr Dolan : I hear what you are saying and the only comment I feel I should make in that case is that I would disagree with you that there were significant contributing factors that existed and we did not detect and include in our report. But we have different opinions on that.

On a final note and on the subject of significant organisational issues - that should have been included in the PelAir final report under at least contributory factors but wasn't... Here is a section of Hansard of particular relevance taken from the 28/02/2013 public hearing:
Senator FAWCETT: Do you happen to have looked at the Indonesian report from 6 November 2008 into a Dornier aircraft that had its undercarriage collapse after a heavy landing?

Mr Dolan : No, that is not one that I can recall having looked at.
Senator FAWCETT: I merely raise that to highlight the point that my understanding is that the ATSB actually spent some time instructing, supporting and helping the Indonesian government in terms of their ability to conduct aviation accident investigations?

Mr Dolan : That is correct.

Senator FAWCETT: As I look at the scope of the report, whilst it was fairly clear from their examination that in this case it was pilot error—a fast approach, inappropriate crew interaction and other things—they were very brief but quite good in highlighting that things like the runway and safety area airport facilities oversight and the level of compliance were not up to speed. They were quite blunt about making those observations around other government agencies and around the recommendations that then flowed in the report to those other agencies and the operator, which can then clearly be tracked.

Noting the Air France report looking at the A330 that had the icing problem, and EMS accidents in the USA, all of them appear to take the same basic analysis model you have started with but put quite clear emphasis on organisational factors that you are saying, even having looked at the Chambers report, are not applicable. Does it concern you at all that we seem to be out of step with our near neighbours as well as probably the world leaders in aviation?

Mr Dolan : Important though it is, the Norfolk Island investigation report is only one of a considerable number of reports we produce on an annual basis. Each investigation results in those reports. We have an assessment as to scope, taking account of a range of factors, and in a number of cases, because we think it is necessary for the purposes of the investigation to go all the way to organisational factors both at the operator level and the regulator level, we will quite often go there and make quite clear statements and findings in relation to it.

Senator FAWCETT: When did you say that starts? At the start of your investigation process?

Mr Dolan : It is in the course of the investigation. We have critical reviews as necessary, which sometimes result in a variation of scope. While in a practical sense availability of both our expert investigators and the broader resources to support investigations are in play there, it is also about whether it appears that organisational factors have had an influence in this area, and, if the evidence is sitting there in the course of the investigation, we will go there. And there is a whole range of reports I could draw your attention to where we clearly have done that. I think our reports, taken as a whole, are up there and quite comparable to those other countries.

Senator FAWCETT: In this report in particular, looking at the information you have provided to us—and some of those emails are now in the public domain—clearly the accident investigation officer, the officer in charge, proceeded initially on a whole-of-systems basis. If I recall correctly you had a discussion with Mr McCormick or an officer of CASA around the fact that it was a systems approach, but then made a comment back to the investigating officer that CASA now appear to have changed their view on having it as a systems approach. Not long after that the ATSB approach seemed to have scoped out all of the organisational factors. Can you offer an explanation to the committee for why that changed and the scope was reduced, if you had that original review and you started off as ATSB saying that this was best practice and you were going to look at all the organisational factors?

Mr Dolan : We do not appear to have a common understanding. From my point of view and the conversation reflected in that email exchange that went not to the general set of organisational factors but to the point that we had sitting with CASA at that point a critical safety issue. We were saying, based on where we were then, here is this particular issue in relation to guidance as to what happens en route, the receipt of weather information and so on and that we think it is important. We though this important issue was systemic and in initial conversations that seemed to be where CASA as a regulator were focussing—that is, there is a possibility we will need to change our guidance and other materials. When they reviewed that they formed a view that that was not where their attention as the regulator should be and turned their attention to compliance with the existing system. That exchange of emails is trying to relay—apparently not with clarity—to others now reading it how I recall the conversation about what was going on.
IMO it is simply unacceptable & reprehensible that both these senior executive figures (at least) still have jobs; let alone that they now think it is acceptable for them to oversee & set the ToR for Pel-Air for a Judicial Inquiry?? Yeah bring it on...

I'll be back...

Last edited by Sarcs; 9th Jan 2015 at 04:07.
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