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Old 10th Jan 2015, 23:54
  #2612 (permalink)  
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
PelAir MKII: M&M, Beaker, Sanga Contributory Factors?? - You Bet!

Reality of current status quo...
So what we have left in the post Stray/Bills era is 3 x non aviation Commissioners (unbelievable, I know), a lapdog called Sangston, the loss of 200 years worth of investigation skill and a Murky Machiavellian who continues to leave the government of the day frightfully exposed should ever a serious occurrence occur and be attributed in part or whole to issues identified publicly yet covered over!
...then from Sunny...
Why would a sane person NOT suspect official corruption?
Why indeed? A question that no doubt has passed through the mind of any of a number Senators involved in or having a passing interest in the PelAir debacle. Example from 24/02/14 Estimates:
CHAIR: How did it go from a critical incident to a 'don't worry about it' incident?

Mr Dolan : That is a matter we did rehearse with the references committee. In short, our initial assessment of the issue of guidance as to dealing with the situation, weather deterioration and what was planned, we overassessed it as critical at an early stage and by applying our methodologies we concluded by the end of the process that it constituted a
minor safety issue.

CHAIR: Can I commend you. You look really well. You look less stressed than you used to for some reason.

Mr Dolan : It is probably the lack of the beard.

CHAIR: With that particular incident of which I just spoke no thinking person would believe that bureaucratic answer. You cannot go from a critical incident to a minor one or whatever it was without something happening on the journey. Anyway, we will not go back there. To any sensible person it sounds like either a cover-up or a balls-up.
However for my 1st of the year Sundy Cogitation I'd like to further reflect on some passages of Hansard from the 28/02/13 AAI public hearing that focussed on 'Contributory Factors' - & the lack there of in the PelAir final report:
Mr Dolan : As I tried to state—and perhaps I am not making myself clear—the principal purpose of an accident investigation, or an occurrence investigation, is to understand 'cause', which in our case we do by way of identification of safety factors and safety issues. Our attention, quite reasonably, remains on that. Our mandate is really to look at, and to understand to the extent necessary, the context and the relevance of the context within which the occurrence happened. There is still nothing in our assessment that we could see, acknowledging that there were deficiencies in CASA's surveillance and activities, and acknowledging that there were problems with the way Pel-Air operated its safety management system, that was going to lead us to the question of contributing safety factors and, more particularly, to the identification of areas for safety improvement. We were conscious that CASA, for it is regulatory purposes, was undertaking steps in relation to the pilot, in relation to Pel-Air as the operator and, indeed, in relation to itself in terms of those improvements, so the question was: if there is an intervention from CASA in terms of rectifying some problems of noncompliance, what is the extent to which we have to retrace that territory in the interests of safety improvement? They are the balances we are undertaking in the course of scoping and re-scoping our investigations.

Senator FAWCETT: I understand your talk about balancing and not going over the same ground, but where another agency has already done the work, and that report is now presented to you, and that agency has identified—again I go back to paragraph 4.1:

It is likely that many of the deficiencies identified after the accident would have been detectable through interviews with line pilots and through the conduct of operational surveillance of line crews in addition to the surveillance of management and check and training personnel.

It says here:

If a systems audit is conducted with inadequate product checking—
that is, the line pilots—
CASA is unable to genuinely confirm that the operator is managing their risks effectively.

Are you still maintaining the position that that is not an organisational influence or a risk control that was a contributing safety factor, in terms of not only the incident pilot but also the fact that the rest of the line pilots indicated similar lack of compliance and lack of understanding, to this incident and potential like incidents?

Mr Dolan : That is our position, Senator Fawcett, and clearly you disagree with it. It is the influence of those factors on the accident flight in particular which always has to be the principal but not the only focus of our investigation. It is the influence of those known factors in the events of this flight that we always have to come back to, because of the task that we have been given as the accident investigator.

Senator FAWCETT: You have used the term 'known factors'. I put it to you that, had you received this report before the issuing of your final accident report, they would have been known factors because they are spelt out in black and white. I take you again to the diagram you have on page 13, where you look at risk controls and you ask question: what could have been in place to reduce the likelihood or severity of problems at the operational level?

Again, I go to the Chambers report, where it talks about inspector capability and performance. It talks about the fact that an inspector needs to have a level of investigative skill to drill down to find the deficiencies that are genuinely serious and often complex. Not all inspectors have this capability and it seems that this characteristic is assumed to exist in an inspector. It then goes on to talk about the scratching-the-surface approach and the fact that the inspectors, in Pel-Air's operation, were not even aware of the routes that they flew, or the fact that the majority of their operation was EMS as opposed to cargo. Coming back to your table, surely what could have been in place were inspectors who were competent and informed, as well as an appropriate oversight program. Does that not fit the definition of your risk control?

Mr Dolan : Those sorts of circumstances certainly fit in to the picture of what would constitute organisational issues. Where we appear to be at odds is in the question of the level of contribution of those factors in the particular occurrence that we were investigating. That is why we have the position that we have taken. We carefully reviewed the chamber's report, and the basis on which we responded as we did was the issue of influence, contribution, cause.
For the benefit of those interested these were the contributory factors in the PA final report:
Contributing safety factors
• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.
From my previous post I quoted from the same 28/02/13 Hansard where DF mentioned an Indonesian NTSC investigation:

Here is a link for that investigation report - DORNIER 328-100 PK–TXL; EXPRESS AIR FAK-FAK, PAPUA REPUBLIC OF INDONESIA 6 NOVEMBER 2008

This is part of the section of that report to which Senator Fawcett refers:
1.17.4 Airport Emergency Planning

Based on the lack of emergency personnel and equipment at Torea Airport, Fak Fak, Papua, to respond to an aircraft accident, it was clear that emergency planning and exercising did not meet the ICAO Annex 14 Standards.6

ICAO Annex 14 contains Standards and Recommended Practices with
respect to Airport Emergency Planning.

Paragraph 9.1.12;
The plan shall contain procedures for periodic testing of the adequacy of
the plan and for reviewing the results in order to improve its
Note.— The plan includes all participating agencies and associated

Paragraph 9.1.13
The plan shall be tested by conducting:
a) a full-scale aerodrome emergency exercise at intervals not
exceeding two years; and
b) partial emergency exercises in the intervening year to ensure that
any deficiencies found during the full-scale aerodrome emergency
exercise have been corrected; and reviewed thereafter, or after an
actual emergency, so as to correct any deficiency found during such
exercises or actual emergency.

ICAO Annex 14, paragraph 9.1.14 states that:

The airport rescue and fire fighting services shall have a plan that
shall include ready availability of coordination with appropriate
specialist rescue services to be able to respond to emergencies where
an aerodrome is located close to water/or swampy areas and where a
significant portion of approach or departure operations takes place
over these areas.

Paragraph 9.2.2 states that:

Where an aerodrome is located close to water/or swampy areas and
where a significant portion of approach or departure operations takes
place over these areas, specialist rescue services and fire fighting
equipment appropriate to the hazards and risks shall be available.
And this is from the conclusions section (findings):
3.1.10 The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.
3.1.11 The DGCA had not filed a difference with ICAO with respect to its inability to comply with the Annex 14 Standard for runway end safety areas at Torea Airport, Fak-Fak, Papua.
3.1.12 The airport did not meet the ICAO Annex 14 Standard with respect to the airport emergency personnel, equipment and exercising of an airport emergency plan.
Finally these are the relevant recommendations to the DGCA that the contributory factors helped generate...:
5.5 Recommendation to the Directorate General of Civil Aviation
The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the Torea Airport, Fak-Fak, Papua runway complex to ensure that runway end safety areas (RESA) are established that meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14.
Particular attention should be given to:

• ICAO Annex 14 Paragraph 3.5.2 (Standard) that a runway end safety area (RESA) shall extend from the end of a runway strip to a distance of at least 90 meters.

If the DGCA is unable to meet the RESA Standard in accordance with ICAO
Annex 14, it should file a difference with ICAO as soon as possible.

5.6 Recommendation to the Directorate General of Civil Aviation

The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) ensure that the operator of Torea Airport, Fak-Fak, Papua surveys the Torea Airport runway complex and ensure that the runway dimensions promulgated on aerodrome charts are accurate.

5.7 Recommendation to the Directorate General of Civil Aviation

The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the procedures and equipment used by the Toera Airport, Fak Fak, Papua, Rescue and Fire Fighting Services to ensure that they:

meet the minimum requirements specified in the International Civil Aviation Organization’s Annex 14.
Now compare that to the organisational/ regulatory oversight issues that were highlighted both in the CAIR09/3 report (ref: post #2653), in the FRMS (Cook) SAR and in the Chambers report - oh that's right that was all classified as irrelevant & simply scoped out of the Final Report...

I'll be back...
Sarcs is offline