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Old 1st Feb 2015, 20:16
  #689 (permalink)  
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
Memory of an elephant - MKII

Horatio: "...I have probably posted this story earlier in this thread or on another thread on this topic, but to have Dr Michael Walker conduct the ATSB's review on this report given his obvious close relationship to Dolan an his emotional investment in the original report STINKS TO HIGH HEAVEN..."

Totally agree with your sentiments HL - however my memory dims on when you may have posted such a twiddle.. Could you perhaps jog your memory a little more or point me in the right direction to where I may track down a transcript of this occasion...

Here are some links to the now banished (not forgotten) 2nd Senate Thread that took up the CV and the huge COI in the bureau (under Dolan)in re-investigating it's own abysmal PelAir Final Report:

Theorists vs realists
Not sure I'll be personally voicing an opinion on the Doc on here anytime soon but the first indications are not entirely promising - apparently the following image was attributable to Doc Johnny:

(my brain hurts just looking at that theoretical Doc masterpiece.) -

Please...please Miniscule bring back 'Reason' & Alan Stray (or his look-a-like). And Miniscule while we are at it please pay attention to the excellent advice/response freely provided by AIPA in regards to ASRR recommendation 5...:

Recommendation 5
5. The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience.

AIPA strongly agrees with this recommendation. However, despite the Government and the ASRR Panel rejecting the Senate Inquiry recommendation that the Chief Commissioner should have that experience and noting the multimodal role of the ATSB, our full support remains with the Senate recommendation.

AIPA rejects the Panel’s view that aviation expertise provided by a part-time Commissioner is sufficient. Our view is that aviation is by far the most complex of the transport modes and the related operational expertise is more easily applied across the other modes.

AIPA also notes the Panel’s view that the Pel-Air investigation and report were an aberration in terms of how the ATSB should be viewed. In light of the material presented to the Senate Inquiry, such a conclusion appears charitable at best. {Spot on it..}

Kharon:- "...It's bad enough that Dolan and McComic created the unsightly aberration, worse that they attempted to deny ownership of it; but to allow Dolan control of the investigation for a second time beggars belief. The absence of an Indonesian invitation says it all really..."

Totally agree "K" but after reading the following from the Canuck press it maybe a Godsent that we're not invited to the slugfest...: AirAsia Flight QZ8501: Indonesia's aviation safety practices under fire
Memory of an elephant.
However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...

From 3.5 Report preparation (November 2010 to March 2012) of TSBC report:
At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.

They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.
But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...

However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):
1.17 Organisational and management information
The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.

Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-

1.17 .1 Fuel Policy and Practice
• Inadequate fuel policy for Westwind operations.
• Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
• No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
• No alternate requirements specified for remote area and Remote Island operations.
• The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
• Criteria to obtain weather updates not specified in Operations Manual.
• Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
• No consideration of loss of pressurisation and an engine failure.

1.17 .2 Operational Control
• No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
• Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
• The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
• In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.

• Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.

1.17.3 Training
• Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
• Inadequate documentation of training programs.
• No formal training for international operations.
• Inadequate training records for pilot endorsement and progression.
• Inadequate records of remedial training.
• Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
• No mentoring program for First Officer to Command.
• Deficiencies in training records identified.

1.17 .4 Fatigue Management
• Over-reliance on FAID as the primary fatigue decision making tool.
• Inadequate adherence to FRMS policy and procedures.
• Excessive periods of 24/7 stand by.
• Lack of FRMS policy regarding fatigue management for multiple time zone changes.
• Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).

1.17 .5 Drug and Alcohol Management
• Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.

These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.
Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture... Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5(PDF 6032KB)...

The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..

18Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)
Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA?

How indeed??
Hmm...interesting I noticed this from Eddie at the bottom of that page...:
Look Left Quote:
but overlooked the simple fact that if the go-around was conducted according to the manual (pressing the TOGA buttons) then it probably would not have happened.
I agree Look Left, the simple fact that an error occured in the cockpit in spite of correct organisational checks and balances(SMS), is overlooked.
The blind adherence to the James Reason model can lead to interesting results when there is either an accidental or wilful violation.
Oh & by the way top stuff Soteria & the intel Sot's and the subtleties Creamy...

Ps For Ziggychick good luck today & stare the buggers down...on the subject here is one from the BK chronicles - The Seaview disaster: conscience, culture and complicity - oh memories...
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