Transair and the Regulator.

[Tarkeeth]

Just heard that tonights 7.30 report on the ABC will cover the above issues.

Perhaps that should read the Regulator and Transair!!

[OpsNormal]

I wonder just how much the ATSB is now being inundated by incident reports from industry as a consequence of this recent re-awareness of late?:E :E

[Time Bomb Ted]

Did it happen? Was it on? Who saw it?

Ted

[captain_cranky]

http://www.abc.net.au/7.30/content/2006/s1812886.htm

[KRUSTY 34]

I asked the question in a previous thread; "Why didn't CASA shut these guys down years ago?"

What followed was a diatribe of legal excuses and gobblygook!

It appears now that the question is being asked by more than one interested party.

It blows me away to think that in the 21st Century we still have a regulator that is either unwilling or unable to protect the travelling public from these type of operators.

The question needs to be asked and it needs to be answered.

Shane Urquhart and the other families of the victims deserve nothing less.

[Lefthanded_Rock_Thrower]

What if there is not an answer to the questions ?.

What if this terrible accident happened purely through one mistake by the crew on that day, note that crew and aircraft had flown that route many many times, on the same approach in equally miserable or worse weather and survived.

This is a storm in a tea cup, I would tend to agree that the regulator looks a tad silly having appeared to change its mind mid stream.

In my opinion, Mr Urquhart is entitled to some closure ( as is other PPRUNE regulars involved ), but they are hardly a constructive part of the process, grieving families have a very narrow agenda.

Do a search on PPRUNE, there are many many accidents, C206-Horne Is, C210-Groote, C210 - Sweers, where the families spend tens of thousands of dollars and years of their lives trying to prove the pilot / operator are negligent.

How many operators want their aircraft to kill crew/pax ?.

[Fidoda]

Lefthanded_Rock_Thrower,

Grieving families may have a very narrow agenda but you can hardly blame us. I don’t know if you’ve ever experienced losing someone in such a sudden devastating way but I’m sure you can empathise with how horrendous it is to have a conversation with your loved one the night before and then never have that privilege again.

I don’t think there is any doubt that the pilots mad a mistake on the day but the fact is Transair clearly promoted a poor safety culture – one that seemed to be endorsed by CASA.

Transair have been made accountable, although CASA still state that none of their operational or maintenance problems identified contributed to the accident. Again, the words “Poor Safety Culture” spring to mind! Mr. Urquhart, myself and other relatives of the victims may chose to spend money on making others accountable and again can you blame us! I guess until someone walks in our shoes it may seem like we have a “narrow agenda”.

Cheers,
Fiona Norris

[Lefthanded_Rock_Thrower]

Hi Fiona,

I certainly do not blame the families for wanting answers, there is only one way i could understand your pain, and i hope that never happens. I guess i also would have a narrow agenda, other than making me feel better, what will it achieve ?.

There is a basic legislative frame work put in place by CASA that defines how we operate safely, that is the CAR's, CAO's, AIP's, CAAP ( i'm sure you know what i'm talking about ).

For AOC holders there is an additional document, the ops manual, that covers operation/company specific issues.

"Poor Safety Culture", that is a very subjective catch cry. There is legislation in place from CASA to ensure what did happen, was not supposed too, and then post accident modified to ensure it does not happen again, this is how it works.

Many unfortunately have died before Paul to put the current legislation in place, these rules are cast in blood.

You may have heard recently from disgruntled staff that also offered their personal interpretation of how poor the safety culture was, but put it into perspective. There is nothing more a disgruntled employee wants to say more than " i told you so", this is not constructive.

Transair have operaed for many many years, why is it that Pauls flight was the unlucky one ?, i often think of the swiss cheese model, on that day all the holes lined up.

Safety in aviation is a risk management strategy, grounding all aircraft and revoking all pilots licences is the only way to ensure no one dies in an aircraft.

I have never worked for Transair and have no vested interest in the organisation, it saddens me to see families attacking their perceived adversary when they should be trying to get on with life.

You could dedicate your life to putting Transair out of business or making CASA pay, when you succeed someone with the same business plan will step in and take his place and nothing will change in CASA.

Cheers,

Joshua Cox

[bushy]

Fiona
There are many who cannot, and will not possibly understand the terrible experience that you have had, and the effect this has on you. We must forgive them, for they lnow not what they do.
I have "walked in your shoes", albeit a long time ago. The memories and emotions have faded over the years, but the loss is still there.

You have every right to make every effort to do what you consider necessary to find out what happened, and help prevent a repeat of disasters of this nature in the future. I am sure your input and influence will be constructive. and must be respected.

I am sure you are well aware that aviation is a very complex affair and great efforts are made to find the factors that cause these things to happen.
But more complex and incomprehensible are the rules, the regulatory processes, the legal system, and the people involved.
Often, they work in mysterious ways, their miracles to perform. CASA makes lots of rules, and does audits, as it believes it should. It calls itself a "safety authority" (Overseas authorities do not use the word "safety" in their title) and believes it controls safety. Safety is really controlled by the people who are doing the job, working as a big team, and checking one another. But people can, and do make mistakes. I suggest you look at Dick Smith's web site, and see the mistakes that are listed, including the accidental inflight shutdown of an engine in a 737. CASA can find fault with almost any operator, if they wish.

I have no knowledge of, or experience with Transair, and I mke no comment on their integrity or otherwise.

In the Air New Zealand crash at Mt Erebus there were a number of things not quite as they should be before the cresh, and a whole lot more nasty things after the crash. The legal processes were long and far reaching. One honest man who I greatly admire, stood up in court, and admitted a serious mistake. A respected judge was one of the casualties of the legal processes. No-one was jailed.

But slowly and quietly all the baddies disappeared, and Air New Zealand went on to become the great airline that it is today.
Accident investigators learned a lot from those processes, and often refer back to it as the beginning of a new era in accident investigation.
These things work in mysterious ways, their miracles to perform. Sonetimes the obvious things do not appear to be done, but the end result is good.

No doubt there will be legal processes on going from the Lockhart river crash
and these can be frustrating, testing times.

Fiona, you are obviously a strong, sensible woman, and will cope. There are many on PRUNE and elswhere who do understand, and wish you well.
And if you think that silly old bugger in Alice Springs can help. send me a PM.

Good luck.

[Dog1]

Left Handed Rock Thrower,

I am sorry, but reading your threads, I must disagree with some of your notions on accident causation.

For example... What if this terrible accident happened purely through one mistake by the crew on that dayIn the next post, you refer to James Reason's swiss cheese model...
... i often think of the swiss cheese model, on that day all the holes lined up.According to James Reason, "Organizational acidents have multiple causes involving many people operating at different levels of their respective companies." (Reason, J. 1997. Managing the Risks of Orgnisational Acidents, Ashgate, Aldershot, p1)

Reason explains, through his swiss cheese model, that the 'one mistake by the crew on that day' is not a sufficient explanation for an accitents cause.Pilot Error or more widely, Operator Error has not been accepted as the conclusion of an investigation into an organisational accident for a very long time.

"Poor Safety Culture", that is a very subjective catch cry. Safety culture, to those who have studied it is not subjective, it is a very observable phenomena.

Just as a person can be judged by their actions, so can an organisation. Specific observable actions and behaviours, discovered by the investigators through interview of 'disgruntled staff' can lead investigators to conclude objectively that a poor safety culture existed. I refer you to chapter 9 of the book mentioned above, as it expands quite well on the concept of safety culture. It is available at the Joondalup campus of ECU.

My point is that while aviation is indeed a 'risk management strategy' the methods used to manage those risks, the regulations and the standard operating procedures are often bent, forgotten or 'overlooked' by commercial organisations in order to increase capital gain. It takes a robust regulator to ensure that organisations comply with the regulations and standard operating procedures in order to ensure a safe environment for all users of the aviation system.

The 7.30 report seems to have uncovered a weakness in the methods used by CASA to enforce the stated safety systems. I thank Fiona for her continuing efforts. It takes this level of scrutiny to highlight weaknesses in the regulator, empowering them to force organisations to comply with safety systems.

So, in answer to your question...other than making me feel better, what will it achieve ?The end result: The crew and passengers in our skies and people on the ground over which we fly, will be exposed to reduced levels of risk.

[asac]

Fiona I have great sympathy with what you are attempting to do and agree with dog 1 that hopefully we all learn and improve air safety and move on; sadly in the case of CASA this is seldom true. CASA has a culture of deceit, evasion and cover-up. My involvement with them has been a lesson in bureaucratic cock-ups and cover-ups. I would bring to you attention the situation at Albion Park. CASA has made major errors in what it has allowed to occur at Albion Park and now is involved in a massive cover-up which involves, to quote their own internal e-mail, the application of Teflon. CASA does not apply the regulations as been previously stated; CASA is sometimes actively involved in assisting operators to get around the regulations. At Albion Park CASA has issued improper classifications to some of the limited category aircraft based there, has included concessions on the certificates of airworthiness that fly in the face of the regulations and have allowed aircraft to fly over housing estates for the past four years. The regulations clearly state these aircraft are banned from flying over built up areas. Although CASA has been sent Video and photographic evidence it writes to people denying it happens. It is impossible not to happen because the airfield is now surrounded by housing estates and totally unsuitable for the operation of limited category aircraft. These violations are still happening today. For those who wish to debate this fact they should first read the AAT decision at Bankstown on Top Gun. This was another example where a delegate of CASA was bending regulations for particular organizations. It should be no surprise to the public, and an internal scandal at CASA, that the same person is now up to the same set of tricks at Albion Park. If you need assistance in clearly showing the absolute disregard that CASA has for public safety and its own regulations then I suggest you contact the action group at Albion Park. These people will confirm your worst fears about CASA. You can also e-mail me.

[LeadSled]

Fiona,
ASAC expresses some very strong feelings, he (if that is so) sounds to me like an ex-CASA bloke I know who believed the aviation law should be what he thought it should be, not what it actually is.
It is simply NOT TRUE that aircraft certified in the Limited Category cannot fly over built up areas, the operational limitations for ALL Limited Category (and many Experimental certificated aircraft) are as entered on the Annex attached to the Limited Cat. C. of A., and forming a part of the C. of A., and compliance is required by law.
As ASAC is so far off the beam with his comments about Albion Park, perhaps you should treat his other comments with caution.
All the Historic Aircraft Restoration Society (HARS) aircraft have straight forward C.of A’s issued in accordance with the regulations, and they are operated accordingly. Most of the flying HARS aircraft are in the Operational Index Zero category, the operational restrictions are the same as for a Standard Category C.of A. aircraft.
After all, many of the pilots of the larger aircraft are current airline pilots, do you really think they are going to put their day jobs on the line and operate illegally.
Tootle pip!!
PS: I am not a member of HARS.

[Lefthanded_Rock_Thrower]

Dog1,

i guess you missed ,my point,

Accidents do sometimes just happen, unfortunately not all accidents can fall into the systemic or cultural category, systemic or culture indicate a trend of behaviour, how many metros hit the hill in LHR ?.

Aviation is risk management, for eg, when we arrive at a location, how often is the met significantly different to the forecast ?, how can we ensure it is not, have a full time met guy/gal there, but that is not financially viable right, so met forecasting is done by satelite from Mel or Brissy.

So if we arrive at a location and the weather is worse than forecast, this should be a major incident right ?, it could and probably has cost lives in the past.

To suggest that all risk can be removed from aviation is absurd ( not saying you did ), to say there is a level of maintenance that can be administered to ensure your aircraft will never break down is absurd ( no saying you did ), do you see my point, there are still many unknowns, combined with best guess, some SOP's and a very small amount of exact science.

But still the biggest safety issue is the flight crew, how can we ensure they/we are performing at 100%, 100% of the time, or make the right decision when required.

In my opinion it gets very hazy what actually works, one thing i am certain of is that many if these safety catch crys are mere hot air. no agruement from me, good maintenance, good training and relevant thorough SOPs are the essential ingredients for a "safer" operation.

Safe and aviation is like playing a safe game of russian roulette, it just helps if you are spinning the barrel of john waynes 50 shot revolver, as opposed to the conventional six shooter.

It was a sad accident, but is turning into a witch hunt.

"What goes up might come down"

[wateroff]

I don’t think there is any doubt that the pilots mad a mistake on the day but the fact is Transair clearly promoted a poor safety culture



Yes Your'e right - regular meetings were held to come up with new and innovative ways of how to be "less safe" .

Prizes were given to those with the most jackass ways to fly and break rules, thus 'promoting' the poor safety culture.

Choose your words more carefully please!

[Lefthanded_Rock_Thrower]

quote "but the fact is Transair clearly promoted a poor safety culture" end quote.

One can get themselves into a pickle using such statements.

Take the emotion out of it and you'll see that Transair "must" have been a compliant operator to be granted an AOC.

I believe if CASA looked close enough at any operation they would find issues that would probably warrant an RCA or two, that does not mean the operator is "unsafe".

Further to that point, it is infrequent for an audit on an AOC holder not to have atleast one RCA issued, regulations changes, different FOI's have different interpretations of legislation etc etc.

If CASA "knew" Transair was "unsafe" ( read an accident waiting to happen ) they would be obliged to shut them down, immediately. If they did not, someone in CASA will probably go to prison ( Duty of Care ).

So it does not seem so clear cut in that light.

Accidents do happen, that why they are accidents, not events / occurences / incidents / actions.

[joysticks]

These days enough accidents have occured to prove that the "Safety Culture" needed to ensure safe operations from pre-boarding to disembarkation requires a "safety state of mind".
The Leadership and Role Model for this way of thinking and operating is the General Manager.
You should find a statement saying this in the Transair (and other RPT operators) Ops Manual.
This philosophy of "Safety First" has to percolate all the way down from the GM to the apprentice looking for a left handed spanner.
What is required to make this work for pilots is a GM who can see this is the only way to go, (safety is no accident), a Chief Pilot with freedom to make his own independant decisions, Check/ Training staff who are knowledgeable and fair, and good initial and recurrency training.
This is not too much to ask from an RPT Operator who is licenced to take my family from A to B is it?
In my view these are the areas that CASA need to look at in the first place of any AOC holder and chase the paper trail later.
Imagine then if you had a GM and followers who looked only at the "bottom line".
The message from the top becomes "save every minute of flight time, join the holding pattern in a way that suits our revenue rather than the published chart, carry those maintenance snags until it is convenient for revenue to report it, take all the short cuts you can etc. etc".
Does this lead to a "Culture of Safety"?
Does this lead to risk taking?
Does this lead to a non standard GPS approach?
Does this lead to a descent below LSALT when not visual?
etc. etc.
Indications are the aircraft was not at fault.
What do you think!

[Lefthanded_Rock_Thrower]

Joysticks,

all of what you see as regarding safety ethos is a part of any audit, 1-do they have SOP's that address safe operation, 2- are they following those published procedures.

With regards to the bottom line, all operator must be acutely aware of the bottom line, where the problem appears is when ABC Air Charter next door will do the Charter for $100 less.

To sit down and work out exactly what an aircraft costs to run, then add say about 20% profit, is about $650 dollars an hour for a C310/B58, there are still operators out there putting aircraft out for $500 and less, how do they do it you ask.

Take a close look at the Helicopter mustering world, if you sit a Robinson Safety course, they show how a R22 cost around the $400 mark to run, there are operations out there that have advertised $250 per hour, no cost for ferry to the job, interesting isn't it ?.

This type of corruption is in many facet of aviation, the parts not protected by a contract, many organisations that have direct competition ( especially GA ).

A good operator will walk a very fine line between the bottom line and doing things safely.

Logically CASA should be acutely interested in the financial situation of a company, an FOI or AWI are not the right people to be looking at the finances of a air operator.

I have seen 5 or 6 audits and have never seen a CASA accountant on the audit team. This would be a good thing to see happen, if a company is not able to afford proper maintenance and training, how are they going to afford proper maintenance and training, catch my drift ?.

Hey, lay off the left handed spanner jokes :ok:

[boeingwest]

"Take a close look at the Helicopter mustering world, if you sit a Robinson Safety course, they show how a R22 cost around the $400 mark to run, there are operations out there that have advertised $250 per hour, no cost for ferry to the job, interesting isn't it?"

Interesting?? It is VERY interesting LHRT.... I have witnessed first hand 2 operators and the goings on... blatant "who gives a **** I'm 150 hrs over" attitude makes me cringe. I shall say no more... this message will self destruct.... :cool:

[Kiaruku Kid]

Okay Okay - I know I am going to recieve some flack but perhaps? just perhaps a little inside information could be useful. I have no axe to grind but the speculation is hijacking the topic.
SOP's - having worked for TA I can state that until mid Nov 06 there was very little in written SOP even a corporate governance statement. In fact the methodolody in the training department was as has always been since the initial setup to get on the job with a more expereinced aviator as soon as practical. It is was also common practice that the ICUS pilots recieved minimal or sometime no formal assessment as a trainer. The CAR 217 organisation was never operated correctly for years. It may have also been lost that the LHR accident Captain was a Supervisory pilot and base manager - so as such he MUST have held the highest professional standard at the time. The question as to why he permitted and maybe flew the approach is still unknown - but the number of pilots flying for this operator right up to closure without RNAV may be an indicator.
I have flown with nearly every pilot involved with TA - and I have seen nearly all possible SOP variants in that time including some that were outright dangerous.
The fact that SOP's were spoken not written has always surprised me that there were only a small number of incidents. The incidents from the ATSB site are mainly crew related and can stem back to the procedures within the cockpit - not necessarily maintenance related. What is of interest is that did the pilot in command of the incidents report them to the ATSB as per their legal requirements or does the ATSB only act upon the company reported items. Will action be taken against the PIC's for their breakdown in procedure?
The action taken by CASA does not surprise me - when the EVU first came out there was a 2 month delay before action started - the question of CASA is why was a forensic audit NOT conducted on the 8th May 2005? A close look at the CAR 217 would have found some dramatic failings - the training of the CAR 217 flight crews, the experience of the crews and right down to who was doing what check !
Whilst all this will probably come out in the coronial enquiry the fact that the CASA did not act in time will surely not be missed. Perhaps the relationships between the CASA office and the operator need to be examined. It is a reminer to all involved that the names in the logbook can bite your arse for many a year that follows.
(Bunker doors - 'closed and locked')

[sox6]

Lefthanded_Rock_Thrower

Good point re the finances. Same applies to safety culture. Most regulators (and accident investigators) are ex line engineers or pilots. Very few have much idea about business or the socilology of a bad operator.

This thread is also worth a look.
http://www.pprune.org/forums/showthread.php?t=257700

[Kiaruku Kid]

Sox and the left handed rock thrower have raised very genuine points - CASA require as part of the initialissue a statement of financial viability of an organisation. Does this involve more than a cursory glance by the regulaotry services centre? or is the model properly costed against known industry costs?
Surely the financial records of a company in operation - especially after an accident are examined ? Then the affordability for maintenance, training and safety can be openly sighted.
I appreciate the commercial confidentiality regarding shareholdings etc.. but basic operational profit and loss should be available to the regulator - affordable safety rings a bell!
What was the financial status of the concerned company in the months leading up to the accident? what during the CASA action? What caused the AOC to be 'surrendered'?
Rock on the coroner's inquest - there a re more and more rocks which need to be turned over here!

[Lefthanded_Rock_Thrower]

Sox,

"Very few have much idea about business or the sociology of a bad operator", i would have to disagree with the last part of this statement.

An FOI or AWI with a solid aviation background, covering a number of different operators will have exactly that, they will know exactly where to look and for what.

Sitting some university module would be in comparision to experience, a waste of time. it may augment the knowledge of the experienced FOI / AWI, thats about it.

Having an FOI with a flying school back ground looking at an RPT operation would be a useless event.

Cash flow and balance sheets are not the realm of an FOI or AWI.

[sox6]

"An FOI or AWI with a solid aviation background, covering a number of different operators will have exactly that, they will know exactly where to look and for what."

They don't seem able to draw a line before the accident though do they? If they highlight problems they are reliant on the organisation to fix them. If the organisation is weak then the response is weak and the resulting spiral becomes very visible to ALL after the accident.

Perhaps we need a different type of Inspector.

[Lefthanded_Rock_Thrower]

Sox,
That argument is baseless, one accident that appears not to be systemic or cultural, how can any one anticipate an honest mistake.
FOI's and AWI's being who they are today has probably averting thousands of accidents.

I am not sure whether you are suggesting a sociology/accident prevention specialst, to identify a bad safety culture. From my experience university trained specialists are as usefull as tits on a bull, HR etc etc.

There is still a great deal of mis-information regarding this organisation, to quote Kiaruku Kid "AOC to be 'surrendered'", now thats not the truth is it ?.
Where as the CASA webite states "At the request of the operator", see my point ?.

Kiaruku Kid, with respect, you state that many of the SOP's were not in the Ops Manual, such as what, fuel flows/TAS for operations, check lists, pax manifests, tech logs ?, what exactly ?, what position did you hold within the organisation, if you saw information missing in the ops man, why didn't you inform management ?, if it was safety orientated when did you inform ATSB ?.

i have flown with some of TA products, and was not impressed, but they were no different to a similar operator out of FNQ. How do you explain that ?.

TA is in my opinion no different to any other operator in GA, even the bigger shiny operations have had huge "occurences" that luckily did not cost live, purely by luck, this is a witch hunt, as suggested earlier, did they offer prizes for the biggest mistake of the week ?.

[sox6]

"FOI's and AWI's being who they are today has probably averting thousands of accidents."

Perhaps you could expand on that expansive claim please.:suspect:

Or are you confusing accidents with RCAs from your earlier statement "if CASA looked close enough at any operation they would find issues that would probably warrant an RCA or two"? :hmm:

Though last time you then did said that having those RCAs "does not mean the operator is "unsafe"". Or are you now saying that there many unsafe Australian operators saved by effective FOI's and AWI's? :cool:

[Lefthanded_Rock_Thrower]

Averted thousands of accidents, what are you unsure of ?, how would you like me to expand that expansive claim ?:) .

Here's a question, do you think having RBT units at random locations around all capital citys saved lives last night ?, i certainly do, same applies for CASA takes a similar role by doing audits, setting out legislation, ramp checks and licence testing.

RCA - If you've seen an RCA, you'll know that it can be issued for a range of reason from a spelling mistake in your ops manual to being caught with a pilot flying line operations on an expired medical. I would be suprised if a spelling mistake in an ops manual could ever be the cause of a fatality.

All operators in Australia enjoy "safer skies" because CASA/ATSB/ASA are always on the ground somewhere, always looking at the relevance of legislation ( although very slow to act at times - CAR 206 ), regularly auditing operators looking for excursions from legislation or SOPs, the list goes on.

In my opinion CASA are not perfect, neither am i, but imagine our industry without them ?.

[Kiaruku Kid]

LRT many items were deficiecnt - and NOT the realm of the ATSB until an incident occured - and many more were raised but have not seen the light of day yet over the deficiencies in the organisation. What was missing mmm? Let me think? Incorrect checklists with some strange interpretation of CAR 232 approval! No written policy on multi crew who does what etc! No documentented SOP for crew adherance! No safety policies and awareness information! the list is many.
As for advice to company - many attempts were made but the process was not taken up in time - in fact it was not until the last 2 months before we saw any light in the company manuals.:=
Yes the products are all similar and some are not impressive - but as usual it was very much up to the individuals to gain the information and set the standard they wanted - it was never spelt out in company policy.
As for the safety meetings - well I have sat on a few of them and there was no investigation just blame laying and no changes to SOP to ensure reoccurance was minimised - but that is now a fact as the ATSB found when examining the safety system.:O
As for the 'surrender' or the 'requestof the operator' the fact that the barristers bill was going to be enormous and the lack of an effective safety reporting system where the last straws.

[18-Wheeler]

Drove past the Transair office earlier today, all the furniture is gone and it's been cleaned out. :(

[Kiaruku Kid]

Hopefully to pay the debts - piots are still waiting for there payouts as usual - nice tight xmas. LW is in PNG skulking under the TRansair PNG banner. mmmm!! how much is that costing the ex staff !!

[Break Right]

Kiaruku Kid,

Was wondering if you ever work for either Transair,PNG or Aus????:confused:

[wateroff]

:ugh: :ugh: :ugh: :ugh: :ugh:

[Capt Splat]

I would like to think that this whole debacle could improve the situation in GA as a whole. I doubt it though.

Transair were probably not up to scratch but then which GA operators are? There must be so many owners/managers of GA companies that should have avoided getting into aviation. You have an accident and then the ATSB says "Well here's your problem!" when everybody else is doing the same thing (or worse).

CASA is useless. Useless. It is the typical government bureacracy that is happy as hell just as long as the paperwork looks good despite it being clear as sunshine that something is wrong.

[Diatryma]

In anticipation of tomorrows Final Report:

http://www.theaustralian.news.com.au/story/0,20867,21493570-23349,00.html

Di :ok:

[Casper]

CASA has already faced a "please explain" from Transport Minister Mark Vaile asking why the problems uncovered by the ATSB were not previously available from the authority's audit and monitoring process.
-------------------------------------------------------------
How can CASA be aware of issues that were reported directly to the ATSB after the accident by confidential reports?

Can the ATSB claim that any of these issues contributed to the accident?

Surely, the ATSBs brief should be to determine just what caused the aircraft to impact terrain!

[Diatryma]

From the ATSB website:

"The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 (TSI Act). Section 7 of the TSI Act indicates that the object of the Act is to improve transport safety through, among other things, independent investigations of transport accidents and incidents and the making of safety action statements and recommendations that draw on the results of those investigations."

Obviously if the ATSB believes it should say something about CASA's performance and any effect on SAFETY - then it will do so - and quite rightly

Di ;)