CASA response to the ATSB report on Lockhart River
I like you GR. You remind me of when I was young and stupid.
Let me guess:
You applied for but weren’t accepted on a RAAF pilot course?
You were accepted on a RAAF pilot course but were scrubbed?
A tip, son: Don’t confuse mature deliberation for inexperienced indecision. Your attempts to demonstrate the length and breadth of your aeronautical knowledge on this forum are merely proving the reverse.
Let me guess:
You applied for but weren’t accepted on a RAAF pilot course?
You were accepted on a RAAF pilot course but were scrubbed?
A tip, son: Don’t confuse mature deliberation for inexperienced indecision. Your attempts to demonstrate the length and breadth of your aeronautical knowledge on this forum are merely proving the reverse.
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Quote: 'The first Instrument Approach and Landing Charts for airports were published in 1928 in a series of airway bulletins. They were really just sketches and diagrams.'
http://www.naco.faa.gov/index.asp?xml=naco/history
I'm not an expert by any means, i've only had gnss rnav for a few months and only a handful of approaches to boot. As such I won't comment on how safe the approach is with foxtrot as a waypoint.
My point is that the IAL procedures we now have came about through a process of trail and error, or refinement may be a better term. See above quote, surely it is not impossible that the current rnav procedures could do with some refinement of thier own???
If the approach and procedures work well thats great, if they could do with tweaking then tweak them.
http://www.naco.faa.gov/index.asp?xml=naco/history
I'm not an expert by any means, i've only had gnss rnav for a few months and only a handful of approaches to boot. As such I won't comment on how safe the approach is with foxtrot as a waypoint.
My point is that the IAL procedures we now have came about through a process of trail and error, or refinement may be a better term. See above quote, surely it is not impossible that the current rnav procedures could do with some refinement of thier own???
If the approach and procedures work well thats great, if they could do with tweaking then tweak them.
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Gorn,
I agree with you 100%.
It was CFIT.
I don't understand why it took ATSB two years and 500 pages of report - when they could have just got you involved and you could have told them it was HUMAN ERROR and they should have just summed it all up in one page and we would have all been able to sleep soundly for the last two years knowing that the skies were safe as long as you are around.
Listen to Gorn everyone. Just follow the procedure without question and CONCENTRATE on what you are doing! It's not rocket science!
Di
I agree with you 100%.
It was CFIT.
I don't understand why it took ATSB two years and 500 pages of report - when they could have just got you involved and you could have told them it was HUMAN ERROR and they should have just summed it all up in one page and we would have all been able to sleep soundly for the last two years knowing that the skies were safe as long as you are around.
Listen to Gorn everyone. Just follow the procedure without question and CONCENTRATE on what you are doing! It's not rocket science!
Di
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Pretty obvious that Diatryma was taking the piss there Gorn, you should probably quit now before further embarrassing yourself.
I waded thru the ATSB report yesterday, I felt Ill afterwards. Sure it was a clear CFIT but the CFIT was just the final result of a lot of other deficiencies in this company. I'm no business man but blind freddy could see that one person holding the roles of Chief Pilot, Managing Director and head of checking training just aint gonna work. The management structure was all wrong. Small CHTR operations with one or two aircraft operate in this manner but not a regional airline. CASA have a lot to answer for IMO, its pretty basic stuff.
Other glaring deficiencies, predominantly related to check & training
A tragic accident that just should not have happened
Cheers
200
I waded thru the ATSB report yesterday, I felt Ill afterwards. Sure it was a clear CFIT but the CFIT was just the final result of a lot of other deficiencies in this company. I'm no business man but blind freddy could see that one person holding the roles of Chief Pilot, Managing Director and head of checking training just aint gonna work. The management structure was all wrong. Small CHTR operations with one or two aircraft operate in this manner but not a regional airline. CASA have a lot to answer for IMO, its pretty basic stuff.
Other glaring deficiencies, predominantly related to check & training
- No CRM or multi crew training provided
- No CFIT training provided
- No GPWS training provided (except an instruction to use common sense)
- No GPS RNAV training provided
- No route famil conducted
- Pilots not formally cleared to line
- Base checks conducted once a year instead of twice
A tragic accident that just should not have happened
Cheers
200
Last edited by TwoHundred; 12th Apr 2007 at 01:35. Reason: typo's
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No CFIT training provided
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So if none of the above courses/training/checks were in place at Transair, why didn’t CASA issue RCA’s during recent audits? What did CASA look at during their audits of Transair? A company that had been going for as long as Transair should have had these systems in place.
I guess the rumours about quick endorsements and training at Transair was true!
I guess the rumours about quick endorsements and training at Transair was true!
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200, not taking a shot at you for your comments,
I do think that while he could have been a cowboy and his senior management should have realised it and dealt with it, it is also up to everyone as individuals not to behave this way.
J
The impression given of the Captain was that he was a 'cowboy', liked flying as fast as possible, turned up for work 20mins prior to departure and other things. I dont think this is his fault though, it more than likely stems from a lack of supervision and guidance from his superior/s.
J
200, you are spot on.
There is clearly a systemic failure but I think that it runs all the way up to the Fed Government.
Instead of running budget surpluses to brag about and fund tax cuts and the pre-election pork barrel, perhaps a balanced budget that saw the money spent on services would be more appropriate. Maybe then CASA would have had the money to pay for the admin support that would allow the Airways Inspectors or whatever they are called these days to get out in the field do the job that was intended.
Maybe a Royal Commission is the only thing that will get to the root of the problem and offer some solutions.
Dr
There is clearly a systemic failure but I think that it runs all the way up to the Fed Government.
Instead of running budget surpluses to brag about and fund tax cuts and the pre-election pork barrel, perhaps a balanced budget that saw the money spent on services would be more appropriate. Maybe then CASA would have had the money to pay for the admin support that would allow the Airways Inspectors or whatever they are called these days to get out in the field do the job that was intended.
Maybe a Royal Commission is the only thing that will get to the root of the problem and offer some solutions.
Dr
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Capt Wally said:
"We all do it?" 
If it wasn't for your last line about 'belief' then I would have assumed a wind up.
We don't all do it, Wally. We make mistakes, we misunderstand things, there are gaps in our knowledge. Sure.
But anyone that calls themselves a professional pilot should be a very different creature when compared to your average mug that drives his own car, with a drivers licence issued after demonstrating basic competency only, in one test, probably sometime around your sixteenth or seventeenth birthday.
You might be being honest, but mate, that is a dangerous attitude, not all that different from the PIC of the accident flight we are talking about here.
I am paid a fair whack of money by my company to operate their aeroplanes their way. Just quietly I think I am pretty good at it, I have been lucky enough to be around some top notch operators and pick up a few tips, and I've had some good training.
One of the things that defines the real professionals is self discipline. The really good operators I have flown with were not just great stick and rudder guys, they had discipline. The reason they could nail just about every instrument approach, kiss an RPT jet onto a runway on their aiming point 9 out of 10 times, was not because they were born gifted pilots. It was because they studied, they researched, and they understood the manufacturer's and the company's SOP. They worked out the best way to do each manouevre, maybe one or two variations for certain conditions, and that is the way they did it, every time they did it, whether they were being watched or not.
Cowboys can jag a couple of beauties every now and then by using inappropriate techniques, or by compromising another factor.
We are not in the 'smooth landing' business. We are not in the 'shave another 30 seconds' business.
We are in the 'get there safely' business.
Professionals can work their magic, within SOP.
Like I said, I make mistakes, I stuff up. But me and a whole bunch of guys and girls around me don't have one set of procedures for line flights and another for check flights. So please don't count me/us in your "we all do it."
We as pilots are essentially no different than car drivers on the road when it comes to behavour & habbits. For Eg. When we see a cop with a radar gun we simply slow down & proceed as by the book, (this equates to being checked by an ATO for Eg., we demonstrate/do the right thing) we do the right thing to the letter of the law on the road & once clear of them the radar gun that is (same as in once we are flying on our own again ) we return to our natural ways. speeding, relaxing the rd rules etc, we all do it.
If it wasn't for your last line about 'belief' then I would have assumed a wind up.
We don't all do it, Wally. We make mistakes, we misunderstand things, there are gaps in our knowledge. Sure.
But anyone that calls themselves a professional pilot should be a very different creature when compared to your average mug that drives his own car, with a drivers licence issued after demonstrating basic competency only, in one test, probably sometime around your sixteenth or seventeenth birthday.
You might be being honest, but mate, that is a dangerous attitude, not all that different from the PIC of the accident flight we are talking about here.
I am paid a fair whack of money by my company to operate their aeroplanes their way. Just quietly I think I am pretty good at it, I have been lucky enough to be around some top notch operators and pick up a few tips, and I've had some good training.
One of the things that defines the real professionals is self discipline. The really good operators I have flown with were not just great stick and rudder guys, they had discipline. The reason they could nail just about every instrument approach, kiss an RPT jet onto a runway on their aiming point 9 out of 10 times, was not because they were born gifted pilots. It was because they studied, they researched, and they understood the manufacturer's and the company's SOP. They worked out the best way to do each manouevre, maybe one or two variations for certain conditions, and that is the way they did it, every time they did it, whether they were being watched or not.
Cowboys can jag a couple of beauties every now and then by using inappropriate techniques, or by compromising another factor.
We are not in the 'smooth landing' business. We are not in the 'shave another 30 seconds' business.
We are in the 'get there safely' business.
Professionals can work their magic, within SOP.
Like I said, I make mistakes, I stuff up. But me and a whole bunch of guys and girls around me don't have one set of procedures for line flights and another for check flights. So please don't count me/us in your "we all do it."
Last edited by ITCZ; 15th Apr 2007 at 12:15.
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ITCZ
Well said.
I have been saying for a long time that small aeroplane operations are not taken seriously enough, and the self discipline is too often lacking. It is only considered as a stopgap training time and so not worth the effort of trying to improve it.
This captain had a reasonable ammount of experience but it appears the general attitude was not good. This comes about too easily when you have a continual stream of young pilots who do not want to be there, and consider it "hard yards" that they have to endure to get on. I know there are some good people there, but the structure of the workforce is wrong and that makes it hard. We need dedicated light aircraft pilots, not elitists.
I also think there are certain similarities with a number of other accidents.
I have been saying for a long time that small aeroplane operations are not taken seriously enough, and the self discipline is too often lacking. It is only considered as a stopgap training time and so not worth the effort of trying to improve it.
This captain had a reasonable ammount of experience but it appears the general attitude was not good. This comes about too easily when you have a continual stream of young pilots who do not want to be there, and consider it "hard yards" that they have to endure to get on. I know there are some good people there, but the structure of the workforce is wrong and that makes it hard. We need dedicated light aircraft pilots, not elitists.
I also think there are certain similarities with a number of other accidents.
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Statue of limitiations !! How handy - I suppose since the accident occured so long ago management will walk away scott free ???
"Too late to prosecute Lockhart River airline: DPP
Queensland's Director of Public Prosecutions (DPP) and the Australian Transport Safety Bureau (ATSB) say no charges will be laid against the airline at the centre of one of Australia's worst air disasters.
Fifteen people died when the Transair Metroliner crashed two years ago at Lockhart River in far north Queensland.
An ATSB investigation showed Transair had failed to report 25 safety incidents in the two years leading up to the crash. Seven were serious matters such as a cabin pressurisation warning.
The DPP was alerted to the incidents but says it is too late to prosecute because of a 12-month statute of limitations.
The ATSB's Julian Walsh says it is not worth his body taking action over the minor incidents either.
"Particularly given that the company is no longer operating, [it] really doesn't justify the resources," he said.
The State Coroner will examining the events surrounding the crash at hearings starting in June.
"Too late to prosecute Lockhart River airline: DPP
Queensland's Director of Public Prosecutions (DPP) and the Australian Transport Safety Bureau (ATSB) say no charges will be laid against the airline at the centre of one of Australia's worst air disasters.
Fifteen people died when the Transair Metroliner crashed two years ago at Lockhart River in far north Queensland.
An ATSB investigation showed Transair had failed to report 25 safety incidents in the two years leading up to the crash. Seven were serious matters such as a cabin pressurisation warning.
The DPP was alerted to the incidents but says it is too late to prosecute because of a 12-month statute of limitations.
The ATSB's Julian Walsh says it is not worth his body taking action over the minor incidents either.
"Particularly given that the company is no longer operating, [it] really doesn't justify the resources," he said.
The State Coroner will examining the events surrounding the crash at hearings starting in June.
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Drag Chute
You have to distinguish between charges being laid for the company breaches (the 25 safety breaches not reported to CASA) and charges being laid for the conduct of the flight that caused the crash. The announcement that the Statute of Limitations prevents prosecution relates to the former.
Is there a case against the company for the crash?
I understand that the company's performance and ops manual may well have been deficient but I doubt that there would be any evidence that they were anything other than a marginal cause, if at all, of the crash. For example, did the ops manual allow for single pilot GPS NPA on a multi-crew flight? Did the ops manual allow for unstabilised approaches? I very much doubt it.
A prosecution is far more than a public shaming exercise. There has to be reasonable prospects of success for the DPP to commence action and what would you get in this case as the company has lost its AOC so presumably has also ceased trading. Any prosecution may well be only flogging a dead horse.
You have to distinguish between charges being laid for the company breaches (the 25 safety breaches not reported to CASA) and charges being laid for the conduct of the flight that caused the crash. The announcement that the Statute of Limitations prevents prosecution relates to the former.
Is there a case against the company for the crash?
I understand that the company's performance and ops manual may well have been deficient but I doubt that there would be any evidence that they were anything other than a marginal cause, if at all, of the crash. For example, did the ops manual allow for single pilot GPS NPA on a multi-crew flight? Did the ops manual allow for unstabilised approaches? I very much doubt it.
A prosecution is far more than a public shaming exercise. There has to be reasonable prospects of success for the DPP to commence action and what would you get in this case as the company has lost its AOC so presumably has also ceased trading. Any prosecution may well be only flogging a dead horse.
The ATSB's Julian Walsh says it is not worth his body taking action over the minor incidents either.
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Toothless legislation
The poiont I am trying to raise is that there is evidence found by the ATSB during its course of examination of the company's safety system found several reportable incidents that were not reported.
These were discovered in the last few weeks of November 2006, and I understand that whilst these actually occured prior to the accident flight in 2005, and hence the statue of limitations; However, the fact that these reports were not acted upon at the time reflects that unless discovered by the ATSB they may never have been reported.
This make a mockery of the TSI Act - there appears to be no teeth in the system. The fact that they occured so long ago, however the lack of their reporting supports the claim that the safety ethos required by the company under Civil Aviation Act 28 may not have been there at all.
If this is the case then what external audit was conducted of this airlines safety management system - or was it only to come to light after the ATSB had completed the Lockhart river report.
Perhaps CASA should be conducting an investigation to determine who or who was not doing their job within the company as 'approved' as key personnel and follow up with their regulatory actions.
How many more 'unreported' incidents occurred in the company's last 12 months of operations?
This may be never know as the company system was obviously not working? What happened to the 'pilot in command' esponsibility to report these incidents to the ATSB? Was this how the deficiency in the safety system was found? Should cross checks be done within the ATSB database to see who is reporting or what systems are working?
The closure of the company may be enough 'public shaming' for some however, the fact that the management of this company can 'get away' with such blatant breechs begs the question of the avoidability of the accident in the first place.
The systemic failings of the company in their approach to safety management was a contributing factor in this accident, therefore, I believe the the managers should be held accountable for their failings. The flow on in regulatory review from this accident will cost others hundreds perhaps thousands to ensure compliance, where the 'closed' company closes its doors.
I am not looking for 'another' royal commission into the fiasco - but it needs the responsible 'departments' to use their powers under their 'acts' to demonstrate to the public that aviation is weeding out the 'shonks'.
Sorry with the questions - I am interested in just how the rules and regulations that an airline is supposed to adhere to can be brushed aside so easily.
These were discovered in the last few weeks of November 2006, and I understand that whilst these actually occured prior to the accident flight in 2005, and hence the statue of limitations; However, the fact that these reports were not acted upon at the time reflects that unless discovered by the ATSB they may never have been reported.
This make a mockery of the TSI Act - there appears to be no teeth in the system. The fact that they occured so long ago, however the lack of their reporting supports the claim that the safety ethos required by the company under Civil Aviation Act 28 may not have been there at all.
If this is the case then what external audit was conducted of this airlines safety management system - or was it only to come to light after the ATSB had completed the Lockhart river report.
Perhaps CASA should be conducting an investigation to determine who or who was not doing their job within the company as 'approved' as key personnel and follow up with their regulatory actions.
How many more 'unreported' incidents occurred in the company's last 12 months of operations?
This may be never know as the company system was obviously not working? What happened to the 'pilot in command' esponsibility to report these incidents to the ATSB? Was this how the deficiency in the safety system was found? Should cross checks be done within the ATSB database to see who is reporting or what systems are working?The closure of the company may be enough 'public shaming' for some however, the fact that the management of this company can 'get away' with such blatant breechs begs the question of the avoidability of the accident in the first place.
The systemic failings of the company in their approach to safety management was a contributing factor in this accident, therefore, I believe the the managers should be held accountable for their failings. The flow on in regulatory review from this accident will cost others hundreds perhaps thousands to ensure compliance, where the 'closed' company closes its doors.
I am not looking for 'another' royal commission into the fiasco - but it needs the responsible 'departments' to use their powers under their 'acts' to demonstrate to the public that aviation is weeding out the 'shonks'.
Sorry with the questions - I am interested in just how the rules and regulations that an airline is supposed to adhere to can be brushed aside so easily.
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ABC News - QLD Regional Matters
Last Update: Wednesday, April 18, 2007
Governments not impressed with Lockhart River outcome
The federal Transport Minister Mark Vaile says he is disappointed legal action cannot be taken against the airline involved in the Lockhart River air disaster.
Transair allegedly failed to report 25 safety incidents before one of its planes crashed on Cape York in 2005 killing 15 people.
But the airline cannot be prosecuted because the alleged incidents occurred more than a year ago.
Mr Vaile says the 12 month statute of limitation appears to be too short a time to take legal action.
Queensland Premier Peter Beattie agrees and has told State Parliament he has asked Queensland's Attorney-General to write to his federal counterpart.
"A 12 month statute of limitation is clearly not practical when it is the Commonwealth's own investigation practices that took that time," Mr Beattie said.
"I mean the investigation took so long so how can you possibly have a 12 month statute of limitation?"
A spokesman for Mr Vaile says the Minister is waiting for departmental advice before deciding whether the Transport Safety Investigation Act should be amended.
Governments not impressed with Lockhart River outcome
The federal Transport Minister Mark Vaile says he is disappointed legal action cannot be taken against the airline involved in the Lockhart River air disaster.
Transair allegedly failed to report 25 safety incidents before one of its planes crashed on Cape York in 2005 killing 15 people.
But the airline cannot be prosecuted because the alleged incidents occurred more than a year ago.
Mr Vaile says the 12 month statute of limitation appears to be too short a time to take legal action.
Queensland Premier Peter Beattie agrees and has told State Parliament he has asked Queensland's Attorney-General to write to his federal counterpart.
"A 12 month statute of limitation is clearly not practical when it is the Commonwealth's own investigation practices that took that time," Mr Beattie said.
"I mean the investigation took so long so how can you possibly have a 12 month statute of limitation?"
A spokesman for Mr Vaile says the Minister is waiting for departmental advice before deciding whether the Transport Safety Investigation Act should be amended.
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Drag Chute
I understand where you are coming from and I am not being critical. I share your frustration.
The audit system used by CASA appears to be a complete joke. Isn't CASA on record as saying that there were some minor issues but that the company did comply which is why their AOC was not withdrawn earlier? Obviously the paperwork can be made to comply with the regulations. The gap seems to be from the operations side of the business, maintenance issues are not written up when they occur but only when the issue is dealt with, pilots are not encouraged to report non-compliance with SOPs (if they exist) etc. etc.
The transgressions are never "on the record" which is what makes any prosecution such a marginal proposition. CASA has a pretty spotty record when it comes to successful prosections for non-compliance and usually only when someone is stupid enough to self-incriminate.
One of the earlier posters referred to the tendency of people to be law abiding when under scrutiny. They are quite correct but it is the cowboys (both in the cockpit and the owners office) who go back to their reckless ways that need to be eliminated. The only way I can see that it will happen is for totally confidential reporting to be allowed. There was such a system once but it became totally distorted to the point that people had no confidence that any report would not boomerang.
I understand where you are coming from and I am not being critical. I share your frustration.
The audit system used by CASA appears to be a complete joke. Isn't CASA on record as saying that there were some minor issues but that the company did comply which is why their AOC was not withdrawn earlier? Obviously the paperwork can be made to comply with the regulations. The gap seems to be from the operations side of the business, maintenance issues are not written up when they occur but only when the issue is dealt with, pilots are not encouraged to report non-compliance with SOPs (if they exist) etc. etc.
The transgressions are never "on the record" which is what makes any prosecution such a marginal proposition. CASA has a pretty spotty record when it comes to successful prosections for non-compliance and usually only when someone is stupid enough to self-incriminate.
One of the earlier posters referred to the tendency of people to be law abiding when under scrutiny. They are quite correct but it is the cowboys (both in the cockpit and the owners office) who go back to their reckless ways that need to be eliminated. The only way I can see that it will happen is for totally confidential reporting to be allowed. There was such a system once but it became totally distorted to the point that people had no confidence that any report would not boomerang.