Australia, New Zealand & the Pacific Airline and RPT Rumours & News in Australia, enZed and the Pacific

Merged: Senate Inquiry

Old 16th Sep 2014, 12:26
  #2181 (permalink)  
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I was just reading the 2008 CASA audit, and was struck by a comment in the executive summary on page 2.

"These aircraft operate mainly from bases at Sydney, Darwin, Nowra, and Brisbane conducting night freight within Australia, and national and international medevac and passenger charter. Airwork operations consist of target towing for the Royal Australian Navy at Nowra NSW using Learjet and Westwind aircraft."

This seems to suggest that at that time (March 2008), the medevac work was charter, and that it was only the RAN target towing that was air work? Thats how I interpret this paragraph. Perhaps it is badly worded, and the medevac was air work. However that is not how this reads.

Alternate fuel for remote islands was required for charter operations, but not for airwork. However this 2008 audit implies that the medevac work was in fact charter.

IIRC from the 2009 audit following the accident, Pelair pilots gave inconsistent answers when asked if they were operating as air work or charter.

The question I have now is which category Pelair were operating under. And which category did the AOC require Pelair to operate under.
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Old 16th Sep 2014, 20:35
  #2182 (permalink)  
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On the good ship Lollypop.

Nicely constructed Sarcs and well argued. Adding the personalities involved into the bare bones discussion gives the whole thing a curiously intriguing flavour. Have a read of the Audit report from the FOIA collection – March 2008; Mike (ret) Nolan was the 'lead auditor' reporting to 'tuther Wodger (manager) at the time. The whole thing is heading in a clearly defined direction until the changes are rung and a line mysteriously appears in the sand. Food for the thinking man, methinks:-

The company is staffed by approximately 120 employees which includes approximately 70 pilots all of whom are subject to the company's CASA approved CAR 217 training and checking organisation.
The audit was scheduled as a result of the inability of the audit team to complete an effective audit of the CAR 217 organisation in October 2007 due to the poor response of the majority of PEL pilots, and check pilot/ATOs to the request from PEL management for the provision of their logbooks. PEL Management accepted CASA's advice of a need to terminate the October 2007 audit and schedule a second audit when all pilots had responded to a subsequent request for the provision of logbooks.
Advice was given to PEL management by the audit team during the first day of the audit that there was no record of FRMS training of flight crew. PEL acknowledged this finding and CASA issued a Safety Alert on the same day.
The audit of the CAR 217 organisation's flight crew training records revealed that while flight crews had been operating under the FRMS for 11 months, the FRMS training required had not been conducted. This non compliance was considered to represent an immediate threat to the safety of operations and CASA issued a 'Safety Alert' on the 12th March 2008 which required operations conducted under the FRMS to cease and operations to be conducted in accordance with CA048. The company accepted CASA's decision and advised CASA on the 17th March 2008 that the required training had been completed. CASA responded on the 18th March 2008 by issuing approval for the company to resume operations in accordance with the FRMS.
Now that is what I call service.

Audit of 20 flight crew training records revealed that approximately 80% contained no evidence of training in Emergency Procedures Training- Life Jackets and Life Rafts or Human Factors Management Training. The company was advised on the 17 March 2008 of this breach of CAR 215 (9) and the CEO responded on the 20 March 2008 advising that the training would be conducted and completed within a week. The CEO also advised that the company had reviewed its training requirements as stated in the OPSM with regard to Controlled Flight Into Terrain (CFIT), Enhanced Ground Proximity Warning Systems (EGPWS), and Crew Resource Management (CRM) and that all pilots would complete appropriate training within I week.
Tick, flick, tick, flick, tick, flick, tick, flick, tick, flick, tick, flick, tick, flick, tick, flick, tick, flick, tick, tick, flick, tick, flick, tick.

There are a number of options available to CASA to respond to such breaches of legislation. In this case, CASA considers that the interests of safety will best be served as a first option, by giving you the opportunity to address the breach and initiate action to ensure there are no similar occurrences.
Bet there's a few who would have relished that consideration, yes indeed.

A special audit was conducted on Pelair’s CAR 217 Training and Checking organisation, following up on October 2007 audit. This resulted in a Safety Alert being issued against the Fatigue Risk Management System. The FRMS had been in place for 11 mths. It was established that no initial or recurrent training of any flight crew had been conducted. The Safety Alert prohibited Pelair from using the FRMS and required them to revert to CAO 48. Pelair reacted positively by rearranging schedules and implementing an immediate training program. The Safety Alert was lifted flight crew were trained and they are currently operating under their FRMS. Management have been cooperative and the REX Board have launched an internal inquiry to ensuring a breach does not occur again. SYD Region is satisfied and are closely monitoring the operation.
My Bold..

Perhaps I'm just too old and cynical – but the line in the sand is obvious. The Senate report, now rendered useless to anything else except historical value, very nearly, but not quite nailed the plot down. All that was required was a bunny and in true magical style, McComic pulled one out of his hat; (which is an alternate spelling of Whazoo).

If, and it's a big IF Fawcett mounts another Senate inquiry into CASA behaviour, motivated by sheer anger, generated by 20/20 hindsight; the questions may just be a little 'sharper'. It's a reasonable bet to take; normally the Pollies, suitably intimidated through lack of expertise, beautifully baffled by pony-pooh, subdued by dismissive attitude and seduced by the 'mystique' give up after an inquiry. If they don't then the time warp machine is plugged in and important matters float away down the back passage of time. The problem for Sleepy Hollow is that Fawcett and Co. are, not only justifiably 'cranky' but have the expertise to see clear through the smoke and mirrors; and, even if they don't, there is a plentiful supply of 'industry' expertise available to provide a helping hand.

The only question remaining, to vex the SP bookie, is that of party politics versus personal integrity.


Last edited by Kharon; 16th Sep 2014 at 21:24. Reason: Non really - just an itch - you know how it is...
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Old 16th Sep 2014, 23:04
  #2183 (permalink)  
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Ah yes Kharon,
The interesting question is who and how it is decided whether tick and flick or "The Barrier" is the CAsA response. Clipboards , pencils and check boxes continue to cover a few inconsistencies at the said group of companies. Board Investigations can always be relied on of course......

I suppose the truth is that this behaviour has always gone on but the hypocrisy by the wegulator and its wabbits galls.
Enough. I'm off down the paddock to watch a few of the wabbits. Know your adversery and all that.

Last edited by Greedy; 18th Sep 2014 at 21:57.
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Old 17th Sep 2014, 08:24
  #2184 (permalink)  
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Pel-Air cover-up saga - 'FRMS & polishing turds'

Top post that man and a good question to boot...
Greedy - The interesting question is who and how it is decided whether tick and flick or "The Barrier" is the CAsA response. Clipboards , pencils and check boxes continue to cover a few inconsistencies at the said group of companies. Board Investigations can always be relied on of course......
Perhaps the truth (&) lies are buried in this extremely defensive rant from the now retired DAS which was brought on by Senator Fawcett's comments - on buckets & wascily weports...

Greedy cont/-
I suppose the truth is that this behavior has always gone on but the hypocrisy by the wegulator and its wabbits galls....
The hypocrisy & the behaviour is indeed more than adequately highlighted in the above vid.

At one point the former DAS resorts to attacking the integrity of his former Manager of Human Factors (03:05) and then proceeds to steer around the real damning parts of the Cook FRMS SAR, with bluff & bluster on how things are oh so much better since he took over etc..etc.

However I diverge and for now let's go back to the two (obviously) tic infected Wodgers...

First we have Wodger one (W1), who tick & flicked his way through the 2008 Pel-Air audit; W1 summary - "All good nothing to see here!" Then unfortunately for W1 DJ through blood shot eyes managed to successfully ditch VH-NGA and had the audacity to survive...

Enter W2 who was tasked with overseeing the next 'Special Audit' of Pel-Air in the aftermath of the ditching. Part of the audit team included HF experts BC & MC who were primarily tasked with auditing the Pel-Air FRMS. Unfortunately for W2 BC was not given to the normal (SOP) perfunctory tick & flick exercise and responsibly took to his task with a complete top to bottom approach: {Ref page 3 FRMS SAR}
The CASA Human Factors Section was asked to conduct a special audit of the PelAir Express Fatigue Risk Management System (FRMS). This audit was completed by (blank) and (blank) over the period 2-21 December 2009. Given the nature of the special audit (initiated due to a recent accident of the operator involving a night ditching), and the high exposure to operational fatigue risks due to adhoc, back of the clock medevac operations, the special audit of the Pel Air Express FRMS was extensive and to a level of detail considered appropriate given the risks.

In the final FRMS SAR BC included a very damning review of previous CAsA oversight attempts of the Pel-Air FRMSRef page 5 & 6 FRMS SAR}
2.2 Review of Previous CASA Audits of Pel Air FRMS
A summary of previous CASA audits of Pel Air FRMS is contained within Appendix A. Key Findings from previous CASA oversight:
o To date only one audit observation (no: 712500 dated 3Dec07) has been found to be fully completed, signed and filed within the CASA system. All other surveillance documentation from previous CASA audits of the Pet Air FRMS are electronic copies (some partially complete) as obtained from individual FOI's or from the Rex Safety Management Group.
o Based -on findings within Pel Air for this audit and the key points raised (observations, RCA's) from previous CASA audits, the existing system continues to display all of the problems previously identified through CASA oversight. It is suggested previous audits did not provide the quality assurance to confirm problems identified had been rectified, as the one signed observation available was signed off on the premise that corrective actions had been agreed but there is no evidence this was ever followed up by CASA.
o There is no evidence that RCA's raised in May 2006 were closed as the sections titled remedial action, root causes and corrective action remain blank. There is no verification or signature by a CASA representative.
o In the absence of further formal CASA reports, it appears many agreed items were not followed up by CASA.
It is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during surveillance (Nov 04-Mar 08) were never appropriately actioned.

There is a lack of any clear evidence to support corrective actions had been implemented and confirmed by CASA that they were effective. If this process is indicative of broader practices of CASA it is considered CASA is exposed to unnecessary risk, particularly if required to provide evidence to support how it approved an operator's system, in this case, their FRMS.
And from page 12 of FRMS SAR
Findings for CASA:
• Previous CASA oversight did not provide sufficient evidence to confirm the Pet Air FRMS had ever been managing fatigue risk to a necessary standard. Much of the correspondence and closure of RCA's was based on planned actions but no evidence was collected to confirm appropriate corrective actions had been completed.
• Only one signed and filed previous CASA audit report could be located with the Bankstown Field Office. All other reports were partially completed electronic copies or those provided by Rex Safety Management Group. It is assumed this documentation is on file somewhere but it could not be found over the period 3-21 December 2009. Hence, it is not known what follow up action was taken by CASA for many audit reports and observations. it any wonder that W2 and the powers to be attempted to cover up (shelfware) the BC FRMS SAR...

It is also of interest to read the Cook RCA recommendations to the YSBK field office at page eleven. Which W2 interpreted, wrote and countersigned RCAs (all apparently on behalf of BC) applicable to BC's recommendations on pages 79 to 87 of the December 2009 Pel-Air SAR(see here)....

Also fascinating is that W2 was able to acquit all the 'on behalf of' RCAs in one single day i.e. 08 January 2010...

So again W2 comes up with the very same conclusions as W1 i.e. W2 summary - "All good nothing to see here!"

Kharon - The only question remaining, to vex the SP bookie, is that of party politics versus personal integrity.
Given the good Senator Fawcett's no back down approach on other aviation matters since the Coalition formed government I don't think he will fold on this issue either, example:


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Old 17th Sep 2014, 21:52
  #2185 (permalink)  
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Spoiled for choice – rather than repeat – posted response – HERE.

Blind Freddy has posted a download link for a handy OCR converted version of the Cook audit in the preceding post.. Certainly worth a read, even if just to see how a real pro writes a report.

Toot toot...
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Old 18th Sep 2014, 03:19
  #2186 (permalink)  
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Charter or Aerial Work?

The introduction to the 2008 CASA audit (a fairly significant audit given in had been rescheduled from 2007) implies the medevac work was charter.

It has always been stated that the company complied with the regulations as alternate fuel was not required for Aerial Work.

So which one was it?
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Old 18th Sep 2014, 07:21
  #2187 (permalink)  
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CHTR, AWK & back to 'Reason' on FRMS.

Top pick up slats... The more layers of the onion you peel off the more murky & smelly this whole thing gets...

Here is the whole passage to which slats quotes from:

Pel-Air Aviation Pty Ltd (PEL) is a wholly owned subsidiary of Regional Express Holdings and holds AOC number 1-1 VAV2-0l issued on the 23 October 2006. The AOC permits the conduct of Regular Public Transport (Cargo Only), Charter and Aerial Work operations in a fleet of 27 above 5700kg turbo prop and jet aircraft. Operations are conducted with 2 pilots
(multi crew). The aircraft types include seven Westwind WW1124, two Westwind 1124A, four learjet L35/36, ten Metro III, four Metro 23, and one Brasilia EMB 120 aircraft. These aircraft operate mainly from bases at Sydney, Darwin, Nowra, and Brisbane conducting night freight within Australia, and national and international medevac and passenger charter. Airwork operations consist of target towing for the Royal Australian Navy at Nowra NSW using Learjet and Westwind aircraft. The company has a current application with CASA to vary their AOC to operate SAAB 340 aircraft for both passenger and freight operations.
The funny thing is slats that some inquisitive bugger from the bureau's investigative team in early 2010 obviously discovered the same discrepancy but was promptly shut down by Wodger's mate MAL(I)U...: 3 Correspondence from CASA to the ATSB regarding the classification of air ambulance flights, received 22 October 2012;(PDF 492KB)
I refer to email dated 31 March 2010 requesting information under section 32 of the Transport Safety Investigation Act 2003 in respect of the Pei-Air investigation A0-2009-072.

CASA has reviewed the Doskite and Pei-Air Aviation Operations Manuals and cannot find any reference to Air Ambulance flights being classified one way or the other.CASA is not aware of any changes from Charter to Airwork in respect of Air Ambulance functions. The matter may require further clarification from Pel-Air. would have thought the regulator should know to within a minute or an inch of its life, what an operator can or can't do and under what classification certain AOC approved ops are conforming to...

Coming back to the PA FRMS and I remembered that the Australian Lawyers Alliance had a bit to say (& no obvious skin in the issue..) on FRMS/CAO48.1 in their ASRR submission #218. On a second read (or maybe fourth read..) I decided it was too good to ignore, so here it is from Section 4 para 4.1 in full:


Mention has been made above in passing of criticisms proferred by the Senate Committee RRAT Report.33 Many of the criticisms made about the ATSB report of the Pel-Air accident investigation34 are outside the scope of this submission, and include systemic issues as and between CASA and the ATSB. One of the substantive systemic issues reported and agreed to have been a shortfall in the investigation report, was CASA’s lack of oversight of the relevant operator’s fatigue risk management, training and checking systems in the context of a CASA Special Audit which resulted in several CASA-issued requests for corrective action by the operator.35

The relevant CASA surveillance which resulted in the requests for corrective action predated the existing FRMS requirements, but post-dated the commencement of CASA’s original Civil Aviation Order 48.1 which prescribes duty flight time limitations.36 This means that minimum rest time for pilots was set by CAO 48.1 and not strictly the subject of a formal risk management system as it might be argued might now applies to such an operator. The issue then becomes less one of FRMS per se, but one of FRM regulatory oversight. Is a prescribed duty time limit easier to enforce and better than a FRMS which leaves such decisions to pilots and operators in the high demand environment of commercial aviation?

Some argue FRMS is the lesser of two evils, but this submission aims to outline the difficulty in coming to a regulatory solution given the competing interests of aviation operational employees and airline management, in the context of the international standards and recommended practices Australia should adopt, but also recognising the difficulties of adopting any particular standards as all have both economic and air safety consequences for airlines and individuals (pilots and passengers).
Pilot groups have argued that the scientific principles and knowledge said to inform the ICAO SARPs are in fact flawed and that both the US Federal Aviation Administration (FAA) and European Safety Agency Rules (EASA) rules in this regard continue to prescribe actual time limits to ensure there is no balancing of safety through “CASA bowing to industry pressure to deliver a less restrictive system”.37

In our submission the criticism for the Panel to note is that the FRMS rules now applicable by virtue of the commencement of the Civil Aviation Order 48.1 Instrument 2013 (No. 1)38 on 30 April 2013 are not only subject to major contrary views but this view was acted upon by a motion to disallow in the Senate which lapsed when the Parliament was prorogued on 5 August 2013 prior to the Federal Election. Since that time, and following the opening of submissions to the present ASRR, a second motion to disallow was made, and is presently pending for resolution in the Senate by 24 March 2014. These indications of public discontent must not be forgotten in determining a way forward for resolving the debate on flight time limitations.

That being said, an element of circularity exists in what can be done about the situation in Australia while still holding Australia out as a State attempting to provide international best practice regulation in accordance with our obligations as an ICAO State. Departure from SARPs in local law is something which directly affects Australia’s USOAP scores unless a notification of differences is filed with ICAO under Article 38 of the Chicago Convention.

The best solution going forward may be, in this instance, to adopt the approach of the US in 14 CFR Parts 117, 119 and 12139 which provides some prescription in relation to duty limitations and makes FRMS use optional, whereas the Australian approach makes FRMS applicable for current and new holders of flight crew licences but not air operators (AOC holders) until 30 April 2016, unless they voluntarily opt in to the scheme. Certainly, the US approach in this instance may be viewed by industry stakeholders as the preferable option, notwithstanding the costs to CASA of amending the present instrument should it be amenable to that approach. In our submission, the compromises in the US approach better serve the interests of both air operators and secure confidence in the safety of pilots for travellers.



The ramifications of flight crews exceeding duty time limitations can, at the extreme, contribute to consequences like the Colgan crash of 2009. It can also have ripple effects in practice (eg, flight delays) which typify the cost-benefit analysis which often emerges as a refrain in all facets of aviation safety regulation: airline operations and management’s demands for flexibility in regulation to get on with business and ensure their services – ie, the “product” provided when one buys an air ticket – operate on schedule, versus the rights and responsibilities of the pilot in command who bears the (regulatory) responsibility for the final disposition of any particular flight including the safety of all onboard. This is not a new issue.

However, recent examples where flight time limitations have operated to cause passenger delays by an airline (in addition to economic losses from having to cancel/reschedule an international flight) in circumstances beyond the airline’s control, indicate that some measure of flexibility might be warranted in the system which eventuates in Australia (vindicating the approach advanced by CASA in the 2013 Instrument).

In March 2013 a Qantas flight from Dallas to Brisbane was delayed by mechanical issues, and on 15 January 2014 Qantas (due to unrelated infractions of US DOT tarmac delay rules) received a civil penalty from the US DOT. In the “Consent Order” which described the steps Qantas took to mitigate the inconvenience for passengers of the tarmac delay, it is revealed the flight, which was delayed by more than 4 hours, was ultimately cancelled because the crew’s duty time limitations were insufficient to complete even a flight to an alternate, and closer, destination (Auckland).

Certainly this would have resulted in disruption to the airline in terms of scheduling both its crew, and a replacement flight notwithstanding the unquestionable air safety benefit (ie, no pilot flew tired). However, it also has several economic consequences for the airline in relation to compensation for delay to passengers under relevant international law which may not be so readily apparent, but which should serve as a reminder of one of the many consequences of inflexibility in flight duty times for flight crew members. Under the Convention for the Unification of Certain Rules for International Carriage,40 under which most if not all the passengers on the Dallas to Brisbane flight, Qantas would have been liable for compensation for proven losses brought about by delay of each passenger in an amount limited presently to 4,694 Special Drawing Rights (approximately $8,200 AUD as at the date of writing).41 In an aircraft that carries over 300 passengers this amount is substantial. Furthermore, under US DOT rules and the airline’s own policies, refunds of fares must be offered in some cases.

An additional complication of matters arises when one considers that, as is the case in the US, pilots may have contractually negotiated limitations on their duty times.

In the US at least, the FAA has taken the view that the more restrictive FAA rules would not supersede collective bargaining agreements where those arrangements were not in conflict with an FAA requirement.42

In summary then, our submission is that the Panel should ensure in any continuing regulatory reform in relation to FRMS, the multiplicity of stakeholder interests be considered, in the light of alternative States’ ways of handling the same competing interests in aviation law (safety/airlines/pilots/passengers).

Hmm....nah makes too much sense...


Last edited by Sarcs; 18th Sep 2014 at 07:31.
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Old 18th Sep 2014, 08:57
  #2188 (permalink)  
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I wonder if it possible the AOC specified charter but the company manual (approved by CASA) specified aerial work.

It seems a central issue. Had the flight been charter then there would have been alternate fuel.
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Old 18th Sep 2014, 23:03
  #2189 (permalink)  
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There are basically two types of people. People who accomplish things, and people who claim to have accomplished things. The first group is less crowded. Mark Twain.
The Canadians who continue to disappoint, delay and generally bugger about with the report into the Australian TSB; are definitely heading for group two. There are one or two concerns floating on the wind about some very murky 'doings' and Canadian cooperation with the dark forces.

For starters, they did promise to 'visit' with certain folk, once their 'team' was picked and boots were on the ground; there was an intention to look at the Senate 'stuff' and to take a broad view of the situation, despite the narrow, restrictive ToR specified. It seems none of these promises were kept; this reflected in email chains which were, initially open, cheery and friendly that changed to carefully scripted 'weasel' words, with a definite change of tone. It seems the ToR were not only to be strictly adhered to but a narrow view was to be taken on that. Disappointing.

Then there is the change of pace to consider, from the bustling 'can do' approach to the meandering, dragging of feet, snail pace we see now. Why?, I expect only the minuscules and their 'advisors' know why. The latest application of the parking brake comes in two flavours: editing and checking, then checking and editing of the edited draft of the first iteration; to be sure, to be sure: and that although divided by a common language, there are no 'technical' errors and that a 'Canadian' definition does not contradict an Australian definition. Disappointing.

Then there is the 'translation' to French to consider, lots of scope there for added delay. If the Canadians must translate the thing to French, why should that delay the 'Australian' version of the Australian ordered report being delivered to the Australian people; who paid for it. This is not a Canadian report which affects Canadian safety or has any bloody thing to do with Canada at all; barring that the Canadian TSB was asked to do it. Why not translate it into bloody Mongolian while you're at it. Disappointing.

Passing strange, the TSBC don't mess about with their own reports; there'd be hell to pay from the government, the tax payers and the aviation community; so why, in the seven hells are they playing at silly buggers with our report. Disappointing.

I regret, my respect for the TSBC is rapidly waning, day by day. I'd have thought they had more self respect. Disappointing.

Heigh ho. Anyway, it's almost not worth waiting for the wretched thing now, being as it's too late to be effective and too embuggered to be of any further practical or intrinsic value.

C'est rien que de la merde- On t'a bercé trop près du mur?

Toot toot.
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Old 18th Sep 2014, 23:12
  #2190 (permalink)  
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Great footage of McComic doing everything except answering the question in Chambers Report and the 89 mill..!
It simply remains the case that the accident aero medical operation would not have been allowed under some other Fatigue Rule systems. That fact should have been communicated within and to both CASA and the ATSB by both parties. It was not. How is the fatigue science to progress if matters are covered up. You have to hand it to Fawcett he is brilliant in this role. I hope us ills of society can keep him applying pressure for some change in this business. (If only to prove Cream Puff wrong !)
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Old 19th Sep 2014, 01:09
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QUOTE "Anyway, it's almost not worth waiting for the wretched thing now" QUOTE.

It would be interesting to see the original and the Canberra "doctored" versions if only to confirm what we already know.

My dogs blue underpants are murdered by setting fire to the wall. (pas plus pour etre vraiment triste).

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Old 19th Sep 2014, 03:32
  #2192 (permalink)  
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So 2008 audit suggests the AOC specifies charter operations. The 2008 audit states that CASA is watching PelAir closely.

Aircraft ditches to 2009 as no alternate fuel - which would have been required for charter.

The operator claims no alternate fuel was required as it was aerial work.

The 2009 special audit (following the crash) states the flight was aerial work. The preamble to this 2009 audit is worded more vaguely than the 2008 audit regarding the categories of operations permitted under the AOC.

2010 email within CASA stating no record of any change from charter to aerial work.

All very odd. Did the AOC change between March 2008 and November 2009? If so, how? During a period when CASA was closely monitoring the operator.

Last edited by slats11; 19th Sep 2014 at 03:50. Reason: Clarification
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Old 19th Sep 2014, 20:44
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In the absence of fresh material, a ramble, (revisit) with your forbearance, in an attempt to answer for Slats 11 one of the many very good, if vexed questions, which remain unanswered.
Slats -"All very odd. Did the AOC change between March 2008 and November 2009? If so, how? During a period when CASA was closely monitoring the operator."
That, along with hints that only six monthly AOC were being issued, up until the 'new' CASA management of Pel Air took over the reigns and smoothed things out begs some interesting questions, which are probably 'awkward' to answer. We must turn to history, which goes back to before the illusion of change, albeit temporary, window dressing of the Chief pilot shuffle, to assist with speculation.

One of the 'problems' the Senate committee had was a very narrow window to wriggle in through. They did a stellar job within the framework provided but were focussed, quite rightly on the ditching only. What the committee managed to reveal – within the confines of their remit – was the tip of an iceberg. We must speculate from here on, but it's reasonable to assume that what they uncovered did truly offend them, hence the call for a deeper inquiry into the 'operations' and actions of CASA within a wider framework.

To be fair, Xenophon (bless) had NFI things were in such a state and was concerned with the surface issues; like everyone else not directly connected to industry. He assumed the government agencies involved were reasonably honest and competent. By the time the awful truth dawned it was too late. The Senate crew initiated the inquiry and had it not been for some solid work from external sources, may never have penetrated the smoke, mirrors and highly polished surface layers of Teflon. The Senate crew only got a glimpse of the beast, but it was enough to call for more and deeper inquiry. The simple fact that the Senate generated some 20 odd scathing recommendations supports the construct. I for one believe what the Senate crew saw, lurking behind the bluff, bluster and spin scared them; it scared industry experts and Fawcett (gods luv 'im) must be counted amongst the 'expert' group. Industry is indeed lucky to have masters Fawcett and Xenophon in the Senate.

The entire Pel Air 'thing' was heading towards a disaster, expanded reference and set to do some serious damage; had it not been for the minuscule and the WLR. It's reasonable to assume that all would be revealed through further Senate inquiry, given the amount and quality of 'evidence' which would be provided. The WLR derailed that wagon, wasted a lot of time and money and despite using a hand picked crew, the WLR still managed to add further fuel to the fire. Now the minuscule had, and still has two potential train wrecks to deal with. Perhaps he believes time will make them go away – news flash – No way.

So Slats, here we sit; should there be a 'proper' open, unrestricted inquiry into the way CASA do business? I believe so. Just one of the more lethal elements will be a comparison drawn between the 'management' of three issues; Pel Air, Airtex and Skymaster. Once you start down that road, Hempel, Quadrio, Barrier, Polar and many, many others are all waiting to greet the traveller, it is not a lonely road. Any half way decent, open, without fear analysis into that handful of case studies is quite capable of fully supporting not only the Senate recommendations, but those of the Forsyth review and demanding more change to system which is not only morally bankrupt, incompetent and dangerous, but has in it's current configuration the potential to cause a FAA downgrade of Australia.

I am not a great believer in the 'smoking hole' theory as a catalyst for change; I do believe the massive economic and social damage being caused by the 'system' will be the harbinger for change as the 'system' and those entrenched within it, slowly, but inevitably strangle the industry.

Was the whole Pel Air thing on the nose, including AOC and compliance with?– In my opinion, on the balance of probability Yes. Was "AWK" category a red herring?, more than likely. Was there a move to lead the Senate committee away from these 'sensitive' areas?; IMO, Yes, beyond all reasonable doubt. Will there be a call from the Senate for a deeper, wider investigation? – well Sir; to my mind, that is the only part of the whole worthy of question and speculation.

What's that old thing about "he who builds on sand". Aye well, enough. The coffee pot sings it's siren song.


Last edited by Kharon; 19th Sep 2014 at 20:58.
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Old 19th Sep 2014, 22:10
  #2194 (permalink)  
Join Date: Jul 2008
Location: Australia
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Its referred to as the Tombstone Imperative Kharon and it is the sad reality of how safety change occurs in aviation. Weather radar, EGPWS, non-toxic materials in cabin furnishings, CRM, stick shakers to name but a few. Look at the title of this thread and it will give you a clue as to the effectiveness of Parliamentary inquiries as a game changer in getting aviation back into worlds best practice. Look at the Part 61 changes. One of the biggest cockups to be visited upon the industry and the wider world doesn't care. Sunny's much vaunted PM&C sit silent on the matter because they simply don't understand what the problem is. As many others have stated, including those who no longer tread the boards (well not under that name anyway) the only way the pollies and the wider public will be shaken out of their complacency is unpleasant images on their TV screens and expose's on ACA and the tabloids.
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Old 19th Sep 2014, 22:29
  #2195 (permalink)  
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A lawyer could argue that three holes lined up here
I. Decision not to carry alternate fuel
II Weather at NI below minima. Weather there is notoriously fickle.
III. Apparent failure of pilot to be aware of weather, and so proceeded past PNR. It appears Nadi passed on incorrect ceiling. It is not clear if pilot received amended weather. Again, air services in the South Pacific are not infallible.

There are a lot of additional issues, but these are the 3 core issues directly related to this crash.

Of these three holes, the only one within the domain of the operator and / or regulator is that of alternate fuel. They have no control over the other variables. Which makes it all the more critical to manage the issue of alternate fuel. Which means the issue of aerial work or charter one of central significance.
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Old 19th Sep 2014, 22:48
  #2196 (permalink)  
Join Date: Jul 2008
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Slats there is a big difference between the requirement to carry alternate fuel and the decision to carry alternate fuel. Given point II of your core issues, that decision rests squarely with one person. So the issue of AWK v CHTR is an interesting technical discussion but not really the core issue IMHO. The core issue is how PeLAir supervised and risk managed these flights given the sector lengths. The crew were given limited guidance and assistance to complete the task. The Regulator knew all this and did very little about it, that I think are the two core issues. The performance of the crew after ToD was all their responsibility.
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Old 19th Sep 2014, 23:14
  #2197 (permalink)  
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Boring - Done to death.

Slats there has never, not ever been any disagreement that there were errors of judgement, James admits he made errors, the Senate agreed he made errors, the accident, apart from the appalling treatment of Karen Casey has, for a very long while now been history. No one is remotely interested.

What has become exposed is the absolutely dreadful performance of the 'authority' and the attempts made to manipulate the reports, misdirect the inquiry and abrogate all responsibility to a pitiful, meaningless 'pilot error' call. Back in the 2000+ posts on this thread stand alone; this has been discussed. To revisit that old, stale argument about fuel and fool, is pointless. However, if you wish to research and reinvent the wheel, do so. But please be sure of the facts you use to back the assertions. Be aware that a very clever lawyer or two and various assorted experts took the argument well beyond the James admitted errors of judgement, for which he paid and still, today pays a stiff price for. The same people delved deeply into what CASA and the ATSB did, before and after the incident and found them wanting. You need to think it through. For instance:-
I wonder if it possible the AOC specified charter but the company manual (approved by CASA) specified aerial work.
The manual, including fatigue, flight planning and fuel policy would be 'accepted' by CASA, not approved. The line between the two conditions being a seriously 'grey' area; the old merry go round of endlessly amending and adding 'twiddles' to an operations manual to satisfy the peculiar tastes of the individual FOI, so that the FOI 'accepts' the manual as part of the certification process. There exists a mountain of tales and stories about getting CASA to 'tick the box' and even Raffety's rule book would be handy; ask any CP who has had the simple pleasure of adding a 'new' type to an AOC, ask his boss how the bank balance held out and then, for kicks, have a read of some of the mind bending dribble written in support. It's a sad indictment and cautionary tale.

Slats - "Had the flight been charter then there would have been alternate fuel."
When McComic stated that R206 was a "good example of bad law", you must understand the statement was made with relish, not in condemnation. It really is a buggers muddle which suits a big "R" regulator very well; the more complex the more exemption etc. and so it rolls on. To a practical man does it matter a bean if the flight was classed as charter, farter or martyr: during the 'acceptance' process the fuel policy, the recommendations, process, calculations and the rationale for the policy edicts should have been in place and thoroughly tested. The simple fact is, they were not and the company was allowed to continue operations without, for many years. That does not get young James completely off the hook, but had there been more 'situational awareness' of the fuel critical nature of the proposed flight and he better educated as to how to 'step around' the traps and pit falls, perhaps there may have been a better outcome. Perhaps not.

Lefty – I know mate, I know. But what's a girl to do?. One must at least learn to ask for dinner and dancing, before the fateful, inevitable event; there is no guarantee of course, that you'll get it.. ..

Last edited by Kharon; 19th Sep 2014 at 23:19. Reason: Gone all PC - no more cussin' - Mummy smack.
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Old 19th Sep 2014, 23:45
  #2198 (permalink)  
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I understand fuel was further limited by commercial limitations placed upon take up at obvious alternates. Been canvassed previously and still doesn't abrogate CAsA or ATSB's duty to provide a measured and accurate response.
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Old 21st Sep 2014, 01:14
  #2199 (permalink)  
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Sunday cogitation - A Stray thought or two.

From a Ferryman post from the 'Wuss asleep at the wheel' thread...
The subjects may be found –HERE - and – HERE - . The thing that drew my attention and earned some admiration was the quality of work which the ATSB is capable of producing – when playing away from home. Some cynics would say – far away from malign influences; I reckon it's pure frustration from our well qualified, competent troops at the coal face. Released and given a chance to shine – they do. Bravo..
Some interesting and shameful parallels are highlighted in those two 'request assistance' investigations...

For the first point of interest (POI) refer to the interim report for AE-2013-223, see here. Under Abstract it says...

"...Later that day, search and rescue personnel located parts of aircraft wreckage floating on the ocean surface.

The New Zealand Navy located the main aircraft wreckage on the seabed at a depth of approximately 59 metres. On 6 April 2013, Navy divers located and retrieved the body of the passenger. The following day the aircraft wreckage and the pilot’s body were recovered by the Navy onto its specialist dive vessel, the HMNZS Manawanui..."

As a result of these can do, prompt actions the CAA investigators were very quickly able to make a number of important observations:
...Once recovered, initial examination of the wreckage indicated that the aircraft had impacted the water with a slight nose down attitude its wings almost level and with a slight yawing movement.

Examination of the aircraft’s propellers indicated that the propellers were under little or no power at the time the aircraft impacted the water. The propeller angles were in a position usually associated with a cruise setting. Neither propeller was feathered.

Examination of the flight controls and control surfaces showed that the flap and gear selectors were in the fully retracted position. Aileron and rudder trim were in a near neutral position, however, the elevator trim was trimmed 21 units nose up.
Although only a short factual interim report the extremely divergent parallels to the PelAir & Hempel cover-up investigations are quite remarkable. And from the tail-end of the report:
The CAA safety investigation is being conducted in accordance with the New Zealand Civil Aviation Act. The objective of the safety investigation is the prevention of accidents by determining the contributing factors or causes and establishing what lessons can be taken for the improvement of the NZ aviation system.

The focus of the investigation is to establish the cause of the accident on the balance of probability. Safety investigations do not always identify one dominant or ‘proximate’ cause.

Often, an aviation accident is the last event in a chain of several events or factors, each of which may contribute to a greater or lesser degree, to the final outcome.
Unlike our current domestic ATSBeaker there is no doubting the intent, integrity & transparency of the above statement from the CAANZ...

You are automatically left with the impression that the Kiwis will leave no stone un-turned to get to the cause of this tragedy. This is further highlighted by the fact that the Kiwis realise they don't have the necessary resources to properly analyse the ATC recordings. They then have no compunctions or reservations in automatically referring to our bureau for assistance. After all, under ICAO Annex 13, that is the way the system is supposed to work...FFS!

PelAir & beyond (BASR).

"K" also makes the point that left un-embuggered by our BASR domestic situation (& the apparently uncontrollable CAsA behemoth) our bureau coalface boys'n'gals still do stirling work...

Just before the PelAir cover-up debacle the bureau put out a glossy paper titled - PAST PRESENT FUTURE. Under the section - The International Dimension (page 65) - it highlights the many positive contributions internationally that the bureau has made, example:
On 31 January 2003, an Ilyushin 76TD aircraft impacted terrain during a landing approach to Baucau, Timor-Leste. The six aircraft occupants were fatally injured by the impact forces. At the request of the government of Timor-Leste, the ATSB conducted the investigation into the accident. The investigation report highlighted that deviations from recommended practice during the approach and landing phase of flight significantly increase the risk of a CFIT event.
The paper then goes on to praise the positive contributions of Alan Stray in overseeing the ATSB involvement in the Indonesia
Transport Safety Assistance Package (ITSAP):
The ATSB appointed Alan Stray, PSM, Director International, to oversee and coordinate the ATSB’s involvement in this important regional transport safety initiative.

The main elements of the ATSB’s contribution to ITSAP are to deliver training and support for NTSC investigators. This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia, and expand opportunities for aviation, marine, and rail investigators to work with ATSB counterparts for extended periods. Support is also being provided on individual transport safety investigations.

Alan's efforts led to him being awarded a Public Service Medal (PSM) :
In January 2009, Alan Stray was awarded the Public Service Medal “For outstanding public service improving aviation safety in Australia and Indonesia”.
Upon reflection how he must now cringe when he reads these words from earlier in the bureau glossy...

"...As a founding member of the International Civil Aviation Organization (ICAO), Australia has played a prominent role in the Council and the Air Navigation Commission (ANC). Since 1974, Australia has consistently been
elected to the council as a Category One State of Chief Importance in Air Transport, and plays a major part in the activities of ICAO. Australia’s role has been underpinned by its perceived integrity and lack of bias, and excellent safety record..."

{Comment: Some of the weasel words in the Albo message & Beaker intro are also, upon reflection, positively vomitus..}



{NB - Part two on the positive NZed Aviation Safety system, where the NAA is uniquely also the AAI. Versus our BASR system with a seemingly uncontrollable big "R" NAA slowly but surely regulating the GA industry out of existence; while our bureau (domestically at least) is a mere hand muppet helping facilitate the CAsA agenda of GA annihilation }

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Old 21st Sep 2014, 21:14
  #2200 (permalink)  
Join Date: Oct 2010
Location: Styx Houseboat Park.
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As played in heaven.

Ever wonder why the All Blacks keep winning – and manage to maintain a seriously formidable record. Their blokes are no bigger, fitter, smarter or any more skilled than our fellahin but they win; even when the score line shows otherwise. I believe the difference is in freedom; the Kiwi's simply have the freedom to improvise and keep the ball alive to obtain the end result – a try. The Australian teams seem hidebound; constrained by complex 'set piece' strategy, beaten into a mentality which depends on complex, stylised micro rule sets; which, once upset lead to confusion, excuses and denial. Individual brilliance is subjugated and improvisation sacrificed to 'herd discipline'. Which is fine, until a size 24 prop has gleefully grabbed you by the ears and is not going to let go; the set piece collapses and no one is looking to recover; just for who's to blame. “No battle plan,” he sagely noted, “survives contact with the enemy.” – Moltke

NZ aviation reflects the All Blacks 'spirit' – sure there is a game plan and rules; but with the shackles of micro management removed and simple, clear cut instructions assist a free running game. It's not only how to win at rugger we should learn from the Kiwi's. Aircraft down in the water – now, who would have ever imagined using the NZ navy to recover the aircraft, quickly, cheaply, effectively, give the troops some real training and a chance to shine. Beaker sure as hell didn't; did he now. Purblind bloody fool.

What's this twiddle got to do with aviation? – well: if Sarcs has headed down the research path I believe he'll take, the thinking man may glean some insight into why the NZ CAA is light years ahead of not only Australia, but of many other enlightened countries in the way they have progressed aviation, not just 'safety'; but in the regulatory and fiscal fields, resulting in increased efficiency naturally leading to improved safety outcomes.. Can't wait for Sarcs, part two – nice catch and bravo for having the patience to tease out the data...

Toot toot..

Last edited by Kharon; 22nd Sep 2014 at 22:02. Reason: Reason? don't need no stinkin' reason.
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