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

Merged: Senate Inquiry

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Old 3rd Dec 2014, 08:13
  #2481 (permalink)  
 
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A word from our (WWIOS) resident TBA members

TBA - Tendentious Bloggers Association...

Beaker...

"...At the simplest level, the answers to the Senator's questions are straightforward - and a fair amount of the information is publicly available.

We are prepared to answer them in whatever forum they arise (with the exception of anonymous rumour sites and some tendentious bloggers)..."

First from Proaviation (Phearless Phelan)...:
Canadian study identifies flawed processes and policies

An independent review of the ATSB’s investigation processes and methodologies delivered its report on schedule this week. But it won’t bring much comfort to industry, nor to a travelling public already uneasy over the revelations of the Aviation Safety Regulation Review; and last week’s grilling of Airservices Australia executives in Senate Estimates over top-level management conflict, concerns over possible whistle-blower abuses and the non-resolution of long-standing operational safety issues.

ATSB had commissioned a “peer review” by its Canadian counterpart, the Transportation Safety Bureau of Canada, in the wake of a series of adverse findings by a Senate committee and widespread media coverage centred on the ATSB’s investigation into the ditching of a Pel-Air Aeromedical Westwind jet at Norfolk Island in November 2009.

The TSB’s terms of reference were to conduct a new and independent objective review of ATSB’s investigation methodologies and processes, working independently of any other person or organisation.. The reviewers were not asked to revisit the Norfolk Island findings, but to review the way the investigation was conducted, and also to review two other investigations – an Augusta helicopter winching accident in December 2011 at Kangaroo Valley, and a Piper Chieftain crash at Canley Vale near Bankstown airport in June 2010.

That meant that at least for now, the deeply flawed Norfolk Island investigation report would remain on the public record indefinitely, presumably as a standing reminder of how not to go about meeting the ATSB’s and CASA’s obligations.

The other two accidents were added to the assignment “in order to provide a useful comparison” of ATSB’s procedures over a wider spread of events.
Perhaps also to identify whether the Norfolk investigation was a random aberration, or par for the course. ProAviation is in contact with several parties who have been equally injured by the arrogance and overconfidence of both organisations.

On the Norfolk Island investigation, the TSBC commented:
The TSB Review of the Norfolk Island investigation revealed lapses in the application of the ATSB methodology with respect to the collection of factual information, and a lack of an iterative approach to analysis. The review also identified potential shortcomings in ATSB processes, whereby errors and flawed analysis stemming from the poor application of existing processes were not mitigated.
Problems identified by the Canadians included “misunderstandings” about the respective responsibilities of CASA and the ATSB, leading to the ATSB collecting insufficient information from the operator, which in turn also hampered the analysis of specific safety issues; weaknesses in the application of the ATSB analysis framework, lapses from normal accident investigation procedure; and the re-categorisation of a ‘critical’ safety issue to ‘minor’, which shifted the focus away from the issue itself – and the potential for its mitigation.

In contrast, the TSB was less critical of the Kangaroo Valley and Canley Vale investigations, despite considerable industry disquiet with their findings.

The TSB Review made 14 recommendations to the ATSB in four main areas:
  • “Ensuring the consistent application of existing methodologies and processes;
  • “Improving investigation methodologies and processes where they were found to have deficiencies,’
  • “Improving the oversight and governance of investigations , and
  • “Managing communications challenges more effectively.”
Findings from the TSB review of the Norfolk Island investigation were:
1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analysed.
5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
9. At the ATSB, the Commission does not formally review some reports until after the DIP [directly interested parties] process is complete. This increases the risk that issues with the scope of the investigation and the quality of the report will be identified too late in the process to be resolved.
10. The lack of a robustly documented feedback process after the Commission review increases the risk that issues with the scope of the investigation and the quality of the report will not be addressed.
11. Ultimately, the lack of a process for the Commission to review the DIP responses, ensure the DIP comments were addressed, and provide DIPs feedback reduced the effectiveness of the DIP process in improving the quality of the Norfolk Island report.
12. Although senior managers were aware of the possibility that the report would generate some controversy, communications staff were not consulted and no communications plan was developed.
13. Once the investigation became the subject of an external inquiry, the ATSB could no longer comment publicly on the report, which hampered the Bureau’s ability to defend its reputation.

The report’s recommendations offer comprehensive fixes to identified problem areas as well as throwing further light on the deliberations of the Canadian team.

The review reported on, but did not criticise the ATSB’s controversial decision not to spend $200,000 on recovering the cockpit voice and flight data recorders, notwithstanding that there were several unique lessons to be learned from a successful night ditching of a light jet in a remote area which was survived by all six occupants.
To be fair to PP that review of the TSBC report was before this mornings revelation that the Miniscule wants Beaker and his fellow commissioners to consider (i.e. DO) re-opening the PelAir investigation.

However if he were to know I don't believe he would have quite put it the way Ben did in this evening's contribution from Planetalking...:
Call for ATSB chief’s removal over Pel-Air report fiasco

Ben Sandilands | Dec 03, 2014 6:40PM | EMAIL | PRINT

Senior mandarins in aviation tried to lock their Minister, Warren Truss, into a position he no longer wants to be in. A very bad career move

Senator Nick Xenophon calling for Dolan's removal from ATSB


The scope for major changes in Australia’s air safety investigator, the ATSB, its aviation regulator, CASA, and their administrator the department of Infrastructure and Regional Development looms large following the Minister’s abrupt call for a fresh look at the Pel-Air crash inquiry report.

A great deal of political and administrative capital was invested in producing and defending the vindictive, unfair and inadequate final report that the ATSB issued, and subsequently defended, concerning the Pel-Air crash of a Westwind corporate jet doing a medical charter into the sea near Norfolk Island on 18 November, 2009.

In what might prove a critical development in the public administration of air safety in this country, that report, released after many delays on 30 August 2012, seems set to be undone, or redone.

As might prove to be the case for Martin Dolan, the discredited ATSB chief commissioner whose testimony before a Senate hearing into the investigator’s botched processes over its Pel-Air findings was rejected by an all party committee.

Independent SA Senator, Nick Xenophon, lost no time in calling for Dolan’s removal “and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and CASA.”

The human suffering aspect of what at first glance seems like a minor hull loss in the middle of the night is difficult to discuss for legal reasons at present. However it was anything but minor for the six people onboard when it was ditched in the sea because it had reached its intended refueling stop at Norfolk Island, on its way from Apia to Melbourne, when it discovered the weather advice it had received was wrong, it was unable to land, and it no reserves to reach an alternate.

Pel-Air, the operator was a mess. It grounded its surviving Westwinds voluntarily after the crash. Its deputy chairman and former coalition aviation minister John Sharp, even gave a media interview in which he admitted there ‘was no plan B’. The operator didn’t even have a written oceanic fueling policy. It was an appalling state of affairs, all seemingly brushed under the carpet by two safety authorities and a federal department.

One of those people on the flight was quite seriously injured, yet more than five years later, she is being appallingly treated, even gloated over by some parties on the basis that Australia’s air regulations in respect of such accidents were so lax/ or non-existent, that anyone using them had no legal protection whatsoever. (Which may not prove to be the case, of course.)

That regulatory vacuum persists to this day, despite lies from CASA under previous management as to how promptly it was going to fix the situation, and an apparent paralysis of that organization under a recently departed head of safety when it came to actually reforming or performing any of its obligations to aviation stakeholders and the public.

However the testimony of Dolan to the Senate, and the tale of administrative incompetence and lack of clear management on his watch during the bungled Pel-Air inquiry that is set out by the TSBC peer review ought to have him out of the door on skates.

The identification of the secretary for Infrastructure and Regional Development, Mike Mrdak with the Dolan, ATSB and CASA positions on the Pel-Air inquiry places him in a difficult position. Mr Mrdak took his Minister, Mr Truss, to a place where the Minister no longer wants to be, which is always in hindsight, a bad, bad move.

It was Mrdak’s department that told Truss to reject earlier calls, including from the Senate committee inquiring into the ATSB, to recover the flight data recorder from the Pel-Air wreckage and redo the findings, which were essentially a lazy and incomplete scapegoating of the pilot in charge of the Westwind.

The privileged Hansard records of the testimony of Dolan, the then director of air safety for CASA, John McCormick, and Mrdak are substantially incompatible with the findings of the TSBC.

It was Mrdak’s department that wrote the original position taken by Minister Truss that there was no point in retrieving the flight data recorder or correcting the accident report. It will be interesting to see if Mrdak can perform the necessary U-turn, and repudiate his previous words, while remaining on top in Infrastructure.

When Minister Truss’s Air Safety Regulation Review panel, chaired by David Forsyth, reported at the end of May this year it anticipated that the TSBC report would be both critical and released in the near future.

It was however, repeatedly delayed, to the point where some feared it mightn’t even see the light of day, given reported resistance to its contents within the ATSB.

The report released on Monday was written in a manner likely to put a casual reader into a coma. But for those who read the full document, it proved highly critical of the ATSB, setting out comprehensive failings in terms of collecting and assessing information.

There was dissent within the investigating team, to the point where a ‘coach’ appointed to assist in the inquiry, sought, eventually successfully, to be relieved of his role.

The TSBC dealt deeply with the disruption caused in the investigation by uncertainty over the appropriate relationship with CASA, which conducted parallel inquiries, including an audit that was withheld from the ATSB, into the Pel-Air Westwind operation subsequent to the crash.

As reported earlier in Plane Talking and examined by a Senate committee into the ATSB’s procedures in relation to Pel-Air, CASA suppressed an audit that found that the crash could have been prevented had the regulator carried out its own duties of oversight over the Westwind operation.

The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report, in which the committee took that rare if not unprecedented step of giving a section of their findings to their lack of confidence in the testimony and conduct of the chief commissioner of the ATSB, Martin Dolan.

Today’s decision to have ‘another look’, which to be clear, is a direction not a suggestion, reflects poorly on Truss’s Labor predecessor Anthony Albanese.

Mr Albanese broke several commitments to deal with the adverse Senate findings into the ATSB, and was ineffectual or unwilling in relation to the Pel-Air issues, which first arose on his watch with ample opportunity for ministerial direction or intervention.

Mr Truss has not escaped criticism in this portfolio either, and not just from Plane Talking. But something has changed, this damaging and disgraceful report will be ‘fixed’ in its procedural or methodological shortcomings, there is already a new Director of Air Safety at CASA, and there may well be further changes for the better in the administration of air safety.
Priceless... I think it is fair to say that Ben fair and squarely hit the nail on the head of probably close to the last nail in Beaker's coffin...

Come on Miniscule you know you want to...

MTF...
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Old 3rd Dec 2014, 08:35
  #2482 (permalink)  
 
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The best thing now would be to let the Canadian TSB do the repeat investigation into the Norfolk Island crash.

After all, justice not only has to be done. It has to be seen to be done.

There are precedents for this. The Canadians have previously investigated a crash in USA that involved an FAA employee.
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Old 3rd Dec 2014, 09:04
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The identification of the secretary for Infrastructure and Regional Development, Mike Mrdak with the Dolan, ATSB and CASA positions on the Pel-Air inquiry places him in a difficult position. Mr Mrdak took his Minister, Mr Truss, to a place where the Minister no longer wants to be, which is always in hindsight, a bad, bad move.
Well, lets all hope that Truss does something about that then, and doesn't waste time doing it as he has so far.

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Old 3rd Dec 2014, 09:21
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Not sure that Truss is finished Frank. I suspect he will outlast a few others.

Many a senior department figure has enjoyed Ministerial support until things reach a critical point. Then they quickly and unhappily discover their function is to be a fuse - that is, to self-destruct and thereby protect a more valuable piece of equipment.
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Old 3rd Dec 2014, 16:02
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The best thing now would be to let the Canadian TSB do the repeat investigation into the Norfolk Island crash.

After all, justice not only has to be done. It has to be seen to be done.

There are precedents for this. The Canadians have previously investigated a crash in USA that involved an FAA employee.
Some assistance from HF experts maybe Mr Ben Cook (now in the ADF ) would be justified.

2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.

Last edited by halfmanhalfbiscuit; 3rd Dec 2014 at 16:11. Reason: Fgfthgggcvvvvvvv
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Old 3rd Dec 2014, 18:42
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Some assistance from HF experts maybe Mr Ben Cook (now in the ADF ) would be justified.
Sorry Biscuit, Ben has moved on again and is now at Vic rail, but I am sure that like most good ex CASA people he will be watching the circus with great amusement.

At least the TSBC has nailed Beaker for what he truly is - a total liability. However Truss is the bigger fool for allowing the beardless one to be reappointed for two years. Tsk tsk tsk Warren the IOS warned you
And what about Pumpkin Head? Seems his little empire has a few splinters in it that are turning into giant sinkholes. But yet again the IOS have been warning Herr Truss. And did he listen? Of course not, he reappointed the man with no neck.
What about the ridiculous MOU between CASA and the ATSB that the Witchdoctor put together? Another piece of ideology formed for sinister reasons. It is yet another failure. But don't worry Minister, the IOS have been warning the big wigs in Can'tberra for eons that this 'removal of ATSB independence' (and that is all it is) was flawed and dangerous. It's an embarrassment and you can imagine the CASA and ATSB meetings in the past where the Skull would bark across the board table at Beaker and say 'get me another coffee, and some biccies, and get it now', and of course Beaker would softly comply. Add that to the CVD debacle, the recent ASA LAHSO shenanigans, credit card misuse at both organisations, Jabiru, Barrier and the list goes on forever!! Yep, a real clusterf#ck of abhorrent proportions

Sarcs, may I? TICK TOCK goes the FAA clock.
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Old 3rd Dec 2014, 21:03
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Truss looked "peculiar" in the HOR yesterday and didn't stay long having "personal business". I doubt he has the stamina to continue although the politicians ego may hold sway. Young Barnaby has a mean and hungry look and the only thing stopping him is numbers loyal to the National Party as opposed to the LNP. Having said this they will be having meetings in a telephone box after the next elections if they continue as they are. Which is a pity because we may then have to look forward to city orientated political party's for future plans for the industry which include aircraft noise over airports and not much more. GA in particular needs regional political representation.


Having read the Albanese transcript of yesterday, he gives me more reason for concern, and to politicize the situation that he presided over with the relevant appointments, nothing is safe in the hands of either.


The IOS would be wise to consider doing a job on MrDak as he seems to be the woodpile in the river Niger.
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Old 3rd Dec 2014, 21:16
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Well, if not the Butler; who dunnit?

Sarcs - {Comment: Dear TSBC I will not - at this stage - retract my 'BOLLOCKS' for the Canleyvale review as I believe you have been severely mislead}".
Sarcs – I'm not sure that the PPRuNe management would tolerate the publication of the Canely Vale chapter from the Bankstown Chronicles; so after much 'consultation' with the BRB and P7, I hope a potted twiddle will suffice.

There exists a document which, for wont of better, we shall call the "Cheese" document, it has quite a history. The final draft was quite short, five pages in all, the initial draft, shorter again, three pages. Draft 1 was provided to the CEO, GM, three Chief Pilots, two CASA FOI, their 'acting team leader', and to two independent 'safety experts'. Although Draft 1 was short, it was pretty much to the point and designed to have an immediate effect on what was identified as a rapidly developing, operationally 'unhealthy' situation; there was no doubt in the authors mind that inevitably, there would be a major accident if the matters mentioned were not addressed quickly and correctly. This was stated in Draft 1 and supported by anecdotal, peer reviewed evidence. The conclusions of that review were supported by no less than four, independent, active chief pilots and two independent safety analysts. Fully aware that the potential for a fatal accident was at an elevated level; the matter was entered into the company Safety Management System (SMS) and 'flagged' urgent for a full SMS meeting.

It was the following day that two CASA FOI arrived 'on site', their manner was noted as angry, impatient, dismissive, one being particularly aggressive. I will not labour the point – in short, the CPO and HOTAC were 'told'. Told to remove the matter from the SMS, not to interfere outside of their own remit and, for their own good, it was better to let CASA sort out the issues, in house and informally. No further action was ever taken by CASA regarding the matter.

Over the next two month period, it was observed and noted by senior pilots that 'things' were deteriorating, rapidly. Another report was prepared. Draft 2 was blunt – it warned that a fatal accident was probable, a time bomb. If immediate changes to training, supervision and operational practices were not made; as a matter of urgency it was no longer no longer a matter of if, simply when.. It was agreed, by all that after the last caning from CASA that the matter should simply be referred to and dealt with by the CEO and SMS management.

To the credit of management a company wide SMS accord was initiated and a review of all 'operating' protocols and policy was commissioned, to define the 'problem' areas and identify changes required. All company divisions and the CEO embraced the concept and wholeheartedly became involved; all except one. The division which employed Andy Wilson and had created the urgent need for 'control'.

After the fatal crash the aforementioned CASA FOI conducted an 'audit' and found that the 'paperwork' was all in order, and that there were no 'operational' aberrations. Which is hardly surprising as they weren't looking for them, tick and flick worked just fine, when it suited their masters purpose.

ATSB were informed of the company concerns, they even subpoenaed the 'Cheese' report which had forecast the accident almost 12 months (to the day) previously. And did nothing. Not even interview the eight senior, qualified individuals, to determine if any of the itemised topics could have contributed. For example, from 'Cheese':- (abridged and slightly edited to protect the innocent).

a) Senior pilots report being personally informed, on several occasions of pilots being 'instructed' to perform operations in a manner which defies most of the sensible and legitimate tenets of sound practice, Wilson repeatedly being the recipient of several of these 'tirades'. The most recent was a serious dressing down, delivered post flight to one of the most sensible, intelligent pilots on staff. The pilot requested a private meeting to explain the event and to seek guidance.

b) In short; the pilot was tasked to Lismore NSW, after a second attempt at the approach, the aircraft was visual at the minima, but, on top of a very low deck of Stratus (lifting fog) which obscured the aerodrome and prevented a landing. The aircraft was diverted to Ballina.

c) This individual later responded to a general question related to the days operation with a sketch of the days events. He was then taken aside and 'briefed' (instructed) on how it should be done and berated for not doing the job in the 'approved' manner. Not to labour the issue the essential points where:-

(i) Slow the aircraft (PA 31-350) to less than 120 knots,
(ii) Stooge about until you identify a roadway which leads toward the aerodrome,
(iii) Get below the cloud and follow the road through the hills until the runway is sighted.
An independent analysis of the Canley Vale accident, from a holistic perspective was provided, in confidence, to both the Pel-Air and Forsyth inquiries. Clearly the Canadian TSB were never provided the information, even the analysis of the flight path was grossly flawed and that fell squarely with the TSBC remit..

If the Pel-Air investigation is to be reopened; then both the Botany Bay and Canely Vale accidents need to be examined in depth. If there is any doubt remaining that Pel Air was a 'reverse' fit up, then an open, impartial, honest inquiry into the death of young Andy Wilson and Cathy Shepard will confirm, beyond a shadow of doubt any lingering notion that CASA and the ATSB have acted less than honourably, in another hidden display of routine normalised deviance.

This is not the time to take your foot off the gas pedal.

Selah.

Last edited by Kharon; 3rd Dec 2014 at 21:32.
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Old 4th Dec 2014, 05:10
  #2489 (permalink)  
 
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ATsB independence & the loaded dog (REPCON).

A most disturbing commentary Mr Ferryman and one that I gather that is held under parliamentary privilege and therefore can be freshly referred to by those that matter.

It is also yet another example of how the ATsB is in non-compliance with its charter to be fully independent:
The independence of the ATSB is integral to the Bureau's safety role. Investigations that are independent of the parties involved in an accident, as well as transport regulators and government policy makers, are better positioned to avoid conflicts of interest and external interference. Being able to investigate without external direction provides an assurance that the findings will be determined and fully reported on without bias.
This is also in contravention to its obligations under ICAO Annex 13
5.4 The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of this Annex.

It should also be noted that now under Annex 19 it is the responsibility of the State to ensure the independence of the State AAI.

If there is one fundamental lesson that should have been learnt from the Senate inquiry into the PelAir cover-up this is it. From all recent evidence - in bureau investigations/prelim & final reports - this is not a lesson that either the department or it's aviation agencies has learnt.

Now we finally get the TSBC peer review report where again the credibility of the ATSB being independent is questioned and made the subject of a TSBC recommendation:
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Kharon - "...beyond a shadow of doubt any lingering notion that CASA and the ATSB have acted less than honourably, in another hidden display of routine normalised deviance..."

From a recently released REPCON it would appear that Kharon is not on his own in his concerns about the now proven to be incestual relationship between the bureau and CAsA:
Reporter's concern

The reporter expressed a safety concern regarding the number of Australian Transport Safety Bureau investigations which have indicated in their report that the Civil Aviation Safety Authority (CASA) have detected issues during their audits but have not taken the appropriate action to fix the issues. However, these reports have then not indicated that this was a contributing safety factor in the accident.
The investigations include but are not limited to AO-2011-102, AO-2011-033 and AO-2009-072.

Operator's response (Operator 1)




In order to respond to this REPCON, it is of benefit to understand the different outcomes likely when comparing a regulatory surveillance activity with the conduct of a safety investigation:
  • Regulatory oversight. Routine regulatory surveillance cannot examine all aspects of an operator on a frequent basis, and it cannot identify all the issues with an operator (or similar organisation) or their operation. More specifically, unless other intelligence or specific concerns have been identified previously to indicate otherwise, such activities generally examine a relatively broad range of aspects of an operation or operator at limited depth.
The frequency and depth of this ‘routine’ surveillance could be expected to be based on factors such as the type or classification of operation and size of the operator or operation.



In general, less surveillance might be expected for smaller operators, for non-passenger-carrying activities and for operators using smaller aircraft.
  • Safety investigations. Safety investigations conducted after an accident or serious incident are often able to identify problems or safety issues that may not be easily detected during a regulator’s routine surveillance activities. More specifically, a safety investigation conducted after an accident/serious incident usually has a more targeted scope as a result of the evidence already gained from other sources, and generally has more time to identify potential safety issues than in the case of a routine audit. Finally, whereas surveillance activities traditionally focus on regulatory compliance, safety issues identified as a result of safety investigations are not restricted to compliance with regulatory requirements.
  • Safety investigation and ‘contribution’. Given their limited resources and many potential occurrences to investigate, safety investigation agencies carefully scope their work to maximise the efficiency of their investigations and the potential for safety enhancement.
Before the ATSB includes a detailed examination of the effectiveness of a regulator’s surveillance activities as part of an investigation’s scope, it would generally need to establish that:
  • There are significant problems (in terms of number and/or level of risk) with the relevant operator’s risk controls and/or safety management processes, which are related to the investigated occurrence.
  • Given factors such as the severity of these safety issues, the length of time they existed, the size of the operator and the nature of its operations, it is reasonable to expect that a regulator’s oversight activities probably should or could have identified these safety issues.
Ultimately, to conclude that any potential problems with regulatory oversight processes were a contributing factor to an accident/serious incident would require the investigation to have, in the first instance, concluded that problems with the operator’s occurrence-specific risk controls and/or safety management processes contributed to the accident/serious incident. In addition, a problem with the design, implementation or other aspect of the regulator’s surveillance processes would need to have been shown (‘existence’) and the conclusion reached that the surveillance problem(s) could have realistically prevented or significantly reduced the likelihood or magnitude of one or more of the operator’s safety issues (‘influence’).



Given this understanding, the following discussion explains why no safety issues associated with regulatory surveillance were identified as contributing factors in the ATSB investigations highlighted by the REPCON reporter:
  • AO-2011-033. This investigation involved a small operator conducting primarily freight charter operations in light, twin-engine aircraft. In terms of the scope of the investigation, the ATSB did not consider a detailed review of the regulator’s oversight activities was warranted. The ATSB report noted that CASA found several problems with the operator after the accident, but these problems were not directly related to the circumstances of the accident and safety issue relating to the operator identified by the investigation.
  • AO-2011-102. This occurrence involved a small operator conducting primarily aerial work and some charter operations with film crew as passengers and, as part of the scope of the investigation, the ATSB obtained CASA regulatory surveillance documentation. The ATSB did not consider that the nature of the safety issue it identified with the operator would reasonably have been identified by CASA during its routine surveillance activities. However, the ATSB did conclude in its report that there were problems with relevant regulatory requirements and a safety recommendation was issued to CASA in that regard. The ATSB continues to monitor CASA’s action in response to this safety issue.
  • AO-2009-072. This investigation involved an aerial work operation and, as part of the scope of the investigation, regulatory surveillance documentation was obtained from CASA and examined. In respect of the safety issue that was identified with the operator, the ATSB considered that it was not an issue that would or should necessarily have been identified as a result of routine surveillance activities. However, problems were found with the general nature of the available regulatory guidance on fuel planning and on seeking and applying en route weather updates, which increased the risk of inconsistent in-flight fuel management and decisions to divert. As indicated in the investigation report, safety action was taken by the operator and CASA in response to these safety issues in an effort to prevent a recurrence of the accident.
Regulator's response (Regulator 1)

CASA has reviewed the REPCON and concurs with the response provided by the ATSB.
Anyone care to add to the list of investigations that question the veracity of the claim that the ATsB is fully independent...

I strongly suspect the Mildura fog incident and the Albury ATR birdstrike incident are candidates for external embuggerance of the ATsB ongoing investigations, but as the reporter (above) indicates there are probably many more...
This is not the time to take your foot off the gas pedal.
Totally agree Ferryman this is by no means over...

Addendum - Performance of ASA 28/11/14 Hansardis finally out not sure what the delay was but maybe this bit had something to do with it...:
Senator XENOPHON: I think it would be good if we could see any minutes in respect of that. Isn't it in the context of Senator Gallacher raising concerns about compliance or noncompliance—I am not saying there was any noncompliance—in respect of certain public works? And then, as a result of a line of questioning from Senator Gallacher, you raise the issue of the AFP being brought in in respect of leaks. It is not an unreasonable proposition, as Senator Gallacher put forward, that there appears to be a correlation between some legitimate concerns being raised in the context of this parliamentary process and calling in the AFP. Indeed, I wonder—and I will seek advice from the Clerk of the Senate—whether it raises issues of privilege.
MTF...

Last edited by Sarcs; 4th Dec 2014 at 06:37.
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Old 4th Dec 2014, 05:35
  #2490 (permalink)  
 
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In short: The regulator's interactions with the operators were pointless.

Couldn't agree more.
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Old 4th Dec 2014, 10:00
  #2491 (permalink)  
 
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So basically, CASA stinks and nothing it says can be relied upon? Furthermore, there will be no change as a result of the review?
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Old 4th Dec 2014, 10:36
  #2492 (permalink)  
 
Join Date: May 2013
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Age: 65
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haven't you seen enough of real world aviation to realise that in the minds of the Clueless Aerosols screwing Aviation the reality never matters.
merely the paperwork.

In short: The regulator's interactions with the operators were pointless.
in a world where you have people incompetent of the engineering running the place it is the thickness of the report that matters, the amount of money you were paid while generating it is crucial, never ever the reality.

we have in australia a truly corrupt system.
dubbleyew eight is offline  
Old 4th Dec 2014, 20:30
  #2493 (permalink)  
 
Join Date: Oct 2010
Location: Styx Houseboat Park.
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Mystery solved, itch scratched.

Sarcs – HERE -has just dramatically altered the betting in the MoP stakes; with 'Stabbed in the Dark' shortening to equal favourite. (Late entry, Filly by 'Sick Joker' out of 'Thick as two', lacklustre performance in previous outings, the punters initially supported as an each way or trifecta bet, to pad out the ticket, believing improvement would be seen with more familiarity to the track. Word from the stable is that the Filly is simply more suited to agricultural pursuits than big race games; the connections entering the filly in an attempt to boost the chances of selling it on. Entered with SP odds at a one in three chance of success.

The spectre of parliamentary privileged information being used to persecute an individual has finally arrived at the table. Lots of scope in that department with CASA running equal favourite. Hansard takes you along a cleverly mapped out pathway to the steel trap, cunningly disguised. The senate crew 'confused' and 'bamboozled' the Slicks (self admitted), then turned the 'Ficks' inside out and got as close to a confession as possible. Not bad; not too shabby at all....

Time permitting the extracts from Hansard will be cobbled together, for without the sidebars, distractions and the clever coaxing the intended victim along the 'right' path, the script is very clear: very clear indeed; as it always is with 20/20 HS.

Toot toot
Kharon is offline  
Old 4th Dec 2014, 20:33
  #2494 (permalink)  
 
Join Date: Jul 2008
Location: Australia
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Recommendation 13 I think is the real black-eye from the Canadians to the ATSB. It is basically saying, as Sen X has been, that Australia is not fulfilling the basic premise of Annex 13 in that investigations must be conducted completely independent from outside influence. On this recommendation alone Dolan's position is no longer tenable and actually confirms the Senate report critique of his performance at the Inquiry. If he is not removed then that will be an indication of how the Government intends to treat the TSBC report.
Lookleft is offline  
Old 4th Dec 2014, 21:55
  #2495 (permalink)  
 
Join Date: Apr 2007
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Choccy frog for Lefty.

...On this recommendation alone Dolan's position is no longer tenable and actually confirms the Senate report critique of his performance at the Inquiry. If he is not removed then that will be an indication of how the Government intends to treat the TSBC report.
Lefty where have you been?? Two short sharp posts that cut to the chase...

With the last one (above) I will help you out with this from NX:
Aviation safety failure

3rd December 2014

Independent Senator for South Australia, Nick Xenophon, has called for a major shake-up of Australia’s air accident investigation system after an independent review found systemic problems with the botched investigation of the Pel-Air ditching off Norfolk Island in 2009.

Senator Xenophon called for the removal of head of the Australian Transport Safety Bureau (ATSB), Martin Dolan, and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and the Civil Aviation Safety Authority (CASA).

The Transport Safety Board of Canada (TSB) conducted an independent review of the ATSB’s investigation of three serious incidents and its report was released yesterday. It found that the ATSB’s investigation of the Pel-Air crash “did not address key issues in the way that the Australian aviation industry and members of the public expected”.

Today Transport Minister Warren Truss called on the ATSB to re-open the Pel-Air investigation because of the serious flaws identified by the TSB.
“The Canadian report and the Minister’s statements are further testament to the ATSB’s incompetence. The Minister is right to call for a re-opening of the investigation, but he’s wrong to ask the ATSB to do it. It needs to be done independently,” said Nick.




The TSB report found:
  • The ATSB was unaware of Pel-Air’s systemic fuel and fatigue management problems that contributed to the crash because “insufficient data were collected”
  • The ATSB investigation led to an organisational focus on “risk level labels” rather than factors that “contribute to advancing safety”
  • Evidence of insufficient oversight by CASA of Pel-Air flight planning and monitoring practices
The TSB report says: “A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved”.

The TSB report supported the findings of the Senate inquiry instigated by Senator Xenophon by the Rural and Regional Affairs and Transport Committee. The Committee, in its 176-page report last year, found that CASA had withheld from the ATSB evidence of its failure to oversee Pel-Air. The Committee found that evidence from the Martin Dolan, head of the ATSB, was “questionable”.

Senator Xenophon said the Government was yet to act on the findings of the Senate report, and criticised the Aviation Safety Regulation Review report, launched last November and completed in June, as “a missed opportunity for reform”.
Now from that I don't get the impression that Nick is going to take his foot off the gas anytime soon... The IOS should continue to throw their support behind Nick - with his now increased power in the Parliament - not only on his muppet head hunting mission but in his mission to rectify everything that is currently toxic & wrong about the executive & middle management teams at the ATsB, CAsA and ASA...

MTF...
Sarcs is offline  
Old 4th Dec 2014, 22:06
  #2496 (permalink)  
 
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Lefty where have you been?? Two short sharp posts that cut to the chase
Its a long story Sarcs but it has now been sorted (Thanks TW)

The Canadians have just revealed that the Emperor has no clothes albeit at the same time saying that his tailor is of world standard.
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Old 5th Dec 2014, 05:08
  #2497 (permalink)  
 
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"The Canadians have just revealed that the Emperor has no clothes albeit at the same time saying that his tailor is of world standard".????


Are they saying he's really well Hung??
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Old 5th Dec 2014, 19:25
  #2498 (permalink)  
 
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Hanged Thorny, not hung.

Interesting, sober piece - HERE – from AA, featuring Chris Manning. There was rumour that Manning was in the DAS race; but that was discounted. Manning has far too much sense, probably no need of and precious little interest in 'that job', considering the Tiger experience and all. But, the AA August article does merrily dance around the proposition and flirts with the notion, just fails to convince.

There are however two remaining top aviation positions which, if the pundits have nailed it down, will need to be filled before forward progress can be made. ASA can wait, for a little while; but, the ATSB must be taken away from the stench of Pel-Air, which is a constant cause for concern to those seeking MH 370. The ATSB leadership is an international embarrassment; to the troops, the industry and given the way 'covert' MH 370 investigations are heading, to the government.

The Canucks finally (eventually) managed to publish a genteel, cleverly structured report on the ATSB which delivered a fairly thorough wet lettuce flogging, even allowing, as Lefty mentions, it managed to black an eye or two. This is all being seen as PC window dressing, framed in 'diplomatic' language. Not being expert on diplomatic double speak, at first read the WFT is this message flashes; however the grown ups assure me that, for exponents of double speak the report was as close to a public humiliation as it is possible to get; without declaring the bleeding obvious.

So, bottom line; Be-a-Cur must go, he has in the past been 'reassigned' within the secret, protected world of the professional public servant. It's not the first job he made a complete dogs breakfast of and had to leave, under a cloud. So new desk and office will not cause any angst and with conscience and humiliation not in his lexicon, life will continue, unabated, within in the shadowy, protected world, unchanged. A good riddance.

That leaves behind his partners in crime, those who willingly and happily raped the TSI act and dropped their daks to cavort about the CASA altar. Which leaves a nasty little situation for whoever is appointed to take over from Be-a-Cur. It must be an outsider, no one in their right minds would try to push the remnants and oddments left behind from the Norfolk imbroglio forward; which leads us to the 'who then' question.

Just a feeling really, but if they could persuade a first rate fellah, like Manning to take the job, even short term and give him a large axe, I reckon things could be improved, in fairly short order over at ATSB. There certainly is no shortage of good material to work with, just sort out the mess at the top, get a few more accident investigators in, get rid of the excess admin to pay for it; and, off you go. I wonder, if Chris Manning is bored with golf and would welcome a diversion from the common round.

No doubt we shall see. But something has to be done and Be-a-Cur must go, for he cannot stay.

Toot toot.

Last edited by Kharon; 5th Dec 2014 at 19:45. Reason: Genitals, gentiles and genteel - need a second coffee methinks.
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Old 5th Dec 2014, 20:50
  #2499 (permalink)  
 
Join Date: Apr 2007
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Angel Be-a-cur to eat his words...

Be-a-cur...

"...At the simplest level, the answers to the Senator's questions are straightforward - and a fair amount of the information is publicly available.

We are prepared to answer them in whatever forum they arise (with the exception of anonymous rumour sites and some tendentious bloggers)..."
Just a feeling really, but if they could persuade a first rate fellah, like Manning to take the job, even short term and give him a large axe, I reckon things could be improved, in fairly short order over at ATSB. There certainly is no shortage of good material to work with, just sort out the mess at the top, get a few more accident investigators in, get rid of the excess admin to pay for it; and, off you go. I wonder, if Chris Manning is bored with golf and would welcome a diversion from the common round.
Kharon now there is a rumour that the IOS/MaM/WIOS/WWIOS/TBA should strongly support & spread around...

Oh but wait there is one resident member of the TBA that already has...:
ATSB to gain in credibility and competency no later than Monday

Ben Sandilands | Dec 06, 2014 7:44AM | EMAIL | PRINT


A replacement for the ATSB chief commissioner Martin Dolan is expected to be announced by the deputy PM and Minister for Infrastructure and Regional Devleopment, Warrer Truss, no later than Monday.

At the moment the prime, but unconfirmed person being mentioned for the role in industry circles is Chris Manning, a former Qantas chief pilot also noted for being a safety consultant who guided Tiger Airways toward to the required compliance with Australia’s safety regulations after its grounding by CASA in 2011.

Captain Manning has been a high profile critic of defence handling of air traffic control procedures at shared civil military airports such as Williamtown (Newcastle) and Darwin. He was, at the behest of Qantas, a voice of caution and concern over the use of common radio frequency self separation procedures at busy airports when AirServices Australia had insufficient staff to meet its ATC obligations.

However in his response to the Aviation Safety Regulation Review to parliament last week, the Minister, in accepting almost all of the recommendations, also said an additional commissioner with aviation technical experience would be appointed to the ATSB or Australian Transport Safety Bureau. Captain Manning’s career would make him a strong contender for either appointment, but nothing has been officially confirmed.

The only thing that is certain at this stage is that Mr Dolan is being replaced. In the aftermath of the Transportation Safety Board of Canada’s peer review of the ATSB’s procedures and methodologies in arriving at its controversial and much criticised findings concerning the 2009 Pel-Air ditching near Norfolk Island it is clear that Mr Dolan’s position as chief commissioner is untenable.

While the anodyne version of that quite detailed peer review is that it found that errors had been made by the ATSB the actual document details a shambles in the management of the investigation, and failures to properly collect and assess information.

The ATSB’s accident report was however defended by the current secretary of the department of Infrastructure and Regional Development, Mike Mrdak, and Mr Dolan. A Senate committee that inquired into the conduct of the ATSB (and CASA) in relation to the production of the report unanimously expressed dissatisfaction with Mr Dolan’s testimony.
The committee included coalition senators Bill Heffernan, its chair, and David Fawcett, as well as independent Senator Nick Xenophon, who not only pursued a range of issues in the two aviation authorities, but helped bring to light previously undisclosed documents related to a confidential Pel-Air audit in CASA and associated matters.

Those disclosures reflected adversely on CASA and the ATSB.
The inability of the ATSB under Dolan to adequately and convincingly deal with a relatively minor accident set off a festering controversy that brought the safety investigator and CASA, the regulator, into disrepute. That episode may be coming to an end, but the task of rebuilding respect and ensuring the best safety outcomes in both bodies remains.
If true one of the first port of calls that CM should make - besides those outstanding Military ATC SRs - is to get an update on where Be-a-cur's Mildura Fog incident (love-in) investigation is at... Judging from Ben's previous article - Damning review of ATSB Pel-Air investigation released - in comments from about here it would seem that incident is still causing much consternation and is very closely related to the infamous 'critical' to 'minor' safety issue with the PelAir cover-up:
Confirmed Sceptic - Weather forecasting is very good, but not perfect. When you quantify the various elements and do a simple statistical analysis of how often you should expect an accident or serious incident from our “she’ll be right, mate” fuel policies, you get Mildura. And Pel-Air. Care to bet how many people will perish the next time the dice roll the wrong way?
NX/RRAT Committee head-hunting mission - next stop ASA I reckon...


MTF...

Addendum - Ode to Be-a-cur

Simply Marvellous Horse-pooh (SMH).


Last edited by Sarcs; 5th Dec 2014 at 21:47.
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Old 5th Dec 2014, 21:59
  #2500 (permalink)  
 
Join Date: Jul 2008
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Dolan to be replaced by Chris Manning?

ATSB to get new leadership no later than Monday | Plane Talking
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