Merged: Senate Inquiry

[Kharon]

Holidays and handicaps.

TC welcome to the wild wood, pull up a stump, take your boots off, sit a while and have a cuppa.

TC. - "I doubt the CEO even knows its happening with fear and suppression the orders of the day".

That is abundantly clear; Heff was all over the 'tension' issues and even the famous 'man at the back of the room' could see, even without the assistance of Heff the rift, tension, and dismissive arrogance of the three clearly divided parties. The disconnect between 'them' and the forgotten coal face reality is easily discernable; ignored during the escalating squabbles over power and money. Why in the seven hells, Stabbed in the Dark (SID) was ever entered into the Holiday Cup stakes is no longer a mystery. It's apparent the SID stable is too busy with badge wearing tomfoolery and touchy-feely, American style self hypnosis (deception, if you like), feel good clap trap to realise how the snake oil salesmen and bookies have been 'at it'.

IF SID, metaphorically speaking, had any 'balls' a sit down with the inestimable Houston would be requested, to seek his assistance and wisdom in a quest to clean out the rats nest. Rats?, easily identified; SID should watch, (not just look) at the video, without the rose tinted aviator sunglasses and wings. Even to 'not the sharpest sausage in the packet' that which needs to be seen, is clear. Then clean them out, all of them, Monday – before they end up with a hastily slaughtered scapegoat, thus allowing the OS holidays to continue, unabated. Or, simply resign, with an exit statement; which could be a much better option, for clearly the 'whole' job is beyond SIDs' oft displayed limited capabilities. (Chuckle) Maybe Bea-Cur has a job for SID; salary cut of course, but he's so short of talent at the moment SID could be another administrative star, within a fortnight...

TC – "It seems you guys are in the same boat with the top jobs being given to the most inexperienced, mealiest mouthed, shallowest, emptiest, corporate bankword spouting, issue suppressing, ladder climbing yes men available."

The 'system' and those who run it needs to be examined, in depth. I believe the same murky influence, that which has been manipulating the system for two decades has a hand in the 'selection of the most suitable candidate' game of rort the system.

Perhaps there's hope. I don't believe any more than the Senate committee that the LAHSO operation at Melbourne is 'high risk'; it is however 'simple'. That's to say it is easily understood by the public, even the ABC got a fix on it and could boil it down to the sort of simple, easily digested breakfast food the punters like. But, never the less, LAHSO has all the earmarks of the thin end of a large wedge, driven with determination.

I know there are some very bright ATCO and that there is a strong 'bond' of association. Have ATCO's considered building their very own by-pass. Heffernan shows the way, there is a very good, highly qualified board, led by Houston who are, according to Heff, being kept in the dark and under utilised. Heffernan and Sterle lead a committee which is begging for a concise, warts and all report. This becomes a trigger for a meeting to discuss that report and involve the 'big' board at Senate level. Discussion between the Senate committee and Houston could just turn this around. At worst the board could no longer claim 'ignorance', those who treated them like mushrooms would fall directly in the line of fire, as to continue to deny there is a 'problem' risks the 'big' board personal reputations and credibility. Claim parliamentary privilege through the Senate committee (Cheer); they have a proven track record of preventing backlash, acting on solid evidence and Houston (bless) a proven reputation for fair play, honesty and rock solid common sense.

It may not be the answer to a pagans prayer; but it's an avenue worth exploring. Get some top cover, generate a report, take it to the grown up's and wait. This committee is on a roll and there will never be a better time, than now while even the useless media have a passing interest; even if it is only to find another stick to beat Abbott with.

Toot toot..

[Sunfish]

Kharon:

I know there are some very bright ATCO and that there is a strong 'bond' of association. Have ATCO's considered building their very own by-pass. Heffernan shows the way, there is a very good, highly qualified board, led by Houston who are, according to Heff, is being kept in the dark and under utilised. Heffernan and Sterle lead a committee which is begging for a concise, warts and all report.

My Father taught me that it is axiomatic in institutions that you can bypass One level of incompetence and bad management, but not Two.

To put that another way; If your bosses boss is also an arsehole you have no recourse.

In the case of Airservices, CASA and the ATSB the "bosses boss" is Mr Mrdak and his Department, not the various Boards, they are mere window dressing. It is also clear that Mr. Mrdak does not want trouble from any of the above organisations and that the Federal Government views aviation issues as requiring the same level of attention as prisons - there are no votes in Aviation at present.

I say " at present" because I have reached the conclusion that the only possibility of reform will require the creation of a minor party - the aviation enthusiasts party, that has a mission of affecting the Senate numbers, most probably by standing candidates and doing cross party deals.

To put that another way, unless Aviators can threaten the major parties with the potential loss of a marginal Senate seat, you are wasting your time.

Boycott the lot of them. Talking to them only gives them an excuse to say they "consulted".

[Kharon]

A two bob -'Yeah-buttal'.

Sunny, I would ordinarily agree with the bulk of your construct; I can agree without a seconds hesitation that Mrdak has a lot to answer for, none of which will never be 'publicly' sheeted home to him. The acquisition of wriggle room, flack jackets, bomb proof shelters, escape hatches and golden parachutes are second nature; as is gathering in 'the wood' as useful leverage.

There is, in this iteration one small difference; that is this Senate committee. Fawcett has written some peerless articles which are worth reading, they provide an insight. That he is fully aware of CASA machinations and 'modus operandi' is a given; study the Night Vision (NVG) case for a further insight. There is more, a lot more, but you get my drift.

You do not need to delve deeply into the past to pick out a trend; start with the pilot training inquiry, work forward to the last little brouhaha with the ASA – (a.k.a. the Slicks and Ficks club). I'd say that since the pilot training thing; there has been a steadily increasing flow of data, facts, evidence and complaint onto the desks of the Senate committee members. Happily, and for all the right reasons, the heavy weight forward pack, Heffernan and Sterle have found a way to express their long standing frustration with the 'governance' of aviation. They may have suspected, but were beaten back by tricky technical details, bluff, spin and fairy stories; swamped in 'the mystique'. Their finely tuned BS meters running on high alert but unable to scratch the itch. Until a Pel Air medivac ran out of noise and options over Norfolk, one dark and stormy. Even then the issue was not on their primary radar, but when it did appear they set work, with the gloves on, until it became apparent someone was taking the Mickey. Gloves off, game on, industry supporting and fetching the drinks.

None of the progress made through the inquiries, leading up to the recommendations made by the committee and the resultant Forsyth review (even the ATSB motherhood review, if it ever gets published) would have been gained without (a) United industry stepping up to the marks and (b) a committee who read, understood, knew how to use the information provided, had the wit and faith to use it; and, the courage to see the job done.

Now I read here a lot of negative comment, stating that the Senate is variously a side show; essentially ineffectual window dressing, neutered and simply wasting time. Time will tell, but IMO that is an incorrect assessment. They have identified the road block to airport issues, pilot training, ATSB reporting (or lack thereof), CASA perfidious bastardry and have a very clear picture of where the skeletons are buried. Industry provided information, the Senate acted. QED.

Why should the administratively crippled ASA be overlooked. Blind Freddy can see it's a basket case above the coal face layers. Bloated, smug, self satisfied, disingenuous, confused and seriously rorted. Without facts, 'evidence' and a briefing it is impossible for the Senate committee to do much more than the sterling job we have so far witnessed. They provide real value and a stellar service to industry for money we invest in them. They have ASA management down, but not quite out. Want things changed, get off your arses, draft a confidential report, claim privilege and watch the result. Remember, it may be possible to isolate and punish one ATCO, it would be a hell of a job to nail the whole crew. It is difficult, but not impossible to eliminate one senior public servant who manages the circus we call aviation in Australia. But it's not a hydra, kill the head the rest dies, or is shrivelled up in the bright light of exposure. The money saved would just about feed the third world.

Question - who hired the Three Stooges comedy act: McComic, Dolan and Staib, and why??

There now, AUD $00.20 spent as best pleased me.....

[Sarcs]

Newsflash - TSBC release peer review report

News release

TSB completes its independent review of the ATSB’s investigation methodologies and processes

Gatineau, Quebec, 1 December 2014 – Today, the Transportation Safety Board of Canada (TSB) released its independent peer review of the Australian Transport Safety Bureau’s (ATSB) air investigation methodologies and processes.

The ATSB requested a review after its investigation report (AO-2009-072) into the November 2009 ditching of a Westwind 1124A aircraft near Norfolk Island, Australia, received public and political criticism. The review did not include an actual reinvestigation of the Norfolk Island occurrence, but rather examined how that investigation, along with two other investigations similar in scope, was conducted.

“We saw the potential for mutual learning when we accepted the review request,” said Kathy Fox, Chair of the TSB. “We will now examine if any ATSB investigation best practices should be adopted here in Canada.”

The TSB review compared the two organizations' methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization and found they met or exceeded the intent and spirit of those prescribed.



However, while there were some ATSB best practices identified in the review, the TSB also found that there was some room for improvement, and has made 14 recommendations in the following four 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
• More effectively managing communications challenges

“We have communicated our findings and recommendations to the ATSB for their consideration and action as appropriate,” added Ms. Fox. “Sharing our experiences and expertise is part of our commitment to advancing transportation safety, and when called upon by international partners, the TSB is prepared to assist when feasible.”

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053

The Norfolk Island investigation

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.

First of all, an early misunderstanding about the responsibilities of the Australian Civil Aviation Safety Authority (CASA) and the ATSB in the investigation was never resolved. This led to the ATSB collecting insufficient 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.

Poor data collection also hampered the analysis of specific safety issues, particularly fuel management, company and regulatory oversight, and fatigue (the ATSB does not use a specific tool to guide investigation of human fatigue).

Weaknesses in the application of the ATSB analysis framework resulted in those data insufficiencies not being addressed and potential systemic oversight issues not being analyzed. Ineffective investigation oversight resulted in issues with data collection and analysis not being identified or resolved in a timely way.

All three peer reviews conducted on the Norfolk Island draft report identified issues with respect to factual information, analysis, and conclusions. Many of these concerns were never followed up after the review process was complete. The ATSB process does not include a second-level review to ensure that feedback from peer reviews is adequately addressed.

After investigation reports have gone through peer and management review, they are sent to directly involved parties (DIPs) for comments. In the Norfolk Island investigation, the DIP process was run twice: once when the report was in its initial draft, and the second time after it had been revised. However, there is no process to ensure that the ATSB communicates its response to DIPs' comments. Formal responses to DIPs increase their understanding of the action taken in response to their submissions, and may make them more amenable to accepting the final report.

In the Norfolk Island investigation, the Commission's review of the report took place immediately after the first DIP process was completed, 31 months after the occurrence. At this stage in an investigation, it is difficult to address issues of insufficient factual information since perishable information will not be available and the collection of other information could incur substantial delays. At the ATSB, the Commission does not formally review some reports until after the DIP process is complete, and in any event, there is no robustly documented process after the Commission review to ensure that its comments are addressed before the report is finalized. Both of these aspects of the ATSB review process increase the risk that deficiencies in the scope of the investigation and the quality of the report will not be addressed.

A safety issue was identified in this investigation concerning insufficient guidance being given to flight crews on obtaining timely weather forecasts en route to help them make decisions when weather conditions at destination were deteriorating. When the safety issue was presented to CASA, it was categorized as “critical”, but in the final report it was described as “minor”, which caused significant concern among stakeholders. The TSB Review observed that this shifted the focus of the discussion to the label and away from the issue itself—and the potential for its mitigation.

In the final stages of the investigation, senior managers were aware of the possibility that the report would generate some controversy, but communications staff were not consulted and no communications plan was developed. 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 response to the Norfolk Island investigation report clearly demonstrated that it did not address key issues in the way the Australian aviation industry and members of the public expected.

Comment: BOLLOCKS! But then we all expected that didn't we...

But after this triple load of bollocks I'm definitely taking the TSBC off my Xmas card list...

The Kangaroo Valley and Canley Vale investigations

The review of the Kangaroo Valley and Canley Vale investigations showed that when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the result is more defensible.

In contrast to Norfolk Island, the Kangaroo Valley and Canley Vale investigations underwent regular critical reviews and used the ATSB analysis tools effectively, which gave rise to well-documented decisions, and revised data collection plans and analyses. In the Canley Vale investigation, additional information collected as a direct result of a critical review guided informed decisions with respect to the investigation of regulatory oversight.

In the Kangaroo Valley investigation, the target timeline outlined in the ATSB Safety Investigation Quality System (SIQS) for a Level 3 investigation was exceeded, despite significant effort by the team to expedite the investigation. This may indicate that these targets are unrealistic, the investigation was incorrectly classified, or that other work had influenced the published investigation schedules. Significant delays in completing an investigation increase the risk that stakeholders' expectations with respect to timeliness will not be met.

Nevertheless, because of the teams' active engagement with stakeholders in the Kangaroo Valley and Canley Vale investigations, expectations with respect to schedules were well managed and timely action was taken on safety issues.

In the Canley Vale investigation, events prior to the occurrence raised questions with respect to regulatory non-compliance and oversight. The report states that issues of regulatory non-compliance did not contribute to the occurrence, and the analysis tools were indeed effectively used to support this. However, the report could have benefitted from a more thorough discussion to clarify the underlying rationale for this conclusion.

Unlike Norfolk Island and Kangaroo Valley, the Canley Vale investigation included a closure briefing, which provided an opportunity to discuss lessons learned.

Absolutely undeniable clap trap...

MTF...

[slats11]

Maybe time for a letter to the PM requesting he instruct the ATSB to immediately implement the Senate recommendations. I am sure many here would sign such a letter.

Difficult to be on the world stage over MH370 is the Canadian TSB has identified serious errors in the ATSB report - a report that Dolan himself acknowledges he is not proud of.

This whole issue has been unsuccessfully swept under the mat. Better for the Aust Government to pull it out and deal with it transparently than have someone else (FAA) pull it out for them.

Slats11

[Sarcs]

Planetalking on the Canuck's report.

Damning review of ATSB Pel-Air investigation released

The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.

This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.
The report also casts light on internal frustrations and divisions within the ATSB investigation.

If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised reportup, as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.

This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.

The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation...

...

The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.

Second rate isn’t good enough for Australia.

Hear..hear..Ben; & TICK TOCK miniscule and M&M...

MTF...

[slats11]

So we have a report:
1. Which Dan concedes he is not proud of
2. Which an independent Senate committee was very highly critical of
3. Where Dolan had to rely on regulations not in force at the relevant time in order to defend his decision not to get the recorders
4. Which is condemned by the independent (sort of) Canadian TSB review
5. Which is not respected by the industry, and which falls short of the expectations of the Aust public

How can this aberaton be allowed to stand?

At high school this would get "Resubmit" in big red letters.

Slats11

[Soteria]

Team Abbott losing its grip

The wheels are falling off Team Abbotts undercarriage!
Incompetent Government agencies, MrDak's veneer wearing thin, budget blowouts, a Deputy Prime Minister who sits drooling in a rocking chair, a Prime Minister that is more untrustworthy than Lucifer himself, a dysfunctional PMC and and PMO (Peta Credlin) and so the ticking time bomb goes!

Abbott may have had his mea culpa but the entire stinking bunch of them are having their pony poo'ulpa. Lies, deceit, dysfunction, obsfucation, cover ups, bugger ups and fu#k ups and so it goes. Indeed tick tock goes
the play school clock. I am looking forward to reading through the TSBC report in detail, however a cursory look revealed numerous donkey pellets laying about the floor of which the Government has been trying to avoid stepping in. However too late, they have finally stood in a big steaming one
Now although the report is politically cautious and doesn't go for the jugular in a manner that the IOS would approve, it says enough in the sense that it highlights that 'Houston there is a problem'. Now how MrDak, Crudlin, Slugger and the loose bowels Truss handle it is an entirely different story. I agree that the Canuck report is probably softer than Dr Aleck's handshake, however Ben does do a good job on Plane Talking at sifting through the chaff.

Tick tock, it's time for the Australian Aviation Party to be formed...

[Frank Arouet]

TRUSS MISLEADS CONSTITUENTS

[Frank Arouet]

QUOTE Poor data collection also hampered the analysis of specific safety issues, particularly fuel management, company and regulatory oversight, and fatigue QUOTE


So who was it that considered little or no information relevant to the investigation?


Who said it was not likely that any information obtained would not lead to any commensurately significant safety or learning improvement?


Truss does not have my confidence and I object to being mislead.


Both he and his predecessor Albanese need "disappearing".

[Sarcs]

Bollocks retraction to the TSBC.

I must apologise forthwith to the Canucks.. Still reading through the report but the extreme effort of adhering to the restrictive ToR...

"The terms of reference and the scope of the TSB Review excluded re-investigating the Norfolk Island ditching; rather, the Review was to focus on how the investigation was conducted."

...has not diluted any of the professionalism of which the reviewers have displayed in taking to the task.

There are some deep messages that need to be learnt from if the ATsB is to recover any of their once respected reputation on the world stage of AAI and once again be an effective air safety watchdog.

What is truly evident is that the involvement of CAsA in a parallel investigation - for what would have to be said as being for devious reasons - has had a profound impact in the conduct and performance from the investigative team up to middle and executive management at the bureau...

This conflict of interest was very carefully crafted & outlined in sub-paragraph 3.7.3.1

3.7.3.1 Misunderstanding of the roles of ATSB and CASA

Independence is critical to the work of an accident investigation body whose sole mandate is to improve safety. Parallel investigations by other agencies to fulfill their respective mandates should have no bearing on the actions of an independent safety investigation. In the Norfolk Island investigation, there was no real barrier to prevent any avenue of investigation or examination of the regulatory process itself. However, there was a misunderstanding that affected the quantity and quality of the data available for analysis.

The Norfolk Island ditching occurred four months after structural changes made the ATSB fully independent: on 01 July 2009, the ATSB had ceased being a division within the Department of Infrastructure, Transport, Regional Development and Local Government, and became a separate statutory agency. These changes should have had the effect of reducing the likelihood of any influence by CASA on an ATSB investigation.

However, at a December 2009 progress briefing to ATSB management, one of the risks to the investigation discussed was the CASA parallel accident investigation. Afterward, perceptions of how this issue had been resolved differed. The IIC believed he had been instructed not to cover the same areas as CASA, since the regulator was conducting a parallel investigation.

Meanwhile, the Commission and ATSB managers believed it was well understood that the investigations were fully independent and that there were no barriers to the ATSB investigation.

In addition, there were several communications between the IIC and the Chief Commissioner on the issue of regulatory action planned by CASA against the pilot. These communications did not clarify the independence of the ATSB investigation, and the IIC continued to believe that he had been instructed to avoid duplicating CASA's efforts.

The IIC's misunderstanding of the roles of CASA and the ATSB was never resolved. It resulted in information not being collected from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence prevailed in the company in general.

To be fair to the bureau they were only trying to adhere to the spirit and intent of the newly minted MoU, unfortunately the other side was not playing by the Queensberry rules and systematically set about undermining and unsettling the IIC into distraction... And the rest as they say would have been history but for a 4 Corners program a nosey independent Senator and the non-partisan Senate Committee...

So again apologies TSBC.. Just a pity about the time delay and the fact you were hamstrung by the ToR - as I fear your excellent report (so far) may well be lost in the 'Bankstown Chronicles'...

MTF...much more..

Ps Well done Ben...

{Comment: Dear TSBC I will not - at this stage - retract my 'BOLLOCKS' for the Canleyvale review as I believe you have been severely misled...}

Addendum: AA online - Canada’s TSB publishes critical review of ATSB

[Soteria]

CASA, ATSB, MOU, PMO, POO........

3.7.3.1 Misunderstanding of the roles of ATSB and CASA

Hmmm. This 'cosy MOU' between both foul smelling organisations was the brainchild of the Witchdoctor. The Doc wouldn't have tried such a trick had one Allan Stray or Kym Bills been running the ATSB show still. However with the not so intelligent Beaker and his sidekick the very weak Jules Verne, the Doc saw his chance, and hey presto, the ATSB becomes the CASA's bitch. Sign here please!
One doesn't really need to hypothesise as to why such a cosy relationship was crafted and promulgated by Fort Fumble's elite

Addendum: I was 'chipped' by somebody who didn't like my reference to the Doc's weak handshake, even if true. Well to balance things out I might add that T. Abbotts Chief of Staff, Peta Credlin, not only has a giant body, giant head and giant hair, she has a very strong vicelike handshake! 10/10 in fact.

[Sarcs]

Timeline of embuggerance (TOE) nearing completion

The TSBC total focus was on the bureau actions/inactions throughout the entire PelAir investigation, however we (the WWIOS) are not so restricted... In the TSBC report - especially in 3.3 Data collection (November 2009 to September 2010) - there are many clues to how FF very cleverly distracted, manipulated and obfuscated their true intentions for their pre-determined outcome.

First on the CVR/FDR recovery assessment:

Considerable research was conducted into the options and associated costs for recovering the flight recorders from the wreckage. By policy, military support was not available unless commercial options did not exist. It was determined that a portable decompression chamber would be required on site for any diving operation because of the depth of the water, which would have driven the cost of recovering the recorders to more than AUD$200 000. On 25 January 2010, the ATSB Chief Commissioner decided that this would not be an efficient or effective use of ATSB resources, given what was known about the circumstances of the ditching and the availability of other sources of data and information.

A copy of this review (incamera) I assume was what Senator X was brandishing around here:

Non-retrieval of CVR/FDR - Dolan obfuscation 22/10/12 hearing - YouTube

What should not be forgotten was that CAsA had earlier been approached to chip in for the recovery of the CVR/FDR, to which they declined on the grounds of lack of funds:

5Correspondence from CASA to committee clarifying statements made at 22 October 2012 hearing, received 1 November 2012;(PDF 163KB)

Then there was the wedge placed into the mix by CAsA which led to a blurring of the lines of responsibility when it came to reviewing the area of regulatory oversight - 3.3.6 Information on regulatory oversight:

Throughout the investigation, ATSB staff and management consulted or briefed CASA staff and management. Attachment A of the Memorandum of Understanding between the ATSB and CASA (October 2004) indicated that, upon agreement by both CASA and ATSB, a CASA officer might participate in the ATSB investigation. In this instance, no CASA officer was designated.

This is interesting because if CAsA did designate an officer to participate then that officer would be bound to confidentiality by the restrictions in the TSI Act. Probably not a desired outcome by CAsA and may have had an effect on the proposed enforcement actions on the pilot at the time.

CASA had conducted a special audit of Pel-Air from 26 November to 16 December 2009, after the ditching. The IIC was concerned that reviewing the special audit report might bias the ATSB investigation, and so did not request a copy. The ATSB received a copy of the CASA special audit report in July 2012, during the DIP process.

The IIC may have saved us all a lot of grief if he had requested a copy of that report but the intense pressure applied by CAsA conducting a parallel investigation was already evident, this was IMO a critical point in the investigation to which the ATsB were never to recover from...

12Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)

Then there was the matters of the CAIR 09/3 report and the infamous Chambers Report:

On 28 July 2010, CASA briefed the ATSB on the findings of its regulatory investigation into the ditching, which it had done in parallel with the ATSB investigation.Footnote 12 The team leader obtained a copy of the CASA investigation report in March 2011.

An internal CASA audit report dated 01 August 2010Footnote 13 critically analyzed CASA's oversight of Pel-Air and its ability to oversee the wider industry. The ATSB had not known about this report during the investigation, and so it was not taken into account during decisions as to the scope of the investigation.

Both of which we now know CAsA deliberately sat on to further obfuscate and blur the lines of responsibility supposedly outlined in the newly minted MoU for the conduct of parallel investigations...

Remember this from Tezza...:

From: FARQUHARSON, TERENCE
Sent: Thursday, 22 July 2010 12:36
To: McCormick, John
Cc:
Subject: FW: Pel air Accident VH-NGA Final Report [SEC=UNCLASSIAED]

The attached PelAir report has been finalised. Subject to one final confirmation of the fuel calculations by (blank) (being conducted this week), (blank) is comfortable with the report's content, to the extent that it correlates with the AAT material to be submitted shortly and that there are no differences that can be highlighted by the opposing legal team.

The release of this report will provide Ops with the material to begin consideration of any further action that may be necessary against the any of those involved in the accident.

When has confirmed the fuel calculations, would like to discuss in general the report with ATSB. In any discussions would not provide the ATSB with a copy of the report but would talk about the salient points. This is in keeping with the spirit of the MOU.

Your approval to release the report is requested.

Regards

MTF...

[Sarcs]

Miniscule statement to the Parliament

At 09:01 am in the HoR the Miniscule made a statement...

Here is part of that statement under the heading - ATSB Governance :

ATSB Governance

The Government fully supports the vital role of the ATSB.
Independent investigation of accidents or incidents remains a critical element of the safety system, helping us understand the causes and hence the sources of risks to safety. This helps to avoid future accidents.
If the system is to work well, industry must cooperate in providing information during accident and incident investigations and in reporting incidents generally.



The Government will take a number of actions to give effect to this commitment including:

• the appointment of an additional ATSB Commissioner with aviation experience; and
• issuing a new Statement of Expectations to the ATSB once the Commission and the Government has had the opportunity to review the findings of the Canadian Transportation Safety Board review of the ATSB publicly released earlier this week.

Madam Speaker, yesterday the Canadian Transport Safety Bureau (TSB) released its independent report into the Australian Transport Safety Bureau (ATSB).

The ATSB tasked the Canadian TSB to undertake an independent review of their investigation methodologies and processes, how they were applied in specific cases and how this compared to international best-practice standards.

The TSB review looked in detail at three separate investigations, one of which was the Pel-Air inquiry which as Members may recall was the subject of a Report by the Senate Rural, Regional Affairs and Transport Committee.
While the Canadian TSB found that ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, they found that in the case of the Pel-Air investigation, there were errors made.

I am concerned that the TSB report raises some concerns about the application of ATSB methodologies in the investigation into the ditching of a Pel-Air off Norfolk Island in 2009.

As a consequence, I have asked the ATSB Commission to give serious consideration to reopening the investigation.

On a related point, as I have just announced I will shortly be appointing a new Commissioner to the ATSB with a specific background in aviation. This will fulfil an undertaking made by the Coalition prior to the election.

I have asked that the fresh review of the Pel-Air accident should take into account the findings of the TSB's report.

Also covered briefly by AA online...: Truss calls for fresh look at Pel-Air ditching

You Tube

Well I'll be buggered...

Reckon it is only a matter of time before we hear that Beaker has gone on an extended leave of absence...

MTF...

[slats11]

Re-opening ATSB PelAir investigation

Always amusing when a Minister finally stops trying to defend the indefensible.

[Frank Arouet]

The bloody evidence has been compromised. Most probably on purpose and just in case of such an eventuality.


Is the new commissioner in addition to, or in replacement of the present. Oh, I see an overlap. Two snouts in the trough now.


Truss is finished.

[thorn bird]

"12Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB) "

The latter part of this document clearly shows that CAsA under the skulls direction, stitched up the crew of the westwind, ably assisted by his sociopathic attack dog wodger wabbit.

CAsA today is still pursuing DJ in a vendetta of maleficence that beggars belief.

Sorry Mr. Truss we have all heard you have a bad dose of the ****s.... unfortunately the Aviation industry has had the ****s for a lot longer than you have, may be a different virus, but ours is more debilitating.

Your authority, CAsA, for which YOU have oversight, are on an orchestrated process of destroying the general Aviation industry in this country.

If this is not your governments policy you are being severely lied to.

I suggest you do some research into Polair, Airtex, Barrier, John Qadrio, Hardies, Jabiru and Your mates, Pel Air & Dominic James & Karen Casey.

Ask your Minder pumpkin head if he wiped a severely disabled flight nurse, looking for some sort of resolution, as if she was a splash of cow **** stuck to his trousers. A really nice bloke.

Then there are a lot of rumors surrounding him and the sale of the secondary airports , something about destroying floodplains with uncertified asbestos contaminated fill, sourced from a Lebanese company??? does the name obede ring a bell?

The corruption by CAsA has consequences for a lot of innocent people Mr. Truss, broken people, broken marriages, broken bodies and broken lives. These are the detritus left behind by your out of control regulator

It will take a lot more than appointing another ex RAAF type to dip his snout into the trough of public funds to convince me that the whole system isn't completely corrupt.

The ATSB is a CAsA bitch, only a very brave or very naïve person would have any communication with either without a lawyer present.

The rule of the regulator is upon us people, the rule of law is redundant.

Note to the FAA: would you please get down here and downgrade Australia, Your nationals are at risk.

Nothing will happen in the way of reform in Australia until the government is severely embarrassed and it becomes a political issue.

You were severely lied to last time.

Since then the industry here has tried, but simply doesn't have the resources.

[Sarcs]

A word from MMSM Steve...versus

Steve 'don't have an opinion' Creedy got reasonably fired up today...well sort of...:

DEPUTY Prime Minister Warren Truss has asked the Australian Transport Safety Bureau to re-open its controversial inquiry into the Pel-Air crash off Norfolk island in 2009.

The ATSB was forced to defend its handling of the investigation before a Senate Committee after irregularities emerged in its handling of the Westwind jet crash in November 2009.


All six occupants of the jet survived the night-time ditching of a CareFlight medical evacuation from Noumea but CASA suspended the licence of pilot-in-command Dominic James and the airline grounded its Westwind operations.
Captain Dominic James, a former Cleo Bachelor on the year nominee Source: News Limited





The ATSB took almost three years to produce a report that identified mistakes by the flight crew relating to fuel planning and weather checks as contributing safety factors and to a lesser extent criticised the available guidance on these issues from the company.

The Senate committee was formed after an ABC Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.
Mr Truss announced today as part of the government’s response to a report in aviation safety chaired by industry veteran David Forsyth that a review by the Canada Transportation Safety Board had found the ATSB made mistakes in its investigation.

“While the Canadian TSB found that ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, they found that in the case of the Pel-Air investigation, there were errors made,’’ Mr Truss said.

“I am concerned that the TSB report raises some concerns about the application of ATSB methodologies in the investigation into the ditching of a Pel-Air off Norfolk Island in 2009.

“As a consequence, I have asked the ATSB Commission to give serious consideration to reopening the investigation.’’

Mr Truss said he had appointed an additional ATSB commissioner with aviation experience and would be issuing a new Statement of Expectations to the bureau once the government had the opportunity to review the findings of the Canadian review...

Not sure if Dom would appreciate the resurfacing of that pic...

Come on Steve you can do better than that mate...

MTF...

[Sarcs]

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...

[slats11]

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.