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

Merged: Senate Inquiry

Old 30th Dec 2014, 19:34
  #2581 (permalink)  
 
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Unless Dick Smith is prepared to use his influence in the Howard/Credlin government or support a popular candidate against Barnaby Joyce in his electorate, the only tiny glimmer of hope is the non-major party aligned Senators.

At least people are finally realising that the Laborials really don't care two stuffs. As far as they are concerned, CASA, ATSB and Airservices are doing their real jobs really well.
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Old 30th Dec 2014, 20:20
  #2582 (permalink)  
 
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Talking

...the Howard/Credlin government
Sums it up nicely Creampuff!
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Old 31st Dec 2014, 03:37
  #2583 (permalink)  
 
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Curiously intriguing.

Playing around with a 'parallel' chronology is an interesting pastime while digesting Christmas plum pudding; many curious little anomalies fall out. For instance, the White –Sangston email chain from the AAI evidence squeezes the 2004 MoU into the frame as being the 'active' MoU for the Pel-Air ditching event investigation, rather than the unsigned (at the time) 2010 version. There are subtle differences (see appendix A); which exclude such things as the AILU (CASA White) becoming 'actively' involved. Then we have the small matter of the parallel investigation which got off the mark remarkably quickly, compared to the usual pace at which these events have, historically, taken place. CASA could have requested and been granted a 'representative' to be taken in as part of the 'team', but the AILU swinging into top gear, jumping the gun and getting embroiled begs some interesting questions.

There's the small matter of the IIC getting all bent out of shape and going postal; not mention Cook and Christie' s high dudgeon departures. The Canadians 'mention', in veiled terms these and other 'aberrations'. It leaves you wondering, was TSBC given "all" the information; or, just left to make the best they could off of a very narrow window (keyhole?).

I find it hard to believe that the ATSB is even going to be allowed to investigate the ATSB, let alone under the Sangston ToR, it's outrageous. The whole thing smells off, leaves a bitter aftertaste and a lingering smoky finish. One thing for certain sure, there is no way that we can ever trust or rely on any future ATSB report while the same crew (on both sides) are running the show, just dare not trust 'em. But then, what else could you expect from anyone who starts an email, to the man who's been most affected by the botched Pel-Air report with the derogatory salutation "G'day Mr James" and continues in a similar, condescending fashion right through to the end of missive.

"Nick Xenophon, come on down and bring your mates with you". Start with a resolution to not accept anymore perverted, fractured or slightly disingenuous reports on accidents. The Darwin Braz and Canely Vale both could stand an official brush down and a tune up, if they are to accepted by a Coroner. They cannot possibly be relied on for a legally safe decision as they stand, considering the large black cloud over the tarnished ATSB track record, under the auspices of the 2010 MoU.

Hogmanay is the last day of the old year; what a great time to clean out the dross. Have a good one, stay safe and Plan B like crazy. You just never know when it's your turn, had a mate booked DUI one late-ish night a couple of years back, heading home on a jinker trail in a Qld State forest; half asleep aback a horse, which knew it's way home from the pub perfectly well. Toot toot:..............

Last edited by Kharon; 31st Dec 2014 at 07:41.
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Old 31st Dec 2014, 09:50
  #2584 (permalink)  
 
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Danger 2015 a year of renewal, regaining trust & credibility or oblivion??

I find it hard to believe that the ATSB is even going to be allowed to investigate the ATSB, let alone under the Sangston ToR, it's outrageous.
IMO - if the self-serving, self-preserving Bea-cur & the sanctimonious Sanga & Jules are left in place and to their own devices (reference the disgusting Sanga ToR) 2015 could well be the last year of existence for the ATsB as we now know it...

Oh and how different it could have been if on receiving the Miniscule directive the above mentioned trio decided to come clean, clear the slate & delegate (as is allowable under Annex 13) the PelAir re-investigation to a credible signatory to the Chicago Convention - such as a TSBC, a NTSB or even the Singapore AAIB.

But we can't have that as there is now too much to lose, too many skeletons in the closet and too much evidence of embuggerance & obfuscation that a grown-up, competent State AAI could not possibly fail to uncover. Not to mention how embarrassing it would be if the lead Aussie agency that is currently heading up the search for possibly the greatest aviation mystery of all time - i.e. the disappearance of MH370 - were found to have been complicit and helped facilitate the PelAir cover-up...

However for the final time - in 2014 at least - let us once again revisit the 'timeline of embuggerance' (TOE) in reference to the Ferryman post (above):
There are subtle differences (see appendix A); which exclude such things as the AILU (CASA White) becoming 'actively' involved. Then we have the small matter of the parallel investigation which got off the mark remarkably quickly, compared to the usual pace at which these events have, historically, taken place. CASA could have requested and been granted a 'representative' to be taken in as part of the 'team', but the AILU swinging into top gear, jumping the gun and getting embroiled begs some interesting questions.
This is indeed both intriguing and confusing... Here are the referenced passages from the two MoUs - 1st 2004 Appendix A:
ATTACHMENT A- Participation in Investigations

The Parties may agree that a CASA Officer will participate in an ATSB investigation. The CASA Officer will be required to sign an agreement acknowledging their rights and duties, appropriate to the level of their involvement in a transport safety investigation.

Where a CASA Officer is participating in an ATSB investigation they will be under the direction of the Investigator-In-Charge (IIC). The CASA Officer will be given access to evidence to the extent necessary to enable the IIC to effectively complete the investigation.

The ATSB will not normally seek to participate in CASA regulatory investigations, but may request participation in, or information from, any defect investigation undertaken by CASA. ATSB Officers who participate in a CASA investigation must comply with any lawful direction given to them by the CASA Officer-in-Charge of the investigation.
2010 MoU:
ATTACHMENT A- Participation in investigations

1. Participation in investigations will be co-ordinated through the Manager ALIU, CASA and the Director Aviation Safety Investigations, ATSB.
2. The Organisations may agree that a CASA officer may act as an observer or an external investigator for the purposes of an ATSB safety investigation under the direction of the Investigator In Charge (IIC). The CASA Officer will be required to sign an agreement acknowledging his or her obligations and duties, appropriate to the level of their involvement in a transport safety investigation.
3. The CASA Officer will be given access to evidence to the extent necessary to enable the IIC to effectively complete the investigation.
4. The ATSB will not normally seek to participate in CASA regulatory investigations, but may request participation in, or information from, any investigation undertaken by CASA. ATSB Officers who participate in a CASA investigation must comply with any lawful direction given to them by the CASA Officer-in-charge of the investigation.
Okay so there are subtle differences mainly in the lines of reporting but the question is which version were they operating under in the case of the PelAir investigation??

Well according to what the TSBC were led to believe it was the 2004 MoU that was being adhered to (from TSBC peer review report):
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.
{NB: IMO the last line in bold is also significant because prior to PelAir this was a normalised process in cases where AOC holder compliance & regulatory oversight may have been contributory to an accident/incident}

But then two paragraphs down we again get the confusion...:
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.
Footnote 12 quote...

"...Civil Aviation Safety Authority (CASA), Accident Liaison and Investigation Unit, Accident Investigation Report 09/3: Israeli Aircraft Industry Westwind: VH-NGA: Operated by Pel-Air Aviation Pty Limited: Norfolk Island, 18 November 2009 (Canberra: 21 July 2010)..."

See what I mean?? Hmm...but apparently ALIU Whitey was never confused - from the infamous, once hidden CAIR 09/3:
Synopsis

The Accident was notified to the Australian Transport Safety Bureau {ATSB) who in turn notified the Civil Aviation Safety Authority (CASA) on Wednesday 18 November. The ATSB decided to conduct an investigation. The CASA Manager Accident Liaison and Investigation Unit (ALIU) was tasked with conducting a parallel investigation for CASA purposes. An investigation into the circumstances of the accident was commenced the
next day. CASA informed the ATSB of the investigation in accordance with sub section 4.1.2 of the joint MOU.
Okay so then let us refer to the two MoUs in regards to parallel investigations - 1st 2010 MoU:
4.1 Parallel investigations:
4.1.1 The ATSB may undertake 'no-blame' safety investigations in accordance with the TSI Act and CASA may separately undertake investigations with a view to possible safety-related action pursuant to its functions under Section 9 and/or Part IIIA of the Civil Aviation Act.
4.1.2 As soon as reasonably practicable after either the ATSB decides to conduct an investigation, or CASA decides to conduct an investigation in relation to a matter that would be a reportable matter to the ATSB, each organisation will notify the other organisation.
4.1.3 If either organisation considers an investigation conducted by the other organisation is creating an unreasonable impediment to the performance of their functions, they will raise the matter with the other organisation.
4.1.4 With respect to its own investigation, each organisation will seek to gather evidence from original sources in the first instance and then, where
practicable, on the basis of information provided by the other organisation.
2004 MoU:
5.1 The parties may undertake separate parallel investigations into an aviation occurrence. In this circumstance the parties agree that the purpose of the ATSB and CASA investigations will be promoted and structured so that there is a clear publicly perceived difference between them, so that the ATSB maintains its prime role as an independent, no-blame investigation agency and CASA's role as
the safety regulator is not compromised.
5.2 Both patties will cooperate to ensure, to the extent practicable, that an
investigation conducted by one party does not impede on an investigation orfunction of the other party.
5.3 If either party considers an investigation is creating an unreasonable impediment to the performance of their functions, they will raise the matter with the other party.
5.4 The ATSB acknowledges that it is not an auditor of CASA's management or operational practices, procedures or decisions. If the ATSB considers that an investigation is likely to extend to involve consideration of CASA's management or operational practices, procedures or decisions (beyond consideration of CASA's regulatory framework), the ATSB will immediately raise the matter with CASA's Deputy Chief Executive Officer before proceeding to investigate that part of the investigation.
With the possible exception of the Lockhart River investigation, it would appear that historically it was very rare for CAsA to instigate a parallel investigation on initial receipt of an ATsB notification of an occurrence. Normally CAsA would only become involved in an accident/incident investigation once the ATSB preliminary report had been published and that report indicated areas of regulatory concern. Even then CAsA would be more inclined to instigate a Special Audit and possibly ask to include one of its own in the ATsB investigation of a non-fatal GA (Airwork) incident.

Yes indeed all 'curiously intriguing' but with the Sanga missive not much will be revealed unless of course a certain Senator - who now potentially holds the balance of power - has anything to say about the farce that will be the PelAir re-investigation...

Catch you next year cheers & beers...
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Old 31st Dec 2014, 20:07
  #2585 (permalink)  
 
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Devilish detail.

2004 MoU - 5.4 The ATSB acknowledges that it is not an auditor of CASA's management or operational practices, procedures or decisions.
It the ATSB cannot 'audit' the CASA part of an accident or incident, then who can?

If the ATSB considers that an investigation is likely to extend to involve consideration of CASA's management or operational practices, procedures or decisions (beyond consideration of CASA's regulatory framework), the ATSB will immediately raise the matter with CASA's Deputy Chief Executive Officer before proceeding to investigate that part of the investigation.
Surreal; It's all a bit like the head Bobby at the local nick ringing up the boss of an armed hold up gang and saying that it is believed that the operation he has planned for Tuesday 'may' be illegal and apologising for 'investigating', in advance.

Boss Plod - "You get in and out by 1000, we'll be there at 1130". "Just letting you know that there will be an investigation, but make sure your villains have cleaned up afterwards and, perhaps, ask them to hang about to 'assist' with the investigation.

Boss Villain – "Certainly, once the get-away car is safely on it's way, I'll have the boys bring in coffee and doughnuts; we'll have a nice little chat and tut-tut about the terrible state the world is in". "I can even get my Word Weasel to draft a report, save you a bit of time, how's that?"

Boss Plod – "That would be nice, all good, see you Tuesday then, Ta-ta".

Now, that's not corrupt, no Sir, it's just the spirit of cooperation shining through to ensure that business as usual is not disturbed. Smooth as silk.

CP -Prepare for a masterclass in using the infinite flexibility of language to choose any approach you like from time-to-time to justify anything you like from time-to-time time::::
Toot - groan - toot...

Last edited by Kharon; 31st Dec 2014 at 20:12. Reason: Rough running in #3 Cylinder, probably a mixture problem.
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Old 31st Dec 2014, 22:04
  #2586 (permalink)  
 
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Wow! New Year..new page now let's clean out the dross.

And a happy New Year to you Mr Ferryman would you like a dollop of cream on your donuts??

Love it "K" first choccy frog for '15 perhaps...

Now, that's not corrupt, no Sir, it's just the spirit of cooperation shining through to ensure that business as usual is not disturbed. Smooth as silk.

& the quote from Creamy is top shelf...
CP -Prepare for a masterclass in using the infinite flexibility of language to choose any approach you like from time-to-time to justify anything you like from time-to-time time::::
Just re-winding a couple of weeks before we move on and down the new page...remember this from Ben - Reopened Pel-Air inquiry could be on slippery slope to ruin??
Nevertheless, the Minister acted, and on 6 December, based on very, very good advice, Plane Talking reported that a replacement for the chief commissioner of the ATSB, Martin Dolan, would be announced, and some serious work on the matters identified in the TSBC report would occur.

That appointment hasn’t yet occurred, and the report in Plane Talking is either wrong or premature. Since then Plane Talking has seen correspondence which would suggest to a reasonable reader that a determined effort to frustrate what might be the Minister’s best intentions (or not) is underway.

It seems like the iron clad rule of life in public administration in Australia, that it takes precedence over the elected executive branch, and will run right over the top of injured or damaged parties without any concern other than keeping Ministers compliant, and administrative decisions untouched, is being pursued with determination.

But not necessarily success. The Pel-Air genie is out of the bottle, and Australia is in the humiliating position of attempting to maintain the validity of a nasty second rate accident report that by world’s best practice is a joke.

Mr Truss could emulate his Labor predecessor, Anthony Albanese, and run away from accountability for the quality of the report, and the woeful lack of progress in reforming and administering the air safety regulations of this country. It might however be very wrong to assume he is that weak, and no such assumption is being entertained here for the immediate future.

The problem for Mr Truss, and the ATSB and CASA is that the work done by his own coalition colleagues, Senators Bill Heffernan and David Fawcett, Labor’s Glenn Sterle, and independent Nick Xenophon, is notably and in copious detail, damning of the conduct of Martin Dolan, and the former director of air safety for CASA, John McCormick, and uncovered matters relating to the conduct of CASA and the ATSB that are in Hansard for everyone to find and digest.

Make no mistake, that conduct in relation specifically to the Pel-Air matters, as well as some necessarily broader issues, was second rate, prejudicial to damaged or injured parties, sub-standard by world’s best practice and inherently contrary to the safety interests of airlines and their passengers flying within or to and from this country.

Pel-Air, in the TSBC, and in the Senate committees that have probed those matters, is a small plane crash indicating much bigger questions need to be asked about the conduct of both authorities, as well as the now discredited position taken by the secretary of the department of Infrastructure, Mike Mrdak, that there was no safety benefit to be had in re-opening the crash inquiry.

The senators named above have no intention of letting this matter go through to the keeper. They will keep hammering away at this until the matters are cleared up, and Mr Dolan removed from his role at the ATSB, in the process of dealing with more serious safety administration issues.
Which IMO deserves a bucket of choccy frogs but there you go.

Well since the Miniscule's fateful speech to the Parliament & apparently one passing strange, brief MH370 telephone interview with Bloomfield (Dolan on MH370 - "Ad libitum"?? ) it would appear that Beaker has gone MIA which I suppose is normal practice for most Public Servants over the Xmas hols:
Christmas closure

The ATSB’s offices will be closed for normal business from Thursday 25 December 2014 to Friday 2 January 2015, with only priority services available.

Immediately reportable Incidents and accidents can be reported to the notifications line on 1800 011 034.
Written aviation notifications can be reported online.
Confidential safety concerns (REPCON) can be reported either online or a phone message left on 1800 020 505. These will be processed from 5 January 2015.
General enquiries can be made on 1800 020 616.
Requests for flight crew licence checks during this period will be processed from 5 January 2015.
The Commissioners and staff of the ATSB would like to wish everyone a safe and happy Christmas and New Year. Please take care if you are travelling during the holidays.
& this from the JACC in charge of the MH370 search in the SIO - MH370 Operational Search Update—
23 December 2014
:
The Australian Government remains committed to the MH370 search. While search operations will continue uninterrupted over the Christmas period, there will be no MH370 Operational Search Update on Wednesday, 31 December 2014.
However Beaker seems to have this infatuation (if it is Beaker..) with talking to the international media, here he was again talking to the New York Times on Monday our time - In Shadow of New Search, a Long Aviation Mystery Remains Unsolved:
“We remain confident that we will find the missing aircraft in that search area, but obviously because it is about probability, we can’t give an absolute guarantee,” Martin Dolan, the chief commissioner of the Australian Transport Safety Bureau, said Monday morning in a telephone interview.
Hmm...think someone needs to get a muzzle on the Beaker...

Addendum last post for 2014:

From the Sanga missive which refers to the TSBC peer review report it would seem that the new fall guy (other than DJ of course) will be the IIC, example:
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.
Which is partly true for indeed the IIC did drop the ball, cave in to pressure and subsequently going all insular with the carriage of the PelAir investigation:
3.7.2.1.3 Company and regulatory oversight

In this investigation, very little of the data collected documented the actions taken by the regulator to oversee Pel-Air's operations or the actions taken by Pel-Air itself. Data collection at Pel-Air consisted of interviews with the occurrence crew and the Westwind fleet manager and a review of documents Pel-Air had provided. Investigators had not interviewed additional Pel-Air crews to determine the extent to which the flight planning and fuel monitoring deficiencies observed in the occurrence existed throughout the company, and only one management interview had been conducted over the course of the investigation.

Similarly, no interviews were held with CASA operations inspectors who were familiar with the operation and oversight of Pel-Air, and several key documents, including the CASA special audit of Pel-Air, were not obtained until very late in the investigation.

The lack of data in these areas was felt throughout the investigation. Two examples of this are the removal of a finding with respect to Pel-Air's oversight of its aeromedical operations,Footnote 20 and the lack of any analysis of CASA's oversight of Pel-Air.

The reasons for inadequate data collection in these areas will be discussed below in the section on governance of the investigation.
But that doesn't mean that the Team Leader(s), GM Sanga, Chief Commissioner Beaker & co get off Scott free... Let us take a look at the section mentioned above and ID where the above mentioned cop some flak (in red):
3.7.3 Management and governance of the investigation

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 (1) believed it was well understood that the investigations were fully independent and that there were no barriers to the ATSB investigation. {(1) After the Senate AAI report you gotta laugh at that one..}

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.
Oversight of investigation

Accident investigation bodies are entrusted with conducting comprehensive, impartial investigations into transportation occurrences in order to improve safety; staff complete the investigation work on behalf of the agency. There should be several layers of oversight and multiple processes to ensure that the output of the investigation is rigorous and defensible.

At the ATSB, the levels of oversight above the IIC are the team leader, the GM and the Commission. Quality-control processes, in addition to regular supervision by the team leader, included analysis coaching, critical investigation reviews, and peer reviews.

Although the processes in place provided multiple opportunities to address problems with the data quality and analysis, as described above, the lack of effective communication and weaknesses in the follow-up meant that certain issues remained unaddressed throughout the investigation:
  • Critical reviews were conducted periodically during the investigation but did not identify specific shortcomings in the data collection or analysis. The TSB Review team repeatedly heard that the critical review process was a valuable opportunity to discuss how to manage investigation risks, but that it was high level and unlikely to identify shortcomings related to data sufficiency or analytical rigour.
  • The GM and the team leader relied upon the expertise and judgment of the IIC when communicating the “critical” safety issue to CASA, and did not review the underlying analysis.
  • The breakdown in the analysis coaching did not prompt any action on the part of the team leader to explore the reasons for it, or to address weakness in the quality of data or analysis.
  • Multiple peer reviews were commissioned over the course of the investigation. The IIC appears to have been unaware of the latter two peer reviews until they were complete, indicating ineffective communication between the IIC, the team leader and the GM. Although the IIC responded to each peer review, he was working in isolation, and it was left to him to accept or reject the peer reviewers' input. In the end, a number of critical points raised by the reviewers were not addressed and did not result in additional data collection or analysis.
  • The report passed the team leader's review, but the GM found it to be analytically weak. Rather than returning it to the team leader or IIC, the GM personally edited the report so that the analysis was supported by the available information. WTF??
Attempts to address problems with the quality of the analysis relied on peer-centred processes rather than on direct intervention by the team leader. In addition, few steps were taken to ensure that these attempts resulted in adequate analytical support for the report findings. This approach was evident at all levels, as indicated by the GM's decision to revise the report himself. Ultimately, ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.

A number of factors underlying this indirect approach were identified to the TSB Review team.
  • There was a change of team leader, and some of the critical events, such as the breakdown of the analysis coaching, took place in the transition period.
  • During the Norfolk Island investigation, the ATSB was undertaking an atypical number of high-profile level-2 investigations that were consuming significant resources and attention. For example, the second team leader was deployed to a major investigation outside the country as the IIC was completing the initial draft of the Norfolk Island investigation.
  • There was a backlog of investigation reports, and the GM was trying to deal with it by editing reports himself, while at the same time as addressing the issues of analysis and team oversight.
Yep no doubt about it t'was very, very ugly...

I'll be back!
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Old 1st Jan 2015, 00:09
  #2587 (permalink)  
 
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Stop Press -Hot, off the wire.

From Katoomba of all places. Good catch Sarcs.......

Hah! – it's quite a long march from Katoomba in the NSW Blue mountains to New York; and why the NYT would be interested in anything Be-a-Cur has to utter, off the official JACC script is passing strange. The Muppet is on holiday – Sangsome confirmed this in his off hand response to some very serious questions raised by James. "G'day Mr. James, sorry be we are closed for the holidays, dontcha know??; buzz off and come back next week". So how was Be-a-Cur so easily contacted during his well earned time away from the mill?. Magic, private line, personal mobile, tin cans on strings? - It is, for certain sure, that even if there had been another ET event and one of our own gone missing in 'mysterious' circumstances, the Muppet would not disturb his repose or Christmas pudding gulping to investigate, using his very own 'beyond-all-reason' model. Nope, some minion would be sent out, with a tin foil hat, a candle and a stack of paperwork, to scratch about for clues.

So has the beardless one, the spaghetti loving Muppet gone rouge and started Skype-ing any and all journalists on line to pass along his priceless one line words of wisdom, hope and cheer. Whatever happened to a terse 'no-comment' and passing out the JACC media centre telephone numbers?, I wonder.

Beyond passing strange me thinks; it's too bloody weird for words.

Toot toot (Which in ET language means "beam me up Scotty").

The last couple of CP posts have earned a key to Tim Tam cupboard, make me smile each time I read them. Bravo CP....
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Old 4th Jan 2015, 00:52
  #2588 (permalink)  
 
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MH370 v QZ8501 SAR/AAI - Like chalk & cheese so far?

Have been monitoring much of the MSM press coming out of the AirAsia disaster - most is simply indifferent regurgitation after regurgitation; some is really bad and irresponsible; while a very small % is good factual & enlightening journalism.

The following are two good examples that also have - obvious & not so obvious - Australian connections for which we should be very proud...

1) How Would You Rate Malaysia's Air Disaster Preparedness?

2) AirAsia flight QZ8501: faces from a lost flight

Quote from number 1):
Fact: Malaysia does not have an official air crash investigation agency.


The lack of an independent government investigative agency responsible for civil transportation (aviation) accident investigation is a complete surprise, after what we’ve been through. Malaysia has too many so called national disaster management councils but their responsibilities overlap or are limited in scope to tackle the MH17, MH370 or even the QZ8510 flight in a year full of aviation disasters. Indonesia has BASARNAS (National Search And Rescue Agency), their national disaster management agency leading the investigation and is the first point of contact for information and for other nations who wish to assist.
From all reports in recent days - on the AirAsia SAR mission - the Indonesian's BASARNAS has coordinated and performed exceptionally well in extremely difficult circumstances. This is in direct contrast to the way the Malaysians oversaw the first critical days of the MH370 SAR effort:
..Everyone remembers the information chaos that ensued right after Malaysian Airlines Flight MH370 went missing, and again when MH17 was shot down by a missile. It was disarray with Malaysia Airlines (MAS) and the acting Transport Minister scrambling to get the facts out to the media and the public...
It should be noted that at one time most of the problems that beset the Malaysians SAR effort for MH370 would have been almost perfectly duplicated by the Indonesians. Many would say that BASARNAS has become a hell of lot more of an effective agency - in co-ordinating SAR missions - since their association with Australia's AMSA under the Indonesia Transport Safety Assistance Package (ITSAP).

Included in the ITSAP program is a relationship between the ATSB and the Indonesian's AAI the NTSC:
The main elements of the ATSB's contribution to ITSAP are to deliver training and support for investigators from the ASTB's Indonesian counterpart agency, the National Transportation Safety Committee (NTSC). This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods.
It should also not be forgotten that for a long time the person responsible for overseeing this mentoring program was none other than Alan Stray, who for his exemplary efforts was awarded a Public Service Medal by the former GG Dame Quentin Bryce (reference: Sunday cogitation - A Stray thought or two.).

Therefore much like the current efficient, full & frank, transparent activities of BASARNAS I expect that the NTSC will conduct the AirAsia flight QZ8501 investigation in much the same manner... And given the apparent similarities/parallels (so far) to the AF447 disaster there will be much to be learnt from the NTSC final report that ironically could possibly cause political reverberations internationally & back here in Oz...

Which brings me to the 2nd article - Quote 1:
The might of human ingenuity and technology has focused on reducing aviation's dangers to virtually nothing. But still, according to industry consultant Gerry Soejatman, risks exist.
"As comfortable as we are, and as safe as the statistics are, flying is inherently risky," Soejatman says.

"We rely on the training and the safety systems that have been developed over the years; that's what makes it safe ... and it is safe. But if we are careless, we have to remind ourselves that it is dangerous to fly."
Parts of that sound very familiar to the ToR in a certain Senate inquiry that was titled "Pilot training...blah..blah..

Quote 2 - the PelAir irony:
The immediate task for Indonesian investigators will be to retrieve the vital flight-data recorders from what remains on the sea floor of the Karimata Strait. The "black box" – which is actually brightly coloured for visibility – will play a key role.

The plane lies in relatively shallow water of about 50 metres, a far less onerous recovery task than the one confronting authorities searching deep water for Malaysian Airlines Flight 370.

The AirAsia A320's cockpit voice recorder will contain up to two hours of recordings, which will allow investigators to listen to QZ8501's 53-year-old Captain Iriyanto and first officer, Frenchman Remi Emmanuel Plesel.

But it is the flight data recorder that holds a larger wealth of information, with up to 72 hours of flight time information about the plane's engine settings, air speed, positions of flight control and altitude.

Investigators already have information from air-traffic control such as voice and radar recordings – particularly from the Mode S transponder system – as well as the weather on the day of the crash from meteorologists.

"The key will be to find those recorders, download them and then see what they tell you. They effectively guide the investigation," Australian Transport Safety Bureau spokesman Joe Hattley says.

"You don't know where you are going until you get good data."
What's this....another official ATSB spokesman - other than Bea-Cur - who dares to state the bleeding obvious on the subject of the importance of recovering the CVR/FDR...

But then it happens again..... someone from the ATSB (other than Bea-Cur ) who dares to speak and possibly have an opinion...:
"You have to be a very big airline to survive an accident," ATSB spokesman Stuart Godley says. "Any significant accident has bankrupted most airlines, and it is really only the big airlines that have survived."
All very passing strange & definitely MTF...

I'll be back...

Ps Choccy frogs and a goldstar to the Fairfax crew...
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Old 4th Jan 2015, 04:11
  #2589 (permalink)  
 
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A gauntlet, foresooth.

A very 'enigmatic' post from an inscrutable Sarcs; a challenge (must be a choc frog in it). Hmm, lets see what the research wizard has winnowed from the chaff. Well there's two better (as in journalistic improvement), if 'fluffy' (Marosszeky quotes) articles from the mainstream media, which do go beyond the usual dribble, both being researched and very well written. Perhaps someone could send them to that GT fool, as an exemplar....

There is well deserved praise for Alan Stray's Indonesian AAI protégés, who really have excelled so far in all departments, including an impeccable demonstration of the spirit, intent and execution of ICAO Annexe 13 obligations. As 13 is the unimpeachable 'code' of all sensible, responsible, honest accident investigators, it's laudable, although not surprising that the teachings of Alan Stray have found root and flourished. Well done Indonesia, well done Mr. Stray..Bravo ...

And well done – BASARNAS – another first class, collaborative Australian/Indonesian training effort; resulting in first class SAR services done nicely in the finest traditions of the excellent AMSAR; which does not allow Muppets on deck; or, to speak on their behalf. Bravo....

I believe the subtle Sarcs message is twofold. Firstly the disgraced Australian ATSB is shown to still be lacking in essentials by comparison with the impeccable actions of an investigative body, trained by the same man who greatly assisted the ATSB to be, once upon a time, a first class outfit. As opposed to the shambles it has become under the current 'leadership'. Nuff said...Secondly, perhaps this is the start of a campaign to have the Senate insist, not request, but insist that Alan Stray, or his nominee revisit the wreck of Pel-Air, in an attempt to remove the very large CASA induced blot on the ATSB copy book. First rate notion, provided the Senate committee calls for a hand in the game. (After all, they did trigger the review).

Sarcs has been particularly cunning with the rest of his puzzle, in order to draw any inferences, first we must ask questions. Why is Be-a-Cur having little 'snippets' published off-shore?; why is it that for the last five years the only 'quotes' we get are from the unspeakable Uriah Heep of aviation? and who is 'pushing his barrow' in an attempt to regain his long lost reputation?. That's all fairly self evident; but, crafty Sarcs brings in three doyens of the Alan Stray school of investigation and their own quotes; in the published articles. Quotes which beg the biggies – has the ATSB worm finaly turned?, and, who 'green-lighted' them to speak?

Looking back at the not-so-happy snap of that trio, pre departure Mascot for the Ukraine, you could, from the body language get the idea that there was a restrained fury, lurking not too far from the ATSB sub-surface. Now people the calibre of Godley, Hattley or Soejatman are 'professionals' in every sense and not given to discussing the lunch menu with the press, or talking out of school. So we are, once again left to wonder, which are the winning numbers for next weeks lottery? Perhaps the psychic, voice mail analyst Walker can tell us at the next BRB séance......

Sarcs – Handing over.

Scratch wooden head, amble off to feed the elephants, cussing in a good natured manner.
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Old 5th Jan 2015, 04:50
  #2590 (permalink)  
 
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‘Taking over’…err I think??

Wow Ferryman there is no doubt about you..while I'm trying to make sense of some new dot arrivals you’re off making more dots - your either psychic or you've already got the script in your back pocket...

For mine there are some 'passing strange' goings on at the bureau which are definitely not SOP - well at least since Beaker (with M&Ms hand up his backside) took over with his muppetshow pantomine - & IMO deserve closer examination...

First there was that spin & wonder reply to REPCON AR201400079 - that the more discerning could interpret as a signed confession that the bureau no longer investigates regulatory oversight as possibly being part of the causal chain (risk mitigation) to an accident. But the most intriguing thing with that bizarre reply was it just so happened to be published on the very day the miniscule delivered his PelAir directive...WTF??

After the miniscule directive we then have the rumoured sin-binning of Beaker... But he either can't help himself and has gone rogue; or he is under some Mandarin's directive to begin muddying the waters in regards to the MH370 search effort; & subsequently starts leaking to the international press...

Then early in the new year ’15 we get expert opinion & comments from some senior TSI team members in regards to the AirAsia disaster… When before all such commentary - well for the last 6 years at least - was carefully sanitized, PC’d & re-re-regurgitated by the resident spokes-muppet Beaker (ps he has even got his own bureau sanctioned blog)...

"...Quotes which beg the biggies – has the ATSB worm finally turned?, and, who 'green-lighted' them to speak?.."

Hmm…perhaps we have an announcement pending in reply to this part of the Miniscule directive {& ASRR (Forsyth) recommendation 5}...

From the Miniscule speech:
...On a related point, I have just announced that I will shortly be appointing a new commissioner for the ATSB with a specific background in aviation. This will fulfil an undertaking made by the coalition prior to the election and also one of the recommendations of the report…
From the Rev Forsyth’s report:
To improve the ATSB’s governance, the Panel recommends that an additional Commissioner be appointed, with extensive aviation experience
IM(humble)O you could not go past an exemplary individual like Alan(PSM)Stray for that extra commissioner’s position...

However I also believe you could ‘kill 2 birds with one Stray’ & go one better and make him the chief commissioner. If that were to happen then it would be possible to finally turn the page on the PelAir debacle - & the Beaker BASR regime - which has inflicted serious damage to the reputation & integrity of our air safety watchdog the ATSB.

When the Indonesian BASARNAS finally find & recover the flight QZ8501 CVR/FDR it is a reasonable bet that the Stray mentored NTSC will ask the ATSB (Annex 13 CH5.1) to analyse the recordings in their Canberra laboratory. Maybe in a quid-pro-quo it could be suggested by - AS or his nominee - that the NTSC delegate (as per A13 CH5.23) an investigator to oversee the PelAir re-investigation; or better still - in the continued interest of détente - hand the whole lot over to the Indons for review would be the really decent & honourable thing to do…

Certainly beats the alternative i.e. the Sanga missive & Dr Walker delegation:
Kharon - Perhaps the psychic, voice mail analyst Walker can tell us at the next BRB séance...
In case you were wondering here is a link for that Doc Walker co-authored research piece: AVIATION RESEARCH REPORT B2005/0108 ...

Hmm…I’ll be back…

Last edited by Sarcs; 5th Jan 2015 at 05:11.
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Old 5th Jan 2015, 06:24
  #2591 (permalink)  
 
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You have lost me Sarcs with your reference to the Dr Walker paper. Are you saying that its symptomatic of the current state of the ATSB or that it will be relevant to the Air Asia investigation?
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Old 5th Jan 2015, 18:47
  #2592 (permalink)  
 
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RSVP? - Nope, not invited.

Sarcs – "or you've already got the script in your back pocket.
Oh, how I wish; anyway, all your fault, you know full well I cannot resist a puzzle. As usual, your 'dots' just add to the growing picture which the international audience seem to have glimpsed of the once feted, now denigrated Australian safety 'watchdogs'. Humiliated and publicly exposed for just one of the many not quite accurate accident reports; castigated by their Canadian peers, condemned by government sponsored report and still denying all responsibility for their behaviour. ATSB should be an international pariah just for failing to publish a report on the Pel-Air life vest issues, let alone the rest of it. Important safety equipment failed when it was most needed, the last line of defence for those alone, in darkness in a hostile sea, far from help. The powers that be may not think that an important function of an AAI or a NAA, but you can bet the rest of the world does. It is completely beyond all sensible reason. (Rant over – feel better now).....Where was I:

One thing is certain, the Indonesian AAI want the tapes and will retrieve them. The politely invited, expert and properly equipped Russian crew (thank you Vlad) will recover them; won't be talking about it either. But then neither will the sent home, surplus to requirement Australian crews. Perhaps GT would like to speculate on why for the first time, in a very long time an ATSB team has nor been invited to the party; now that would make a fine story for an intrepid aviation commentator. Although it will probably take a political analyst to tease out the real reasons, I just wonder if Australia is not a little on the international nose. We know CASA, the department and ATSB show open contempt for the findings of the Senate committee, Forsyth and the TSBC, but they seem to have forgotten that those findings and recommendation have all been made 'public'. It's reasonable to assume that other NAA bodies in the region have read those results and have decided to avoid being tainted, by association with the mess. The ATSB have demonstrated, very publicly that they are not a 'sound' organisation and given the political sensitivity of the current accidents in the region, no one is willing to risk the slightest whiff of anything not strictly legitimate. I expect Australia is a practical choice to analyse the tapes; but will they be asked to do it, without strict supervision?

I agree that the NTSC could simply ask to use the facility but will bring their own trained specialists to take care of business. It would be a fine thing to have Stray (or the like) called in to oversight Pel-Air Mk II. It remains however a crying shame that there is a need to re-open an investigation. It's bad enough that Dolan and McComic created the unsightly aberration, worse that they attempted to deny ownership of it; but to allow Dolan control of the investigation for a second time beggars belief. The absence of an Indonesian invitation says it all really.

Yes Minister, the red face in the mirror is, most certainly your own...

Toot toot.
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Old 6th Jan 2015, 08:48
  #2593 (permalink)  
 
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Dr Johnny Walker & trouble in the archipelago.

Theorists vs realists:
Sorry Lefty nearly missed this -
You have lost me Sarcs with your reference to the Dr Walker paper. Are you saying that its symptomatic of the current state of the ATSB or that it will be relevant to the Air Asia investigation?
Not sure I'll be personally voicing an opinion on the Doc on here anytime soon but the first indications are not entirely promising - apparently the following image was attributable to Doc Johnny:



(my brain hurts just looking at that theoretical Doc masterpiece...) -

Please...please Miniscule bring back 'Reason' & Alan Stray (or his look-a-like)... And Miniscule while we are at it please pay attention to the excellent advice/response freely provided by AIPA in regards to ASRR recommendation 5...:

Recommendation 5
5. The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience.

AIPA strongly agrees with this recommendation. However, despite the Government and the ASRR Panel rejecting the Senate Inquiry recommendation that the Chief Commissioner should have that experience and noting the multimodal role of the ATSB, our full support remains with the Senate recommendation.

AIPA rejects the Panel’s view that aviation expertise provided by a part-time Commissioner is sufficient. Our view is that aviation is by far the most complex of the transport modes and the related operational expertise is more easily applied across the other modes.

AIPA also notes the Panel’s view that the Pel-Air investigation and report were an aberration in terms of how the ATSB should be viewed. In light of the material presented to the Senate Inquiry, such a conclusion appears charitable at best. {Spot on AIPA...love it..}
Kharon:- "...It's bad enough that Dolan and McComic created the unsightly aberration, worse that they attempted to deny ownership of it; but to allow Dolan control of the investigation for a second time beggars belief. The absence of an Indonesian invitation says it all really..."

Totally agree "K" but after reading the following from the Canuck press it maybe a Godsent that we're not invited to the slugfest...: AirAsia Flight QZ8501: Indonesia's aviation safety practices under fire
Highlighting the depth of Indonesia's air safety problems, the transportation ministry announced harsh measures Monday against everyone who allowed AirAsia Flight 8501 to take off without proper permits — including the suspension of the airport's operator and officials in the control tower.

The routing permits of all airlines flying in the country also will be examined to see if they are violating the rules, said Djoko Murjatmodjo, acting director general of air transportation.

"Who knows if other airlines are also doing the same thing," he said.

The crackdown comes as searchers continue to fight bad weather while combing the Java Sea for bodies and wreckage of the Airbus A320 that crashed Dec. 28, killing all 162 passengers and crew on board.

The plane was travelling between Surabaya, Indonesia's second-largest city, and Singapore on a Sunday. Officials have since said its permit for the popular route was only for Monday, Tuesday, Thursday and Saturday, and that AirAsia quietly switched three of those days. Officials in Singapore, however, have said the plane was authorized to fly on Sundays from its end.

Applications for specific routes take into account issues including air traffic rights and airport takeoff and landing slots.

While the airline is being investigated, Indonesia has banned all AirAsia flights between Surabaya and Singapore.

AirAsia Indonesia President Director Sunu Widyatmoko said by text Monday that the airline will co-operate with the government during the evaluation, but would not comment on the permit allegations until the process is complete.

Violation of the regulations would boost legal arguments for passengers' family members seeking compensation, said Alvin Lie, a former lawmaker and aviation analyst. But he added AirAsia would not be the only one to blame.

"The Surabaya-Singapore flights have been operating since October ... and the government didn't know," he said. "Where was the government's supervision?"

Murjatmodjo said key individuals who allowed the plane to fly without permits would be suspended while the investigation is pending.

The ministry also issued a directive Dec. 31 ordering all airlines to provide pilots with up-to-date weather reports before they take off, he said. Currently, it's up to the captain and co-pilot to research and evaluate flying conditions before departing. In other countries, carriers' flight operations departments perform that task for them.

He also planned to meet Monday with the Corruption Eradication Commission to discuss whether to investigate AirAsia's operations. Business in the country is commonly conducted using bribery, with payoffs often seen as the most efficient way to get things done.

After Indonesia deregulated its aviation industry in the 1990s, dozens of airlines emerged making air travel affordable for the first time for many in the world's fourth most populous nation. But accidents in recent years have raised urgent questions about the safety of Indonesia's booming airline sector, with experts saying poor maintenance, rule-bending, and a shortage of trained professionals are partly to blame.

AirAsia, which began operations in 2001 and quickly became one of the region's leaders in low-cost air travel, has not experienced any other crashes and is widely considered a benchmark for safety and professionalism.

It is not known what caused Flight 8501 to crash into the Java Sea 42 minutes into what was supposed to be a two-hour flight, though Indonesia's Meteorology, Climatology and Geophysics Agency says bad weather appears to have been a factor. Just before losing contact, the pilot told air traffic control that he was approaching threatening clouds, but was denied permission to climb to a higher altitude because of heavy air traffic. No distress signal was issued.
There is certainly no love lost between the political elite and the bureaucrats in the Indonesian archipelago...

I'll be back...
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Old 6th Jan 2015, 19:47
  #2594 (permalink)  
 
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Press and prestige.

[after reading the following from the Canuck press it maybe a Godsent that we're not invited. etc].
Given up on the 'press', can't be shagged; too much waffle, dribble and wild speculation for my digestion. I'll just wait and see what facts are offered.

"There is certainly no love lost between the political elite and the bureaucrats in the Indonesian archipelago."
Now that's fact; just can't see the Indonesian government poncing about with three years to report and having a Senate inquiry into that report or; hanging about waiting a half year for the response; or, waiting for an election (spell check): or ordering a mild review of where the regulator failed and colluded with the AAI to 'slant' a report away from embarrassment; then asking for an external peer review; then sitting on that for a half year; then releasing it at holiday time. No Sir, they'll just line the buggers up and send them off to bed; no supper.

On the plus side, Be-a-Cur seems to have been awful quiet on the Indonesian accident. Thought - maybe I'm reading the wrong part of the news; perhaps I'll try the 'fine dining on the cheap section'. Maybe there I'll find detailed explanation of the 'mind reading map' system intended for Pel-Air MkII......

Toot toot.....

Last edited by Kharon; 6th Jan 2015 at 19:50. Reason: Thinking in Asian mode; damn near put Erection instead of election.
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Old 6th Jan 2015, 21:02
  #2595 (permalink)  
 
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Sarcs, I've seen one of those diagrams before, it was produced by my raving narcissist boss. I was so amazed at the convoluted nature of the scrawl that I took a copy.

Such diagrams reveal that the writer has no practical idea about what the actual "linkages" - the lines joining the subjects really are and lacking that knowledge, cannot turn such an incoherent mess into anything even slightly useful, let alone into a coherent, ordered, prioritised operating plan.

If this is what the ATSB or CASA call "strategy" then God help us.
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Old 6th Jan 2015, 23:20
  #2596 (permalink)  
 
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The "Doc Johnny diagram", if it purports to represent links in a chain of events, shows at balloon #3 CAsA AOC approval process. It should have headed the diagram #1 with all subsequent time line balloons radiating from it.

At great risk of opposition, I say;

The flight was an Aero Tropics flight, flown in an aircraft with Aero Tropics written down the fuselage, using Aero Tropics tickets, issued by a subsidiary travel agent of Aero Tropics, on an Aero Tropics RPT route, but flown by Transair pilots in a Transair aircraft.

The AOC was faulty.

This is the first link in the causal chain of the accident and had it been addressed by a competent regulatory authority, the accident would have been prevented. It also shows where the culpability lies.

The diagram supports this theory but is in error in the first line of balloons in so much as balloon #3 should have headed line 1 with the other six balloons on line 2.

Someone may be able to photostrop (sic) /edit this diagram to show what I'm trying to portray. That concept is beyond me.
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Old 7th Jan 2015, 02:39
  #2597 (permalink)  
 
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Thanks Sarcs for the clarification. I actually thought that the premise of the report that you linked to was QI as it suggested that a straightforward transcript of a CVR didn't provide a complete picture. Much the same way that an email(or a posting on PPRuNe) can be misinterpreted as tone and intent can get lost in the mere placing of words on paper. Either way it didn't seem to get any traction.

The first time that style of diagram appeared was in the QF1 report. It is an attempt to put the Reason model in a box and as you have highlighted it may be theoretically impressive but doesn't give a real time indication of what contributes to an accident. Like a lot of HF specialists from a cognitive psychology background they lack the practical knowledge of what happens in a flight deck. To academics or bureaucrats (you know who they are),they are all wise and all knowledgeable.
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Old 7th Jan 2015, 09:30
  #2598 (permalink)  
 
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Memory of an elephant.

LL - The first time that style of diagram appeared was in the QF1 report. It is an attempt to put the Reason model in a box and as you have highlighted it may be theoretically impressive but doesn't give a real time indication of what contributes to an accident. Like a lot of HF specialists from a cognitive psychology background they lack the practical knowledge of what happens in a flight deck.
Absolutely spot on Lefty and I believe you will find that the Doc was also responsible for the QF1 causal chain diagram (Boeing 747-438, VH-OJH Bangkok,Thailand)...

However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...

From 3.5 Report preparation (November 2010 to March 2012) of TSBC report:
At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.

They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.
But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...

However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):
1.17 Organisational and management information
The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.

Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-

1.17 .1 Fuel Policy and Practice
• Inadequate fuel policy for Westwind operations.
• Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
• No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
• No alternate requirements specified for remote area and Remote Island operations.
• The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
• Criteria to obtain weather updates not specified in Operations Manual.
• Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
• No consideration of loss of pressurisation and an engine failure.

1.17 .2 Operational Control
• No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
• Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
• The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
• In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.

• Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.

1.17.3 Training
• Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
• Inadequate documentation of training programs.
• No formal training for international operations.
• Inadequate training records for pilot endorsement and progression.
• Inadequate records of remedial training.
• Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
• No mentoring program for First Officer to Command.
• Deficiencies in training records identified.

1.17 .4 Fatigue Management
• Over-reliance on FAID as the primary fatigue decision making tool.
• Inadequate adherence to FRMS policy and procedures.
• Excessive periods of 24/7 stand by.
• Lack of FRMS policy regarding fatigue management for multiple time zone changes.
• Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).

1.17 .5 Drug and Alcohol Management
• Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.

These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.
Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture... Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5(PDF 6032KB)...

The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..

18Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)
Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA?

How indeed??


I'll be back...

Last edited by Sarcs; 7th Jan 2015 at 09:49.
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Old 7th Jan 2015, 20:25
  #2599 (permalink)  
 
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As the penny drops.

Sarcs - "[to] point out why it is simply unacceptable for the re-investigation to be conducted by the ATs
Nice dot joining Sarcs, clearly spelling out the issues which involve CASA and the ATSB 'top management' in a truly disgraceful event. Big response though, crumbs, we get the Dr. John, dog, pony and mind reading show, why am I so undewhelmed? Does anyone realise what the Pel-Air scandal truly was; ye gods, what does it take to get anyone off their arse in this country. You can get fired and prosecuted for calling a female work colleague 'Sweetheart', you can be tossed into the street for breast feeding a child in the movies, but play at silly buggers with an investigation into an air accident and it's off to lunch with the SMH, or all expenses paid to Montréal.

I can't believe 'they' even have the nuts to try it on, let alone have Dolan running it. Hells bells, they may even get away with it – then what? Why is it you can never find a Senator when you need one. Makes me wonder if all the estimates rhetoric and inquiry recommendation are just so much egocentric hot air, feeding public image and keeping the flaccid balloon of government aloft.

It is no where near good enough, not by a bloody long shot.

Put it another way - Johnson was fired from the ministry for denigrating the boat building fraternity. Hawke gets a government issue chocolate frog, (rum flavoured).

Time to wake up.

Last edited by Kharon; 7th Jan 2015 at 21:11. Reason: Late thoughts, after steam off selection.
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Old 7th Jan 2015, 20:53
  #2600 (permalink)  
 
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Kharon - Why is it you can never find a Senator when you need one. Makes me wonder if all the estimates rhetoric and inquiry recommendation are just so much egocentric hot air, feeding public image and keeping the flaccid balloon of government aloft.
Well said.

Lookleft - The first time that style of diagram appeared was in the QF1 report. It is an attempt to put the Reason model in a box and as you have highlighted it may be theoretically impressive but doesn't give a real time indication of what contributes to an accident. Like a lot of HF specialists from a cognitive psychology background they lack the practical knowledge of what happens in a flight deck.
Others have used that style of diagram effectively. See Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq by Scott Snook, published in 2002. Snook used a very similar diagram to illustrate linkages between the various organizational factors contributing to the shootdown.
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