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Old 8th Jan 2015, 06:29
  #2601 (permalink)  
 
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Of bureaucrats and spin doctors

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).
Kharon, Minister Johnston received his major pineapple because he made a very public spray which embarrassed poor Tony, plus Minister Johnston, although well connected, has had only a relatively short political career and not enough time to entrench himself in the system and collect enough aces up his sleeve to pull out for an occasion such as the one recently
Chairman Hawke on the other hand has hand a long and robust political career dating back at least 35 years in which he has learned and practised his bureaucratic skills, and we all know what they are. He has many notches (and scalps) under his 'wide' belt, and he would have enough dirt on every living and breathing politician, and beyond, to ensure he retains a robust, long and profitable political career until such time that he chooses to retire with his nice taxpayer funded career superannuation mega-nest egg.
These guys in Can'tberra play a spectacular game of survival. You don't last as long as Mr Hawke by having an I.Q of 80. People like Craig Thompson as an example aren't patient, they want it all now, today, in one giant hit, and they screw up and become short term trough dwellers. People like Mr Hawke are much to smart for the average consumer to understand

On a side point, I also heard this week, rumour of course, that Terry is close to leaving the S.S CASA come the end of January, once Skates has settled in to Sleepy Hollow. It has been suggest that one P.Boyd may take up the Far'Q'hard'son mantle and become assistant DAS
God help us if that rumour is true........tick tock

Last edited by Soteria; 8th Jan 2015 at 07:27.
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Old 8th Jan 2015, 12:37
  #2602 (permalink)  
 
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organisational theory

Hey Lefty,

If a modicum of organisational theory had been applied to the Pel-Air investigation, we may well have got a decent flight safety outcome
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Old 8th Jan 2015, 20:17
  #2603 (permalink)  
 
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Look Left
but overlooked the simple fact that if the go-around was conducted according to the manual (pressing the TOGA buttons) then it probably would not have happened.
I agree Look Left, the simple fact that an error occured in the cockpit in spite of correct organisational checks and balances(SMS), is overlooked.
The blind adherence to the James Reason model can lead to interesting results when there is either an accidental or wilful violation.
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Old 8th Jan 2015, 20:29
  #2604 (permalink)  
 
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Here we go round the Mulberry bush.

L.Left –"Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air."
Good point Lefty and in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion. For sake of argument lets 'assume' (we may, safely take a small risk) that the ATSB investigators were competent and they followed the well trodden path a 'bog-standard' accident investigation should take. The report even allowing for the 'theoretical' should have got us to within a bulls roar of the why, how and wherefore; it may have even provided some peripheral causal reasons which assisted in defining the desired end result – risk mitigation. There were several valid, not overly theoretical issues which did make it into the final report; RVSM, flight and fuel planning, lack of operational support, fatigue, lack of 20.11 training, etc, (don't ever forget, CP responsible for all) from which a reasonable operator could make adjustments to SOP, in an effort to mitigate the risk of reoccurrence. I don't have too many problems with the notion of 'theoretical', provided it can be translated, by the operator into practical fixes. So far the ATSB investigators are free and clear, reputation intact.

It's what happened next that got me cranky (just a bit): Sarcs at # 2653 has gone to some trouble to point out the direction a perfectly serviceable accident 'report' was being driven and IMO, in deference to the law, he has treated the 'aftermath' with kid gloves. For the thinking man, joining up the remaining dots to form the final picture is a piece of cake. The Senate inquiry got there and so did PPRuNe (bless).

It has been a long, slow difficult process since then: the Senators didn't waste too much time, their report was out in a timely manner; but since then, purgatory. Forsyth, then TSBC, then miniscule response, at the end we get (headline) "Pel-Air to be reinvestigated".

The academics and theory of 'how' to investigate an incident which happened, what ? five years and a bit ago have not changed and have had precious little to do with what transpired after the IIC report was 'edited' and produced. It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far.

The comment below followed an article published by Australian Flying re the re Pel-Air MKII.

Sceptical • 10 days ago

Head of Aviation Investigations at the time of the report? Ian Sangston.

Told of factual errors prior to release of the report? Ian Sangston.

Head of Aviation Investigations for the new report? Ian Sangston.

Conflict of interest?
Just about says it all. The background noise? Oh, that's the playroom clock; tick, tock, tick, tock.

Last edited by Kharon; 8th Jan 2015 at 21:15.
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Old 9th Jan 2015, 02:08
  #2605 (permalink)  
 
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Pel-Air MKII & the bollocks factor??

The spot on Sceptical comment followed the Anderson comment;...
...A very dark day in ATSB history was when that farcical report was released.
ATSB credibility in the aviation sector (and undoubtedly the others as well) - Gone!.

Martin Dolan must now be removed from his post as head of the ATSB - the report and the circumstances surrounding it left no doubt the ATSB was happy to have CASA dictate the content of reports and direct inquiries.
The words 'collusion' and 'deceit' come to mind

ATSB independence, impartiality and integrity - None!...
...both comments perfectly highlight what should have happened once the Pel-Air MKII was formally announced but due to the morally bankrupt individuals involved didn't...
It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far.
Totally and utterly agree... But to support the Sceptical & Anderson opinionated commentary let us take perhaps one final look at the now recorded evidence (some hearsay, some factual) presented in the TSBC peer review report and the Senate AAI inquiry.

Quotes from TSBC report supporting Sanga COI:
The GM was making these revisions himself, and he did the same for the draft Norfolk Island report. It was in the course of this work that the GM concluded that the available data did not substantiate classifying the safety issue on guidance for en-route weather-related decision making as significant, and modified the report to recast it as a minor safety issue.
From under the section 3.7.3 Management and governance of the investigation:


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:
  • ...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...
  • ...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...
...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 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...
All of which IMO proves beyond doubt why the current GM of aviation investigations should not be anywhere near the Pel-Air MKII re-investigation; which includes sending vomitus missives to the DIPs...
Next - quotes from TSBC report in regards to Beaker:
When the Commission reviewed the report in June and July 2012, the commissioners expressed concern that there was insufficient factual information and analysis in the report to support a finding related to oversight of aeromedical operations by Pel-Air. The Commission was also concerned that the CASA special audit of Pel-Air was not relied upon more extensively.
Communications among commissioners indicated that there was concern with the lack of analysis of the adequacy of company and regulatory oversight, especially in light of the CASA special audit report. However, this concern did not result in changes to the report.
Passing strange that both those quotes would appear to be in direct conflict with Dolan's evidence given in the AAI public hearings...

1st Hansard quote 22/10/12:
Senator XENOPHON: How do you reconcile the ideals set out in your submission with the fact that the CASA special audit does not make it into your report? There is no mention of it. Serious organisational issues with respect to Pel-Air do not make it into your report—how can that be?


Mr Dolan : We do not explicitly refer to the CASA audit report in our investigation report. We provided the committee, which probably has not had a chance to consider it yet, with our assessment —

Senator XENOPHON: Sorry, have you not had a chance to consider the CASA special audit?


Mr Dolan : No, we have reviewed it carefully, and we have reviewed it carefully in the light of our report.
There were a range of factors that were highlighted in the CASA special audit that we believed we had already addressed, particularly in the factual basis of our report.


Senator XENOPHON: But why didn't you mention the CASA special audit in your report? It goes to systemic issues, it goes to organisational issues, it identified a number of deficiencies in relation to Pel-Air's operations, yet not one mention of it is made in the ATSB report about an incident involving a Pel-Air aircraft.
2nd Hansard quote 15/02/13:
Senator XENOPHON: When did you ask for the CASA special audit conducted on Pel-Air?

CHAIR: It was a short while before you concluded your report, as I recall.

Mr Dolan : It was at a late stage in the process, yes. We can get you the exact date.

Senator XENOPHON: It was at a late stage in the process. Can I suggest to you the only reason you asked for that CASA special audit, which was not provided to you by CASA, was that Mr James's lawyers had contacted you, Mr Sangston, saying, 'We understand there's a special audit and we'd like to get a copy of it.'

Mr Sangston : Sorry, Senator; I was just looking up that date.

Senator XENOPHON: My understanding is that it took Mr James's lawyers until as late as 3 July 2012 to write to you saying, 'We understand there's a special audit; we'd like to get a copy of that special audit,' and that until that time you had no awareness of the existence of that special audit.

Mr Dolan : No, I do not think that is true. Mr Sangston may wish to disagree with me.

Senator XENOPHON: Or was it that you thought it was not relevant to provide to Mr James as a directly interested party?

CHAIR: As I understand it, there was a press release in 2009 from CASA saying that they were going to have the audit, so the world knew about it.

Mr Dolan : We were aware that CASA was undertaking a special audit.

Senator XENOPHON: When did you get a copy of that?

Mr Dolan : As I say, Senator, it was very late in the process.

Senator XENOPHON: After 3 July 2012?

Mr Dolan : Yes, Senator, I believe it was in late July or early August.

Senator XENOPHON: You are aware that CASA had conducted a special audit, but you did not think it was relevant to your investigations to get a copy of that special audit into Pel-Air?

Mr Dolan : We were happy that our investigations were covering the territory we needed to cover in understanding the facts.

Senator XENOPHON: Sorry, could you say that again, I could not hear you?

Mr Dolan : We were happy that our investigation was covering the relevant territory. On analysing the special audit report—and I believe we supplied a table reflecting this to the committee—we satisfied ourselves that the major lines of inquiry that had been undertaken through the special audit were ones that we had also turned our minds to.

Senator XENOPHON: But how do you know without seeing the document? How would you know that? How would you know that you are satisfied with a particular line of inquiry when you have not even seen the report? You were aware of the report but you did not bother to ask for it?

Mr Dolan : We do not as a matter of routine seek special audits. Special audits are for the purpose of CASA's regulatory activities. We try and keep our investigations, as much as we can, separate from what CASA has to do. It is not as a matter of default that we would see and try to rely on CASA regulatory investigations as a basis for our work.

Senator XENOPHON: But in the context of the memorandum of understanding about the exchange of information between the two agencies, in the context of this investigation, in the context of Mr McCormick expressing his views that they were changing their rhetoric and hardening their view and concerns within your organisation about egg on ATSB's face and CASA's face, you did not think it relevant at all to obtain a copy of a CASA special audit into Pel-Air, the very airline that was involved in this incident? I just do not get it. How can you explain it to—to use Senator Heffernan's terminology—the reasonable man, the reasonable person at the back of the room? What has gone wrong here that you did not get the CASA special audit?

Mr Dolan : As I said, Senator, we do not as a matter of routine seek special audits. CASA undertakes special audits for their purposes; we undertake investigations for our purposes. There are times when it may be helpful to us to take a look at what CASA has been doing but it is not something we would consider as a matter of default.

Senator XENOPHON: What a terribly glib answer, Mr Dolan. You are investigating an accident where six people could have died. You did not see the relevance of getting the special audit? This is not a routine matter. You are actually in the midst of an investigation and you deliver a report nearly three years after the event that cannot, on any reasonable standard, comply with ICAO annex 13. There are reports from Nigeria and Lebanon, from countries that could be seen as developing countries, that comply with ICAO annex 13. Do you consider you have complied with ICAO annex 13 with this report?

Mr Dolan : Yes, Senator.

Senator FAWCETT: Bearing in mind time, I note that we have just come to that issue of annex 13. I note in your submission you highlight that you have requested a number of exemptions or notified departures from that in a number of areas. My comment would be that I think, if those departures have resulted in this report, then they should be re-examined because they are clearly, in terms of the information flow from CASA to yourselves around the role of the regulator and operator as well as the individual, and all the other issues like fatigue that roll into that, there were clearly a number of contributing factors that were not considered in any thorough way in the report. I think those exemptions should, perhaps, be revisited because they do not meet the test, as Senator Heffernan would say, of the reasonable man at the back of the room.

Mr Dolan : I hear what you are saying and the only comment I feel I should make in that case is that I would disagree with you that there were significant contributing factors that existed and we did not detect and include in our report. But we have different opinions on that.

On a final note and on the subject of significant organisational issues - that should have been included in the PelAir final report under at least contributory factors but wasn't... Here is a section of Hansard of particular relevance taken from the 28/02/2013 public hearing:
Senator FAWCETT: Do you happen to have looked at the Indonesian report from 6 November 2008 into a Dornier aircraft that had its undercarriage collapse after a heavy landing?

Mr Dolan : No, that is not one that I can recall having looked at.
Senator FAWCETT: I merely raise that to highlight the point that my understanding is that the ATSB actually spent some time instructing, supporting and helping the Indonesian government in terms of their ability to conduct aviation accident investigations?

Mr Dolan : That is correct.

Senator FAWCETT: As I look at the scope of the report, whilst it was fairly clear from their examination that in this case it was pilot error—a fast approach, inappropriate crew interaction and other things—they were very brief but quite good in highlighting that things like the runway and safety area airport facilities oversight and the level of compliance were not up to speed. They were quite blunt about making those observations around other government agencies and around the recommendations that then flowed in the report to those other agencies and the operator, which can then clearly be tracked.

Noting the Air France report looking at the A330 that had the icing problem, and EMS accidents in the USA, all of them appear to take the same basic analysis model you have started with but put quite clear emphasis on organisational factors that you are saying, even having looked at the Chambers report, are not applicable. Does it concern you at all that we seem to be out of step with our near neighbours as well as probably the world leaders in aviation?

Mr Dolan : Important though it is, the Norfolk Island investigation report is only one of a considerable number of reports we produce on an annual basis. Each investigation results in those reports. We have an assessment as to scope, taking account of a range of factors, and in a number of cases, because we think it is necessary for the purposes of the investigation to go all the way to organisational factors both at the operator level and the regulator level, we will quite often go there and make quite clear statements and findings in relation to it.

Senator FAWCETT: When did you say that starts? At the start of your investigation process?

Mr Dolan : It is in the course of the investigation. We have critical reviews as necessary, which sometimes result in a variation of scope. While in a practical sense availability of both our expert investigators and the broader resources to support investigations are in play there, it is also about whether it appears that organisational factors have had an influence in this area, and, if the evidence is sitting there in the course of the investigation, we will go there. And there is a whole range of reports I could draw your attention to where we clearly have done that. I think our reports, taken as a whole, are up there and quite comparable to those other countries.

Senator FAWCETT: In this report in particular, looking at the information you have provided to us—and some of those emails are now in the public domain—clearly the accident investigation officer, the officer in charge, proceeded initially on a whole-of-systems basis. If I recall correctly you had a discussion with Mr McCormick or an officer of CASA around the fact that it was a systems approach, but then made a comment back to the investigating officer that CASA now appear to have changed their view on having it as a systems approach. Not long after that the ATSB approach seemed to have scoped out all of the organisational factors. Can you offer an explanation to the committee for why that changed and the scope was reduced, if you had that original review and you started off as ATSB saying that this was best practice and you were going to look at all the organisational factors?

Mr Dolan : We do not appear to have a common understanding. From my point of view and the conversation reflected in that email exchange that went not to the general set of organisational factors but to the point that we had sitting with CASA at that point a critical safety issue. We were saying, based on where we were then, here is this particular issue in relation to guidance as to what happens en route, the receipt of weather information and so on and that we think it is important. We though this important issue was systemic and in initial conversations that seemed to be where CASA as a regulator were focussing—that is, there is a possibility we will need to change our guidance and other materials. When they reviewed that they formed a view that that was not where their attention as the regulator should be and turned their attention to compliance with the existing system. That exchange of emails is trying to relay—apparently not with clarity—to others now reading it how I recall the conversation about what was going on.
IMO it is simply unacceptable & reprehensible that both these senior executive figures (at least) still have jobs; let alone that they now think it is acceptable for them to oversee & set the ToR for Pel-Air MKII...call for a Judicial Inquiry?? Yeah bring it on...

I'll be back...

Last edited by Sarcs; 9th Jan 2015 at 05:07.
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Old 9th Jan 2015, 05:31
  #2606 (permalink)  
 
Join Date: Aug 2014
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Of things incredibly ridiculous

It would seem that Sangston is following the CASA ICC model and making sure he is judge, jury and executioner. Unfortunately Sangston once had great potential until becoming Beakerised.
So what we have left in the post Stray/Bills era is 3 x non aviation Commissioners (unbelievable, I know), a lapdog called Sangston, the loss of 200 years worth of investigation skill and a Murky Machiavellian who continues to leave the government of the day frightfully exposed should ever a serious occurrence occur and be attributed in part or whole to issues identified publicly yet covered over!

Message to the world - Why in the name of all things sacred are you allowing the ATSB to be involved in any international matter? These dodgy muppets couldn't find one of Kharons Choccy frogs in a 3 centimetre hole!
Dear world, continue at your own peril. You've been warned.

TICK TOCK
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Old 9th Jan 2015, 05:58
  #2607 (permalink)  
 
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Why would a sane person NOT suspect official corruption?
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Old 9th Jan 2015, 20:53
  #2608 (permalink)  
 
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Cold hard facts and broad daylight.

If the Sarcs post above does not shake the foundations and get some minuscule response, it's time to throw the wings in the third drawer, hang up the RM's and learn to knit properly. In the face of such stark, compelling evidence any form of wet lettuce treatment simply indicates that we have no aviation regulatory oversight, risk management or accident investigation system at all, at least none that we may rely on.

Heard it told better last evening at the BRB, one of the more whimsical souls kicked off with a cracking good story which kept us amused for some 20 minutes, it had the lot. Too much to relay verbatim on PPRuNe, I shall attempt a humble potted version, just so as you can make sense of the voting.
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

The scene was set in a room which was very like those brilliant prints, the ones you see of dogs playing poker and snooker, card table, eyeshades, cigars, a drink at every elbow. Deepening shadows form away from the low hanging light which throws a yellow light directly onto the piles of chips, ashtrays and the cards.

The table has a couple of vacant seats, but the players have obviously been sitting a while, engrossed in conversation during the game, comfortable with sleeves rolled up, ties loosened. The dealer, Pearly White was just collecting the used cards and getting set to deal another hand. Now Pearly was known for not wasting a lot of time shuffling as he pretty much new where every card in the deck was; and, being as this was a game where cheating was expected none of the other players was too concerned as up to seven cards were allowed up each sleeve. The door of the room slowly opened a few inches about then and a pale, bearded face slid around the edge and peered in; like lightning, the thought 'fresh meat' flashed around the table.

Pearly glanced nervously at his boss, who nodded; his boss Furky was not to trifled with, not in a money game. But there was no help for it, they needed a sixth to make the game work properly. With five professional card sharps at the table, a mug; or, in the parlance of that group, a Muppet was needed. "Sorry" says Muppet "just locking up, saw the light on, got to watch the pennies". "Come in, come in" says Pearly, "just having a few hands of cards to pass the time waiting for the first draft of that bloody report; won't you join us?"

As Pearly was saying his piece, the Choirmaster (so called because he sang more songs than any other known human being) found a clean glass and poured a generous dollop of hooch into the same and offered it to Muppet, "Here mate" he crooned, "take a dram and sit a while; been a long day". Well, Muppet knew his Mum would be worried if he stayed out late and his dinner would be in the dog; but on the other hand, he was under pressure, his new blow up doll had developed a slow leak and what with no TV at home, he thought, perhaps just this once, he may sit a while with the 'lads'. Thought to action, he stepped into the room and into history. "Thanks mate, don't mind if I do" were the last honest words he uttered.

Well, the drinks kept coming, Muppet kept winning (just enough), the jokes were hilarious and the cigars were, he admitted first class. "Got a mate at Dunhill" says the Joker (famous for comic antics and risqué shirts). Long story short, one of the players Wodger, a.k.a. Passion fingers made a silly mistake – a card sharp's gaff – the ace he had in his right cuff fell out when he hastily stretched across the table to mop up Jokers spilled drink (he always mopped up for those above him on the slippery ladder).

"Hey, what's this now" cries Muppet, wisely he refrained from saying the 'cheating' word as even he knew that this was fighting talk and he only had his Swiss Army pocket knife about him (present from his Uncle Alec) he also knew the rest were all 'packing'. "Shan't play any more" he huffed, petulant like, as he started to get up. "Sit" barked the Choirmaster, "let me explain how our little game works" (no option you see, for if Muppet blabbed, well, the jig was up and that was a hanging matter in card sharp circles). "You see" purred the choirmaster in his most luxurious voice; "it's a rigged game, we all know that so it's fair you see; but, we do need fresh money in and to do that we need a 'Pasty'". "Patsy" Muppet automatically corrected; "No, we like Pasties" crooned the Choirmaster, "the crust can be tossed away after use". "Anyway we have a big game coming up and if you play along, we'll cut you into the pot".

The long and the short of it is that Muppet turned up for the next event, ponied up his ante and took his share of his winnings, and with a light heart and heavier pockets toddled off, not a care in the world. His Mum was cross, but a flash of cash into the biscuit tin soothed her troubled brow. Being made aware of a criminal conspiracy troubled him not a whit and he'd developed a fondness for playing with a stacked deck and for a while, life was just peachy.

- - - - - - - - - - - - - - >>>>><<<<<<<<< - - - - - - - -

It was a bloody good yarn and underpinned the short debate.

Q1: was Dolan brought into the fiasco before or after the decision to weld two sides of a story into one convenient, easy to carry package? Split vote – 50/50. There can be no doubt he knew of it. But, whether he elected to become part of it, having discovered what was occurring; or, part of the team which engineered the whole thing to accommodate the easy transition from 'independent' to CASA catamite, could not be decided.

Q2: Based purely on Hansard evidence, is it reasonable to question whether fairy stories were told and to whom; Senate or TSBC? Funny result this one. Dead even 25% split for one of the two choices; the rest went for both. Unanimous was that the industry, government, press and public had been subject to a taking the Mickey Bliss master class.

Q3: Based purely on Hansard evidence, is it reasonable to question if there was a serious breach of TSI S24? Unanimous, unequivocal - Yes.

Q4: Is it acceptable that the Senate committee sit on it's collective rump and allow the ATSB to investigate ATSB. No brainer the cry – Unanimous resounding - No.

Q5: Should the whole matter be referred to the AFP to determine, once and for all, if there was a criminal conspiracy to mislead parliament, defraud the public and pervert a critical accident investigation?. Unanimous resounding - Yes.

Well that's how the voting went, it was quick, argument free and for once, not interrupted by shouts of Bollocks. Darts?, well some of the guests were from the sub-continent and not as familiar with the subtleties of the game as they were of those at cricket. Good showing though; A+ for effort and definitely top marks for sportsmanship.. Phir milengae......

Toot-toot...

Last edited by Kharon; 10th Jan 2015 at 18:14. Reason: TTypo's - heigh ho.
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Old 9th Jan 2015, 22:55
  #2609 (permalink)  
 
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I keeps tellin' ya: Successive governments continue to be very happy with CASA and ATSB, because CASA and ASTB continue to do their real jobs, really well. People like Mssrs Mrdak, Dolan, Aleck and Hawke know the real job of agencies like CASA and ATSB - they've been playing the government game for a loooooong time.

CASA and ATSB continue to be perceived as doing a really good job, by the people who matter.

CASA and ATSB continue to be perceived as saving punters from the 30,000' death plunge. That's why the response to almost every event that results in a perceived risk to aviation safety in Australia almost always results in more regulation and more power and resources for regulators.

Almost nobody in governments care that there may be little-to-no causal link between anything CASA or ATSB does, or thousands of pages of regulations, and changes in safety risks in reality. Not enough, at least, to put their vote in parliament where their mouth is. If the presumptive response to issues like CVD is to destroy some careers, who cares? It's 'safer' that way.

The people who make and break governments perceive Australia's "enviable aviation safety record" to be the product of brave regulators and competent accident investigators. Australian aviation would degenerate into dangerous criminality, and it would be raining VH-tailed aluminium, but for the thousands of pages of rules, a wise regulator to fearlessly and consistently enforce them, and a wise accident investigator to learn from and improve aviation safety as a consequence of in-depth, expert, independent accident investigations. Punters imagine that the adults in organisations like Qantas watch and listen, with bated breath, as experts from the regulator conduct fine-tooth comb audits and carry out frank and fearless regulatory action to keep the airline on the safe, straight and narrow path of compliance.

The accidents that do occur are, of course, nothing to do with the thousands of pages of regulations (unless there are too few of them) or the way in which the regulator or accident investigator were doing their jobs (unless there was an unfortunate, one-off, out-of-character, 'lapse', immediately corrected by working out an MoU).

The punters don't know - and, more importantly, don't want to know - that CASA and ATSB don't really make much positive difference to aviation safety.

The punters don't want to know the implications of the travesty and sick joke that was CASA's and ATSB's response to the ditching of NGA.

The punters don't want to know that the Frankenstein that is the regulatory reform program has burnt and will continue to burn hundreds of millions of dollars to continue to produce the regulatory equivalent of the Spruce Goose: An expensive, complex and useless waste of space like the Australianised Seasprite. If something's useless, what harm can it possibly do?

The punters don't care that those blocks of land from which those dangerous and noisy little aircraft operate are being turned into warehouses and high rise by rich property developers with 'friends' in governments.

The punters just want to feel that governments are protecting them from the 30,000' death plunge.

People in the GA community don't matter. They don't make or break governments. That's why there's bi-partisan apathy towards the plight of GA.

The Laborials know that the chances of a major hull loss in Australia are infinitesimally small and it's a coin toss as to which 'side' will be in power if it happens. They also know that there's almost no measurable causal link between anything CASA and ATSB does on the one hand and the objective (versus perceived) risks to aviation safety on the other. There's therefore no political advantage in one 'side' taking the risk of making the aviation sector a differentiator between them and the other 'side', by actively intervening in the aviation sector. If one 'side' were to, for example, implement a policy of 'promoting' aviation, the other 'side' could attribute subsequent accidents to that policy. That 'side' would be perceived as increasing the risk of the 30,000' death plunge and that could affect that 'side's' electoral chances.

Best instead for both 'sides' to maintain a 'hands off' approach to the 'independent' safety regulator and 'independent' accident investigator, so that there continues to be plausible deniability of responsibility. The occasional parliamentary inquiry and rhetorical fist waving provides the facade of accountability. As I said at the time, if you'd deleted the names, you wouldn't have known from reading Hansard that there'd been a change of government: The people who'd been roundly criticising the regulator pre-election were strenuously defending the regulator post-election.

(However, it must be said that the facade is becoming increasingly shabby and obvious even to the unskilled in the dark arts of politics. That's why there's increasing realisation in the electorate that there's little difference between what the major parties do when in government - hence the name "Laborials".)
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Old 9th Jan 2015, 23:19
  #2610 (permalink)  
 
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"Those who can make you believe absurdities can make you commit atrocities". (To support the BRB consensus).

Last edited by Frank Arouet; 9th Jan 2015 at 23:26. Reason: Something I penned in The Bastille circa 1717
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Old 11th Jan 2015, 00:54
  #2611 (permalink)  
 
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PelAir MKII: M&M, Beaker, Sanga et.al Contributory Factors?? - You Bet!

Reality of current status quo...
So what we have left in the post Stray/Bills era is 3 x non aviation Commissioners (unbelievable, I know), a lapdog called Sangston, the loss of 200 years worth of investigation skill and a Murky Machiavellian who continues to leave the government of the day frightfully exposed should ever a serious occurrence occur and be attributed in part or whole to issues identified publicly yet covered over!
...then from Sunny...
Why would a sane person NOT suspect official corruption?
Why indeed? A question that no doubt has passed through the mind of any of a number Senators involved in or having a passing interest in the PelAir debacle. Example from 24/02/14 Estimates:
CHAIR: How did it go from a critical incident to a 'don't worry about it' incident?

Mr Dolan : That is a matter we did rehearse with the references committee. In short, our initial assessment of the issue of guidance as to dealing with the situation, weather deterioration and what was planned, we overassessed it as critical at an early stage and by applying our methodologies we concluded by the end of the process that it constituted a
minor safety issue.

CHAIR: Can I commend you. You look really well. You look less stressed than you used to for some reason.

Mr Dolan : It is probably the lack of the beard.

CHAIR: With that particular incident of which I just spoke no thinking person would believe that bureaucratic answer. You cannot go from a critical incident to a minor one or whatever it was without something happening on the journey. Anyway, we will not go back there. To any sensible person it sounds like either a cover-up or a balls-up.
However for my 1st of the year Sundy Cogitation I'd like to further reflect on some passages of Hansard from the 28/02/13 AAI public hearing that focussed on 'Contributory Factors' - & the lack there of in the PelAir final report:
Mr Dolan : As I tried to state—and perhaps I am not making myself clear—the principal purpose of an accident investigation, or an occurrence investigation, is to understand 'cause', which in our case we do by way of identification of safety factors and safety issues. Our attention, quite reasonably, remains on that. Our mandate is really to look at, and to understand to the extent necessary, the context and the relevance of the context within which the occurrence happened. There is still nothing in our assessment that we could see, acknowledging that there were deficiencies in CASA's surveillance and activities, and acknowledging that there were problems with the way Pel-Air operated its safety management system, that was going to lead us to the question of contributing safety factors and, more particularly, to the identification of areas for safety improvement. We were conscious that CASA, for it is regulatory purposes, was undertaking steps in relation to the pilot, in relation to Pel-Air as the operator and, indeed, in relation to itself in terms of those improvements, so the question was: if there is an intervention from CASA in terms of rectifying some problems of noncompliance, what is the extent to which we have to retrace that territory in the interests of safety improvement? They are the balances we are undertaking in the course of scoping and re-scoping our investigations.

Senator FAWCETT: I understand your talk about balancing and not going over the same ground, but where another agency has already done the work, and that report is now presented to you, and that agency has identified—again I go back to paragraph 4.1:

It is likely that many of the deficiencies identified after the accident would have been detectable through interviews with line pilots and through the conduct of operational surveillance of line crews in addition to the surveillance of management and check and training personnel.

It says here:

If a systems audit is conducted with inadequate product checking—
that is, the line pilots—
CASA is unable to genuinely confirm that the operator is managing their risks effectively.

Are you still maintaining the position that that is not an organisational influence or a risk control that was a contributing safety factor, in terms of not only the incident pilot but also the fact that the rest of the line pilots indicated similar lack of compliance and lack of understanding, to this incident and potential like incidents?

Mr Dolan : That is our position, Senator Fawcett, and clearly you disagree with it. It is the influence of those factors on the accident flight in particular which always has to be the principal but not the only focus of our investigation. It is the influence of those known factors in the events of this flight that we always have to come back to, because of the task that we have been given as the accident investigator.

Senator FAWCETT: You have used the term 'known factors'. I put it to you that, had you received this report before the issuing of your final accident report, they would have been known factors because they are spelt out in black and white. I take you again to the diagram you have on page 13, where you look at risk controls and you ask question: what could have been in place to reduce the likelihood or severity of problems at the operational level?

Again, I go to the Chambers report, where it talks about inspector capability and performance. It talks about the fact that an inspector needs to have a level of investigative skill to drill down to find the deficiencies that are genuinely serious and often complex. Not all inspectors have this capability and it seems that this characteristic is assumed to exist in an inspector. It then goes on to talk about the scratching-the-surface approach and the fact that the inspectors, in Pel-Air's operation, were not even aware of the routes that they flew, or the fact that the majority of their operation was EMS as opposed to cargo. Coming back to your table, surely what could have been in place were inspectors who were competent and informed, as well as an appropriate oversight program. Does that not fit the definition of your risk control?

Mr Dolan : Those sorts of circumstances certainly fit in to the picture of what would constitute organisational issues. Where we appear to be at odds is in the question of the level of contribution of those factors in the particular occurrence that we were investigating. That is why we have the position that we have taken. We carefully reviewed the chamber's report, and the basis on which we responded as we did was the issue of influence, contribution, cause.
For the benefit of those interested these were the contributory factors in the PA final report:
Contributing safety factors
• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.
From my previous post I quoted from the same 28/02/13 Hansard where DF mentioned an Indonesian NTSC investigation:


Here is a link for that investigation report - DORNIER 328-100 PK–TXL; EXPRESS AIR FAK-FAK, PAPUA REPUBLIC OF INDONESIA 6 NOVEMBER 2008

This is part of the section of that report to which Senator Fawcett refers:
1.17.4 Airport Emergency Planning

Based on the lack of emergency personnel and equipment at Torea Airport, Fak Fak, Papua, to respond to an aircraft accident, it was clear that emergency planning and exercising did not meet the ICAO Annex 14 Standards.6

ICAO Annex 14 contains Standards and Recommended Practices with
respect to Airport Emergency Planning.

Paragraph 9.1.12;
The plan shall contain procedures for periodic testing of the adequacy of
the plan and for reviewing the results in order to improve its
effectiveness.
Note.— The plan includes all participating agencies and associated
equipment.

Paragraph 9.1.13
The plan shall be tested by conducting:
a) a full-scale aerodrome emergency exercise at intervals not
exceeding two years; and
b) partial emergency exercises in the intervening year to ensure that
any deficiencies found during the full-scale aerodrome emergency
exercise have been corrected; and reviewed thereafter, or after an
actual emergency, so as to correct any deficiency found during such
exercises or actual emergency.

ICAO Annex 14, paragraph 9.1.14 states that:

The airport rescue and fire fighting services shall have a plan that
shall include ready availability of coordination with appropriate
specialist rescue services to be able to respond to emergencies where
an aerodrome is located close to water/or swampy areas and where a
significant portion of approach or departure operations takes place
over these areas.

Paragraph 9.2.2 states that:

Where an aerodrome is located close to water/or swampy areas and
where a significant portion of approach or departure operations takes
place over these areas, specialist rescue services and fire fighting
equipment appropriate to the hazards and risks shall be available.
And this is from the conclusions section (findings):
3.1.10 The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.
3.1.11 The DGCA had not filed a difference with ICAO with respect to its inability to comply with the Annex 14 Standard for runway end safety areas at Torea Airport, Fak-Fak, Papua.
3.1.12 The airport did not meet the ICAO Annex 14 Standard with respect to the airport emergency personnel, equipment and exercising of an airport emergency plan.
Finally these are the relevant recommendations to the DGCA that the contributory factors helped generate...:
5.5 Recommendation to the Directorate General of Civil Aviation
(DGCA)
The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the Torea Airport, Fak-Fak, Papua runway complex to ensure that runway end safety areas (RESA) are established that meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14.
Particular attention should be given to:

• ICAO Annex 14 Paragraph 3.5.2 (Standard) that a runway end safety area (RESA) shall extend from the end of a runway strip to a distance of at least 90 meters.

If the DGCA is unable to meet the RESA Standard in accordance with ICAO
Annex 14, it should file a difference with ICAO as soon as possible.

5.6 Recommendation to the Directorate General of Civil Aviation
(DGCA)


The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) ensure that the operator of Torea Airport, Fak-Fak, Papua surveys the Torea Airport runway complex and ensure that the runway dimensions promulgated on aerodrome charts are accurate.

5.7 Recommendation to the Directorate General of Civil Aviation
(DGCA)


The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the procedures and equipment used by the Toera Airport, Fak Fak, Papua, Rescue and Fire Fighting Services to ensure that they:


meet the minimum requirements specified in the International Civil Aviation Organization’s Annex 14.
Now compare that to the organisational/ regulatory oversight issues that were highlighted both in the CAIR09/3 report (ref: post #2653), in the FRMS (Cook) SAR and in the Chambers report - oh that's right that was all classified as irrelevant & simply scoped out of the Final Report...

I'll be back...
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Old 12th Jan 2015, 02:09
  #2612 (permalink)  
 
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Deism.

I believe the existence of regulation should be based solely on natural reason and personal experience without reference to revelations brought about by precedence or opinion or interpretation of reports written by so called authoritative sources with scant regard to science, engineering or economy. Nor of human self preservation in an alien environment, by agenda driven personal or political crusades using testimony of cherry picked witnesses.


I may be a Deist, but CAsA and ATSB are not the Deity.
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Old 12th Jan 2015, 08:55
  #2613 (permalink)  
 
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BRB Special award.

Whoever he is and whatever does, Mr. Jim McDowell has earned his Choc frogs (yes Sot – plural). His response to the review conducted by the inestimable Rev. Forsyth and Co is not salted with bias or larded with self interest. I would commend it to anyone who seeks a sane, balanced approach to any problem. The submission does not presume or attempt to influence. It is a plain spoken attempt by a honest man to see both sides of the coin and find a solution to a small problem made into a molehill by vested interests.

Jim McDowell. Quotes in no particular order: have a read, five short pages: they are of little importance in the big world; but Golly, for good, solid, common or garden sense, stand unbeaten. I say Bravo and well done Sir; the missive may not move mountains, but I'd bet you sleep with a clear mind and wake the next day ready to calmly face whatever the cards may hold............

"An association, as a sports aviation advocate, is representing the risks of its members whereas the statement above seems to propose that the association is subject to the risk – clearly not so. The association is merely a mechanism for aggregating the risk for the benefit of the regulator (CASA)".
"It is ironic that a government that stands steadfast against compulsory unionism is prepared to implement systems that require compulsory membership of an organisation in order to fly aircraft that CASA does not want to regulate directly, quite often in situations that result in perverse and draconian outcomes."
"It is usually regarded that a person or body to whom parliament delegates its rule making powers cannot delegate those powers unless it is within the terms of that delegation. Further, it is considered that such rulemaking powers should not be delegated to a private body for the reason that such powers may be used in an oppressive or discriminatory manner."
Extra frog for the C.S. Lewis.

Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.
Toot a toot, toot.....

Last edited by Kharon; 12th Jan 2015 at 21:42. Reason: Furgot ze looking fink;
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Old 12th Jan 2015, 12:58
  #2614 (permalink)  
 
Join Date: May 2013
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Australia was one of the drafting nations and signed on to the document in 1948.

The document is the "Universal declaration of Human rights".

section 20a
quote" No person shall be forced to join an association" unquote.

You would think that the legal brilliance (I am being derisive here) behind CAsA would have known this.
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Old 12th Jan 2015, 13:41
  #2615 (permalink)  
 
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Of things that are total folly

D8;
section 20a
quote" No person shall be forced to join an association" unquote.
You would think that the legal brilliance (I am being derisive here) behind CAsA would have known this.
The problem is that there are people at CASA who are so full of themselves that they believe they are reside upon a plain that is above the entire human species. And give them a PHD and they think the entire universe rests in their palm!

I kinda like Mr McNamara, interesting character, and this quote of his sums up CASA really;
“All the evidence of history suggests that man is indeed a rational animal, but with a near infinite capacity for folly. . . . He draws blueprints for Utopia, but never quite gets it built. In the end he plugs away obstinately with the only building material really ever at hand--his own part comic, part tragic, part cussed, but part glorious nature.”
― Robert S. McNamara
If he was still alive I would gladly share a chocy frog with him and Kharon

Last edited by Soteria; 12th Jan 2015 at 20:29.
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Old 12th Jan 2015, 20:31
  #2616 (permalink)  
 
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When I read this, I immediately thought of CASA Avmed:
Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.
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Old 12th Jan 2015, 23:38
  #2617 (permalink)  
 
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It gets better.

“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience. They may be more likely to go to Heaven yet at the same time likelier to make a Hell of earth. This very kindness stings with intolerable insult. To be "cured" against one's will and cured of states which we may not regard as disease is to be put on a level of those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.”

Last edited by Frank Arouet; 12th Jan 2015 at 23:38. Reason: Infants, imbeciles and domestic pets. No potplants?
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Old 12th Jan 2015, 23:42
  #2618 (permalink)  
 
Join Date: Aug 2014
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Creampuff, agreed.
Unfortunately due to much good work being undertaken by the IOS there are no more Choccy frogs available this week. However your post does not go unrewarded and two packets of snakes and a roll of Mentos has been dispatched immediately to a former airport near you.

Frank, Pot Plant Pete lives on and said to say hello .

Regards
IOS affiliate
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Old 13th Jan 2015, 10:17
  #2619 (permalink)  
 
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Oppressive and discriminatory powers.

Jim McDowell
"It is usually regarded that a person or body to whom parliament delegates its rule making powers cannot delegate those powers unless it is within the terms of that delegation. Further, it is considered that such rulemaking powers should not be delegated to a private body for the reason that such powers may be used in an oppressive or discriminatory manner."
Great submission Jim, but apparently you haven't had any dealings with our esteemed [public] body so far.

http://www.infrastructure.gov.au/avi...m_McDowell.pdf .
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Old 13th Jan 2015, 21:09
  #2620 (permalink)  
 
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My turn..

For my sins (trying to puzzle out a Sarcs question on the TSI Act) I strayed into section 25A of that Act; David Fawcett and his 'closing the loop' questions and remarks must have triggered some kind of subconscious thinking pattern which has been demanding answers for a while now. Anyway - 25A Responses to reports of, or containing, safety recommendations.

First glance at 25 A you may be forgiven for thinking well, here's horsepower, for when a safety recommendation is issued there are rules which must be followed. The natural question which jumps out is with the requirement to respond cast in stone, why then are there so many open loops? and there are a lot. There is a PAIN report (thanks P7) which examined in some detail Coronial recommendations from fatal accidents over a ten year period, contained within and examined by that report were those issued by the ATSB related to the case.

Now CASA may with impunity politely ignore the coroner and they do; the record of actually 'closing the loop' on coronial recommendations is 'slim' – possibly anorexic. But the ATSB have, through the Act, actually got some real clout. Why is this not used? I wondered.

Being a legal dunderhead it took me a while grasp the Oh so subtle escape paths; but even those may be effectively blocked by a determined "Commissioner"; one not so determined could cooperate, for within the work of the Word Weasels, for there is a mile of wriggle room. For example:-

25A Responses to reports of, or containing, safety recommendations
(1) This section applies if:

(a) the ATSB publishes a report under section 25 in relation to an investigation; and

(b) the report is, or contains, a recommendation that a person, unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action.

(2) The person, association or agency to whom the recommendation is made [must give a written response to the ATSB, within 90 days of the report being published], that sets out:

(a) whether the person, association or agency accepts the recommendation (in whole or in part); and

(b) if the person, association or agency accepts the recommendation (in whole or in part)—details of any action that the person, association or agency proposes to take to give effect to the recommendation; and

(c) if the person, association or agency does not accept the recommendation (in whole or in part)—the reasons why the person, association or agency does not accept the recommendation (in whole or in part).

(3) A person commits an offence if:

(a) the person is someone to whom a recommendation is made in a report published under section 25; and

(b) the person fails to give a written response to the ATSB within 90 days setting out the things required by paragraphs (2)(a), (b) and (c) (as applicable).

Penalty: 30 penalty units.
Intriguing, the part highlighted [in brackets] despite all the sound and fury and penalty unit threats simply requires that 'a response' be given.

E.g. ATSB recommendation - "Pilots will wear one green and one red sock".

To which CASA respond "this is silly, we reject your recommendation". (Shades of Python).

Which leaves the ATSB up a pole; CASA have 'responded' which is all that the 'law' requires. Now it may be that the result of an expensive, properly conducted, expert investigation has identified a string of valid reasons for making the recommendation, explained the detailed reasoning, examined the evidence, exposed the holes in the cheese and clearly demonstrated, beyond a reasonable doubt, that socks cause accidents. To whom and where do ATSB go next to appeal their case and get a reasonable ruling. The short answer is nowhere; they're stuck with it. Which of itself is passing strange.

Part of the answer (IMO) may lay within the very Acts which govern such matters and gave rise to the risible MoU. BUT the 'law' is there and it becomes very much a matter of the 'will' of the Commissioner how much 'law' will apply. It is interesting to (a) study the amount of SR which have not been issued during the Dolan regime of beyond all reason; and, (b) the amount of recommendations which are not 'fully' addressed (in limbo); (c) the changes to MoU; (d) the changes in Commissioners independent 'powers' and; last but not least (e) the volumes of un-addressed recommendations which, if we were not playing at silly buggers may, conceivably, have prevented repeat accidents similar in nature.

My own favourites are the ones from 10 or so years ago which were to be 'addressed' through the "new" legislation, coming soon. Bollocks, plain, pure, unmitigated, undiluted Bollocks.

Fawcett nearly got there you know; so close but, alas, no cigar......

It's deep, but there you go Brother Sarcs; it is, I believe my turn to set the puzzle and ask the questions (of which there are many)....

Toot......toot....

SIUYA "If recent NSW ICAC 'results' are anything to go by TB, hopefully an invitation to a giant arse-kicking party, a very public DCM, and perhaps some time in the 'big house'."
..........

Last edited by Kharon; 13th Jan 2015 at 22:25. Reason: Telphunus interuptus.
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