Merged: Senate Inquiry

[Kharon]

Cheers Creamy; I sometimes wonder if, behind the cynical, tough outer carapace there lies a tough cynical old geek, secretly revelling in being a fighting member of the IOS – in deep cover. Lukim U. (wink and big smile-here-; if I could get 'em to work)

[Sarcs]

ASRR: Roadmap to recovery

The negative commentary we are seeing on here in regards to the ASRR report for me highlights how toxic the culture in CASA has become under the Skull. IMO that man has wrought more damage in his time than any of the other DAS/CEOs combined, rule 101 divide & conquer. I'm with Ben...Will heads of CASA, ATSB now go?...the angry man & Beaker should be frog marched out of their respective caves immediately...

Comment from Ben's article:

“The Panel considers that the Pel-Air report was an aberration, and not typical of the high standard that the ATSB usually attains.
The Panel recognises that the ATSB is putting measures in place to prevent a re-occurrence”

It occurs to me that there is nothing in the above statements which leads to the conclusion that the Pel-Air crash will be re-investigated.?

As far as I remember, there is also nothing in the terms of reference on the Canadian inquiry which will allow it to recommend a new investigation.
If the CTSB finds that all the relevant paperwork was completed & all the relevant boxes ticked, they must find that the investigation was completed correctly….

Even though without the FDR’s, the ATSB couldn’t possibly have analysed the complete range of information, before arriving at its (possibly incorrect) conclusions.

Comment: Perhaps too much water/ocean....under the bridge??

Although the ASRR report seems to conveniently step around the PelAir debacle, there is an underlying message in the following paragraphs of the Exec summary...

"...The Australian Transport Safety Bureau (ATSB) has been heavily criticised in Australia for its report into the 2009 ditching of a Pel-Air
Westwind off Norfolk Island1. Canada’s Transportation Safety Board is completing a review of the ATSB and will report shortly. The Panel
considers that the Pel-Air report was an aberration, and not typical of the high standard that the ATSB usually attains. The Panel recognises
that the ATSB is putting measures in place to prevent a reoccurrence. To improve the ATSB’s governance, the Panel recommends that an
additional Commissioner be appointed, with extensive aviation experience.

ICAO requires that countries formulate a State Safety Program (SSP), which Australia has done. The Panel considers that Australia should
develop the SSP as a strategic plan for the aviation safety system, under the leadership of the Aviation Policy Group. To implement this plan,
the Department of Infrastructure and Regional Development should play a stronger policy role in the SSP, providing policy guidance while
respecting the operational independence of CASA, the ATSB, and Airservices..."

Even though the TSBC review appears to be, on the surface, just another tick-a-box routine I still believe it will be pivotal in the grand scheme of things (i.e. the international connection). The ASRR report says as much with the references to Annex 13 & 19, that and the recommendation for an extra commissioner with aviation experience.

What the ASRR report also provides (finally) are the true ToR that the Canucks are working to:

Scope of TSB independent objective peer review of ATSB

Proposed Objectives

To provide the ATSB with an independent objective peer review of its investigation process/ methodology, and of the application of its methodology to at least two selected occurrences (including the Norfolk Island occurrence).

To identify best practices from both organizations that would be shared to improve existing processes and methodologies.

Proposed Scope of Work

1 — Exclusions
The TSB will not re-investigate the Norfolk Island occurrence and will not provide an ‘investigation report’ specific to this occurrence.
This review will be internal to the TSB and ATSB only. The TSB will not communicate with, or interview, any persons external to the ATSB as part of this review.

2 — Review of the Investigation Methodology

The TSB will collect information and conduct a comparative analysis of the ATSB and TSB investigation methodologies, including the approach for the risk assessment of safety issues. The analysis will also include a comparison the two methodologies to the relevant provisions of Annex 13 to the Chicago Convention. This benchmarking analysis will identify the strengths (best practices) and the weaknesses (gaps) of each methodology.

3 — Application of the Investigation Methodology

The TSB will review the Norfolk Island investigation and at least one other ATSB investigation to assess whether the investigation methodology was properly applied. The review team will ask questions such as: Was the process followed? Were the proper tools, systems and resources in place and effectively used? Was the investigation conducted in a thorough manner? Was all significant information adequately considered and analysed? Were organizational and human factors adequately considered? Would we have done things differently? This review will identify any best practices and any issues or gaps in the application of the existing methodology.

4 — Management and Governance of the Investigation

The TSB will review the Norfolk Island investigation and at least one other ATSB investigation to assess the ATSB’s approach to the management and governance of the investigation process. The review team will ask questions such as: How was the investigation managed? How were key decisions made and by whom? Was there adequate documentation and guidance to support decision-making? Were the key decisions based upon solid factual information and robust analysis? Would we have done things differently? Are there any legislative impediments to the conduct of ATSB investigations? This review will identify any best practices and any issues or gaps in the governance and management of the investigations.

5 — Investigation Report Process

The TSB will review the ATSB investigation report process and how it was applied in the case of the Norfolk Island investigation and at least one other ATSB investigation to assess its effectiveness at achieving the desired outcome. The review team will ask questions such as: Was the process followed? Was the report review conducted in a thorough manner and was it effective? Is the analysis contained in the report complete and thorough? Are the findings and recommendations well supported by facts and robust analysis? Were the comments received from directly involved parties adequately considered and was the disposition of these comments full communicated? Would we have done things differently? This review will identify any best practices and any issues or gaps in the investigation report review process.

6 — External Communications

The TSB will review the ATSB approach to external communications (i.e. vis-à-vis the media, public, stakeholders and politicians) throughout the investigation and report production process, upon the release of the final report, and in the weeks following the report publication to assess its effectiveness at achieving the desired outcome. The review team will ask questions such as: What was the methodology and was the process followed? Was information provided in a proactive manner? Were messages crafted with the anticipated stakeholder reaction in mind? After looking at the business process, the TSB will look into the communications issues specific to Norfolk Island and its aftermath. The review team will ask further questions such as: Was the reaction appropriate in response to the television show Four Corners? Why was the ATSB unable to convince the Senate Committee and possibly the public of the validity of its processes? Would we have done things differently? This review will identify any best practices and any issues or gaps in the external communications process.

7 — Deliverables

The TSB will prepare and submit a detailed written report to the ATSB summarizing the results of its review, its findings and its recommendations. The report will contain the following sections:

• Introduction
• Description of the review process and methodology
• Analysis and findings for each section
• Review of the Investigation Methodology
• Application of the Investigation Methodology
• Management and Governance of the Investigation
• Investigation Report Process
• External Communications
• Conclusion and recommendations

The TSB will provide a draft report to the ATSB for review and comments. The ATSB comments will be considered by the TSB and the report will be finalized.

8 — Independence

The TSB will carry out the work described in the preceding sections in an independent and objective manner. The TSB will be fully responsible for the conduct of the review and for the analysis of the information collected. The final report will present the independent views of the TSB.

In the interest of transparency and accountability, the TSB will make its final report public (i.e. post it on its web site). Advanced notification of the release and advanced copies of the report will be provided to the ATSB. Once the report is public the ATSB will be able to reference the report and disseminate it as it sees fit without any restrictions.

The ATSB will provide full cooperation and access to the necessary files, manuals, policies, procedures, and personnel.

Reading between the lines I think there is enough scope in those ToR to really effect a change to the running of the ATsB and get them back to SR (sensible reason). After all it is not the crew on the coalface who are the problem but the numbnuts in the lofty offices above...

[SIUYA]

Sarcs...

Proposed Scope of Work point 5:

Investigation Report Process

The TSB will review the ATSB investigation report process and how it was applied in the case of the Norfolk Island investigation and at least one other ATSB investigation to assess its effectiveness at achieving the desired outcome. The review team will ask questions such as: Was the process followed? Was the report review conducted in a thorough manner and was it effective? Is the analysis contained in the report complete and thorough? Are the findings and recommendations well supported by facts and robust analysis? Were the comments received from directly involved parties adequately considered and was the disposition of these comments full communicated? Would we have done things differently? This review will identify any best practices and any issues or gaps in the investigation report review process.

ATSB Transport Safety Report, Aviation Occurrence Investigation AO-2009-072 Final Report:

SAFETY ACTION

The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisations. In addressing those issues, the ATSB prefers to encourage relevant organisations to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

As far as I can see there were no safety recommendations, so the TSB Scoping doesn't really seem appropriate if it was intending to look at recommendations, does it?

[Kharon]

Curiously intriguing.

There's a fair bit of wriggle room for a bookie in that script (thanks ASRR). Working out the odds the determination of TSBC to protect a solid reputation must be factored in; then there's the integrity of the investigating panel to consider; the current 'mood' of the minister and Senators to weigh in. The IOS entries in the race cannot be discounted, nor can the 'treatment' the WLR has prescribed for the DAS and ATSB be ignored. Beaker and McComic between them, with Wodgers assistance, royally screwed the Pel Air pooch.

Not very often do I wish to be a fly on a wall (high risk job) – but I concede it could be a handy trick.

[Sarcs]

TSBC conundrum??

Kharon:

Working out the odds the determination of TSBC to protect a solid reputation must be factored in; then there's the integrity of the investigating panel to consider; the current 'mood' of the minister and Senators to weigh in. The IOS entries in the race cannot be discounted, nor can the 'treatment' the WLR had prescribed for the DAS and ATSB bi ignored.

And there's the rub do we truly expect the good investigators at the TSBC, who make their living out of solving (on the face of it) what went wrong across the broad spectrum of a causal chain (Reason Model) and in compliance with Annex 13 Chapter 5, to just rubberstamp their review??
{Comment: Despite the ToR I would suggest that the natural curiosity of the Canuck AAI investigators will have them flicking through the Senate PelAir report and viewing the 4 Corners program both of which are readily accessible off the internet.}

so the TSB Scoping doesn't really seem appropriate if it was intending to look at recommendations, does it?

Totally agree SIUYA it does seem limited in scope. However what does give me some hope are the very lines that you quoted...

"...Was the report review conducted in a thorough manner and was it effective? Is the analysis contained in the report complete and thorough? Are the findings and recommendations well supported by facts and robust analysis? Were the comments received from directly involved parties adequately considered and was the disposition of these comments full communicated?..."

The TSBC adhere strictly (no notified differences) to Annex 13 Chapter 5. Chapter 5 refers you to the ICAO Manual of Aircraft Accident and Incident Investigation, this manual is very much Reason oriented (reference Ch 3 para 3.2), & provides guidance on ICAO accepted practice/methodology of accident/incident investigation.

Chapter 3 ORGANIZATIONAL INVESTIGATION, Paragraph 3.5 METHODOLOGY (my bold):

3.5.1 The application of the Reason Model to accident and incident investigation

The organizational investigator will often rely on other groups to identify active failures, local factors and failed or absent defenses. As this information becomes available, the organizational investigator will be in a position to consider the underlying organizational and systemic factors which enabled the situation to develop.

In the event of a major investigation, there may be daily briefings which will enable the organizational investigator to become aware of the progress of other groups. It may be appropriate, however, for the organizational investigator to arrange for a member of each group to act as a contact and report information which may have a bearing on organizational issues.

In the early stages of the investigation, the organizational investigator may need to attend or review key interviews conducted by other groups such as ATC or Operations. This will ensure that potential organizational issues are not being neglected during the interview. As the investigation progresses there may be a need to conduct interviews specifically directed at organizational issues.

In addition to relying on information from sources such as interviews, and documents, the organizational investigator may choose to collect information via additional means such as structured survey interviews, or questionnaires.

The organizational investigator should develop a listing of the organizations that played a role in creating potential local or systemic factors. For example, if the accident is remote from the organization headquarters, there may be an intermediate level of supervision involved. Similarly, when outsourcing is used for example for aircraft maintenance, there may be several contractual relationships established involving multiple organizations. In this case, the relationship between each organization should be well understood to identify breakdowns in the management oversight and communications. Finally, as the investigator comes to understand the organization’s structure, there must be consideration of the government relationship with the organizations related to the issuing and continued oversight of the operations and/or maintenance certificates.

Potential organizational weaknesses may become apparent during the investigation. Yet these organizational weaknesses may have had no role in the development of the accident. If no evidence subsequently emerges to link these weaknesses with the active failures, local factors and defenses of the accident scenario, the organizational investigator should not list these weaknesses among the accident factors. Such findings should however be included in the accident report and if applicable they should be a subject of a safety recommendation. It might be appropriated to place such findings under additional information in the accident report.

We are all now fully aware that the ATsB pretty much scoped out of their report all organisational issues (including CAsA oversight of PelAir) as not being contributory to the ditching. However, according to the above methodology, the TSBC may have an entirely different view on this and the OI's most definitely falls within the remit of the TSBC ToR…

“…Would we have done things differently? This review will identify any best practices and any issues or gaps in the investigation report review process…”

The TSBC ToR…

2 — Review of the Investigation Methodology

The TSB will collect information and conduct a comparative analysis of the ATSB and TSB investigation methodologies, including the approach for the risk assessment of safety issues. The analysis will also include a comparison the two methodologies to the relevant provisions of Annex 13 to the Chicago Convention. This benchmarking analysis will identify the strengths (best practices) and the weaknesses (gaps) of each methodology.

…also means that the Canucks, especially in light of the Senate inquiry findings, will have to consider as part of their ‘comparative analysis’ and in light of the FRMS special audit report & the Chambers Report…

“…Reopening of investigation
5.13 If, after the investigation has been closed, new and significant evidence becomes available, the State which conducted the investigation shall reopen it…”
…to see whether they would have, under their methodology, have come to the same conclusion as Beaker & his fellow Commissioners.


{Note: The ToR also, by design, should encompass both the initially notified and intended Critical Safety Issue & ATSB Prelim Report (Jan-Feb 2010) and the subsequent about face that the bureau took at the time.}

IMO the ToR are definitely not a tick-a-box routine and there is certainly sufficient scope for the TSBC to make some fairly constructive recommendations to the ATsB.

Also as "K" said..."Working out the odds the determination of TSBC to protect a solid reputation must be factored in..." is particularly relevant when the eyes of the international aviation community and the travelling public are focussed on our neck of the woods in respect of the MH370 search & investigation..

[Kharon]

Idle speculation.

I just wonder exactly what the Senate team make of the current shenanigans; it's not as though there is no scope for them to act and there's certainly lots of juicy tid-bits on offer. What a smorgasbord of choice. The discarded Pel-Air report (insult one), the dismissive rhetoric in Estimates (insult two), the 'run-around' answers to direct questions (insult three), the flaunting distraction of the WLR (insult four) or the blatant, purblind, arrogant 'finger' publicly delivered on the CVD issue (insult five). There's more, but you get the idea.

These are (for politicians) as honest, informed, intelligent a crew as industry could have wished for – and they seem to care. Cometh the hour. etc.

I would keep an eye on the Senate ball, they just don't strike me as the type to slip away into the night. They may yet call the bully's bluff and that will be worth watching....Time will tell the tale.

Note to self – buy more popcorn.

[thorn bird]

"Reason: Good housekeeping day."

I thought that was what "Mini's" were for??

[Sarcs]

Thank God for the birds??

Well finally the ATsB interim report into the ill-fated ATR72, VH-FVR has been released: AO-2014-032

From report...

"...Subsequent to the occurrence on 20 February, the aircraft was operated on 13 sectors, the last of which was a scheduled passenger flight from Sydney to Albury, NSW on 25 February 2014. On descent into Albury the aircraft passed in close proximity to birds, which alerted the captain to the possibility of a birdstrike. There were no indications that a bird had struck the aircraft but on the ground, the aircraft’s pitch trim system fluctuated abnormally.

The captain conducted a walk-around inspection with an expectation of bird damage to the left side of the aircraft. The only abnormality found was a deformity to a fairing at the top leading edge of the vertical stabiliser, which might have been the result of a birdstrike. The captain advised maintenance watch who dispatched an engineer to inspect the aircraft.

The engineer used scissor lift equipment to inspect the tailplane and confirmed that the fairing might have been damaged by a bird but that there was also significant structural damage on top of the tailplane. The aircraft was grounded and the ATSB advised..."

The investigation is continuing and will include review of the:
•meteorological data
•data from the flight data recorder
•data from the cockpit voice recorder
•closed circuit TV footage
•aircraft operator’s procedures and training
•aircraft maintenance records
•maintenance organisation’s procedures and equipment
•arrangements between the aircraft operator and maintenance organisation
•aircraft manufacturer’s maintenance instructions
•information as it becomes available during the repair process.

Makes for a fascinating read but like so many of these types of investigations it leaves you with more questions than answers...

Here is Ben's, not surprising, take on it so far...:

Virgin Australia flew 13 passenger flights in broken turbo-prop

Where on earth is CASA as well as Virgin Australia and the Minister for Aviation in relation to the shocking update by the ATSB in the case of a damaged 68 passenger ATR72 turbo-prop that was allowed to fly 13 times in scheduled service after a turbulence event on a Sydney-Canberra flight in February?

The core elements of the ATSB report show that Virgin Australia’s engineering contractor and the airline failed to identify and understand serious damage done to this aircraft in the turbulence event.

The aircraft was then allowed to carry passengers for thirteen sectors in that state before an in-flight crisis five days later approaching Albury from Sydney where it was grounded after landing, and remains to those day, pending repairs if indeed it can be repaired.

These are scandalous disclosures. No one in the general flying public in this country expects that a contract maintenance organisation could be so bad at its job that it failed to understand and identify the grave safety of flight issues apparent on the Virgin turbo-prop on 20 February.

It is after all, what the maintenance provider is paid by Virgin to do, rather than scratch their heads and release the aircraft back into service.

It’s Virgin’s inescapable legal obligation to ensure that all aircraft are safe before flying. It didn’t ensure the safety of these 13 flights. It’s CASA’s role to enforce and maintain a safe level of oversight on airline operations and ensure that those who carry out aircraft maintenance are competent and effective.

It’s the Minister’s responsibility, particularly as the leader of the Nationals, to make sure that rural and regional air services, including those that fly him and his colleagues to and from Canberra, are safe. It’s called Ministerial responsibility.

How on earth did this situation arise with this aircraft, and what steps have been taken to ensure that whoever screwed up so badly, within Virgin, and within the contractor, never get to imperil the safety of flight in this country in this manner again?

This may seem harsh. But flight safety standards are by necessity harsh. The harsh reality is that 13 passenger loads were exposed to a broken aircraft, and that is intolerable. Read the ATSB document linked to above very carefully, as it contains inferences and disclosures that are very disturbing.

A statement will be issued by Virgin Australia today and will be added to this report as soon as possible, and further reports on this matter will of course be posted as to future developments

"Where on earth is CASA as well as Virgin Australia and the Minister for Aviation"...not to mention where have the ATsBeaker been for nearly three months since the prelim report was meant to be released; or (benefit of the doubt) have they just been told to sit on their hands (& prelim report) while the ducks have been realigned?? Either way it just increases the intrigue...

Let's see Miniscule we've got the ASRR report to respond to; the TSBC review report to be released; the CVD matter to address...the list goes on..

The Tango comment from another PT article...ATSB Mildura fog crisis report delayed for good reasons is particularly pertinent to this (further) non-transparent bureau investigation:

Tango


Posted June 8, 2014 at 4:23 am | Permalink

When Rome is burning do you wait for the report before you get out the fire trucks?

While you may not be able to solve all the problems, you can solve the one in front of you to some degree or in totality.

To delay sounds like more of the Pel Air crash.

In Alaska they remoted the weather stations and even back in the day, we had manned stations all over the state (about the average size of one of the Australian States). We had a population of 150,000 in those days. If that could be managed.

If this was that critical and it looks to be from over here, then it required immediate action even if longer term and better solutions were worked on and out.

Delaying just the report a year, which will become 5 or until something happens is pretty bizarre.

Once again it is cross Ts, dot Is and make sure all is in order before we breath.

Busy times ahead Miniscule..TICK TOCK!


PT Update:

Virgin Australia statement:

The safety of our guests, crew and aircraft is our number one priority at Virgin Australia and we have strong protocols in place to ensure the safety of our operations is maintained to the highest standard.

While this is an isolated issue, we are working with the ATSB, the aircraft manufacturer and our maintenance provider to identify what has occurred. As the investigation is ongoing, it would be inappropriate for us to comment in any further detail at this stage.

Generally speaking, Plane Talking would rather responses to stories stand alone.

However the ‘protocols in place’ referred to didn’t work. If they didn’t work, they need to be made to work, because the fact that they didn’t work seriously compromised the safety of 13 Virgin Australia flights, and if anyone doubts that, damage to the control surfaces on the tail of an airliner, and damage that escapes detection, is a truly serious matter.

The term ‘isolated’ is perplexing. This was a failure that applied to the relationship and quality of service between an airline, a contractor, and its fleet of turbo-props. If you are a regional or Canberra flyer, how would you feel about the term ‘isolated’?

[Kharon]

Fluff and nonsense.

Is it just me? while happy to have the latest report and some 'facts' to consider, the wording of the ATR investigation seems a bit – 'twee', for the wont of better, fluffy or something:-

The first five paragraphs are totally and utterly irrelevant. Except 20/02/14 VH-FVR departed schedule Sydney – Canberra – Sydney.

That's a full page of fluff to say Routine operations to Canberra and until TOD Sydney. Why bother?

Then later we get the high drama of a runway change 16 R to 16 L – then the information that – surprise, surprise, the Seat belt sign was on and the checklist was almost complete. Nothing of any great value so far - and we are now at paragraph 10. Where the FO started the descent – on AP. Wow, invaluable, that's way cool. Are you not diverted? Ah, but wait – now we come to it.

At 1640 and about 8,500 ft, the crew noticed the airspeed going up quickly and the speed trend excessively high. The first officer reduced engine power and used touch control steering to temporarily disconnect the autopilot before manually raising the nose to control the speed. The aircraft felt ‘heavy’, requiring the first officer’s two hands on the controls to move from the then -4° pitch angle (aircraft nose-up/down). The first officer expected that the pitch correction would be sufficient to arrest the speed trend.

Deconstruct the paragraph, I'll give you a start – airspeed "going up quickly" ; they were 235 KIAS, top speed 250 KIAS; define time line, provide ROD, provide TOAT, provide wind, provide temperature then think inversion layer or, sheer line, or updraft, or stable mountain wave; or even trim fault. But airspeed going up "quickly" is just 'fluff'. Anyway – power off – trim up – two hands - no fix – why not?. Was the auto trim running against the FO input?, had the skipper got his boot braced against the prong? This is a definitive moment and we get "speed going up quickly".

The captain was unsure if the first officer’s control inputs were sufficient to avoid an over-speed so put one of his hands on the controls and disconnected the autopilot to raise the nose further.

Watts on first, Who on second etc. etc. for the next three paragraphs. Then a paragraph worthy of a channel 7 headline, just before an advertisement break :-

To both crew members, what happened next was unexpected and unclear.

High drama indeed.

Suddenly, the crew felt high positive g,[3] the controls felt different and spongy, and cockpit warnings activated.

Somewhere, as yet undefined, between TOD, the "suddenly" moment and 230 KIAS stable; a leg got busted, the elevator channels had split and despite previous "heavy" and "spongy" feeling controls – "suddenly" all is well again - except for some annoying warning lights.

Grounded – Oh, you bet! Engineering next. Despite the window dressing, duty times and the like, (they do fail to mention what the engineer had for morning tea though) you get a sense of more to it. Although it may be just the tabloid style of reporting that gives the impression.

At about 2300 the engineer borrowed a nearby stand to provide a platform at about wing height.

If this is representative of the 'new' style ATSB report, the Murdoch press may be interested in using it. It's not a bad 'press release', not too bad at all – but as an interim report on a serious event......Well we got a nice picture of the aircraft taxiing in....Stellar.

Please Senators, can we have our ATSB back.

[dubbleyew eight]

word is that it is just heads down in CAsA, rally all the support possible from the airlines for the new regs and just soldier it out.
nothing to be changed....

[Sarcs]

Here's a thought??

Maybe the 'Fluff & bull****e' ATR prelim report (tabloid pg 2 article) is pitched for the man at the back of the room to get a handle on, it certainly seems to have helped with the (always behind) MMSM...:

Damaged Virgin Australia plane flew 13 times, says safety report

• 

A VIRGIN Australia plane flew 13 times with structural damage following a turbulence event on approach to Sydney, a preliminary report has found.

An initial investigation by the Australian Transport Safety Bureau (ATSB) found damage “consistent with an overstress condition’’ was likely to have occurred on February 20 as the plane made its approach to Sydney.

While the 68 passenger ATR 72 turboprop was initially removed from service and an inspection carried out, it was back in the air the next day.
It was not until five days later, following a suspected bird strike as the plane descended into Albury, that the damage linked to the February 20 event was discovered. By that time, the plane had already flown 13 more times.

According to the ATSB report, it was about 4.40pm on February 20 when, as the aircraft made its approach to Sydney at an altitude of 8500 feet, that “the crew noticed the air speed going up quickly and the speed trend excessively high’’.

The first officer reduced engine power and used touch-control steering to temporarily disconnect the autopilot before manually raising the nose to control the speed.

But the captain was unsure if the first officer’s control inputs were sufficient to avoid an “overspeed’’ and put one of his hands on the controls and disconnected the autopilot to raise the nose further.

“The captain believed he indicated his intention to take over control, and while the first officer could not recall it being verbalised, he was aware of the captain’s actions,’’ the report says.

“The first officer recalled that he took his hands off the controls, releasing touch-control steering in the process. Shortly after, concerned about a high nose-up attitude, the first officer put his hands back on the controls. To both crew members, what happened next was unexpected and unclear.

“Suddenly, the crew felt high positive (G-force), the controls felt different and spongy, and cockpit warnings activated.

“At some point, the cabin crew called the cockpit and advised that the senior cabin crew member had injured her leg and that it might be broken.’’

The inspection on February 25 “found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser’’.

“There was also some minor damage to the rudder,’’ the report says.
The ATSB says its initial examination showed that “differential force on the control column that resulted from the captain and first officer applying an opposing force exceeded the differential force required to generate a pitch disconnect’’.

“Each pilot was then controlling the elevator on their side of the aircraft in opposite directions for a brief period before the first officer released his control column.’’

The ATSB investigation is ongoing.

In a brief statement, Virgin Australia said the safety of guests, crew and aircraft was its No. 1 priority.

“While this is an isolated issue, we are working with the ATSB, the aircraft manufacturer and our maintenance provider to identify what has occurred,’’ the airline said.

See the Oz almost perfectly regurgitates the original bureau tabloid, why?? Because it is well censored (PC'd) and appeals to the average punter without giving them nightmares. Not to mention it is perfect for the lazy journalist to copy and paste, flick off and get back to the bar..job done!


{Poor old Oz were forced to publish that prior to midnight when SC puts out the rest of his ****e, notice there is no journo staking a claim to that article..please..please RM bring back AK}

On the other hand the Oz aviation mag is pitching to more of a captive audience. Here is their brief, less sensational, summary of the story:ATSB reports on Virgin Australia ATR structural damage

See less fluff & BS but probably even more politically correct (PC) with no aspersions on any DIPs or on the quality of that lowest of low reports...

This comment at the bottom of the AA report is probably the closest either article goes towards the half dozen hefty elephants in this disgusting tale (so far):

Damian says: June 11, 2014 at 7:30 pm
It does make you wonder what could have ultimately happened had the bird strike/possible bird strike not occurred

Yep does make you wonder Damo old son...

But for really guts and no prisoners commentary you can't go past the comments on Ben's article (that by the way came out < 2hrs of the prelim being released), from HERE.

Hmm..still not much comment on that (IMO) crock of a report {comment: maybe we've all become complacent on the standard of BASR bureau reports these days..}

Although there is a TANGO sidewinder towards the bottom...

Tango Posted June 12, 2014 at 1:48 pm | Permalink


Its all in keeping with the more client friendly CASA and ATSB brief.
We don’t want to upset our customers (and if they kill their customers too bad)
So it all makes sense and if you aren’t flying in the airplane, what the heck (maybe the maintainer should have to accompany the aircraft after they say its fine!)

Like his form..MTF

[Sarcs]

MMSM & FMSM: More meat on the bureau tall tale bones.

Damn if he hasn't heard me??

Well it appears the MSM has taken up the ATsB ATR essay challenge, starting with SC (MMSM) with his midnight deadline article...:

Virgin defends safety after turboprop woes

VIRGIN Australia has defended its safety protocols after a regional turboprop aircraft flew for 13 sectors after an inspection by engineers failed to detect significant damage to its tail section.

An Australian Transport Safety Bureau report released this week showed the ATR 72 was damaged during an incident on February 20 but was not grounded until February 25.

The manufacturer subsequently recommended replacing the plane’s horizontal stabiliser, elevators and vertical stabiliser.

Virgin said this week that safety was its top priority and it had “strong protocols in place to *ensure the safety of our operations is maintained to the highest standard”.

“While this is an isolated issue, we are working with the ATSB, the aircraft manufacturer and our maintenance provider to identify what has occurred,’’ it said.

The plane began flying abnormally on approach to Sydney on February 20 and the incident was serious enough to injure a senior cabin crew member, prompt the pilots to request an ambulance and make a PAN call, a level below a full-blown emergency.

The ATSB was advised initially of a turbulence-related event and began an investigation because of the injuries to the flight attendant.

Two aircraft engineers from Virgin’s contract maintenance operator were told that the pilots were not sure what had happened but the aircraft’s pitch controls had disconnected and there had been a possible overspeed, where the aircraft’s airspeed exceeds safe working limits.

The engineers established that the plane had been subject to a force of 3.34 times the force of gravity and exceeded the acceptable weight limit for the aircraft.

It was removed from service to be inspected and the two engineers brought in a third colleague to continue the inspection overnight.

The third engineer was led to understand that a turbulence inspection had been requested after the pitch controls had disconnected in moderate turbulence.

He also understood that one of the duty engineers had done quite a detailed walk-around of the aircraft in daylight and found no signs of defects.

The manufacturer specified in this case a general visual inspection of the fuselage, stabilisers and wings, with more detailed inspections if any anomalies were found, as well as a more detailed inspection of the wing attachment fittings.

The third engineer borrowed a nearby stand and inspected the upper surface of the wing, rear fuse*lage and tail by torchlight before finishing work and returning the next morning.

“No defects were identified from any of the inspections and the aircraft was returned to service the next day,’’ the ATSB said.

The issue re-emerged on a Sydney-Albury flight on February 25 when the aircraft passed close to a flock of birds. While there were no indications that a bird had struck the aircraft, its pitch trim system fluctuated abnormally.

“The captain conducted a walk-around inspection with an expectation of bird damage to the left side of the aircraft,’’ the ATSB said. “The only abnormality found was a deformity to a fairing at the top leading edge of the vertical stabiliser, which might have been the result of a birdstrike. The captain advised maintenance watch, who dispatched an engineer to inspect the aircraft.’’

That engineer used scissor lift equipment to inspect the tailplane and confirmed that the fairing might have been damaged by a bird but that there was also significant structural damage on top of the tailplane. The aircraft was grounded and the ATSB began investigating.

Its initial examination of recorded data found that both the first officer and captain initially pulled on the control column but shortly afterwards, as the vertical load factor was increasing through 1.8G, the first officer began to push the control column.

“The differential force on the control column that resulted from the captain and first officer applying an opposing force exceeded the differential force required to generate a pitch disconnect,’’ the report said. “Each pilot was then controlling the elevator on their side of the aircraft in opposite directions for a brief period before the first officer released his control column.’’

Damage included broken carbon components, cracked joint sealant, a deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser and some minor damage to the rudder.

“The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser,’’ the report said.

The investigation continues.

IOS Mark: 8/10 Comment: Very well PC'd, needs work on the sensational factor (refer to GT for future guidance), consider a more grabbing headline next time..

The other mob actually beat the deadline, here is their effort:

Virgin plane kept flying for five days with 'significant structural damage'

Virgin Australia Regional Airlines operated one of its turboprops on 13 sectors after an incident that the airline later suspected might have caused "significant structural damage" to the tailplane, says an initial report from the Australian Transport Safety Bureau.

The 68-seat ATR-72 aircraft, registered as VH-FVR, has been grounded in Albury for more than three months awaiting replacement of the horizontal stabiliser, elevator and vertical stabiliser, which provide stability and control to the aircraft.

The grounding came five days after an initial incident on February 20, in which pilots reported moderate turbulence as they approached landing on a flight from Canberra to Sydney.

The ATSB said the pilots advised the engineers that the pitch controls had disconnected, with a possible overspeed. From the onboard equipment, the engineers were able to establish there had not been an overspeed, but that a vertical load factor of 3.34 gravity force was recorded that exceeded the acceptable limit for the aircraft weight.

A flight attendant broke her leg during the incident, and the ATSB report said an engineer had inspected the upper surface of the wing, the rear fuselage and the tail by torchlight that evening for signs of damage, but had not identified any defects and the plane was returned to service the next morning.

The aircraft was then operated for a further 13 sectors over the following days, including a final passenger flight from Sydney to Albury on February 25. The ATSB said on descent to Albury, the aircraft passed close to birds, which alerted the captain to a possibility of a birdstrike.

"There were no indications that a bird had struck the aircraft, but on the ground, the aircraft's pitch trim fluctuated abnormally," the report said.
The captain alerted the maintenance team to a deformity in the vertical stabiliser which may have been a result of a birdstrike and an engineer was dispatched to inspect the aircraft.

The ATSB said the engineer used scissor-lift equipment to inspect the tailplane and found there was "significant structural damage" on top of the tailplane. The aircraft was grounded for repairs and the ATSB was advised of the situation.

"Later information from the operator suggested that the damage to the tailplane might have been a result of the occurrence involving [the aircraft] on February 20," the ATSB said.

The ATSB interviewed the pilots and engineers and inspected the damaged aircraft at Albury. A final report on the investigation is not due until February next year.

In response to the initial ATSB report, Virgin issued a statement saying the safety of its guests, crew and aircraft was its number one priority as an airline and there were strong protocols in place to ensure the safety of its operations were maintained to the highest standard.

"While this is an isolated issue, we are working with the ATSB, the aircraft manufacturer and our maintenance provider to identify what has occurred," Virgin said. "As the investigation is ongoing, it would be inappropriate for us to comment in any further detail at this stage."

The airline paused growth in its ATR fleet this year, having left an aircraft delivered last September on the ground amid weak demand and talks with the Civil Aviation Safety Authority about improving its procedures after the integration of Perth-based Skywest into its regional arm.

However, Virgin regional head Merren McArthur said this month that she expected the aircraft grounded at Albury to be repaired within a month or so, and for the other grounded aircraft to join the flying fleet within a similar time.

Virgin has deferred the delivery of six more ATR aircraft and Ms McArthur said the timetable would depend on market demand.

IOS Mark: 9/10 Comment: PC factor needs work but acceptable. Headline is excellent but suggest it is a tad light on for SF (sensational factor). Top marks for beating the deadline...


Associate Professor for IOS Affairs...Sarcs

[Sarcs]

'Save our bureau!' - AIPA sub 197

Some of us may remember from the PelAir & Pilot training Senate inquiries the sensible, rational contributions made, both in submissions & hearing appearances, from the AIPA mob...

Many on here may say that AIPA and it's members (by design) are too far removed from the current machinations and sheer embuggerance being subjectively inflicted upon the GA (IOS) industry. However it should also be remembered that most of the AIPA members hail originally from a GA background and although they've reached the pinnacle of their careers as professional aviators, they owe a lot to the grass roots of the industry.
Many AIPA members also still actively participate at a recreational, private pilot/aircraft owner level while employed and once retired. There is also the significant fact that AIPA depends on its existence on actively promoting the aspirations of future aspiring airline pilots (WANNABES).

IMO this puts the AIPA, and other similar {big end of town} airline unions/lobby groups, in rather a unique position as being far enough removed to give an objective view of the current status quo of our ailing industry. Therefore it was with some interest that I read sub #197 from AIPA. This submission is measured, somewhat politically correct (and many may not totally agree with the recommendations) but it does show that Nathan Safe & crew are totally plugged in when it comes to the ToR of the ASRR...

The AIPA passage on the ATsB provides an excellent starting point and IMO summarises perfectly the current problems, (of our once proud aviation safety watchdog) of the ATsB, while highlighting the importance of preserving a totally independent State AAI..

SOB :

The ATSB

In October 2012, AIPA made a submission to the Australian Senate Rural and Regional Affairs and Transport References Committee Inquiry into Aviation Accident Investigations (the “Pel-Air Inquiry”). The Committee’s final Report is a vital document for the Review.

However, we believe that our submission for the most part addressed a range of issues that remain directly relevant to the Review’s Terms of Reference and we strongly recommend that you read it separately from the Senate’s final report. It can be found at: https://senate.aph.gov.au/submissions/comittees/viewdocument.aspx?id=31a52199-58c6-4cd8-ad9e-646f2356b23a

For the present purpose, we do not believe that we need to quote large slabs of our Pel-Air Inquiry submission. However, the following brief synopsis will not do justice to the detail of the argument in our submission nor will it establish the full context. Subject to that caveat, what we said was:

• the ATSB report on the ditching was too little, too late to improve aviation safetyas a result of that event;

• the standard of the report was the antithesis of that expected from the ATSB by the broader aviation community;

• the report appeared to have been rendered of little use by the dead hand of bureaucracy, which then raised questions about why that might have been the case;

• we questioned whether an over-emphasis on the ”no blame” philosophy has overshadowed, if not obscured, the importance of the ATSB’s primary role to improve transport safety;

• we then examined the seismic shift in the relationship between ATSB and CASA from the Lockhart River Coronial Inquiry and the publication of the Pel-Air report;

• the Miller Review was commissioned to redress the “serious, ongoing animosity between” CASA and the ATSB;

• Miller came from the law, which is all about allocation of blame and punishment, to review the relationship with an organisation that eschews those very tenets;

• Miller’s recommendations were adopted by Government and the ATSB was pushed into the background;

• Miller, undoubtedly for all of the right reasons, stated:

“…Ultimately, the ATSB's contribution will be judged, not by the quality of its analysis, conclusions and safety recommendations per se, but by the influence those recommendations have on improving the aviation safety system.”

• we didn’t think it appropriate to judge ATSB against the inaction of those to whom the safety recommendations are addressed; and

• the ATSB became “institutionally timid” and essentially stopped making safety recommendation of any note, but enjoyed a vastly “improved” relationship with CASA.

While clearly AIPA’s submission straddles the first and second objective of this Review, the reality is that the Senate Inquiry largely underlined that the effectiveness of the ATSB had largely been sacrificed in the interests of not upsetting CASA. Had the same Senate Committee inquired into the Lockhart River accident investigation, it is highly likely that it would not have been the ATSB that was side-lined in the aftermath.

AIPA maintains the view that the large scale adoption of the Miller recommendations has had the effect of negatively influencing the true intentions of paragraphs 12AA(1)(b) and (c) of the Transport Safety Investigation Act 2003 (TSIA) by repressing the independence of the ATSB and suppressing holistic examination of the aviation safety system.

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety. Current knowledge, post the Senate Inquiry, suggests not.

AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.

Recommendation 3

AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and (c) of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

In regard to the appointment of the ATSB Executive, AIPA is very conscious that ‘profiling’ has its limitations and that the key to success is very much about ‘the right stuff’’ and less about career paths. We will always have a preference for operational experience in executive positions of entities that have a profound influence on aviation safety, regardless of what type of entity is involved. ‘Operational experience’ includes experience as a safety specialist or as a regulator that can be shown to be appropriately proximate to the actual conduct of flight operations. AIPA recognises that there may be a need for appointments within the ATSB Executive for career public servants, but, subject to our ‘right stuff’ caveat, we have deep reservations about such appointments at any level above Deputy CEO (however designated).

TOP STUFF AIPA! Suggest IOS take the time to read the whole AIPA submission it is definitely worth the effort...MTF

[Kharon]

Other ear to the ground.

Anyone got an idea, or care to make a bet when the Forsyth report is due for Senate debate – must be soon, although it seems they are still sorting budget chaff from the public wheat.

Just thinking out loud, but if the Forsyth and Pel Air recommendations get melded; and handed back, Truss will have a lot to think through. Mind you, I'd expect the Senate crew to be there, holding his hand and making sure he signs the 'right' paperwork.

"Time – gentlemen, please".

[Sarcs]

Bored vs Board vs Bureau

Hope you don’t mind “K” but your excellent post got swamped by the Boratous contribution on the Truss thread and I dearly wanted to pick up where you left off so…

Take a bow industry; take two, if it pleases.

The patterns which emerge from the submissions are clear; it's interesting though that only the 'professional pilot' groups had anything significant to say about the ATSB, others made mention but the core issues were taken head on and best addressed by the following: - AFAP - : - AIPA- : -VIPA.

The ATSB submission, like Oliver simply asks for more porridge and can be as easily dismissed as the pathetic (bloody disgraceful) – press release – doled out as an 'interim' report on the ATR incident. Annexe 19 - indeed.

There was also a notable ASRR submission from the UNSW Aviation Faculty that focussed entirely on the damning findings of the Senate PelAir (AAI) inquiry, here it is in full: ASRR sub 160

SUBMISSION TO THE AVIATION SAFETY REGULATION REVIEW
January 2014

Abstract:
The need for the Aviation Safety Regulatory Review arises because of systemic deficiencies and inadequacies in the present system. This submission makes the case that the systemic failures identified by the Rural and Regional Affairs and Transport References Committee Report entitled "Aviation Accident Investigations", and dated May 2013, may have occurred because of inadequate supervision of the activites of both CAA and ATSB. In this submission, it is argued that both CASA and ATSB will function better in future if overseen by Boards of Directors which have similar influence and control over their Executive Directors as occurs in the commercial world. The Directors of such Boards should be chosen for their expertise and independence. The reporting line between the organisation and the Minister should be that the Executive Director Reports to the Board, and the Chairman of the Board reports to the Minister. In this way the Minister will be able to influence the general direction of responsibilities, but not be able to unduly influence the agencies into making decisions which are not backed by technical knowledge, expert judgement and data.

The role of CASA is arguably too general, in that CASA has executive, enforcement and judicial powers in matters of aviation law and contravention thereof. This can and arguably has led to conflicts of interest within the organisation. It is recommended that a separate body, with expertise in judicial and enforcement matters, be charged with recommending a different structure to devolve some powers to other commonwealth agencies.

In the case of ATSB, the organisation should be resourced suitably to conduct their investigations independently and in a timely manner. The recent example of the Pel-Air investigation (ATSB report) in which systemic regulatory and management issues were apparently ignored, could perhaps be avoided by the use of a more formalised process. If CASA processes themselves are a contributing cause of risk, then ATSB must be able to so conclude without fear or favour. Improving aviation safety must be the prime objective.

The existing Memorandum of understanding (MoU) between CASA and ATSB and/or its interpretation is inappropriate as it appears to have unduly influenced ATSB independence. The MoU should be discarded or re-written.

It is the opinion of the writers, having canvassed a wide rage of industry personnel, that the industry has lost significant respect for both CASA and ATSB.

It is essential that restructuring occur to ensure both organisations become once again suitably effective, and to renew this respect This can only be achieved by restructuring and implementing Boards of management and changing responsibilities and reporting lines.

1. Introduction

The need for the Aviation Safety Regulatory Review arises because of systemic deficiencies and inadequacies in the present system. The Review (as defined by the Principal Objectives and Outcomes) would arguably not be needed if, in the past, there was suitable oversight of the core agencies, being the Civil Aviation Safety Authority and the Australian Transport Safety Bureau.

It is assumed that the reader will have a detailed knowledge of the Rural and Regional Affairs and Transport References Committee Report entitled "Aviation Accident Investigations", and dated May 2013, hereafter referred to as the 'Report". This Report provides essential reading as background to the Outcomes expected in the Review.

A thorough reading of the Report and the submissions has led the authors of this submission to believe that the Executive Summary thereof provides a reasonable summary of matters and events. In particular there are troubling statements in the Executive Summary, three of which are quoted here as they appear to underpin systemic issues in both agencies.

The Executive Summary, page xx, states in part "What is clear is that CASA's failure to provide the ATSB with critical documents, including the Chambers Report and CASA's Special Audit of Pel-Air, which both demonstrated CASA's failure to properly oversee the Pel-Air operations, contravened the Memorandum of Understanding (MoU) in place between the two agencies and may have breached the terms of the Transport Safety Investigations Act 2003 (Chapter 7). The committee takes a dim view of CASA's actions in this regard."

The Executive Summary p xxi states in part "To simply focus on the actions of the pilot and not discuss the deficiencies of the system as a whole is unhelpful. It is disappointing that CASA and the ATSB continue to assert, in the face of evidence to the contrary, that the only part of the system with any effect on the accident sequence was the pilot". This follows the earlier statement, page 1x, "The committee takes and different view and believes the ATSB processes have become deficient. .. .'

While these are only three examples, the Report, plus the numerous detailed recommendations of the Report, suggest that there are systemic deficiencies within the management of both agencies. Addressing these deficiencies will assist significantly in the improvement of the management of aviation safety in Australia, and provide a way forward to satisfy the Outcomes of the Review.

2. The Regulatory Structure of CASA and ATSB

The Commonwealth Department of Aviation was created in 1982 to manage civilian air transport activities, these being formally held by the Department of Transport. In 1988 the Civil Aviation Act was passed, establishing the Civil Aviation Safety Authority (CASA). The investigative functions were further devolved in 2003 with the Transport Safety Investigations Act which established the Australian Transport Safety Bureau (ATSB). It is expected the reader is familiar with the Civil Aviation Act 1988 (CAA88) and the Australian Transport Safety Investigation Act 2003 (ATSI2003) to understand the roles and responsibilities of the organisations.

2a) The Civil Aviation Safety Authority {CASA) CASA's responsibilities are prescribed in CAA88 Section 9. The following is a short summary list
1. Developing and disseminating clear and concise aviation safety standards
2. Developing effective enforcement strategies to secure compliance with the safety standards
3. Conducting comprehensive surveillance of the aviation industry
4. Conducting regular reviews of safety to monitor the aviation industry's performance and to identify safety trends and risks
5. Issuing operational certificates to aviation organisations
6. Issuing licences, aircraft registration and other permits
7. Carrying out timely assessment of international safety developments
8. Encouraging the aviation industry to maintain high safety standards through education, training and advice
9. Making aviation industry management and the general aviation community aware of the importance of safety and compliance with the rules
10. Promoting full and effective consultation and communication with all people and organisations that have an interest in aviation safety.

CASA is managed by a Director of Aviation Safety, and while there is a Board, at present the reporting line of the Director of Aviation Safety is directly to the Minister, not to the Board (Report 2.26). A policy of Reporting directly to the Minister may result in the Minister unduly influencing matters, to the extent of possibly ignoring technical facts or professional safety judgements which imply that a contrary position is in the interests of safety. A proper structure would be for the Director of Aviation Safety to Report to the Board, who reports to the Minister.

CASA's functions include the responsibility for overseeing and implementing the development of safety policy, for legislation, for policing, for making decisions about guilt or innocence of those which it accuses of contravening legislation and in setting penalties. The separation of powers of the Executive, the Judiciary and the Enforcement arms of government as occurs in criminal law does not exist in CASA. Few other legal systems in the world (except perhaps those of dictatorships) have such all-encompassing responsibilities (and in effect total control) over a system. It appears that CASA's diverse responsibilities may well result in internal conflict, or role confusion, unless very carefully managed and overseen by a Board with suitable expertise. There is a case to move the policing responsibility (and perhaps personnel) to the Federal Police, as it is federal legislation that is being policed. Certainly this is a complex matter that should properly be reviewed by a body of experts.

It is arguable that, in any case, the present Board members are insufficiently expert in aviation matters to effectively oversee strategy and operations, particularly given CASA's diverse responsibilities. There is no mention of aviation as an area of expertise for any of the current CASA Board Members listed in the "Biographies of Board members" on the CASA website. A stronger oversight might well have ensured a more focused and timely writing of the "new" Civil Aviation Safety Regulations 1998, some of which have not been seen in first draft form despite that process being active for over 15 years. The complexity of some of those regulations that have been rewritten is sufficiently high that individuals and organisations may not comprehend all the detail, leading perhaps to inadvertent contravention.

There is ample evidence in the literature and on the websites of, for example, the Australian Institute of Company Directors (www.companydircetors.com.au), and the Global Network of Director Institutes (Global Network of Director Institutes (GNDI)), that there is need for Company Board members to be chosen on the basis of merit, independence and integrity, including an understanding of the dynamics of the business and marketplace, and that Boards with a diverse membership are most effective. This concept provided perhaps a useful model.

We believe that the CASA Board has not provided, or not been able to provide, sufficient oversight of CASA to ensure its multiple roles role have been executed in a way which is expected by the stakeholders (the industry, the public and government). It is therefore important that the CASA Board be strengthened by adding additional members with aviation expertise, and that the Director of Aviation Safety report to the Board. Issues of potential Conflict of Interest can be handled in the usual ways by disclosure and by member omission from decision-making which affects that member's own affiliations.

In addition, to ensure that the Directors role is maintained within the confines of the strategy set by the Board, contact with the Minister should be via the Chairman of the Board.

2b) The Australian Transport Safety Bureau (ATSB) ATSB has a Chief Commissioner and two Commissioners. As described in the ATSB website, none appear to have any technical expertise in accident or safety investigation, and none in aviation operations.

There is no Board. Arguably this lack of oversight can (and perhaps has) led to actions and outcomes, some of which form the basis of the criticisms of the Report. The forming of a Board which includes a wide range of technical expertise would help ensure that ATSB keeps within its remit of undertaking and reporting objectively on any safety issues. The ATSB independence is essential, as it is a technical committee, which should not be manifestly able to be influenced by politics. Should those issues involve CASA (or any other federal or state agency) then it is logically clear that ATSB must be able to make that case and report it without fear or favour, to ensure the travelling public is best served in matters of safety.

Contact between the Chief Commissioner and the Minister should be via the Chairman of the Board.

The Pel-Air Report is not of sufficient quality to be useful for the improvement of aviation safety, or to engender confidence in the Industry.


Consideration should be given as to whether the NTSB of the US or other national agency should be given the task of undertaking a fresh investigation and writing an independent report ATSB should only undertake this under revised management.

3. Conclusion

The authors have avoided the temptation to write in detail about the many issues raised in the Report, and re-iterate our belief that the Report is a balanced view of facts and judgements. We are comfortable with all of the recommendations of the Report, although many will automatically or subsequently be addressed by the implementation of Boards with appropriate membership and responsibilities.

The separate recommendation by Senator Xenophon that a separate administrative person (an Inspector General of Aviation Safety) be implemented to oversee both CASA and ATSB might be useful as an interim measure while the new Board structures are being considered and implemented, but is probably not necessary once Boards have been established. In any case management by an individual or overview by an individual cannot bring the benefits of breadth of experience and expertise which overview by a well-constituted Board should bring.

While we have not specifically addressed each point of the published Terms of Reference, we believe our generic discussion is of value across most of the principal objectives.

There you go a balanced, sensible, well reasoned argument for the ATsB to ditch the bureau concept and adopt the board concept. Sure would beat the hell out of this embuggerised BASR approach currently being deployed by the ATsB/CAsA senior management stooges.

Perhaps the Miniscule, while the TSBC is in town, should get a briefing from the Canucks on how the board system works (i.e. Pros &Cons)??

SOB Miniscule...

MTF...

[Kharon]

Spoiled for choice – again..

Cheers Sarcs – I was going to bring up the Uni submission, on this thread – it's first class and much more the Senators line of country. We are spoiled for choice at the moment, Boratous and the big spin machine firing up distracted me from the good oil. I expect the 'minders' and researchers associated with the Senators have already provided the team will a solid briefing and it's a fair bet this stuff has been read.

A birdie whispered in my ear that today, after questions the WLR may get an airing in Senate. Then we may get a glimpse of the future – we shall see.

[Sarcs]

The Grey embuggerance.

Trolling (as you do..) through HoR Hansard I came across an adjournment speech from the Member for Grey, which perked my interest...

"...Mr RAMSEY (Grey) (21:05): Tonight I want to bring to this place the plight of and challenge for the air service in Coober Pedy in the north of my electorate..."

Now I had been monitoring this story for sometime, reference article example...

Runway changes could hamper regional aviation and force airlines including Rex to curtail outback services


...but the last I'd heard CAsA had for once seen common-sense and this seemed to be reinforced in the context of the Member for Grey speech:

..When these amendments were made, in 2012, I thought common sense would get the best of it—that we would not have to worry about this, because no-one could be so stupid. In fact these aircraft have been landing on this strip for probably about 15 years, without incident. One would think that with that kind of record it should not be all that hard to grant the same exemption that the aircraft have had for all of that period. I have had numerous conversations with Rex and CASA over this issue. In their latest letter CASA assure me of the following:

I would like to reiterate that the widening (upgrading) of Coober Pedy's runways is not required, unless the aerodrome operator wishes to do so as a business decision …

OK so what is the Member's point?? Well the next 2 paragraphs tell the story...:

But CASA are telling Rex, the operators of the aircraft, that they need to go back to Saab and develop a flight supplement that will allow for the narrow-runway landings. They have ordered some simulator tests, and that sounds all reasonable and fair, except that Saab no longer make aeroplanes, so you can see that they may not be totally interested. My point is that if this costs Rex a significant amount of money to develop—maybe $100,000—I do not think they will retain the service into Coober Pedy.


So while CASA are telling us there is nothing to worry about, I am deeply concerned. If the development of the flight supplement with Saab is to cost more than the route is worth to Rex, the flight service will cease on 12 February next year. I continue talking to CASA and they say that it will all be well in hand and will all happen. I just worry about the sands of time drifting out. This has been going since 2012. We are now only seven months away from February, so it is of great concern to me that things are moving too slowly.

The shades of Grey and the parallels with the CVD embuggerance started to steam up like a hot pile of elephant pooh, you know 15 years of safe ops on an exemption etc..etc..

...So I then referred to the REX ASRR submission where I found this:

...It is understood that one of the aims of the regulatory reform program is to enact safety outcome based regulations rather than prescriptive regulations. Rex supports the concept of safety outcome based regulations but unfortunately does not always see this carried out in practice. For example, the proposed amendment to CAR 235A effectively removes the ability for CASA to facilitate air operations where equivalent levels of safety can be achieved. It does this by prescribing the method of compliance rather than the safety outcome required.

The new CAR 235A will require operators using runways narrower than the arbitrary default standards set by ICAO to have procedures for the use of narrow runways set out in both the aircraft’s Aeroplane Flight Manual (AFM) and the operator’s Operations Manual. If the manufacturer does not supply the necessary narrow runway certification then the operation is prohibited. For the Rex operation, SAAB has indicated they will not engage in further flight testing to gain narrow runway operation certification to comply with the ICAO aircraft reference codes (ARC). The SAAB AFM does currently make provision for narrow runway operations, however they are not in accordance with the mandated requirements of the CAAP and therefore not acceptable under the proposed new CAR 235A. The new rule will prohibit Regional Express Airlines, Pel-Air Aviation and Air Link from operating into airports with narrow runways thus denying essential air services to some remote regional communities.

For Rex, this will prevent operations to Coober Pedy where it and Kendell Airlines have operated continuously since 23 August 1986. Coober Pedy Airport has a 30 metre wide runway with a homogenous 18 metre sealed centre section and to date CASA has seen fit to issue Regional Express with an exemption (CASA Instrument EX37/12) from the requirements of the current CAR 235A. The new prescriptive CAR 235A will remove CASA’s ability to issue such exemptions in the future and will prevent Rex from operating to Coober Pedy after the exemption instrument expires on 28 February 2015. This is despite more than 27 years of demonstrated safe operations...

No guesses to who has been briefing the Member for Grey and expand the safety case to 27 years...


That then got me thinking what's with all these recent FF moves to suddenly endeavour to become compliant with the ICAO SARPs??


I then decided to refer to the relevant SARP for Airport runway width requirements i.e. Annex 14 Ch 3 para 3.1.10.





Hmm.....so maybe (like the CVD 30 yr un-notified difference) FF were feeling vulnerable because they hadn't notified a difference to para 3.1.10??


So once again off to our convoluted 97 page AIP GEN 1.7 (H18/14) and x-referenced with the 84 page 2011 version (H12/11), & that was when the penny began to drop...


First latest '14 ND

H18/14 Para 3.1.10 - The existing standards will be strengthened to ensure code 2, 3, & 4 aircraft are operated from fully compliant runway widths…

You kind of think well why bother with the notification?? Then..

H12/11 Para 3.1.10 - Australian legislation permits some variation on runway width.

Wonder how many other little known NDs the FF ICAO compliance crew have been tasked to eradicate??

Hmm..here's a thought for the rumour mill.., maybe the FF numbnuts have got wind of an upcoming surprise (special audit) from the FAA/ICAO??

MTF...

[dubbleyew eight]

australia is a sovereign nation. why do we cede control of our aviation regulatory environment to the FAA or to ICAO ....or to the European Arse'oles Stopping Aviation?

answer we have in CAsA people who are so clueless as to what they should be doing that they will refer and defer to anyone untouchable by the masses just as long as the half million a year salaries keep on flowing.

utterly cluelessly incompetent CAsA.

[Kharon]

I forget just exactly how many 'differences' we have logged into the ICAO system; but it's a fair lump of a document (97 pages says Sarcs), almost a thick as some countries entire rule set.

It's passing strange that suddenly up goes the rent and everyone scrambles to 'compliance', but in the hard areas. Hard in that there was always going to be stink when an aircraft which has for years and years managed to land on a 'narrow' track; or, CVD pilots are singled out for the treatment.

Maybe the circus is coming to town and there is a desperate need to be seen 'tidying up'; but where to start ?. Brain fart – pick on the contentious areas, make a big stand, thump the safety tub and shake funding tambourine. Then you see we can, in truth say – "Oh we are trying to reduce the non compliance; but we end up in a battle at every turn, as you can see". "But look, don't worry, y'all come back in another five years now; we'll have it all tickety boo by then". "More tea Vicar?, try the iced Vo Vo's".

Perhaps it's just happenstance, it may even rate as coincidence; who can fathom the depths of the regulators tormented, twisted mind.

Toot toot, book early for Christmas......

[Frank Arouet]

It would appear that CasA are shirking any hint at adherence to the recommendations, namely recommendation 30 below, which is self explanatory and contradictory given the letter previously posted, Extract below.
The action taken by CasA provides that the applicant must pay to prove his stated previously satisfactory condition and clearly moves the burden of proof from the regulator to the pilot and fails to give the DAME the recommended freedoms to exercise his/her ability to renew aviation medical certificates. If the DAME recommends the pilot be further assessed it is his responsibility, not CasA’s.


No doubt these will become "renew by CASA only" medicals and the AVMED Branch continue unabated and unshackled as before.


Is this the first Nigerian in the woodpile?
　


" QUOTE" 30. The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. "QUOTE’


"QUOTE" At the resent time, CASA is aware that CAD testing in Australia is only offered by Dr Elizabeth Livingstone, Designated Aviation Opthalmologist at the Livingstone Eye Clinic in Sydney (61-2) 9362-5820. Please note appointments are necessaryand there will be a fee charged. Any expense incurred will be your responsibility. "QUOTE"