Merged: Senate Inquiry

[Sarcs]

Post ditching (1734 days & counting) - In the eyes of the investigator.

Kharon:

Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB 'sovereignty' during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from 'Serious' to 'Minor'? In short, have the Pel Air books been 'cooked'?

Bugger “K” stole my thunder… …oh well relegated to gap filler yet again…

Ok before we start working through the ‘timeline of embuggerance’ (TOE) an update on the MoP Stakes from the Senate: Possible imposition of a penalty on a witness before the Rural and Regional Affairs and Transport References Committee or a person providing information to the committee

{Note the Committee Senators (Stewards) membership includes one loud, outspoken BIG MACK}

Kharon:

In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF 'White hats' grab the spell book and start weaving - preparing a proper response. All good until it was realised CASA were going to have 'egg on their face', had the ATSB not backed down. Perhaps that 'GWM report' was prepared to riposte the ATSB brick bat. "We're on top of this" says Sleepy Hollow.

In the eyes of the TSBC: It would first be prudent to refer to what we know they have been scoped to review in regards to PelAir. From ATSB AQON 4 Senate Estimates (24/02/14) RED said:


The Transportation Safety Board of Canada (TSB) has agreed to review the ATSB’s investigation methodologies and processes. Specifically, the review is examining the ATSB’s:
• Investigation methodology and its application
• Management and governance in relation to investigations
• Process for compiling an investigation report
• Approach to communicating with persons and organisations external to the ATSB in relation to an investigation

As part of the review, the TSB has undertaken to examine the application of the ATSB methodologies to the Norfolk Island investigation and two others.
The review was instigated in response to Senate References Committee criticisms that the ATSB investigation of the Norfolk Island accident did not comply with the requirements of ICAO Annex 13 or the ATSB’s written standards. The review is also intended as part of the ATSB response to Inquiry recommendations concerning the adequacy of the ATSB’s investigation policies, procedures and training.

The exercise is not a reinvestigation of the occurrence, and hence the TSB has not sought to reinterview involved parties. Howevers part of eviewing the ATSB’s investigations, the statements and other evidence of involved parties have been available to the review team.

Therefore it would be safe to assume that the TSBC would be reviewing most, if not all, the published under privilege documentation from the Senate AAI inquiry, which would include the following 2 documents:

1. Correspondence from the ATSB to CASA regarding a critical safety issue, received 22 October 2012;(PDF 2663KB)
2. Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)

As RED indicates the TSBC will review the PelAir report against the recognised international standards for AAI (as outlined in ICAO Annex 13) and not on any domestic arrangements i.e. the MoU.

On the subject of safety issues identified, in the course of an investigation, by the AAI as needing prompt action and a SR promulgated Annex 13 states:

Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.

RESPONSIBILITY OF A STATE RECEIVING
SAFETY RECOMMENDATIONS

Action on safety recommendations
6.10 A State that receives safety recommendations shall inform the proposing State of the preventive action taken or under consideration, or the reasons why no action will be taken.

Note — Nothing in this Standard is intended to preclude the State conducting the investigation from making proposals for preventive action other than safety recommendations.

The ATsB intent to compliance with the Annex is outlined in s25A of the TSI Act.

So in terms of 1. (Attachment one above) the TSBC would give the ATsB its 1st tick i.e. the investigators have identified a CSI and have basically
written a DRAFT of the soon to be notified SR. However it would probably be seen as passing strange, not normal practice, that the ATsB are essentially giving the intended SR addressee a ‘heads up’.

I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect ofthe lack of regulation or guidance for pilots when exposed to previously unforecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.

But maybe this is a good initiative because the letter does goes on to say…

“….In later telephone calls to me, you suggested that the receipt of this letter would allow you to 'kick-start' CASA's consideration of, and response to the issue.

Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB's initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA's commitment to address the safety issue is appreciated…”

And indeed the ‘White Hats’ (as “K” calls them) stepped into action and started proactively addressing what they assumed would soon be a published ATsB SR, published an update to OS 09/13 (see 4.4 of CAIR 09/3) and started writing NPRM 1003 OS.

So maybe the TSBC would have given the ATsB leeway and understood that in the interests of better relations (as this was seen as a test case for the newly just minted MoU), that this little divergence from SOP could be advantageous.

However on reading the internal email at 2. this acceptance of diverging from SOP IMO would have come to a resounding conclusion (crash):

We were discussing the potential to reflect the intent of our new MoU that describes the 2 agencies as 'independent but complementary'. We discussed the hole that CASA might have got itself into by its interventions since the ditching, and how you might have identified an optimum path that will maximise the safety outcome without either agency planting egg on the other agency's face.

Right now, I suspect that CASA is entrenching itself into a position that would be hard to support. If we were to contemplate an exit strategy, or an 'out', then CASA would need to recognise that it is 'in' something in the first place. This is my take of how I see their position at the moment.
When the aircraft ditched, both the flight crew and the operator stopped their Westwind Aeromedical operations.

CASA coached and guided the operator very well as they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pei-Air are now operating again. The same thing hasn't happened to the flight crew. While they may not have been the 'Aces of the base', they were following the relevant procedure provided by both CASA and their operator. This is an opportunity for CASA to follow the same approach with the flight crew as they have done with the operator.

As a systemic investigator, we see 3 separate slices of 'Reason cheese' with aligned holes ( flight crew, operator & rule-maker), and we want to seal all those holes. The operator has now been realigned, and I think CASA has done a very good job in helping them. For the flight crew, they do need realigning to ensure they now meet the updated Ops manual requirements. For the rule-maker, I would be extremely satisfied if they then proactively realigned everybody's understanding of this operational risk, and how it can be managed in the future.

As we discussed yesterday, following the ditching, everything went (metaphorically) 'up in the air'. CASA has done a good job in realigning Pei-Air while it was still in the air so that it returned to earth with a much better take on how to manage this risk.

Unfortunately, they took action on the flight crew without first contemplating their end-game. If they reframe their pre-emptive action with the flight crew to show that they had managed all the levels of safety management by simply putting the pilots' permissions to fly on hold until they had found the problem and remedied it, then they would look far better than if they tried to prosecute the probably indefensible and hardly relevant.

We will be telling this story in our final report, if not earlier, so why not make the most of this opportunity for both agencies to publicly work harmoniously, in a parallel direction?

IMO any good TSBC investigator could well relate and be most disturbed by the angst that this fellow investigator was feeling at this point in time. The massive conflict of interest is beyond obvious and directly in contravention of the spirit & intent of Annex 13.

Hmm…think I’m going to have to have more parts to this as I’ve just discovered a couple more errant dots and I’m yet to look through the eyes of the other investigator…

MTF…

[thorn bird]

"CASA coached and guided the operator very well as they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pei-Air are now operating again. The same thing hasn't happened to the flight crew. While they may not have been the 'Aces of the base', they were following the relevant procedure provided by both CASA and their operator. This is an opportunity for CASA to follow the same approach with the flight crew as they have done with the operator".

And as we know, there was no attempt to realign the aircrew. The Skulls trained attack dog, Wodger Wabbit, in his personal inimitable style, moved straight to embuggerance.

Couldnt nail the crew with prosecution because they had broken no laws, not to worry, Wodger is a past master at administrative embuggerance.

Unfortunately the captain chose not to lie down quietly, and aced the inutile Wodger mandated requirements. Cost him dearly, losing his house in the process, but he dogedly completed each new imposition Wodger set until CAsA had little choice but to return his licence.

Wodger of course would never leave it there.

There are rumours that, as Wodger has done to others who've displeased him, of a wispering campaign following the captain around Australia, wherever he has sought employment, that it might not be in that companies best interests to give him a job.

[Kharon]

The art of bookmaking and the breaking of wind.

Sarcs – sorry mate; I didn't think my twiddle was more than a fart in the thunderstorm you kicked up. I'm just trying to run a book and a bookie needs to work the SP odds, which means reading the wind and other auguries. So, may I assume that Canadian Club is now an official entry? Even money, down to odds on is the best I can do, if you're quick.

I wonder though, the TSBC brief and remit 'could' be construed a few ways; from tick-a-box through to the full Monty. But I like your research, it makes sense and presents a sound construct of a possible cause (motive- if you like) for the antics we watched during the Senate inquiry. It is a righteous starter – but will the TSBC run it? and will the minuscule see the benefit to having his much vaunted, all powerful CASA dragged through court; does he have any other option?. I'd say it's more a bloody big time bomb, than a thunderstorm – if proven. There are great benefits from the doing of it, but will the minuscule see them ?

One thing though, the 'white hat' troops (those remaining) will breathe a lot easier when the sun returns to Sleepy Hollow. IF the PM department gets involved, I am reliably informed that the top two, if not three layers will achieve 'an altered state'. This can only be a good thing. Without the support of the dark lord, the minions, catamites and willing accomplices become fair game for the 'White hats' and payback is as an evil a bitch as Karma.

Thorny – if Sarcs is on target and he finds the breadcrumbs, well Kevlar is ok for light ordinance, but the big guns are refining the firing resolution, computing coordinates and range. Interesting times – for all I should say.

Aye well, it's all Bliss, wind and speculation; we just won't know until Truss decides that industry is a priority and gets off his arse and blinks. Once for yes, twice for no. Heh heh, unless one of the Senate decides Truss is not the Sphinx, but an ostrich.

The sexual life of the ostrich
Is stranger than that of a man

Toot toot..

[Sarcs]

Part two – Addendum

Kharon:

If the AFP investigation and the Canadian audit turned up the same conclusions; possibly two things would happen (1) the minuscule would 'sit' on the CTSB report (2) the AFP information prompted Heffernan, Stearle and Xenophon to bring on the MoP.

Before we can move on to Part three (i.e. through the eyes of the AFP) couple of loose ends need addressing…


Previously: For better or for worse the ATsB, in keeping with the newly minted 2010 MoU, have given FF a heads up on a CSI, that would in a normal course of events (& anywhere else in the world) have progressed to the promulgation and publication of an SR. However as history will show this never happened. It would be a further 917 days ('heads up' correspondence 26/02/10 to Final Report 30/08/12) before anyone outside of the bureau, FF and PelAir were any the wiser on any identified safety issues from the Norfolk ditching investigation :

Fuel planning and en route decision-making

Oversight of the flight and its planning

This would definitely have caused the TSBC some consternation, as it is not their SOP for dealing with identified safety issues (they’re very much in the SR camp). Nor does it reflect the spirit & intent of ICAO Annex 13. So definitely no tick there…

Following the chain of the 26/02/10 ATsB CSI ‘heads up’, the TSBC would have also been bemused( & probably quite disturbed) to have read the response correspondence dated 26 March 2010, especially when FF referred to the bureau correspondence as a DRAFT transport Safety Report for AO-2009-072…

Reference pg 38 - Answers to questions taken on notice on 21 November 2012, in Canberra;(PDF 4052KB)
Dear Mr Sangston

I refer to your letter dated 26 February 2010 regarding draft Transport Safety Report AO-2009-072.

CASA's comments on the safety issues raised in this report are attached.

Please contact John Grima,

Yours sincerely

Richard White

Manager Accident Liaison and Investigation Unit

Nowhere is it stated in the bureau correspondence that the notified CSI was intended to be a DRAFT version of the TSR AO-2009-072, so what were FF playing at?? Actually, I believe, it to be a very clever (but devious) legal move by FF…

In the TSI Act under s25 (Reports) it states…

..(2) The ATSB may, at any time before an investigation has been
completed, publish, by electronic or other means, a report in
relation to the investigation if it considers that the publication of
the report is necessary or desirable for the purposes of transport
safety.
(3) A published report may include submissions that were made by
persons to the ATSB in response to a draft report, safety action
statements or safety recommendations.
(4) A published report must not include the name of an individual
unless the individual has consented to that inclusion...”

And in s26 (Draft reports) it states…

(1) The ATSB may provide a draft report, on a confidential basis, to
any person whom the ATSB considers appropriate, for the purpose
of:
(a) allowing the person to make submissions to the ATSB about
the draft report; or
(b) giving the person advance notice of the likely form of the
published report.

{Comment: I will leave this to the legal eagles (as it is probably a grey area legally & FF LSD are more than likely taking the piss with the definitions) but for this knuckledragger the fact the bureau have not contested the FF assumption, that this was a DRAFT TSR, effectively ceded control of the identified CSI to FF. Again the bureau was outplayed & out manoeuvred...}

You can read the rest of the FF reply at your leisure but from the TSBC perspective the debate that ensues thereafter should never have been conducted the way it was. MoU or not, the investigation team should not have been subject to defending their findings, & identified safety issues, prior to the publication of a safety recommendation (as per ICAO SOP). This is tantamount to interfering with an investigation under the jurisdiction of the State recognised (& supposedly independent) AAI and is a serious breach of international conventions i.e. Annex 13 & now Annex 19.

These breaches are best summarised by Mr Bryan Aherne in one of his supplementary submissions (PDF 856KB) (which again the TSBC would be privy to):

3. Evidence:

a) Outcome Bias.

Email from Martin Dolan to ATSB Investigator and General Manager Investigations written 10 February 2010:

Thanks very much for this. My discussion yesterday with John McCormick gave me some confidence that CASA was looking for systemic answers and amenable to our approach. Since then CASA has changed its rhetoric and seems to be hardening its view that there has been a regulatory breach that needs to be addressed.
I think it would be helpful if you and other addresses could meet with me so that we agree the best way to manage our relationship with CASA in the course of this investigation.

Analysis:
It is very clear that the ATSB had decided on a systemic investigation approach but that simply because CASA changed its rhetoric the ATSB did too. This is evidence of a weak State safety investigator that allowed itself to be influenced by the regulator whose shortcomings may have been exposed in any systemic investigation.

b) Prejudice and Outcome Bias

Email: Wednesday 18 August 2010 From CASA Officer to Director of Aviation Safety and Deputy Director of Aviation Safety
Re: ALIU Accident report Norfolk Island ditching VH-NGA

The above referenced report is now complete………….I have discussed the report with the ATSB and there are no differences in the key areas which will eventually be published by them in their report. I have aligned the report with the submission made by …our Westwind FOI Subject matter expert in yesterday’s AAT meeting.

Analysis: For CASA to have confidence that there would be no differences from the key findings (made by CASA) in an ATSB report which was still two years away from being complete is strongly suggestive that a meeting of the minds had occurred and an outcome agreed. This is evidence of prejudice and outcome bias.

c) Lack of independence of the ATSB and its investigators

Email: 6 August 2012. ATSB officer to General Manager Investigations

…Many of my arguments that have been rejected have been ones where I have applied safety management methods and tolls and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead….To make useful comments on these matters relies on a belief in and use of contemporary safety management theories and methods. To me this was particularly evident when CASA’s Norfolk Island audit report came into our hands and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA’s findings not mine! When I have to rely on CASA’s opinion to persuade the ATSB how can I claim that the ATSB is independent when it investigates CASA?

Analysis: This shows that the ATSB undermined the independence of its investigator. It also shows that the ATSB is unduly influenced by CASA or it shows a crisis of confidence at the ATSB. Either way the ATSB is clearly not independent of CASA.

d) Breach of International Conventions

Australia is a signatory to article 37 of the Chicago Convention, ICAO, Part IV International Standards and Recommended Practices.

As such, three International Standards (International Standards are defined as 'shall', International conventions intend to foster standardisation, consistency and efficiency and when it comes to safety- shared learning) under Annex 13 have not been complied with, namely Annex 13, 5.4 which states:

"The accident investigation authority SHALL have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of Annex 13"

It is also worth noting (again) that now under Annex 19 it is the responsibility of the State to…

“..In the operation of the SSP, the State maintains the independence of the accident and incident investigation organization from other State aviation organizations…”

Hmm…Part three to follow!

[Kharon]

Baffled, bewildered and embuggered.

Sarcs – good show, again. One thing (amongst the many) which intrigue me is the apparent breach of TSI 24, seems to me it's writ large but gets pushed aside with focus on 25 and 26, even the inimitable Aherne side steps the issues. Applying the Creampuff Cock-up v conspiracy theorem is a tough call on this little episode; lets have a little look-see at what was 'in the bag' before the rip, tear and bust boys got busy. Had CASA played a straight, 'low key' bat, there were gold stars for all.

a) The new MoU and AILU could have had a pre launch test run; to smooth out the kinks. ATSB come up with a CSI, CASA white hats go to work. TICK and gold star and no skin loss.

b) CASA then quietly acknowledge that there were some minor 'oversight' issues, the FOI responsible had been 'tuned up'; they were working on the revised fuel rules and were awaiting industry feed back; they had modified the 'operator' problems and the flight crew had been tested; and, in fact, proactive, deep dish safety culture was breaking out all over. Happy as Claggy, high fives and gold stars all around.

c) The crowning glory - ATSB could have produced a learned briefing on 'safety equipment' and new knowledge on 'ditching survival'; the CSI would have been vindicated, a new spirit of cooperation established and all would be rosy in their garden. High fives and gold stars all around. Bravo; etc. Great return on our safety investment.

So WTF went so horribly wrong with the preordained, carefully planned hatch, match and dispatch of Pel Air? Got me beat. So, while we wait for the next Sarcs chapter; I'll entertain us all with a fairy story. Now, are you sitting comfortably?, good, then I'll begin.
- - - - - - -- -- - - - - - -
Once upon a time (back in the day) in a land far, far away lived a King who had formed an alliance with a powerful Emperor to ensure that his modest kingdom had powerful allies and access to wealth; required to ensure that his little kingdom remained secure. For a while the little kingdom flourished, new trade routes were established and lucrative contracts with other states were negotiated and generally life seemed pretty good. Then came the day of 'the report'; a wet bedraggled minion had inconveniently been rescued at sea, telling tales of a great storm that had swamped the Kings vessel, which was now lost to the depths.

Well, mostly in those distant times, the loss of a ship or two was to be expected and ordinarily, this would be of no great concern to the King; but the timing was inconvenient. There were other matters of great import which depended on safe transportation and the King needed to make certain that this little, insignificant incident didn't upset those matters. So, he sent for the Grand Vizier (GV). The King understood that it was within the power of the GV to make this little incident disappear; unbeknownst to him was the total lack of subtlety with which the GV ran his bailiwick and the creatures he employed to do his bidding.

King – "Look here GV, there are some important matters of state which are delicately balanced and the Emperor is starting to ask difficult questions about financial matters; so I need to have the loss of the 'Nightingale' smoothed over, quickly and neatly; can you do it?"

GV – "No problem majesty; I've got just the man to do it, we'll blame the storm and the Captain; that only leaves the busybodies over at the Mariners Trust to deal with; but they are under control with a new contract so we'll see to it, and you will owe me one – deal?"

So, they shook hands and the King put it out of his mind. The GV disappeared to his dungeon lair, brooded on the puzzle for a little while, then sent for one of his trusted creatures from the Golden West Mafia (GWM) crew. It had been the GV 's habit to recruit his henchmen from the GWM, no past GV would have them in the building, but they suited the GV just fine as they seemed to understand his little ways. The Deputy Grand Vizier (DGV) lumbered into the chamber, wheezing and looking furtive, but eager as always for mischief and gold.

The GV explained the situation and asked who was the 'best' man for the job. The DVG seeing a chance to foster and promote his own clan rumbled "I've got just the man GV, I'll send him a carrier pigeon directly".

GV - "Excellent, I have to take a little trip to the holiday island of Lubby-Loo for a while; so, get this done and watch the shop, there's a good chap".

Now, as it happened the DGV had three of four of his own clan he wished to assist up the ladders, but there were some snakes to beat down and the little game of hide and seek the GV wanted suited his dark purpose, very well indeed. After much thought, a plan was hatched, the pigeon despatched and (as they say) the rest belongs to history. Or should have, however..

The DGV plan was cunning; subtle and effective, but the DGV had underestimated not only the naked ambition of his hand picked clan members, but their inability to resist a soap box and that the plan would only survive until it was handed over. Second and third agenda's were quickly generated and this, as history will show was where it all started to go pear shaped..
- - - - - - - - - - - - - - - -

This is a thread of long pages; and I believe Brother Sarcs has a little MTF, so I'll stop here and, if you're good, you shall have the rest of the tale, tomorrow..

Sponsor; the IOS chapter for why bother with fiction when the truth is more bizarre. a.k.a. TOAST (Totally Obfuscated Agenda Stories and Tales).

Toot toot.

[Sarcs]

Part three – Late entrants to the MoP Stakes

Fair call “K”… Indeed it is all passing strange but, in the current Sociopathic world of FF, IMO fairly predictable behaviour…

After all they’ve got away with embuggerance of industry minority groups/individuals and obfuscating Senate Inquiries for years, so why wouldn’t it work again??

They say the sign of a true Sociopath is they will never entertain the thought that they may actually be wrong... Even when someone has, quite rightly, locked them up and thrown away the key, a true Sociopath will still argue the toss…

But I diverge back to Part three…

Kharon:

One thing (amongst the many) which intrigue me is the apparent breach of TSI 24, seems to me it's writ large but gets pushed aside with focus on 25 and 26, even the inimitable Aherne side steps the issues.

To be fair to the inimitable Mr Aherne he didn’t have the ability of hindsight; nor a DRAFT copy of the AAI report; so he could not possibly predict that the Senate Committee would devote part of Chapter seven to asking whether there had been a… Breach of the Transport Safety Investigation Act:

7.9 The committee remains very concerned by CASA's actions in this regard, and has cause to ask whether the agency is in fact also in breach of the Transport Safety Investigation Act 2003 (TSI Act). Section 24 of the Act clearly states that it is an offence to hinder an investigation:

(1) A person is guilty of an offence if:
(a) the person engages in conduct; and
(b) the person is reckless as to whether the conduct will adversely affect an investigation:
(i) that is being conducted at that time; or
(ii) that could be conducted at a later time into an immediately reportable matter; and
(c) the conduct has the result of adversely affecting such an investigation (whether or not the investigation had commenced at the time of the conduct); and
(d) the conduct is not authorised by the Chief Commissioner.[9]

At para 7.10 - 7.12 it would seem that the primary concern for the committee was the fact that FF had withheld the Chambers Report from the ATsB. Such was their concern that they submitted a referral to the AFP:

7.12 This leads the committee to conclude that CASA may have breached section 24 of the TSI Act by withholding the document. To ensure that any appropriate action is taken, the committee will write to the Australian Federal Police, providing a copy of this report and supporting evidence for review.

Without actually being privy to the official referral for investigation by the RRAT committee, we are left in the dark to whether the referral was actually much broader in scope than merely the Chambers Report and Cook’s FRMS Special Audit report.

Bryan Aherne:

It appears that at least two documents which had cause to significantly affect a safety investigation, was deliberately withheld by CASA from the ATSB, in contravention of the provisions of the TSI Act 2003, the MOU and International Convention.

The provisions of s24 would seem to give the AFP a great more latitude to investigate the full gambit of the AAI report and supporting evidence. Indeed it would be unprofessional, unwise and extremely remiss for the AFP to do other than a full top down investigation, especially as this was a totally non-partisan referral effectively submitted under the authority of the Parliament.

Therefore it is more than safe to assume that (much like the TSBC) the AFP, once accepting the referral, would have examined all of the available documentation collated by the AAI inquiry. But unlike the TSBC the AFP would not be limited by a ToR and in the course of compiling a chronology of events/ chain of evidence, would be making further inquiries.

Above in Mr Bryan Aherne’s Supplementary Submission (PDF 856KB),under the heading Prejudice and Outcome Bias, Mr Aherne quotes from part of a CAsA officer’s email:

Email: Wednesday 18 August 2010 From CASA Officer to Director of Aviation Safety and Deputy Director of Aviation Safety

Re: ALIU Accident report Norfolk Island ditching VH-NGA

The above referenced report is now complete………….I have discussed the report with the ATSB and there are no differences in the key areas which will eventually be published by them in their report. I have aligned the report with the submission made by …our Westwind FOI Subject matter expert in yesterday’s AAT meeting.

The full email read something like this (reference - Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report;(PDF 1193KB) )…

…(redacted)………the above referenced report is now complete and I have signed this and placed a copy on trim….You indicated that the report should not be made available outside CASA until you had accepted the report and authorised it for release should it be asked for by third parties . I have discussed the Report with the ATSB and there are no differences in the key areas which will eventually be published by them in their report. I have also aligned the report with the submission made by (redacted)..our Westwind FOI subject matter expert, in yesterday’s AAT meeting.

Finally the flight plan information supplied by Jeppesen indicates that there was insufficient fuel on board to cater for the worst case depressurisation scenario. Can you please review the final report and advise me that you approve its wider distribution should that be necessary. A coordinated enforcement meeting will take place tomorrow and the report will be discussed in that forum. I will print a copy of the report and leave it with (redacted) for your perusal. Please advise me if you accept the report…

In the eyes of the AFP this email would certainly have piqued their interest but IMO it is the subsequent replies (email chain) that would have red flagged an area of interest (possible breach of s24) and automatically necessitated further inquiries.

Eight minutes after this email was sent…

Thank you. There is no need to print the report. I am awaiting the outcome of the Coordinated enforcement meeting and its subsequent recommendation to EMOPS. I will then consider the 'thing' as a whole with DDAS/ADAS et al. Good work; please do not release the report until we have completed a formal consideration. I am not (redacted) suggesting, by the way, that the report will necessarily need more work, it is merely a case of not wanting a great deal of trepidation in the industry if the report was available for all to read, but the actions/recommendations themselves (if indeed there are any recommendations to come out of the next meeting etc) remain unrevealed and open to massive industry conjecture and 'decision making'. Those sorts of pastimes are not to CASA's long term benefit.

The report being talked about is of course the infamously hidden CAIR 09/3, but back to the email chain where finally we get this Dear John (my bold)…

Date: Thursday, 22 July 2010 12:36

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

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

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

Your approval to release the report is requested.

Q/ Did FF ever give the bureau a full, unadulterated version of CAIR 09/3; or (like many other FF withheld docs) was the report never officially requested by the bureau (s32). Therefore FF simply didn’t send them a copy and merely discussed the more salient points of their own report??

Either way this email chain is very much within the bailiwick of the AFP in their investigation of possible breaches of TSI s24…

Which brings me to Part four - late entrant(s) of the ‘MoP stakes’ & another possible reason for the TSBC hold up on the release of their review report – all theory of course..

MTF…

[Kharon]

Two dozen nettles please. (24).

Sarcs – what can I say, terrific work. Brava and unlimited Choc frogs......

Your breadcrumb trail allows the astute reader to find their own pathway; the AFP have a little less (or much more) work to do now methinks. Reading through the story above, as seen through the investigators eyes, rather than the lay perspective, raises some very interesting questions. The most intriguing is why go to such extraordinary lengths and risk so much ?, what was the motive? We have lived, for quite a while now with some of the most unbelievable, unholy cock-ups imaginable; but, (probably much to CP's disgust) either conspiracy, collusion or corruption, all with a capital C seem to creeping slowly, but steadily into the picture. Beating up a pilot or fooling a department head, or beguiling the public is one thing; but messing about with the Senate in this manner is beyond the pale and has ended with a MoP. Theory (Bliss, wind and speculation) being proven correct that is. Even if it's all bollocks, it's an interesting theory and great work....

So, lets see what you have entered for the MoP stakes: 'Canadian Club' will be carrying additional handicap weight; so a prudent even money SP, I think.

Now this new entrant of yours has not been handicapped as it has never raced in this type of event before. Good pedigree though, from a line known for stamina, intelligence and a turn of speed when required. Both stable and trainer have a good record and have not been troubled overly much by the Stewards and first class connections. So: a starting price and form guide for 'Chapter Seven'; hmm, lets see not gelded, out of Commonwealth Coin by Sterling Service, raced well overseas and at home, the bloodlines providing the 'necessary' to win @ 3/2 odds on, we shall revise that after studying the track work results. (Best not to mention my little SP book to the connections eh).....

It remains to be seen what effect these new entrants will have on MoP field.

(Mods and gods permitting) = = = = = = The Legend of Sleepy Hollow; chapter two..

Well, as you can imagine, it took the pigeon quite a while to reach the GWM outpost, being as the plan was fairly heavy. But eventually, exhausted the bird made it through the portals and into the lair of a subordinate GWM Vizier Wannabee (VW). The DGV had, for various, nefarious reasons wanted to bring his protégé into the spotlight. The rumour, now lost in the mists of legend, was that the DVG wanted to retire after a short spell as GV, something to do with arcane pension rights, but wanted his clan properly placed before doing so – anyway. The ladder selected for VW was strewn with snakes of a venomous, aggressive variety, who had staked a claim to the ladder and were prepared to defend it; in that cowardly way snakes have. Previously, VW had fumed and fussed; unfortunately, as a minor unqualified minion, dependant on nepotism, he had neither the balls or brains to tackle the snakes head on. But, the plan of the DVG assured him that the King had specifically directed the GV to 'get this done', which effectively gave VW a lot of tacit clout (for nothing could be committed to writing).

Not being one to let the grass grow and assured of unlimited support from the GV, he started to 'get on with it' as scripted until later that afternoon when the little devil, which we all have attached to our left ear, spoke in a seductive, husky, whispering tone. "Mate, think a little further than the DVG plan; you can really shake this loose, make a great name for yourself, earn some fear, respect, street cred' and clean out those pesky snakes to boot". On and on it whispered until, filled with a great sense of self importance, ego gratifying blood lust, VW set to work – on his own account with a modified script. Without the little devil's advice he decided that a Captains scalp would look butch, dangling from his sporran, which added a certain piquancy to the wicked brew.

With a twirl of the golden pen, he sent his lackeys (dressed as snakes) to work; the full Monte all stops out. Investigations were ordered, audits conducted, little tweeks here, twerks there, special this and special that until no matter which way it went; his name would shine bright in the halls of Sleepy Hollow, so much so that he decided to sign many documents with it. He knew it was naughty, but he figured bugger process, sod policy and damn protocol – I am protected, "paper-work cut to order" was his catch cry. It was with great dreams and schemes the finishing touches were lovingly painted onto the canvas of vaunting ambition. In the VW mind, this was all such an unmitigated success, such a sure fire winner; and, so impressed with his own work was he that, in his haste for fortune and glory several small details were, unfortunately, overlooked. One was the Maritime Trust another was underestimating the cunning of snakes; but greatest of all was the 'soap-box' trap.

The overwhelming temptation to tell a world, (previously dismissive of the diminutive VW), of his well hidden talent, skill and literary ability and his new messiah status proved too much. The left ear devil had overcooked the few common sense instincts and let the daemon of blind ego out of it's fragile cage. Alone, at night burning the midnight oil, VW toiled to create the 'thesis' to end all thesis; a rip snorting, knock 'en flat sort of thing, full of long words and catchy phrasing. Mind you he does tacitly acknowledge some assistance with the 'big' words' from his GWM mate who had a penchant for using big words in the wrong syntax. His logic would be that those who failed to understand his 'vision splendid' could be derided as not having the native wit to comprehend his masterpiece. To do this he decided to 'borrow' from some of those he considered beneath the need to acknowledge their work and that only he could forge their poor efforts into a mighty testament defining his own sublime talents. As most of it was already written, it was really only a quick copy, paste and plagiarise effort, so he was delighted to also have saved his Mum some of the midnight oil bill. One of the great side benefits to this thesis was that some snakes could be bowled out easily as they could be implicated, complicit by extension in the sinking of the 'Nightingale' as they were to have been keeping an eye on the Kings ships and those that crewed them. His chagrin was almost overwhelming when the DVG refused, point blank, to publish it. "Let's save it for a rainy day" said the DVG to a heartbroken VW. But, it must have been quite funny to watch as the snakes tumbled over each other trying to show that 'they' had always done the right thing.

This boys and girls is where you learn that little things can oft times make a big difference. You see in his haste VW had allowed a couple of wolves, disguised as snakes into his happy little party; in desperation to achieve credibility for his dastardly work he needed a couple of 'expert' opinions, to make it all stack up; proper. It was at this point the first indication that a wheel was about to fall off became apparent; alas, VW in a hurry as always failed to notice the tremor and raced on, fully committed to his fate.

But here we must leave the story for today; will the wheel come off the VW bandwagon. We shall see.

E&OE (Just for laughs) Toot toot...

[Creampuff]

You seriously believe the AFP is going to do anything more than spend 5 minutes pretending to care about this, then get back to something important?

Seriously?

If yes: I have some cheap shares in the Brooklyn Bridge for sale.

[scrubba]

referral to the AFP

Given the continuing enthusiasm for the thought of CASA being referred to the AFP for investigation, can someone clarify for me how this works?

The RRAT Committee Report said:

7.12 This leads the committee to conclude that CASA may have breached section 24 of the TSI Act by withholding the document. To ensure that any appropriate action is taken, the committee will write to the Australian Federal Police, providing a copy of this report and supporting evidence for review.

Now to me, the way that the report reads is that "the committee will write", a simple statement of intent. Has the RRAT Committee formally made such a request for AFP "review"?

Can the committee make such a request without the support of the whole Senate? I notice that there is no recommendation to that effect.

If such a referral has been made, how does the public know what progress, if any, the AFP has made?

[just saw the crossover in timing with Creampuff (with whom I entirely agree), but I remain curious as to the process]

[Kharon]

Get real ? – Why?

CP –"You seriously believe the AFP is going to do anything more than spend 5 minutes pretending to care about this, then get back to something important?

.....More chance of selling me shares in the Brooklyn bridge than of convincing me things may change. But, the Sarcs research is very good and as we seem to be stuck in a time warp, it helps to fill in the time by supplying possible solutions to the MoP puzzle. I doubt anyone takes the AFP investigation, any of this charade, my fairy story or even Australian aviation 'seriously'. If they did the body count at the bottom of tall buildings would be much higher. But if you treat it as pure entertainment, realising it's true value is in that, then sanity and a few laughs along the way will be yours.

Scrubba " Given the continuing enthusiasm for the thought of CASA being referred to the AFP for investigation, can someone clarify for me how this works?

How very condescending; and lazy. How about doing your own research 'to clarify' for yourself 'how this works' and then regaling us all with 'your' entertaining analysis. There is great enthusiasm for the entertainment that provides; however if you want to get 'serious', then throw up your research contribution and we shall debate it. Make sure it's all your own work though.....

[Sarcs]

TOE (P3.5) cont/-

Creamy:

You seriously believe the AFP is going to do anything more than spend 5 minutes pretending to care about this, then get back to something important?

Actually Creamy I couldn’t agree more, in fact I was somewhat surprised that the Feds accepted the Senate’s referral at all but apparently they did?? So even if they were to only spend 5 minutes on a cursory look/see, once accepted they would still be bound by protocol and (unlike CAsA apparently) the HOCOLEA principles to at least appear to do a thorough job…

“K” - I doubt anyone takes the AFP investigation, any of this charade, my fairy story or even Australian aviation 'seriously'. If they did the body count at the bottom of tall buildings would be much higher. But if you treat it as pure entertainment, realising it's true value is in that, then sanity and a few laughs along the way will be yours.

Exactly “K”, so while we while away the time…

…the AFP have a little less (or much more) work to do now methinks. Reading through the story above, as seen through the investigators eyes, rather than the lay perspective, raises some very interesting questions. The most intriguing is why go to such extraordinary lengths and risk so much? what was the motive?...

Interesting questions you ask “K”, but for the moment put motive aside because in the eyes of the AFP the primary objective is gathering evidence, tracking down leads, interviewing possible witnesses/suspects and slowly but surely mounting a case that eventually they hope (or not) to present as a brief of evidence to the CDPP. Motive is the job of the prosecutor to establish and not the investigator.

Though I do love the Fairy Story so far and cannot wait for the next instalment…

But back to the timeline of embuggerance…

Previously: We were left with a very interesting email chain that had the DAS, in his usual arrogant way, saying this…

“…it is merely a case of not wanting a great deal of trepidation in the industry if the report was available for all to read, but the actions/recommendations themselves (if indeed there are any recommendations to come out of the next meeting etc) remain unrevealed and open to massive industry conjecture and 'decision making'. Those sorts of pastimes are not to CASA's long term benefit…”

Which says to me that the DAS (at least) was expecting the bureau (as is normal procedure) to soon publish an interim report on at least the CSI. It was just a matter of whether that would be in the form of a SR or an SI. This assumption by the DAS was also reinforced by the fact that a month before his ‘white hats’ had drafted NPRM 1003 OS and he had personally endorsed the proposed amendment to CAO 82.0 (Annex A).

To that point in time the situation, although not SOP, was still recoverable and could have seen the various parties (except for DJ) climbing out of a potentially embarrassing situation that had the potential to highlight serious flaws in their newly minted détente MoU.

However the next email reply (4 days later) from the (obfuscating) DDAS seems to be where everything went South for the next two years??

“…is comfortable with the report's content, to the extent that it correlates with the AAT material to be submitted shortly and that there are no differences that can be highlighted by the opposing legal team…”

People can fill in the blanks but basically the report (CAIR 09/3) matched the evidence (ducks in a row) intended to be presented at the AAT, except the opposing legal team did fervently contest this evidence. Hmm…wonder if the opposing legal team were privy to CAIR 09/3 in its entirety?

Quote from Wodger:

“…When: Thursday, 12. August 2010 11:00-12:00 (GMT+10:00) Brisbane.

Where: Vidcon

Folks,

We need to discuss the current actions in relation to Dominic James in light of the ALIU Report and Len Vegar Statement…”

Anyway back to the last part of the DDAS reply email…

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

Besides another possible breach of TSI s24, & the rather bizarre interpretation by the Deputy Dog that all this skulduggery was in keeping with the new MoU, what I find passing strange was all this high level micro-managing of a matter that should have been more than capably handled by middle management identities. Still we all know that Deputy Dog was in deep virtually right from the get go.Here is a reminder from Senator X at the 15/02/13 hearing:

Senator XENOPHON: Mr Farquharson and Mr McCormick, let's go to the email of 20 March 2010 about whether it is a critical safety issue. The whole issue was downgraded from a critical safety issue to a minor safety issue. I query the role CASA had with respect to that. I will remind you that the email says that there is one group of pilots that has one view which leads to a mandatory diversion, and another group has the opposite view. Putting aside the practicalities, both groups believe they are legally correct. If we find ourselves in an AAT or a court, we once again look a bit foolish if we, the regulator, find ourselves in the position where we have to say there are two conflicting views, one of which has to be wrong, and we have done nothing to rectify it over the years. It is very untidy.

You wanted this downgraded to a minor safety issue because it would have covered you in terms of any potential litigation.

We also know that beyond the above email chain the DDAS was still actively involved in the matter, even acting as the DJ decision maker, on request from Wodger, in the absence of Hoody…

Quote from email sent 07:04 am, 13 January 2011:

In Greg's absence l am referring to you the amended CAR 5.38 notice for Dominic James for consideration and approval.

The amendment is to ensure the objectives of the flight test requirements specified in the original notice can be achieved using simpler aircraft types requested by James due to his financial situation. The attached correspondence provides detailed explanation for the amendment. ·
The draft notice was prepared by Adam and reviewed by Bankstown FOIs and myself. I recommend signing the notice…

Moving along through the publically available information, that surely the AFP would have at least reviewed, we find that the timeline of embuggerance from the email chain goes into a time vacuum for virtually two years until we get to the DRAFT report stage of the ATsB investigation. We then get these three internal emails…



16 - Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB)

17 - Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB)

18 - Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)

Which to be honest are probably more of interest to the TSBC and would largely lose any good AFP investigator. Who would probably assess them as largely irrelevant to their inquiries, except maybe for the last part of the 3rd email…

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

And so ends the trail of evidence (TOE) that we are aware of (i.e. publicly available), of course the AFP would be privy too so much more and they have the powers to interview etc. if they indeed cared to??

MTF with Part Four & the MoP Stakes…

[Ziggychick]

Short and Sweet and Mighty pissed off

Dear PPs

An article in the SMH on 18/08/14 regarding a Pel-Air and me suing.

I found out about the article in Thursday afternoon.
They printed my full name, address, marital sataus and how many children I had.
The only true statement that I remember to the best of my ability are within "quotes"

The rest is unquoted. I did not say any of what they printed.
I have never spoken to the a author, I don't know her.

A clandestine operation.
The aircraft pictured intact. Quick description of events.
The Pissed Off part.
The author and source are literally, all of a sudden attacking me.
My personal details revealed
My alleged blaming of the pilot (he followed the rules and saved our lives, thank you DJ)
Then she bangs on about the MC99 being applicable to us, which it is not.
Finally, walk away with nothing. Pain, struggle financially

How the liars stare into the dark and play
Enjoy it
For now
The light of truth
Reveals
You and You and You and You.......

Media. For as long as my arse points to the ground. I will never speak with you.

Leave me alone.

If any one knows something, please tell me why this would happen
Anyone know this game?


If I have made spelling mistakes, I'm so bloody tired.
Take care,
Ziggy.

[Kharon]

For shame and damnation Australia.

There are those, in positions of power who could, at the stroke of a pen or by making a telephone call end this agony for someone, who through no fault of her own is not only in a world of extreme physical pain; but one of exquisite mental torment.

It's not good enough, no where near.

The Minister could fix it. Mrdak could fix it. Pel Air could fix it. Insurers could fix it. The AsMA could exert enough pressure to get it fixed. For the sake of the cost of one years executive lunches a life of pain, grief and misery could be altered.

Strange place Australia; mountains of public outpouring for those who are dead and cannot be helped; politicians wailing, rending flesh, crying buckets of public tears and no expense spared. Yet to raise a pinky finger to help one solitary soul is a step too far, but gutter tactics are deemed acceptable, even laudable. How cynical, how low, how disgusting is this country becoming? ask Ziggy, for surely she has seen the absolute worst of it and must live each day with that certain knowledge. Shame for Australia.

Othello - If thou dost slander her and torture me,
Never pray more. Abandon all remorse.
On horror’s head horrors accumulate,
Do deeds to make heaven weep, all earth amazed,
For nothing canst thou to damnation add
Greater than that.

Selah........

SMH link

Pel-Air Aviation, a wholly-owned subsidiary of Regional Express Holdings, denies Dr Helm, who lives in Britain, and Ms Casey are entitled to damages.

However, Pel-Air says the 1999 Montreal Convention applies, and although the plaintiffs launched legal proceedings within the two-year limitation period, they did not plead a specific cause of action under the convention and are therefore out of time.

Translation - If you’re slandering her just to torture me, then it’ll be no use to pray for mercy or say you’re sorry. You might as well go ahead and commit every unspeakable crime you can think of, because there’s nothing you could that would top what you’ve already done! (Spark)

[PAIN_NET]

As requested – CAIR 09 – and - 'The Chambers Report' - for those with an academic interest in verifying the conclusions drawn from the first class research into the MoP.

P48. a.k.a. Sandman.

From Zippyshare – CLICK once on the large RED download now button, to avoid unwanted spam......

[Sarcs]

Passing Strange & clarification to redacted STSI

Thank you PAIN makes it so much easier to make quotes of interest...

Example: The now infamous gloss over by ALIU and his fellow investigators here:

0801 UTC NADI ATC provides the aircraft with the METAR for YSNF issued at 0630 ZULU. This was then updated with an Auto SPEC I for Norfolk issued at 0800 ZULU. Wind 290 at 08 Knots cloud overcast (OVC) at one thousand one hundred ft AGL, 21 oC and the dew point was 19oC and QNH Norfolk 1012.

...and here:

The Captain received an in-flight weather report at 0801 which indicated that the weather at Norfolk Island had deteriorated below the minimum conditions which required the holding of an alternate aerodrome. The weather report indicated only a very small difference of 2 degrees between the current temperature and the dew point (21/19).

...and again here:

Having commenced the flight from Samoa to Norfolk Island, the transcript of the Captain's communications with Air Traffic Control (ATC) in Fiji revealed that he received a weather report for Norfolk Island at 0801 UTC which showed that the weather conditions at Norfolk Island had deteriorated from those forecast during his flight planning at Apia.

Which we all now know ultimately led to the bureau totally missing the NADI error in the glossed over 0630 UTC METAR i.e. cloud base 600' instead of stated 6000'. The most embarrassing part being that it was the 4 Corners program that pointed out this error...

On the despicable SMH article (seem to be getting stuck into the MSM today...) I find it more than passing strange that this affront to the senses suddenly appears 3 days after starting the TOE & MoP series...

Slight drift here..

I feel I need to clarify something to a certain STSI who had this to say in the 6 August 2012 internal email (linked in previous post):

There has been an alarming inconsistency in understanding about what is an 'organisational issue'. I have successfully argued for statements about the lack of organisational issues not to be included in the Norfolk Island and 'Tiger One' reports, and I was unhappy to see unflattering comments in Pprune about 'no organisational issues' in the analysis of the Darwin Brasilia report.

These facts lead me to believe there is little understanding of what an organisational issue actually is, and when it is, or is not important. I believe this lack of understanding is widespread.

'Begging your pardon your Honour' but at no time was this little black duck (at least) personally critical of the lack of 'organisational issues' in the YPDN Braz report. In fact, on the contrary, I was critical of the fact that after all the good, factual organisational issues highlighted in that report, that the Safety Action section seemed to totally dismiss this evidence as irrelevant to the causal chain...

Drift over and back to the main game...err I do wonder however if the TSBC would have closely examined this email from an obvious Senior member of the bureau investigative team (that's if he/she is still there??) and had a quiet word or two. As the email IMO more than adequately highlights the dangers of Beaker's BASR approach...

[Creampuff]

Which we all now know ultimately led to the bureau totally missing the NADI error in the glossed over 0630 UTC METAR i.e. cloud base 600' instead of stated 6000'. The most embarrassing part being that it was the 4 Corners program that pointed out this error...

And there is at least one patent error in the transcript itself. How many more errors are there that aren't patent?

[Kharon]

A patent – on errors.

Sarcs "[the] rather bizarre interpretation by the Deputy Dog that all this skulduggery was in keeping with the new MoU, what I find passing strange was all this high level micro-managing of a matter that should have been more than capably handled by middle management identities.

Except by then Hoody (absent on a sicky); Cook and Watson had washed their hands of it. They must have been amazed at the speed and dexterity with which Wodger fixed Humpty Dumpty, all back together again in just a few days short of a Christmas fortnight; despite their expert cautions. They must be prescient, or perhaps just qualified professionals who can read and write the signs. It was always going to end in tears, perhaps less so for the ATSB who were, at least until Beaker took his thirty pieces of silver, doing the right thing.

(Mods and gods permitting) = = = = = = = The Legend of Sleepy Hollow; chapter 3.

For VW, his life was complete; rubbing shoulders with the 'big dogs', sending snappy little notes (the pigeons were all just about knackered) to the DVG at silly o'clock with demands to sign this and execute that; positively bouncing with righteous zeal. The idea of a Captains scalp was first and foremost in his happy thoughts; although it must be said that his first attempt was a failure, of sorts. Whether it was love at first sight or just too much mutual admiration, the first if the Kings captains happily sold out his crew and accepted the VW job offer, but that is a story for another day (see Vol. IX : A nest of Vipers). A secondary target (Survivor) was soon arranged. There would be an appearance in the 'high court' with lawyers swanning about, while he looked on, stern and concerned waiting for his turn at starring. He had even taken some lessons from his Mum on public speaking and with a defined talent for mimicry, he felt sure he could 'win' the case; any road, the 'facts and circumstances' were rigged by the spell weavers to work properly, so no worries.

He was, he felt dealing quite well with not having his report published, being as it was so important not only to his future, but it dealt some savage blows to the pesky snakes. He'd been bragging about it in the tea room to his 'new' cronies and how it would rid him of the non friendly, pesky snake crew. He had even contemplated 'leaking it'. There was a nasty rumour in the kitchens that this was done anyway, and somehow or another it had been passed along to those who knew exactly what it was and how best to use it. Whether VW had leaked it or one of the pesky snakes had left a copy in a bar somewhere is not known; speculation abounds. But it is known that the result was always going to be painful.

Anyway – just as all of this glory was heading his way; the specialist wolves struck their blow. They were proud of their work and unlike the other snakes were not prepared to amend as required to suit the agenda. There were some serious words spoken and the GV, now fully rested from laying about on Lubby-Loo island got involved. The wolves were banished, scattered and denigrated. "No, no, no " said the GV: "this was to be 'low key', routine and was not to involve qualified experts who can't be bullied, bought or budged". About this time Survivor's lawyers chimed in, pointing out that the Captains scalp may be forfeit, but it was not going to be an easy task, there were 'irregularities' to discuss and Survivor's inconvenient testimony to consider. Well, tempers were lost, books were thrown, one senior Vizier (SV) was almost involved in a corridor punch up. The GV bellowed, threatened, cajoled and bullied the rebels into silence. The only problem was that now instead of the sinking being quietly slid under the carpet; it became a full dress affair with everyone from the office cat to the GV himself being involved and a half mile wide paper trail following; with the wolves and snakes following that

In time, the GV got the brakes on and most of the cat back into the bag. "Look here" says GV, "we could end up with some blowback on this; the crew over to Mariners Trust (MT) reckon we may have to catch some of the blame for the sinking". Well, they held a midnight meeting or two, to look at what had been done, including the wolves work and decided that yes; they were potentially in deep do-do. What made it worse was that VW had been spoon feeding only the choicest morsels to the brand new, clueless minion who was the 'go-between' for the MT and GV camps. Green as grass, the minion was not just feeding the selected parts of the VW line to MT, but also some of the less savoury parts.

No longer certain of who had what, there was a lot of 'evidence' to slide out of harms way. As you know, VW had covered it from all possible angles to ensure that whatever way the GV wanted to play it; he could produce a line of paper-work to support it. Once the final plot was executed; the 'excess' embarrassing, inconvenient 'evidence' could be shuffled away, incorrectly filed or lost, for in this practice VW had no shortage of expertise (although no formal qualification).

Over at the MT HQ, they had been playing a straight bat and working within the 'new' rule set. This meant warning the GV that they were obliged to issue a stern, safety warning which put the not only the King in a bad light, but the GV as well. Unconcerned at first, the GV 's tame spell weavers had been working to minimise the damage, same as always; the under the carpet spell was tried and tested true. If the GV just nipped over to the MT and smoothed the way all would be well, provided the master mariners could be persuaded to just not mention less savoury morsels they had been inadvertently gifted. And so it came to pass, for two long, quiet years, while the poison trapped beneath the surface festered. VW nearly recovered from not being published, he had a tame captain and Survivor mouse to toy with at will; he had intimidated some of the pesky ladder snakes; established meaningful relationships with the DVG and the GV. (They had in fact become quite friendly; having similar tastes in extracurricular activities, mutual secrets and a need to stick together). To all intents and purposes, the sinking of the 'Nightingale' had been quietly put aside. Left to a watery grave, alone, unloved and unattended.

And so it would have stayed, had it not been for Survivor who kept asking awkward questions and making friends with some lone wolves, who were outcast from the GV inner circle. Slowly but irrevocably the Survivor pieced the true story together, the wolves of course saw what was coming and decided to assist by asking some very awkward questions themselves, related to their work and why their expert opinions were being overridden and dismissed by what was, in their eyes, a jumped up, unqualified office wallah. And so the thick plottened and festered; hidden away from sight, on the back burner.

Now the King was a parliamentary, constitutional type of monarch, tolerated to an extent by the ruling party of nobles and common folk; but he had to mind his manners. One day, Survivor was overheard discussing the 'Nightingale' affair with one of the governing nobles by a reporter. Curious, the reporter offered Survivor a beer. A little later, across the road in the pub soon enough the story was told. Once the reporter realised that there was to be a noble involved, he set to work on a centrepiece story, with deep research, pictures and all the trimmings. The stench of a rotting carcass being irresistible.

Now children, we must leave the land of Faery behind and proceed very carefully in the very real, wicked world of men; for second coffee awaits (and a muffin, if we get lucky)....

= = = = = = = = = =

There you go Sarcs – enjoy: you owe me a beer you bugger.

Toot toot.....

[Sarcs]

Part Four - Mystery entrant to 'MoP Stakes'.

"K"- There you go Sarcs – enjoy: you owe me a beer you bugger.

Small sacrifice for such an entertaining read...

Goes to show there is a small line between fiction and reality, which brings me to Part Four…

…Beating up a pilot or fooling a department head, or beguiling the public is one thing; but messing about with the Senate in this manner is beyond the pale and has ended with a MoP…

Historically Senate MoPs (after all the rhetorical bluff & bluster) largely all fizzle out to nothing, the affected parties say their piece, no contempt is found and everyone kisses, makes up and pronounces the virtues of a plural democracy…yada..yada..

However the two MoPs accepted by the Senate and referred to the Privileges Committee…


“…In the context of an inquiry by the Rural and Regional Affairs and Transport References Committee into aviation accident investigations and Budget estimates hearings of the Rural and Regional Affairs and Transport Legislation Committee in May 2013:
(a) whether disciplinary action was taken against either a witness before the committee or a person providing information to the committee; and
(b) if so, whether any contempt was committed in respect of those matters…”

…carry a great deal more intrigue, especially as this motion was carried twice and the 2nd time by the Chairs of the RRAT Committee themselves...

Which represents a unique situation, as this unified response indicates that there is no politics involved and that the matter is considered of a serious enough nature that it has the full support of the whole committee.

The Committee Chairs in their MoP also took the unprecedented step to:

(2) That, for the purpose of providing further information to the Committee of Privileges, the Standing Committees on Rural and Regional Affairs and Transport have access to the records of the committee in the previous parliament.

These records would not only include all the publicly available documentation but also all the ‘in confidence’ submissions, the incamera evidence given and the confidential interagency documents, basically all evidence held under parliamentary privilege.


Already we can see that the Privileges Committee have quite a job ahead of them...


The biggest point is that the RRAT committee are determined that the PC can examine all the evidence totally unencumbered by outside influence and free from all bias.


CCC moment: Long bow I know, cause the AFP are more than likely just going through the motions with their inquiries, but maybe there is another reason for the Chairs to include para (2) above. Not sure of the legal perspective but it is possible that by freeing up all information held under privilege from the AAI inquiry they can then also legally give access to the same evidence to the AFP.

As an example if we go back and truly analyse the chain of final bureau internal emails...

16 - Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB)


17 - Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB)

18 - Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)

...we can see that there was a very deep & bitter internal rift within the bureau and some of the anger generated was palpable.

A rehash of the final part of 6 August 2012 email:

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

The (from for all intents and purposes one pissed off STSI) rant in the (6 August 2012 email) has some very clear messages that (still to this day) have quite obviously fallen on deaf ears in the upper echelons of the bureau & FF (who, it appears, are still hell bent on regulating aviation (big R) to within an inch of its life)...

Simply put, as most of this would have been lost in translation for the AFP, what this STSI is saying is that the ‘white hats’ within the bureau were, very reluctantly, forced to accept the FF version of events (CAIR 09/3) as the final bureau version of events. {Comment: Basically (and thanks to PAIN you can check) the bureau ‘Final Report’ is a fleshed out version of CAIR 09/3.}

In the interest of being at least thorough (even if the AFP don’t give a rat’s arse), I believe that the unnamed STSI (probably former) should have been approached to at least give a statement on his/her version of events in regards to their involvement with the VH-NGA ditching investigation.
I also strongly suspect that this individual will be a late entrant and frontrunner to watch in the ‘MoP Stakes’, all theory of course…

MTF…

[Kharon]

Drawing a low bow.

Sacs –"Long bow I know, cause the AFP are more than likely just going through the motions with their inquiries, but maybe there is another reason for the Chairs to include para (2) above. Not sure of the legal perspective but it is possible that by freeing up all information held under privilege from the AAI inquiry they can then also legally give access to the same evidence to the AFP.

To hit a very small target. Sunday speculation; couple or three options for consideration float to the surface for speculation on 'why' take the MoP road.

The lazy cynics can and do mount a good argument which is grounded in solid fact and evidence. Historically, all manner of 'inquiries' and the like have essentially come nought, except for those 'changes' wrought when there has been solid 'political' i.e. Ministerial support and a DAS who could be persuaded to at least enter the debate. There have been some brief periods where 'good sense' prevailed and reform encouraged. There is no need to regurgitate the sad history, students of that topic need no such lesson.

But I wonder; (Sunday ramble following) – Let's consider that the Pel Air ditching inquiry exposed the tip of a less than satisfactory system. That is plain enough for all to see, what was exposed stripped away much of the gilding on the CASA Lilly and tarnished the previously credible ATSB. That is the whole of Australia's aviation safety system oversight exposed to scrutiny and found wanting. This by extension casts doubt over every decision and edict CASA have made; for an example of how deep the wound is, there is no need to look past the TigerAir, Quadrio, James, Barrier, Airtex, Polar or Air North stories; it's all there writ large. Perhaps, the public, politicians and a good percentage of industry don't, can't or won't see the implications: furry muff; no reason why they should. A man like Xenophon however would intuitively 'smell a rat'. But to Fawcett, an accredited, trained, qualified and gifted expert with an inbuilt sense of duty to protect 'his' troops every warning bell must be ringing. Intuitively, cognitively and logically the 'wrongness' is clearly apparent..

The Senate committee must be hopping mad, in a bi-partisan way. Have they been condescended to?, have they been treated with contempt?, have they been bushwhacked by the Department?, is Truss attempting to derail the good intentions of and recommendations made by that committee?. IMO – yes to all.

To determined clever folk, the seemingly impenetrable barriers, which place CASA above the laws of man and the gods must be breached before any meaningful reform of the regulator, which must come before regulatory reform, can begin.

So, the question – is the MoP the Open Sesame (iftaḥ yā simsim) to the fabled thieves cave?

Don't know the answer, but I've bought a ticket to the show (dress circle). It is, I believe going to be a very interesting month or so.

“We’re eyeball to eyeball,” Secretary of State Dean Rusk whispered to National Security Adviser McGeorge Bundy, “and I think the other fellow just blinked.”

End Sunday ramble.

Toot toot.....

[Sarcs]

A true transport safety watchdog vs a Muppet show.

While waiting for the miniscule to blink....on any of a number of pending announcements and responses, which includes the release of the TSBC peer review report... ..., I was reading through the TSBC clear, concise, no BS and thoroughly readable annual report (see here)...

Compared to the current muppets heading up the show, at our once dearly beloved bureau, the comparison is stark and quite frankly I'm envious. The following article IMO truly outlines the difference between a true (independent) safety watchdog and the muppet show we currently have..:

TSB calls on government to fix ‘troubling’ aviation safety deficiencies

The Transportation Safety Board says it’s “troubled” by unsafe practices in Canada’s air travel sector and called on the government to take action in order to prevent serious accidents.

“The slow pace of movement to address safety deficiencies in aviation compared to other modes of transportation is troubling,” the TSB said in its annual report, released Wednesday. “The board will continue to push hard for change.”

The independent safety watchdog listed four major areas of concern : crashes into land or water; collisions on runways; landing accidents; and the lack of safety management systems at small carriers.

In particular, the board drew attention to the fact that Transport Canada doesn’t require small carriers like commuter airlines, helicopter operators and flight training schools to have safety management systems in place.
Together, these smaller carriers are responsible for 94% of all commercial aviation accidents and 96% of all commercial aviation deaths, the TSB said.

“The board is concerned that, in the absence of [Transport Canada] requirements, the passengers and aircraft of these smaller operators are being placed at unnecessary risk,” according to the report.

The TSB added that Transport Canada has done little to encourage airports to prevent collisions on runways, of which there were 381 in 2013, and called for improved procedures and enhanced collision-warning systems.

The annual report also pointed out that Canada lags international standards when it comes to preventing landing accidents and runway overruns.
Transport Minister Lisa Raitt did not immediately respond to requests for comment.

The TSB annual report comes one day after the board released its final report into the Lac-Mégantic derailment and explosion that killed 47 people last summer. It blamed many factors, but singled out Transport Canada for not forcing Montreal, Maine and Atlantic Railway to improve its safety record.

According to the TSB’s annual report, only 3 of 11, or 27%, of its rail safety recommendations have been addressed by Transport Canada in a “fully satisfactory” manner.

The board said it’s concerned that there is no requirement for on-board video and voice recorders on locomotives. It also said further safety measures should be implemented to ensure signals are consistently followed by train crews and to prevent passenger trains from colliding with vehicles.

In 2013, 1,067 rail accidents were reported to the TSB, up 4% from 2012. Accidents involving dangerous goods totaled 144, up from 119.
There were 275 aviation accidents in 2013, down 5% from a year earlier.

The 57 fatalities was slightly higher than the 2012 total of 54.
Financial Post

Another big point of difference with the Canuck system is that their version of FF is completely contained within the Transport Canada and they also have a Transport Minister... (again I am envious).

Back to the TSBC peer review report, word is it is on the miniscule & REDs desk (the bureau muppet doesn't signify..) and has been for quite sometime, which probably means it is not good..

Apparently DIPs were being kept informed on the progress of the report by the bureau's Governance Manager (see here) but now even this joker has gone to ground...

Figures more of the same BS and arse covering by our fully independent safety watchdog?? What a crock!

Muppet Show (MH370 series) - Brontosauri (here) & (head wobble) mi..mi..mi..Beaker take the stage..

You Tube

MTF...