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Senate Inquiry, Hearing Program 4th Nov 2011

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Old 25th May 2013, 01:55
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Thanks

Firstly a thanks to all that have shown support, much grateful to you all.

Around March this year I visited Mr Truss in his office in Canberra. Bumped into John Sharpe in the lobby, (after 3.5yrs of ziltch, he ask "so how are you?" Huh?).
With Mr Truss I kept emphasising the need for new reform. The pending Senate findings given the EVIDENCE was going to be a no brainer. I recall saying this has been an alleged criminal offence involving air safety and that has a direct hit on our travelling public. Needs a fixing.
Disappointed in his email post visit and nil contact since.
I reckon, the AFP should respond and report on all aviation incidents. I'm sure their entry credentials would be ten fold more robust than the ATSB.
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Old 25th May 2013, 07:15
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I have just read the additional comments from Senator Xenophon on the following link. Couple of quotes.

1.8 It is important to note that 'this story' never made it into the final report, or into any other arena. This email clearly indicates there was a belief inside the ATSB that CASA had 'got itself into a hole', and that the ATSB’s priority was avoiding conflict between the two agencies, rather than holding CASA to account. Indeed, the ATSB's report makes no mention of the officer's concerns, and does not even hint at the whole 'story' outlined in the email.

1.22 Ultimately, this inquiry has exposed serious and significant flaws in Australia's aviation safety systems. The general industry attitude towards both the ATSB and CASA is incredibly concerning; it is a mixture of fear, suspicion, disappointment and derision.

1.23 It is my view that CASA, under Mr McCormick, has become a regulatory bully that appears to take any action available to ensure its own shortcomings are not made public. This poses great risks to aviation safety, and the safety of the travelling public. Equally, the ATSB—which should fearlessly expose any shortcomings on the part of CASA and other organisations to improve aviation safety—has become institutionally timid and appears to lack the strength to perform its role adequately. Both agencies require a complete overhaul, and I believe it is only luck that their ineptness has not resulted in further deaths so far. There is an urgent need for an Inspector-General of Aviation Safety, entirely independent of the Minister and his department, to be a watchdog for these agencies.

1.24 In the end, this report raises many questions. But if we wish to bring about change and improve aviation safety, we will clearly need to look beyond our inept regulators and ask: who will guard the guards themselves?




Senate Committees ? Parliament of Australia

Good to hear that the report is being downloaded.

Quite a lot of views happening around 427,000. is 450,000 maybe 500,000 achievable?

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Old 25th May 2013, 22:20
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Report going international....err ICAO: "Please Explain??"

Avweb story out yesterday (today our time):
May 25, 2013

Australian Senate: Norfolk Island Crash Investigation Could Lead To Criminal Probe

By Paul Bertorelli, Editorial Director

In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia’s Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air’s operation that directly contributed to the accident. CASA’s action, says the Senate report, may have violated Australia’s Transport Safety Investigations Act. “It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation,” said Sen. David Fawcett.
The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island enroute from Samoa with a critical but stable patient. The Westwind’s ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight’s captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. Enroute, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB’s accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.

Following the ATSB’s findings, James challenged some of the investigator’s findings but his queries were dismissed by the ATSB. The Australian Senate took up James’ case last year and its probe revealed widespread flaws in the ATSB’s investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that “unequivocally concluded…that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies.” Yet no mention of this report appeared in the ATSB’s findings blaming the pilot.“In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies,” the Senate report said.

Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. “This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That’s why I think we need an inspector general of aviation,” Sen. Nick Xenophone told Australia’s ABC News. “This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB,” he added.

The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB’s chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. “CASA's internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses' evidence that they did not think surveillance was adequate, when CASA's own internal investigations indicate that CASA's oversight was inadequate,” the report said.
And 'wikipedia' has been updated too:
On 23 May 2013 a report was released by the Australian Senate following an inquiry into the investigation of the ditching. This inquiry was sparked by a Four Corners documentary that aired allegations of misconduct by the Australian Transport Safety Bureau and the Civil Aviation Safety Authority.

The Senate's report found that the ATSB accident report was deeply flawed and unfairly blamed the pilot for the accident, and as a consequence the Senate recommended that the accident report be withdrawn and re-done.

The Senate also found evidence of collusion between the agencies, the deliberate withholding of crucial documents by CASA from the ATSB, and found that the heads of both agencies gave testimony that wasn't credible.

The findings of the Senate inquiry were also passed to the Australian Federal Police pending the possibility of charges being laid against individuals involved.
King Mrdacacrat: "Yes Minister it is all a bit embarassing..."

Last edited by Sarcs; 25th May 2013 at 22:59. Reason: "IOS" forever...where's Oleo when you need him!
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Old 25th May 2013, 23:00
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Recommendation 10.

6.41 The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

6.42 The committee is concerned that the ATSB report ATSB report on 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010' could demonstrate a trend where organisational and regulatory factors are not considered appropriately or in sufficient detail by the ATSB, despite post accident investigations by CASA indicating there were significant deficiencies with the operator and appearing to indicate insufficient oversight by CASA. As highlighted in Chapter 5, the committee is also concerned about ATSB attempts to predict future risk for operators. The ATSB should analyse why the accident happened but operators are best placed to assess how the lessons may affect their current and future operations.
(my bold)
Page 81 (103 pdf) paragraphs 6.30 to 6.51 inclusive, provide a solid foundation from which the Senate could build a true picture of the dreadful state in which aviation finds itself right now and the reasons why. So close and yet so far away.

Very much like Pel Air and Barrier – Skymaster was charged by CASA with "indications of significant" etc. However, would an in depth analysis of the many allegations made reveal that the claimed 'deficiencies' were in fact beefed up and manipulated, purely to support the CASA case and had little to do with operational safety – in real terms? The abandoned evidence from two FOI related to the allegations made of Skymaster, needs only to be examined impartially to discern the clearly defined pattern. Subsequent ATSB reports are clearly slanted toward supporting the CASA stance. With Pel Air one has to wonder why then, with similar allegations laid at the feet of both operators, was the matter not as ruthlessly pursued, to placate the gods of "safety" ? Or why was the one operator able to be rehabilitated over a Christmas holiday period, issues blithely waived aside, where the other was hung, drawn and quartered over a much longer period. The true 'safety' issues in both cases have yet to be defined by the ATSB/ CASA combination tag team. Aye; It is all, indeed, passing strange.

What was done with the Skymaster "issues" later, when presented in the AAT defied logic and worse still achieved nothing toward enhancing industry knowledge, except to be afraid. Had there not been an amazing back flip, Pel Air would have ended up with a very similar result to Skymaster. The Coroner dealing with Skymaster will need to ensure that the evidence presented defines the facts and circumstances most precisely.

The final outcome of the two events, both managed by the same office is extraordinary; the diverse ways similar allegations were dealt with by the doyen of aviation safety are unbelievable, the damage to the spirit, intent and meaning of aviation law, through the manipulations and machinations of one or two men is grotesque. That the Australian ATSB should aid and abet these perversions is monstrous.

This report from the Senate does indeed open the gate and is a wonderful tool; but, if Australia is to make the massive quantum leap to probity and accountability, more work needs to be done, much more. This is not the time to sit back, we have a start but it is a long journey. Now, I wonder, can the AFP ferrets chase those wascally wabbits out of their deep burrow, without industry assistance and parliamentary oversight??

Last edited by Kharon; 25th May 2013 at 23:20. Reason: Trying to remove elephants from sense of humour - thats why.
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Old 26th May 2013, 00:28
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in my opinion, the fallout from this report which highlights very considerable organisational failings of ATSB and CASA, taken with the debacle at the AMROBA meeting, Canley Vale, Lockhart, Quadrio, Barrier and a host of other matters, is that no frontline CASA or ATSB staff are going to be able to look aviators and maintainers in the eye until both CASA and ATSB management are cleaned out and a new era begins.

I theeeenk (read pray) that Margaret Stalb was recruited to AsA in time to prevent them going down the same plughole as the other Two.

What concerns me now is low CASA and ATSB staff morale in the face of a possibly hostile industry. While I am quite familiar with regulatory capture, I am concerned that the reverse - a lack of genuine trust and cooperation between regulator and the regulated will set the stage for a major miscalculation on the part of one or more parties and a resulting serious aviation accident.

At the end of the day, CASA and ATSB have a job to do. It will do no good for the GA industry if through bloody mindedness, distrust and timidity we set up for another serious accident that will then be all our faults.


We need to be thinking of "positive mental attitude" and support CASA and ATSB on the assumption that they will make necessary and beneficial, adjustments to their policies. We need to do our level best to be helpful and compliant without being a doormat.


To put that another way, we need to do our best to get along as smoothly as possible and comply as best we can with the regulatory mess and pray that CASA will do likewise. Otherwise we become part of the problem.

Of course if there is no change from the regulator and ATSB then the relationships will worsen, with lethal results for the general public. This is why I pray that PM & C are supporting Mr. Mrdak.

Last edited by Sunfish; 26th May 2013 at 00:44.
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Old 26th May 2013, 02:41
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Steam on.

Sunny with great respect and much affection – Bollocks. These morale deprived, poor little sausages are every bit as much of the problem as the creatures who direct them. Guilty by association; they need to be hounded down, exposed, named, shamed and charged where applicable.

There are FOI out there who couldn't start to write a check system, let alone a supporting manual, pontificating on what 'they' will or will not accept. There are people out there thrice rejected at the point of a legal gun, who are strutting about with their thinly veiled, deep seated problems, using the most despicable of tactics to subvert and manipulate the system in order to justify a 'their safety' case. There are lunatic 'philosophies' being espoused on aircraft handling, enforced by dire threat. There are specifically targeted people, isolated by innuendo and threat. There are ludicrous regulations being added to equally ridiculous policy added to punitive, expensive legal dribble, on a daily basis. There are engineers who don't truly know if using tool 24 instead of tool 25 will land them in jail. There are operators who have spent $100,000 and almost two years to get a simple aircraft onto an AOC. There are operators and pilots who have been decimated on very thin grounds, without a chance of rehabilitation or affordable recourse. etc. etc. etc. The list is very long, documented and available.

Yet PA managed to avoid it all, the blood, sweat and tears and in record time to boot; the only case in living memory of that happening. You have only seen from afar; the tip of a very large, dirty, dangerous iceberg. Positioned safely and cocooned within a warm, sheltered environment, once removed and sanitised by Parliament, you witness the Pel Air debacle. Talk to a Siewart, Butson, Hardy or Killan; get some transcripts, get some "audit" reports, examine some NCN in the raw; and judge for your self, just exactly what we are dealing with here. Reading of swimming about in the dark is nowhere near being there, naked and undefended. Exaggerated?, no – exasperated?- yes. This is no Sunday newspaper beat up, it is real, it is now and happening in a paddock somewhere near you.

I much favour an old testament approach; an eye for an eye suits my current mood. If CASA want my respect, assistance and expertise – they must earn it back, for they have most assuredly lost it. Turn the other cheek, Bollocks....

Steam off - (Ambles off into the dust, mumbling darkly whist scratching same.)

Last edited by Kharon; 26th May 2013 at 02:49. Reason: Certified unlubricated - probably just as well, eh?
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Old 26th May 2013, 03:52
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Intelligently conveyed Sunfish
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Old 26th May 2013, 08:04
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Intelligently conveyed.

But the content is circular nonsense.
We need to be thinking of "positive mental attitude" and support CASA and ATSB on the assumption that they will make necessary and beneficial, adjustments to their policies.
CASA and the ATSB are not supposed to “adjust”, or even make, policy. They’re supposed to implement policy.

CASA and the ATSB implement the most important government policy, very effectively. That’s demonstrated by the fact that you still perceive CASA and the ATSB as the solution and, therefore, the root cause of a problem you perceive.

There is no problem requiring any adjustment of policy. CASA and the ATSB have the full support of the government.
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Old 26th May 2013, 08:39
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While on the subject of CASA bullying, it would be nice to see some common sense in the Aircrew Licencing division. They don't so much think as react to cover their own arses. People are condemned because Aviation Medicine is scared of being sensible. Ask just about any DAME what they think of CASA. It,s usually all bad.
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Old 26th May 2013, 08:47
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Cream puff,

Are you implying it is all part of the civil aviation act and Atsb and casa are just following that direction?

Casa and Atsb could fix a lot of the issues. First job is restoring or getting credibility with individuals and industry. Getting away from the adversarial approach doesn't mean 'being too nice' and not doing the job.

Flyingfox, senator Xenophon mentioned bullying and I think that needs fixing! Even if not true to dispel the belief.
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Old 26th May 2013, 10:32
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No.

You need to know the most important government policy.

Mr Dolan knows the most important government policy.

Mr McCormick knows the most important government policy.

Mr Mrdak knows the most important government policy.

Once you understand the most important government policy, you'll stop wasting your energy on pprune.

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Old 26th May 2013, 10:50
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Charon

I cautioned you a while back to get your mind out of the Goon Show scripts and stop the in jokes and sly superiority. You might recall a suggestion to study some Nietzsche...


Whoever fights monsters should see to it that in the process he does not become a monster. And if you gaze long enough into an abyss, the abyss will gaze back into you.”
― Friedrich Nietzsche

I fear that with your last post you are now beyond use in this debate except to prove Nietzsche right. Perhaps read Sunfish's words tomorrow when you feel better.
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Old 26th May 2013, 10:57
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The dept!

Mrdak has a lot to answer for in the mess. He employed both of these clowns, and sticks by them. I read the report from front to back today. It's a disgrace that our industry has reached this low.
Bring on the changes needed.
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Old 26th May 2013, 11:29
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Cream puff, is it keeping the minister and government out of the spotlight. I'm thinking they haven't done a good job on that one.

Perhaps very fortunate that the press has more interest in afl players sex and drinking lives than aviation.

I reckon you'll be able to cut the atmosphere with a knife at senate estates.

Kharon, consider yourself cautioned. I think you'll be getting a 'show cause' next.

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Old 26th May 2013, 12:42
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QA, SFA, FAA oh it's all too much.

Seems Fort Fumble are feeling the heat? They have advertised for Manager QA Flight Ops and Manager QA Airworthiness. Of course in true Regulator style and having washed up old Pilots and Magic practitioners running the joint, they have not advertised for a Manager QA Safety Systems, even though safety systems has now become the third main disciine at the Regulator. Wankers.
It is interesting how the FAA, CAA, and a number of investigation bureau's around the globe have QA resources, but of course this hasn't been the case at Fort Fumble. Wakey wakey, seems something has awoken the lethargic beast?
It is also interesting how these roles have been rumoured to report to an overall QA Manager, of course that is the Deputy DAS brother-in-law who coincidentally is rumoured to be sitting in the sin bin for a few months! Oh dear, these HR issues just won't go away will they? I know, let's promote the naughty kids!

I also notice that in some circles there is an inkling of support for Mrdak? How bizzare. Almost perverse in my book. He is just another part of the greater problem and deserves nil Kleenex. The only tears I will be shedding is tears of laughter if all of these incompetent clowns are lined up side by side, bent over, pants down around ankles, and getting a giant Queensland size unlubricated pineapple belted up their aft compartment, sideways.

As a side point I have heard that Fort Fumble are going to request additional funding at Senate estimates. Apparently they want to increase the pot plant rejuvenation program, have larger fuel/drop tanks fitted to their comcar fleet for the next time that Capt Star Chamber runs out of fuel, and each employee of the agency will have his/her contracts amended to include the addition of a company provided chamber pot so as to enable a quick release and recycling of contaminated waste; things like regs, the SPM, special audit reports, magical disappearing NCN's, things like that.

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Old 26th May 2013, 12:54
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QA department

Interesting development. I heard a rumour they previously had one years back. They highlighted a lot of issues and as a result got the pineapple treatment. Or was that a false rumour?
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Old 26th May 2013, 21:02
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Kharon:

There are FOI out there who couldn't start to write a check system, let alone a supporting manual, pontificating on what 'they' will or will not accept. There are people out there thrice rejected at the point of a legal gun, who are strutting about with their thinly veiled, deep seated problems, using the most despicable of tactics to subvert and manipulate the system in order to justify a 'their safety' case. There are lunatic 'philosophies' being espoused on aircraft handling, enforced by dire threat. There are specifically targeted people, isolated by innuendo and threat. There are ludicrous regulations being added to equally ridiculous policy added to punitive, expensive legal dribble, on a daily basis. There are engineers who don't truly know if using tool 24 instead of tool 25 will land them in jail. There are operators who have spent $100,000 and almost two years to get a simple aircraft onto an AOC. There are operators and pilots who have been decimated on very thin grounds, without a chance of rehabilitation or affordable recourse. etc. etc. etc. The list is very long, documented and available.
If that is the case, where is your evidence and is it in writing with date time place and names and witnesses?

If it isn't then its just so much hot air. Furthermore, there will need to be a very long list of such actions to make any impression on anyone outside the aviation magic circle.

It is goign to be far easier to help CASA and ATSB make some changes then to try and change things by starting a civil war between industry and regulator.

If we stop being sweet and reasonable and instead go feral then there is increased potential for mistakes to be made leading to another accident, and if that happens, to borrow a few of ATSB's words from the report, we will all have egg on our faces..


In the immortal words of Jack Nicholson; "Why can't we all just get along?"


?rel=0" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen>

Mars Attacks "Why Can't We All Just Get Along?" - YouTube

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Old 26th May 2013, 21:35
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Batter up.

Additional comments. Sen. N. Xenophon.

1.12 Firstly, I believe relationship between CASA's Bankstown Office (responsible for the oversight of Pel-Air and run at the time in an acting capacity by the author of the "Chambers Report") and Pel-Air's management in terms of probity, transparency and impartiality deserves further scrutiny.
1.13 Secondly, I believe it would have been beneficial to publicly examine whether the "demonstrably safety-related" actions taken by CASA against the pilot by CASA were appropriate, reasonable and consistent with other such enforcement. I believe these two issues deserve further consideration.
1.19 It is also important to note the committee's discussion of the ATSB's Canley Vale report. This incident (also a medical flight) tragically resulted in the deaths of both the pilot and the nurse onboard. The ATSB's response to this accident was similar to its report into the Pel-Air ditching. The ATSB also made it very clear in its report that it did not consider CASA's failure to oversee the operator appropriately as relevant. The validity of that view is, I believe, a direct parallel to that exposed by this inquiry for the Pel-Air ditching and equally alarming.
1.22 Ultimately, this inquiry has exposed serious and significant flaws in Australia's aviation safety systems. The general industry attitude towards both the ATSB and CASA is incredibly concerning; it is a mixture of fear, suspicion, disappointment and derision.
1.23 It is my view that CASA, under Mr McCormick, has become a regulatory bully that appears to take any action available to ensure its own shortcomings are not made public. This poses great risks to aviation safety, and the safety of the travelling public. Equally, the ATSB—which should fearlessly expose any shortcomings on the part of CASA and other organisations to improve aviation safety—has become institutionally timid and appears to lack the strength to perform its role adequately. Both agencies require a complete overhaul, and I believe it is only luck that their ineptness has not resulted in further deaths so far. There is an urgent need for an Inspector-General of Aviation Safety, entirely independent of the Minister and his department, to be a watchdog for these agencies.
Well, seems I'm not a lone voice – at least one Senator has managed to cotton onto the mess and although his language is 'politically robust' the warning is, in no uncertain terms, being spelled out. Perhaps those that disagree should send the Senator a "report" explaining exactly where, when and how he and the supporting members got it all so dreadfully wrong. The 'report' could be published on Pprune and CC'd to the members of the committee, the press, and the many thousands of readers here on Pprune who agree with most of the 176 page report.

Algie, sunshine, – the trick is, I put up an argument, you disagree; in a civilised society it's called debate. Now then; anytime you wish to debate the issues – here I stand, ready to be proven wrong. But the results of cheap shots from the sideline could be best seen on the news the other night. The Story featured a 13 y.o. girl being escorted from the football ground, publicly humiliated and nationally identified as one happy to scream invective from the sidelines, but just not quite brave enough to face the man on the paddock – sad comment, good lesson.

Next:-I could take issue with the notion of one Inspector General though, it may be 'operationally expedient' in the short term, but as a long term fix – discuss?

Sunny "If that is the case, where is your evidence and is it in writing with date time place and names and witnesses?".
Be assured, it was where it needed to be when it was required, no hot air in there mate, solid, documented and 'in camera'. There is more for when the time is right: rely on it.

Sunny "It is goign to be far easier to help CASA and ATSB make some changes then to try and change things by starting a civil war between industry and regulator."
I believe many of the problems stem from the industry needing to 'go along to get along'. I believe the time for a sweet and 'reasonable' approach will come, but just not yet. When 'things' are sorted out and we return to where either authority may be relied on, trusted and begins to act in concert with the law, the industry and within the bounds of common decency, then I will be the first to pay compliments, assist and put a metaphorical shoulder to the wheel. Not just yet though; but soon – I hope.

Last edited by Kharon; 26th May 2013 at 21:40.
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Old 26th May 2013, 22:04
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Sunfish, Kharon

Please don't fall into the trap of fighting between ourselves. The 'ills of society' should stick together.

Yes, senator Xenophon didn't hold back in his additional comments!
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Old 26th May 2013, 22:12
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Cream puff, is it keeping the minister and government out of the spotlight. I'm thinking they haven't done a good job on that one.
Your thinking is not informed by reality.

Have you seen any Minister or public official on television with a microphone in his face being asked why he hasn’t resigned over the Pel-Air report?

Next time you’re standing in the queue to get through security screening at the airport, turn to the person behind you and ask: “Do you have confidence in the system of air safety in Australia?” and “Have you heard of the Senate Committee’s report into air accident investigation?”.

It’s all cyber-chip wrapping by now.
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