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Senate Inquiry, Hearing Program 4th Nov 2011

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Senate Inquiry, Hearing Program 4th Nov 2011

Old 22nd Nov 2012, 04:50
  #821 (permalink)  
 
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The CVR would provide very strong evidence of what sounds were actually in the intercom system, with a corresponding strong inference that those sounds were actually heard by the crew. But only the human listening can give first hand evidence of what s/he heard and what s/he interpreted what s/he heard to mean.

True story from someone close to me (I spell the words phonetically to make the point):

Heard in the cockpit: ABC tern rite too wun zero.

ABC: ABC tern right too wun zero.

[ABC’s pilot ‘heard’ an instruction to “turn right, two one zero”. ABC takes up a heading of 210 degrees magnetic. In fact, a second zero was clipped from the instruction to ABC. The words out of ATC’s mouth were: Turn right to one zero zero.]

Heard in cockpit: ABC is your heading wun zero zero?

ABC: Negative, heading too wun zero.

Is that outcome really just the fault of the pilot of ABC?

Rugby League fans may be aware of an hilariously funny song, by Denis Carnahan, about the selection process for the Queensland State of Origin team. The song’s called “That’s in Queensland”, and the first verse goes like this (copyright Denis Carnahan):
Could somebody please help me?

I’m a little bit confused.

When selectors choose for Queensland

Could you tell what map they use?

Where you’re born and where you come from, surely that’s your origin

So could somebody please tell me, what States these towns are in …

Where is Sydney? That’s in Queensland!

Suva Fiji? That’s in Queensland!

Where is Nowraville? That’s in Queensland!

Queensland’s everywhere!
And so it goes. It’s worth a view on youtube.

It struck me that a similar concept applies to the Pel Air ditching matter. I call this song: “Symptomatic Of Other Ills In Society”. It’s in ‘C minor’.

Could somebody please help me?

I’m a little bit surprised

When I’m in a commercial aircraft

Who’s keeping me alive?

The system’s there to protect me: surely that’s my safety net

So could somebody please tell me, who’s helping my Pie-let …

Phone unanswered? Blame the pilot!

Mistake in METAR? Blame the pilot!

Outsourced to NZ? Blame the pilot!

Ops manual deficient? Blame the pilot!

That it’s aerial work? Blame the pilot!

Not RSVM certified? Blame the pilot!

Rules unclear? Blame the pilot!

Hopeless lifevests? Blame the pilot!

Liferaft lost? Blame the pilot!

Audit outcomes? Blame the pilot!

Pel-Air breaches? Blame the pilot!

Lessons learned? Blame the pilot!

Systemic problems? No way! The pilot’s everything!
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Old 22nd Nov 2012, 05:01
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Top post Creamy...laughed so hard nearly fell off the chair!

Dangly Bits are you for real or did you just want to get in the action? I suppose if you really wanted to know you could put in an FOI (if they have them in NZED??) with Airways NZ for the HF transcript for that particular night...although I wish you luck with that as it appears the ATSB weren't successful in obtaining one!
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Old 22nd Nov 2012, 05:19
  #823 (permalink)  
 
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The CVR would provide very strong evidence of what sounds were actually in the intercom system, with a corresponding strong inference that those sounds were actually heard by the crew. But only the human listening can give first hand evidence of what s/he heard and what s/he interpreted what s/he heard to mean.
Is the incompetence, (or unwillingness to gather evidence), sufficient to assume the with-holding of any ungathered evidence ccould constitute a contempt of the Court/ Parliament.

"the whole truth, nothing but the truth, (insert affirmation /or Diety swearing here). The cockpit sounds are NOT insignificant.

So help me God!

You may call it theatre
Yes gaunty, the theatre of the absurd. I'm sure youv'e heard of it?
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Old 22nd Nov 2012, 05:41
  #824 (permalink)  
 
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Brava

Bravo indeed. Splendid post Creampuff except the version I heard was in D major. As in stuff up


Quite made my day that has.
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Old 22nd Nov 2012, 06:34
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Given Creamy's perfect summary in 'C minor' or "K's" 'D major' makes you wonder how the bureau continue's to stand by the report, see here page 6 of yesterday's Hansard:
MD said:We undertook the investigation of the Norfolk Island accident and published an investigation report under those functions and conditions. A number of claims have been made about the inaccuracy of the investigation report or about omissions in the report.

As I indicated, we have provided a range of submissions to the committee addressing the points raised. The latest was yesterday, addressing some assertions that had been made about the fuel planning and management of the accident flight. The ATSB remains satisfied that there is no material error of fact in the report.

We have also satisfied ourselves that, at this stage, no significant new information has been brought to light that requires a formal reopening of the investigation.

I would like to make it clear that the ATSB stands by its report.

Almost totally farcical except in this case it is 'obscene' because this is coming from the 'Australian Transport Safety Bureau'! Or as Senator X mentions on page 4..." A number of pilots have approached me and said that concerns them, because if it goes off to the regulator, to CASA, that may inhibit their willingness to report issues of safety to the ATSB, as the primary safety body for aviation in this country."

Professor McMillan although an obvious expert in the law could best be described as a layman in regards to aviation highlighted perfectly these issues on reviewing the October 22 Hansard:

Prof. McMillan: I am interested that the secrecy provision does not apply to the information-gathering powers of the parliament. This committee has requested information that would otherwise be protected against release under the FOI Act. Clearly that is one way in which a balance has been struck in the legislation.

The other comment that I would make, and this is just an observation from reading the earlier transcript, is that I note the comment of the Chief Commissioner, Mr Dolan, that with hindsight the report could have been a more fulsome report that discussed lines of inquiry that were decided not to be relevant and arguments that were not accepted. Generally speaking, that is by far the better way of ensuring that information gets on the public record in a better form.


FOI is certainly a valuable legal means but it can operate in a fairly random way because of its interaction with exemption provisions and because of the range of documents that are released. (my bolding)[/


Last edited by Sarcs; 22nd Nov 2012 at 08:07.
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Old 22nd Nov 2012, 08:21
  #826 (permalink)  

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Sunfish,

Thank you and I do know about the double bind, having had to compete, and succesfully, over the years gainst operators who continue to operate as such and under the benign supervision of our CASA friends, and I agree with every single syllable and letter of your post.

Just some context around my remarks for you.
I have fairly recently completed a task which involved the building from a blank piece of paper a transport category only AOC with unrestricted worldwide operation and with the highest international SMS, best practise and management accreditations available. It is not BARS which does not even get close. However! Fleet now Citation, Phenom, Challenger and Gulfstream.

100 days between application and grant. This could not have been possible without the proactive support of CASA and a team around me with a great deal of experience and all of four us in "good standing", the COM written from scratch alongside the CASA guide and an internationally accepted template that would ubsequently be used for application to the aforementioned. I hold an further iteration of that in which CASA are particularly interested.

Fairly senior pilot applicant for a job and with the view that he didnt expect us to have one for "at least 18 months, but I can probably help you there", mistakenly asked with a straight face yet "whose Ops Manual did you steal/plagiarise to achieve that then". Your case rests.

Frank Arouet

Your namesake as a well known and oft quoted author had some very insightful comments in that direction and I have experienced it first hand. Usually with Leadsled and T28 as principal actors.


Creampuff,

Indeed, your legal interpretation of the HF content may well be correct, we shall see, and, we should also be agitating for the recovery of the recorders.

As you aver they may or may not shed any further light, but, shouldn't we, if only for the cause of natural justice, make them available. Or does the age old legal principle of letting sleeping dogs lie or in political terms "don't ask a question to which you do not know the answer."

Sarcs

I am sure we must have been watching the same broadcast but I came away even more confident than less with the ATSB and Dolans calm but fearless handling of the whole thing.

Are you suggesting that we reduce the level of inquiry to the "are you still beating your wife" category.

IMHO they got it right, the first AND last time.
They were IMHO prescient in recognising the hornets nest it would inevitably stir up, and the consequences that would follow, they had been there before.
They were going to be on a hiding to nothing as the messenger.
They were not the cause of the accident merely the reporters.


The fairly lengthy exchange surrounding the ATSB changing of an important safety factor from Critical to Less on the same evidence revealed to me the tight rope performance required by the ATSB in maintaining a difficult balance of fairness.

This is the time for more not less calm and reasoned dialogue.
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Old 22nd Nov 2012, 08:27
  #827 (permalink)  

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Sarcs.

Oh and BTW I missed your comments re McMillan at the bottom of the page.
Good point.

I agree with him.

But that process was not then available to the ATSB or if it was then it was not clear, lets hope McMillan clears the way on this so the ATSB or any department in this situation does not have to argue with both hands tied behind their backs and wearing snorkel and goggles.
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Old 22nd Nov 2012, 09:13
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God spare us.
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Old 22nd Nov 2012, 09:32
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If:

- the upshot of all of this is that CASA and the ATSB stick to the line that the only cause of this incident was bad airmanship on the part of the PIC, and

- the basis of that conclusion is that the PIC failed properly to assimilate and make the correct decision in the context of information given to the PIC,

the right thing to do would be get the CVR (if its duration of recording goes back to point at which ‘CASA’ says the information was given to the PIC) to find out the quality and content of the transmissions received.

(I note that even if the proximate cause of the ditching was bad airmanship, it does not excuse the ATSB or CASA from doing nothing about the lifevest and liferaft issue. The silence and inaction on that stuff really makes me sick to the stomach.)

But on the question of the information available to the PIC, let’s continue with the assumption that the PIC received and understood, verbatim, what’s in the transcript.

My reading is that at 0801:31 Nadi makes a transmission addressed to NGA, in these terms:
METAR Norfolk at 0630 Zulu wind 300 09 knots 9999, few 6,000 broken 2400 temperature 21 dewpoint 19 QNH norfolk 1011 remarks closed till 1930 UTC go ahead.
The transcript says that the response from NGA was:
Ahhh ...copy... just say again the issue time for the METAR.
I note that there are no other “Ahhh”s in the transcript quoted above.

Now I’m only a wheelchair-bound geek from Hicksville, and this may be pure speculation, but maybe the crew member who was on the radio felt compelled to respond, so that Nadi knew the transmission had been received, but the “Ahhh” was a verbal ‘head-scratch’ about the “few 6,000 broken 2400” bit. I know that if I were in an aircraft in which that transmission were received by the people with whom I’m fortunate enough to fly, the phrase “few 6,000 broken 2400” in a METAR would produce a ‘WTF?’ moment.

Irrespective of what caused the “Ahhh” and what was going on in the cockpit, at 0802:32 according to the transcript – that’s just one minute after the METAR quoted above - another transmission was sent to and acknowledged by NGA:
Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at 0800 Zulu... auto I say again auto, alpha uniform tango oscar, wind 290 08 knots, 999 november delta victor, overcast one thousand one hundred , temperature 21, dew point 19, QNH Norfolk 1012...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.
So – again assuming all of this has been received word-for-word – on what basis does the pilot get crucified for deciding to continue?

Let’s assume the crew aren’t idiots, and their mutual head scratching resulted in them concluding that the “few 6,000 broken 2400” information may be erroneous, and perhaps instead should be “few 600 broken 2,400”. However, before they ask the question, the SPECI comes through. The SPECI says “overcast one thousand one hundred”.

Is that really the basis on which this entire mess gets pinned on the PIC? Has ‘CASA’ really decided that that piece of information should have resulted in a diversion?

Last edited by Creampuff; 22nd Nov 2012 at 09:33.
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Old 22nd Nov 2012, 09:47
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gaunty

I have fairly recently completed a task which involved the building from a blank piece of paper a transport category only AOC with unrestricted worldwide operation and with the highest international SMS, best practise and management accreditations available. It is not BARS which does not even get close. However! Fleet now Citation, Phenom, Challenger and Gulfstream.
So that'd be this mob then: A First for Australian Business Aviation | International Standard for Business Aircraft Operations (IS-BAO) | NBAA - National Business Aviation Association

I see the good Senator X has caught onto the tautological comment from the DAS that gobbles had in his last post on this thread: http://www.pprune.org/7528218-post825.html

Senator XENOPHON: Just finally from me—again, possibly on notice—can you advise whether CASA has any right to access an operator's internal investigations? What about internal disciplinary proceedings? If Mr McCormick reads this I hope he does not consider this a 'tautological rubbish' question.
(my bold)
Onya Nick!

Sorry Creamy almost missed your post, which is extremely relevant because for some reason the ATSB initially missed the erroneous 0630 METAR that was relayed at 0801 UTC (giving few at 6,000') and subsequently due to the 4C program had to correct their report.

Something that is equally troubling is that in the CASA Accident Investigation Report 09/3 on page 7 there is this statement for the 0801 UTC NADI communication:
0801 UTC NADI ATC provides the aircraft with the METAR for YSNF issued at 0630 ZULU. This was then updated with an Auto SPECI for Norfolk issued at 0800 ZULU. Wind 290 at 08 Knots cloud (OVC) at one thousand one hundred ft AGL, 21°C and the dew point was 19°C and QNH Norfolk 1012.
Which besides leaving out several parts of the true transcript also totally leaves out the details for the 0630 UTC METAR and the pilot asking for the issue time to be repeated.

So my question would be was the CASA truncated version the one that was originally given to the ATSB and hence the reason why they missed the erroneous "few at 6,000 ft" message??

Last edited by Sarcs; 22nd Nov 2012 at 11:25.
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Old 22nd Nov 2012, 12:26
  #831 (permalink)  

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Creampuff me old.

In the unlikely event I ever got into really deep shit you would be on my team.

However if wishes were fishes pigs might fly. AND only if you are able to intellectually separate the cause, IMHO pilot error, from the the inevitable consequences revealed by the ATSB, which after all is their job.

Herr Dolan, "Mein Fuehrer, we are getting our asses kicked on the Eastern Front and our heads handed to us on the Western Front.". Fuehrer in high dudgeon " take zis man outside and have him shot, slowly and painfully"

For me personally on the evidence yes, action: a rug dance about why he had departed from the COM and some serious (CASA did it) retraining a repentance of his sins and a one pager on why he should keep his job.

Yes, by ATSB and

By CASA:
"can I take that on notice" (and hope it goes away, OR write a note to everybody telling them everybody not CASA is an idiot ) by CASA. Unfortunately we can only give an unequivocal 50% answer because 50% of our FOI seem IMHO to having trouble recognizing a duck when they see one.

Proposed Senate Recommendation:

That CASA FOI be trained By the Audubon/Gould Society in the identification and recognition of species Chordata/Aves//Anseriformes/Anatidae.

Now Mac is supposed to speak for CASA, bit I suspect, actually know, the many fine, professional and dedicated staff who know what a duck looks like wonder whatever it is they did on this earth to be cast into perdition. They like most of us are just passengers on the great aircraft of life driven by aberrant pilots.

How the fcuk do we get off.

Sarcs

Yup

And

No

While it is no longer my direct responsibility, I would be as Hef asks, advising name rank and serial number only in front asking back channel how do we sort this legally. It has never go to that point.

IMHO Bill H is much underestimated as in "dumb like a fox". Sen X has a good mind and is genuinely concerned, Sen F despite his clearly impeccable military aviation creds has AFAIK not been tested in the Australian civil crucible. That he has adds a certain "health" to the inquiry, juries out, however, I am of a certain age where I have many high ranking serving military and ex military friends, most I would without hesitation trust with my life, but in a much lesser proportion than civilians would not. I suspect though were we to share the odd case of a good red we would find much to agree on and have much to discuss.
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Old 22nd Nov 2012, 12:37
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Sarcs, "Nuthin Suss" from me. Me and a few of the boys were talking about it and the 4C show. We couldn't remember if he made a MAYDAY call to inform rescuer's of the situation, POB, area to search etc.

Lessons learned type of thing.
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Old 22nd Nov 2012, 20:56
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Gaunty, I'm sure you are justifiably proud of your achievement - developing the full suite of paperwork and CASA approvals in One Hundred days is indeed a feat.

However, there is just one question that bothers me and perhaps you could enlighten me:

You say that the entire responsibiity for the Westwind ditching is to be born by the pilot - Dominic James.

By implication, you are also stating that quibbling over the state of the Pel Air Operations manual, Pel Air procedures (or lack of them), CASA and Pel AIr supervision and training and Air Services Weather reports is irrelevent. The buck stops with the pilot.

Doesn't that conclusion imply that your entire One Hundred Day certification achievement is meaningless?

You cannot deride criticisms of CASA and Pel AIrs operational paperwork as unimportant while at the same time trumpeting the importance of your own paperwork and approvals.

To put that another way, why would you expect your pilots to operate to your standards and procedures when whatever they do, they are going to bear the full responsibility of any accident? Isn't your paperwork merely window dressing?

Please explain.

Last edited by Sunfish; 22nd Nov 2012 at 20:57.
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Old 22nd Nov 2012, 21:30
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Why the book is better than the movie

Hansard Page 7.
Senator NASH: You were just saying then that you had no need to make any recommendations because CASA and Pel-Air had told you what they had done to address the issues. When was that?

Mr Dolan: It was in the course of finalising the reports. Part of the directly involved parties' process, sending a draft report out with identified safety issues in it is to seek information from those parties as to what action they have taken, or propose to take, in response. Our aim is that by the time the report is complete we have good information about action that is taken or proposed and can satisfy ourselves as to whether further action needs to be recommended. So it is an integral part of the way we run our process.

Senator NASH: It is almost as if you have said, 'Here are the issues,' and CASA and Pel-Air have come back and told you what they have done and then you do not make a decision about whether you need to make any recommendations until that point in time—is that correct?

Mr Dolan: That is correct.

Senator NASH: Has it always been the case?

Mr Dolan: I would have to check with colleagues. It certainly has not always been the case; it has been the case for my entire tenure of 3½ years in the organisation and its predated my arrival by a year or two—Mr Walsh?

Mr Walsh: Yes, I think for that specific approachit has been about four years.
Or, to put it the tautological way – our reports started to become risible about four years ago. Should I just wonder why?

Last edited by Kharon; 22nd Nov 2012 at 21:31. Reason: My bold
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Old 22nd Nov 2012, 22:45
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Some critically important aspects of the transcript show why relying on hearsay like transcripts is fraught with risk.

Understand what the transcript process is. Someone is listening to a recording and typing out what they hear.

Have a close look at these extracts, and note some odd things:
… few 6,000 broken 2400 …
…overcast one thousand one hundred…
Note that in the second extract the altitude transmission is typed out in words, but in the first extract the altitude transmissions are typed out in numbers. Note also that in the first extract there is a comma in “6,000” but no comma in “2400”.

Do people make mistakes when typing? You bet.

How do we know there are no errors in the transcript? We don’t.

Do we know that “2400” means “two thousand four hundred” was transmitted? We don’t.

Do we know that the person transcribing didn’t make a mistake and type “2400” instead of “240”. We don’t.

What we do know, for sure, is that:

1. if “few six thousand” was transmitted, that was a mistake by someone – either by the person making the transmission or in the material the person was reading; and

2. we don’t know, for sure, and neither CASA nor ATSB knows for sure, what was heard and understood in the cockpit.

For all we know the “aaaah” moment resulted from the Nadi transmitting and the crew hearing “few six thousand broken two hundred and forty”. A double ‘WTF?’, resolved 30 seconds later by the SPECI. And note that a SPECI can be issued for improvements in the weather.

Someone should fit voice recorders to these aircraft, so that there would be less doubt about what was received in the cockpit…

Last edited by Creampuff; 22nd Nov 2012 at 22:46.
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Old 22nd Nov 2012, 23:03
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gaunty...

Fair comment on CASA. And I agree that there are many fine, professional and dedicated staff there who must be absolutely tearing their hair out seeing the antics of the idiot management team that are presently on public display.

if you are able to intellectually separate the cause, IMHO pilot error
What are the ROOT CAUSES of the pilot error that you're referring to gaunty? Because the way that I'm seeing and hearing it, the buck doesn't stop with the pilot. I'll give you a hint:

The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not minimise the risks associated with aeromedical operations to remote islands. In addition, clearer guidance on the in-flight management of previously unforecast, but deteriorating, destination weather might have assisted the crew to consider and plan their diversion options earlier.
Source: ATSB Transport Safety Report AO-2009-072 What the ATSB found

PS. Don't underestimate Senator Nash either.
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Old 22nd Nov 2012, 23:43
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All and sundry would hopefully be trying to ascertain the facts, based on first-hand evidence, rather than on hearsay and tautological rubbish and ‘CASA’s ‘opinion’ about ‘airmanship’.
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Old 23rd Nov 2012, 00:48
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I would nominate the root cause as failing to get the extant weather in a timely manner.


WHY was there a 'failing to get the extant weather in a timely manner'?
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Old 23rd Nov 2012, 01:13
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Slight thread drift but for all those tautologists there is now a newly formed Tautology Society that is ‘openly recruiting’.



This Society is also being strongly endorsed by the Association for Garbologists, who we all know is at the forefront at hiding all manner of possibly revealing secretive material inside the local rubbish tip. They standby a guarantee that they will bury all potentially incriminating material so deep in the local tip that even the most impressive FOI submission will not succeed in revealing any of those embarrassing documents.

For those of you interested in enquiring about a membership please bare in mind that the society is essentially secretive therefore all enquiries can only be through the post. Here are the address details:

C/- 'Anonymous' (Tautology Society enquiry)

NOTE: Apologies there will be some delay with the address details as some of the society's members have chosen to 'redact' the address as part of an FOI request.
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Old 23rd Nov 2012, 06:54
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'failing to get the extant weather in a timely manner'
But ‘failing to get the extant weather in a timely manner’ is not what ‘CASA’ says is the problem. ‘CASA’ says – that is the whole of CASA apparently – the PIC failed to properly assimilate the information the PIC had, and had the PIC properly assimilated that information, good airmanship would have resulted in a diversion.

The trouble is that CASA’s opinion is based on hearsay and an assumption that may be invalid.

The hearsay is the transcript of radio communications, and the assumption is that the PIC heard, verbatim, what’s in the transcript. Even if CASA’s opinion is based on listening to the ground recording of the actual radio communications, its opinion is still based on the assumption that the PIC heard, verbatim, what’s in the ground recording.

From the ATSB report:
The flight crew reported that, at the time, they were either not aware of or did not recognise the significance of the changed weather that was reported in this SPECI. They advised that if either had realised that significance, they would have initiated planning in case of the need for an en route diversion.
[my bolding]

There’s a profound difference between “not being aware of” something and “not recognising” something.

CASA has decided that:

1. the crew heard all of the SPECI transmission as stated in the transcript, and

2. the crew either:

a. did not understand what the SPECI meant; or

b. understood what the SPECI meant,

and therefore the decision not to divert was the result of bad airmanship.

Very big call to make on the basis of hearsay and an assumption that may be invalid.

Does anyone know if the duration of the CVR recording would be sufficient to cover the 0801:31 transmission and after?

It seems to me to be critically important to find out not only whether all of the SPECI transmitted at 0802:32 was received by NGA, and in precisely what terms and at what signal quality, but also what precisely was received by NGA a minute earlier. It seems to me that any reasonable assessment of what the crew should have assimilated and decided can only be conducted on the basis of what the crew actually heard during the SPECI transmission, in the context of what the crew actually heard a mere minute or so earlier.
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