Senate Inquiry, Hearing Program 4th Nov 2011
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Creampuff me old.
In the unlikely event I ever got into really deep **** 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.
In the unlikely event I ever got into really deep **** 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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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.
Lessons learned type of thing.
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.
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 19:57.
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Why the book is better than the movie
Hansard Page 7.
Or, to put it the tautological way – our reports started to become risible about four years ago. Should I just wonder why?
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.
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.
Last edited by Kharon; 22nd Nov 2012 at 20:31. Reason: My bold
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:
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…
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…
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 21:46.
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.
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:
Source: ATSB Transport Safety Report AO-2009-072 What the ATSB found
PS. Don't underestimate Senator Nash either.
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
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.
PS. Don't underestimate Senator Nash either.
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Let's try a Hypothetical
After the ditching first person out is PIC.( this is fact)
Now the Hypothetical:
To his dismay the aircraft sinks immediately and no one else survives.
Would all and sundry be looking for a way to protect him
After the ditching first person out is PIC.( this is fact)
Now the Hypothetical:
To his dismay the aircraft sinks immediately and no one else survives.
Would all and sundry be looking for a way to protect him
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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ROOT CAUSES of the pilot error
I would nominate the root cause as failing to get the extant weather in a timely manner. ATSB have suggested that this is an underlying causal factor
Other of course have a different rooting cause
Last edited by blackhand; 22nd Nov 2012 at 23:34.
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WHY was there a 'failing to get the extant weather in a timely manner'
Remember, Nominate root cause, nominate remedial action, nominate corrective action.
This concludes the lesson for answering NCNs
Last edited by blackhand; 23rd Nov 2012 at 00:04.
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.
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.
'failing to get the extant weather in a timely manner'
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.
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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Courtesy Ampclamp - a gentleman
Following up this lead, but there seems little interest in doing the right thing and retrieving the boxes. The CVR holds the last 120 minutes and would/should be very useful, for many reasons. But I have bleated long and loud about this issue as have many others. Nuff said - beer o'clock.
Aviation Recorders
100 Cattlemen Road
Sarasota, Florida 34232 U.S.A.
Tel: 941-371-0811 Fax: 941-377-5591
Website: L-3 Communications Aviation Recorders
Documents: L-3 Aviation Recorders Publications Home Page
Kharon, I have been following the thread at Dunnunda for some time. I wish you and the other guys there the very best in your efforts to uncover the truth and to expose any alleged cover up or negligence. Considering the Air France prang location this should be a doddle with any concerted effort . 45 metres is deep and Norfolk is some distance away but far from insurmountable. 4 years is long time to survive in salt water though. Not sure how well those things are sealed. It is about 5.5 atmospheres at that depth.
Have you them directly asked about survivability?
Have you them directly asked about survivability?
100 Cattlemen Road
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Tel: 941-371-0811 Fax: 941-377-5591
Website: L-3 Communications Aviation Recorders
Documents: L-3 Aviation Recorders Publications Home Page
Last edited by Kharon; 23rd Nov 2012 at 06:36.
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Creampuff
I am diverted from answering Sunfish question, more on that later but I cant leave you alone for a moment without you getting all precious.
Could, should, would, not aware, failed to recognise, what in Gods name were they doing up there. Two licensed ATPLs yet.
Why bother to define and promulgate a "SPECI" (is issuedspecifically to bring pilots attention to a significant change to previouslyforecast weather) or METAR fo that matter. Just so pilots could, should, would, not aware, failed to recognise one, without question. Do they have add the words Pan or suchlike in front to get the pilots attention.
The same by your definition "unreliable" HF, I believe 2 are required and were installed, could have provided a simple answer to their "confusion" if in fact their was any. They had a duty of care and the means to clear up absolutely the HF "confusion" particularly in relation to weather.
Fiji NGA request
NGA Fiji go ahead
Fiji NGA request you repeat the current METAR/SPECI words twice.
NGA Fiji etc..
and how do you write that up as a required procedure in the COM, its called airmanship.
Forget what CASA may have deducted/decided, honestly, lets just proceed on the basis they heard the single word SPECI, or weather, or just a scramble of hash with their rego, we've all heard it, and what should have been their actions as pilots or lack of going on from there.
And yes we are in heated agreement about the recovery of the recorders, which I assume is still possible, maybe after 3 years unless they were digital and potted their usefulness is moot.
Why in some evidence I saw (AAT and I am going from memory here) regarding multiple flights across the sectors were all carrying what looked to me like full fuel towards Norfolk save the last few with James in command with I think one exception.
Was this perhaps because that aircraft for one reason or another was no longer able to accept full fuel even if he wanted to put it on.? Hearsay yes "It leaks if you put more than X on so dont" has been put to me that it wont be the first time.
My personal experience with one older aircraft is that the top 4-600 lbs just couldn't be got in.
Nah IMHO CASA and Pelair clearly appear to have/had shortcomings but the root cause is simpler than that according to the ATSB and I personally have not been able to find fault with their basic premise. Punches pulled maybe but after the other day I get that.
My instinct that there is an air of a more serious cover up around this that wont go away.
I'm definitely going to get jumped on now but IMHO the simplest answer is always the shortest way to the truth.
I am diverted from answering Sunfish question, more on that later but I cant leave you alone for a moment without you getting all precious.
Could, should, would, not aware, failed to recognise, what in Gods name were they doing up there. Two licensed ATPLs yet.
Why bother to define and promulgate a "SPECI" (is issuedspecifically to bring pilots attention to a significant change to previouslyforecast weather) or METAR fo that matter. Just so pilots could, should, would, not aware, failed to recognise one, without question. Do they have add the words Pan or suchlike in front to get the pilots attention.
The same by your definition "unreliable" HF, I believe 2 are required and were installed, could have provided a simple answer to their "confusion" if in fact their was any. They had a duty of care and the means to clear up absolutely the HF "confusion" particularly in relation to weather.
Fiji NGA request
NGA Fiji go ahead
Fiji NGA request you repeat the current METAR/SPECI words twice.
NGA Fiji etc..
and how do you write that up as a required procedure in the COM, its called airmanship.
Forget what CASA may have deducted/decided, honestly, lets just proceed on the basis they heard the single word SPECI, or weather, or just a scramble of hash with their rego, we've all heard it, and what should have been their actions as pilots or lack of going on from there.
And yes we are in heated agreement about the recovery of the recorders, which I assume is still possible, maybe after 3 years unless they were digital and potted their usefulness is moot.
Why in some evidence I saw (AAT and I am going from memory here) regarding multiple flights across the sectors were all carrying what looked to me like full fuel towards Norfolk save the last few with James in command with I think one exception.
Was this perhaps because that aircraft for one reason or another was no longer able to accept full fuel even if he wanted to put it on.? Hearsay yes "It leaks if you put more than X on so dont" has been put to me that it wont be the first time.
My personal experience with one older aircraft is that the top 4-600 lbs just couldn't be got in.
Nah IMHO CASA and Pelair clearly appear to have/had shortcomings but the root cause is simpler than that according to the ATSB and I personally have not been able to find fault with their basic premise. Punches pulled maybe but after the other day I get that.
My instinct that there is an air of a more serious cover up around this that wont go away.
I'm definitely going to get jumped on now but IMHO the simplest answer is always the shortest way to the truth.
Blackhand said:
I asked WHY was a 'failing to get the extant weather in a timely manner' THE root cause - not unreasonable under the cuircumstances I reckon, particularly when Backhand's investigation methodology seems to be a 'READY, FIRE, AIM' process that ends with blaming the pilot.
Blackhand replied:
Fair enough Blackhand, but you aren't being asked to answer an NCN.
So in the absence of a reasonable answer I'm left to conclude that inspite of all your supposed experience in both F/W and R/W accident investigation, you really haven't got a clue about ROOT CAUSE analysis, do you?
May as well give up while you're behind Blackhand.
I would nominate the root cause as failing to get the extant weather in a timely manner.
Blackhand replied:
In my experience in answering NCNs that would be rejected, and accused of making excuses for the error. Remember, Nominate root cause, nominate remedial action, nominate corrective action. This concludes the lesson for answering NCNs
So in the absence of a reasonable answer I'm left to conclude that inspite of all your supposed experience in both F/W and R/W accident investigation, you really haven't got a clue about ROOT CAUSE analysis, do you?
May as well give up while you're behind Blackhand.
Last edited by SIUYA; 23rd Nov 2012 at 07:42.
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SIUYA, the question was put about finding the root cause, now you and I may feel that there is more involved, and I have recently had heated discussions with CASA AWI about this; under the "new" paradigm everything else is not include.
For example:
AUDIT FINDING - part fabricated and fitted, no approved data.
My initial response was that this was carried out IAW AC43.
Had it returned as not accepted, after much to-ing and fro-ing including, discussions about Instrument 511, came up with the following that was accepted.
Root Cause - Failed to follow MITCOM procedure
Remedial Action( what was done to fix the problem) - Aircraft recalled and MITCOM procedure carried out - documents attached.
Corrective Action(what was done to ensure doesn't happen again) - Engineer councelled to follow MITCOM procedures, MITCOM procedure in MPM rewritten to ensure no ambiguity.
Now you may feel that this is READY AIM FIRE, and may well be, but this is what Systems Audit is about.
And BTW, I could not give a Frying fruck about you comments reference my experience or otherwise, your bringing of Ad Hominem fallacious argument to the discussions reflects badly on your character
For example:
AUDIT FINDING - part fabricated and fitted, no approved data.
My initial response was that this was carried out IAW AC43.
Had it returned as not accepted, after much to-ing and fro-ing including, discussions about Instrument 511, came up with the following that was accepted.
Root Cause - Failed to follow MITCOM procedure
Remedial Action( what was done to fix the problem) - Aircraft recalled and MITCOM procedure carried out - documents attached.
Corrective Action(what was done to ensure doesn't happen again) - Engineer councelled to follow MITCOM procedures, MITCOM procedure in MPM rewritten to ensure no ambiguity.
Now you may feel that this is READY AIM FIRE, and may well be, but this is what Systems Audit is about.
And BTW, I could not give a Frying fruck about you comments reference my experience or otherwise, your bringing of Ad Hominem fallacious argument to the discussions reflects badly on your character
Last edited by blackhand; 23rd Nov 2012 at 08:46.
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asa and Beaker
The senate hearing at page 28 is as follows:
Question here is:
Where is the evidence Mr. Dolan and why can you not just answer a simple Yes or No and why do you not just in fact, give an answer.
Would help all of us to be more confident that you can get it right and not be influenced by outside influences and take all available information "on-board" and then develop a proper report as is required by Annex. 13
Senator XENOPHON: I want to go to the request for a CASA special audit. That was only requested by the ATSB on 4 July this year?
Mr Dolan: That sounds about right, yes.
Senator XENOPHON: Were you aware that there was a special audit?
Mr Dolan: Yes.
Senator XENOPHON: Prior to 4 July?
Mr Dolan: Yes.
Senator XENOPHON: For roughly what time period were you aware of that special audit?
Mr Dolan: Because we have regular meetings with CASA to talk about various information, we would have been aware of it at the time they kicked it off.
Senator XENOPHON: And you did not think it was relevant for the purposes of your report to obtain a copy of that special audit?
Mr Dolan: Our focus was the en route side of this—
Senator XENOPHON: No, your brief is much wider than that.
Mr Dolan: I know, but we scoped our investigation in that way. We did not see that there was direct significance in the regulatory exercises that CASA was undertaking in relation to the pilot or in relation to the—
Senator XENOPHON: How would you know without seeing the special audit report what its significance would be?
Mr Dolan: We were trying to understand might need changing in the existing rule set that CASA regulates. CASA was giving force to its responsibilities requiring that the existing rule set is complied with—and that is the difference between us as an investigator and CASA as the regulator. So we do not see that it was directly relevant.
Mr Dolan: That sounds about right, yes.
Senator XENOPHON: Were you aware that there was a special audit?
Mr Dolan: Yes.
Senator XENOPHON: Prior to 4 July?
Mr Dolan: Yes.
Senator XENOPHON: For roughly what time period were you aware of that special audit?
Mr Dolan: Because we have regular meetings with CASA to talk about various information, we would have been aware of it at the time they kicked it off.
Senator XENOPHON: And you did not think it was relevant for the purposes of your report to obtain a copy of that special audit?
Mr Dolan: Our focus was the en route side of this—
Senator XENOPHON: No, your brief is much wider than that.
Mr Dolan: I know, but we scoped our investigation in that way. We did not see that there was direct significance in the regulatory exercises that CASA was undertaking in relation to the pilot or in relation to the—
Senator XENOPHON: How would you know without seeing the special audit report what its significance would be?
Mr Dolan: We were trying to understand might need changing in the existing rule set that CASA regulates. CASA was giving force to its responsibilities requiring that the existing rule set is complied with—and that is the difference between us as an investigator and CASA as the regulator. So we do not see that it was directly relevant.
Where is the evidence Mr. Dolan and why can you not just answer a simple Yes or No and why do you not just in fact, give an answer.
Would help all of us to be more confident that you can get it right and not be influenced by outside influences and take all available information "on-board" and then develop a proper report as is required by Annex. 13
Blackhand can be safely ignored. He talks about a "root cause" so he clearly doesn't understand or subscribe to the Swiss Cheese model.
There is a chain of circumstance behind this incident that starts at least as early as the deficient content in the Pel Air operations manual.
There is a chain of circumstance behind this incident that starts at least as early as the deficient content in the Pel Air operations manual.
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Hansard 21/11/2012.
For those unable to easily navigate the Parliament web site.
Download from the Senate - Hansard 21/11/2012.
There are only 33 pages, it is a very quick process.
Download from the Senate - Hansard 21/11/2012.
There are only 33 pages, it is a very quick process.