Senate Inquiry, Hearing Program 4th Nov 2011
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Catch 22?
Operationally, the whole thing of 'that' METAR from Nadi is not too critical; most crew would have a "6000'? WTF" moment. If it were not for the almost immediate follow up report from Nadi, (the carefully spelled out SPECI), then no doubt questions would be asked and clarification requested. But the next report, hard on it's heels would nullify (or make nugatory as we must now say) the previous, probably erroneous report. Some crews may have privately questioned the previous 6000' call, but most would just join the dots and discard it as 'an error', the 'latest' revised SPECI makes much more sense. I could be tempted to bet a bag of sweeties the TAF for Nadi had a similar cloud base and visibility. Face was saved, and perhaps as a courtesy to Fiji, that tiny bit was left out of Mr. Dolan's available evidence.
Thing puzzles me is why it came be omitted from the CASA and ATSB report. It is easily explained; e.g. "our investigation revealed that the ATC in Nadi had inadvertently read 6000 not 600 due to a typographical error, we have addressed this with the Fijian authority"; and endit, off the hook, no foul, no penalty. It is the omissions which now raise the awkward questions.
The 6000' cloud base element was not 'initially' provided; nor was it provided during the two year head scratching period and was only 'discovered' during the 4Corners report.
Why did the ATSB not 'discover' and address the 6000' report error during their research?
Was the omission by CASA of the reported cloud @ 0801 the reason the ATSB failed to mention the erroneous details of 'that' METAR?
FACT : the first version of the Final Report, after the 4Corners revelation, was corrected by the ATSB.
FACT : CASA Accident Investigation Report 09/3 page 7 fails to mention the 6000' CB version @ 0801.
Was the information initially provided to the ATSB deliberately misleading or, is the report a joint effort cobbled together by the ‘parallel’ investigation team under the MOU?
If you put the two reports alongside they almost exactly mirror each other with the exception of 'that' METAR, lately included and not addressed. The CASA report, concluded two years prior included a summary and basic conclusion of the CASA Special Audit Report, which directly conflicts the final audit conclusions/findings, not sighted until 'earlier' this year.
Could this all indicate that during the compilation of the report there was an edict issued prescribing how the conclusions/findings should be written? Was this the work of one pair of hands operating under instructions or a joint effort attempting to brush the incident off as a once in a lifetime non safety related event?
Was the TSI act 'breached' by the CASA manager 'producing' the ATSB briefing? Page 33 of the Transport Safety Investigation Act 2003, part 24 makes the results of nobbling an investigation pretty clear. Then the MOU 4.1 also spells out why this is naughty.
This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof.
Taxi Minister?
Thing puzzles me is why it came be omitted from the CASA and ATSB report. It is easily explained; e.g. "our investigation revealed that the ATC in Nadi had inadvertently read 6000 not 600 due to a typographical error, we have addressed this with the Fijian authority"; and endit, off the hook, no foul, no penalty. It is the omissions which now raise the awkward questions.
Mr Dolan: I will try and add some information to that. As we tried to make clear, there was an initial assessment of the evidence we had available to us, which was essentially about decision-making en route and what informed us and everything else—whether the guidance that was available was reliable. – Hansard.
Why did the ATSB not 'discover' and address the 6000' report error during their research?
Was the omission by CASA of the reported cloud @ 0801 the reason the ATSB failed to mention the erroneous details of 'that' METAR?
FACT : the first version of the Final Report, after the 4Corners revelation, was corrected by the ATSB.
FACT : CASA Accident Investigation Report 09/3 page 7 fails to mention the 6000' CB version @ 0801.
Was the information initially provided to the ATSB deliberately misleading or, is the report a joint effort cobbled together by the ‘parallel’ investigation team under the MOU?
If you put the two reports alongside they almost exactly mirror each other with the exception of 'that' METAR, lately included and not addressed. The CASA report, concluded two years prior included a summary and basic conclusion of the CASA Special Audit Report, which directly conflicts the final audit conclusions/findings, not sighted until 'earlier' this year.
Could this all indicate that during the compilation of the report there was an edict issued prescribing how the conclusions/findings should be written? Was this the work of one pair of hands operating under instructions or a joint effort attempting to brush the incident off as a once in a lifetime non safety related event?
Was the TSI act 'breached' by the CASA manager 'producing' the ATSB briefing? Page 33 of the Transport Safety Investigation Act 2003, part 24 makes the results of nobbling an investigation pretty clear. Then the MOU 4.1 also spells out why this is naughty.
This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof.
Taxi Minister?
Last edited by Kharon; 23rd Nov 2012 at 20:09.
blackhand...
#917
Seeing as you want to stick with the way you addressed an NCN:
WHY was there a failure to follow MITCOM procedure?
#917
Seeing as you want to stick with the way you addressed an NCN:
Root Cause - Failed to follow MITCOM procedure
Gaunty
Are you unable to entertain the possibility – even the remote possibility – that what the crew heard made sense and supported the decision to continue?
There’s no need to resolve confusion, if there’s no confusion.
Doesn’t matter whether the aircraft has 2 HFs or 20. All of them will be affected by the same prevailing propagation and atmospheric conditions.
We both know it's possible for a pilot to receive and understand, with no confusion, a message that turns out to have been misunderstood.
I say again, so there’s no confusion: It is certain that neither CASA nor ATSB knows what the crew actually heard, or what the crew actually understood what they heard to mean.
But again, let’s get out Occam’s Razor. Let’s assume:
- the transcript reflects, precisely, the terms of the transmissions to the aircraft (BTW: I’m certain the transcript contains inaccuracies, at least to the extent it’s capable of different interpretations of what was transmitted)
- the crew received, verbatim, the entirety of the transmissions
- the crew understood that the conditions at Norfolk were below the alternate minima but above the landing minima.
Let’s also assume that the entirety of the pilot population is of the opinion that good airmanship would have a resulted in a decision to divert in the circumstances.
How is it, then, that the system of training, licensing, air operator certification, operational regulation and surveillance results in innocent passengers being put in an aircraft under the command of an ATPL holder, supported by another ATPL holder, who are unable to make a decision that is, apparently, a ‘no-brainer’ to everyone else?
Are there really no systemic issues that may be relevant?
Sunfish: During the ATSB’s most recent appearance at the Committee’s hearings, Mr Dolan dismissed the Reason model as being so-last-century.
These days you just collect a bunch of hearsay, jump to the obvious conclusion, and ignore or cease to continue to investigate anything that might be contrary to the obvious conclusion.
Are you unable to entertain the possibility – even the remote possibility – that what the crew heard made sense and supported the decision to continue?
There’s no need to resolve confusion, if there’s no confusion.
Doesn’t matter whether the aircraft has 2 HFs or 20. All of them will be affected by the same prevailing propagation and atmospheric conditions.
We both know it's possible for a pilot to receive and understand, with no confusion, a message that turns out to have been misunderstood.
I say again, so there’s no confusion: It is certain that neither CASA nor ATSB knows what the crew actually heard, or what the crew actually understood what they heard to mean.
But again, let’s get out Occam’s Razor. Let’s assume:
- the transcript reflects, precisely, the terms of the transmissions to the aircraft (BTW: I’m certain the transcript contains inaccuracies, at least to the extent it’s capable of different interpretations of what was transmitted)
- the crew received, verbatim, the entirety of the transmissions
- the crew understood that the conditions at Norfolk were below the alternate minima but above the landing minima.
Let’s also assume that the entirety of the pilot population is of the opinion that good airmanship would have a resulted in a decision to divert in the circumstances.
How is it, then, that the system of training, licensing, air operator certification, operational regulation and surveillance results in innocent passengers being put in an aircraft under the command of an ATPL holder, supported by another ATPL holder, who are unable to make a decision that is, apparently, a ‘no-brainer’ to everyone else?
Are there really no systemic issues that may be relevant?
Sunfish: During the ATSB’s most recent appearance at the Committee’s hearings, Mr Dolan dismissed the Reason model as being so-last-century.
If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s …
Kharon, if it’s a choice between conspiracy and something else, go for the something else every time.
It seems pretty clear to me that the transcription of the transcript and the references and material dealing with the content of the transcript were changed. But that will be because someone honestly believed that the only material relevant to the foregone conclusion is the SPECI, and therefore the content and implications of the SPECI were the only matters that needed to be dealt with in accurate detail. The error in the METAR, if there was an error, would have unnecessarily confused people, and might have cast unnecessary doubt on the accuracy of the SPECI transcript and other hearsay on which the foregone conclusion depends.
It seems pretty clear to me that the transcription of the transcript and the references and material dealing with the content of the transcript were changed. But that will be because someone honestly believed that the only material relevant to the foregone conclusion is the SPECI, and therefore the content and implications of the SPECI were the only matters that needed to be dealt with in accurate detail. The error in the METAR, if there was an error, would have unnecessarily confused people, and might have cast unnecessary doubt on the accuracy of the SPECI transcript and other hearsay on which the foregone conclusion depends.
Last edited by Creampuff; 23rd Nov 2012 at 21:17.
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Routine Violations: Violations which are a habitual action on the part of the operator and are tolerated by the governing authority.
Exceptional Violations: Violations which are an isolated departure from authority, neither typical of the individual nor condoned by management.
The Reason Model, does indeed allow that deliberate violations fit into the accident investigation paradigm.
Obviously some here believe the first was in play whilst others believe the second.
The straight answer, when I discussed it with the certifying engineer, was that he couldn't give a fluck, he had been doing this for years and CASA could do the other thing. Now of course putting this in a response would mean he would have been given a show cause by the regulator. This is covered by part two of Reason's violations.
Creampuff, I think your razor is getting blunt. Okham's Razor tells us the simplest answer is probably correct and to avoid complicated reasoning.
Exceptional Violations: Violations which are an isolated departure from authority, neither typical of the individual nor condoned by management.
The Reason Model, does indeed allow that deliberate violations fit into the accident investigation paradigm.
Obviously some here believe the first was in play whilst others believe the second.
SIUYA-WHY was there a failure to follow MITCOM procedure?
Creampuff, I think your razor is getting blunt. Okham's Razor tells us the simplest answer is probably correct and to avoid complicated reasoning.
Last edited by blackhand; 23rd Nov 2012 at 23:16.
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A follow up from the Airservices portion of the inquiry.
From Aviation Business:
Aviation Business: Senate inquiry oversteps the mark with abuse
And a quote from someone whose opinion I respect very much:
From Aviation Business:
Aviation Business: Senate inquiry oversteps the mark with abuse
Senate inquiry oversteps the mark with abuse
22 Nov 2012
People sometimes wonder why politicians are held in poor regard, though there has been plenty of evidence lately to answer that question in several jurisdictions.
Earlier this week Federal Senator Bill Heffernan, chairing a Senate Committee enquiring into an ATSB report into the Pel Air accident at Norfolk Island three years ago, rained abuse on Airservices manager Jason Harfield regarding what the senator saw as an oversight on the part of Airservices.
Such an abuse of power in a civil environment might be classed as harassment.
Politicians abusing other politicians is part of their game, however it is generally accepted by the majority of senators that they do not rain personal abuse upon public servants trying to do their job.
These hearings have taken on a decidedly nasty tone, most likely fuelled by evidence provided in camera by people who may have an axe to grind with the ATSB and CASA.
It is unfortunate that senators with little knowledge of modern investigative and safety practices seem to be trying to twist information to seek out issues to attack Government bodies.
Most people in the industry with open minds and relevant experience know the issues of fuel management and weather monitoring are critical safety issues for which the pilot carries primary responsibility.
The spectacle of senators searching for motives in public servants to support accusations from malcontents does nothing to enhance people’s view of politicians.
22 Nov 2012
People sometimes wonder why politicians are held in poor regard, though there has been plenty of evidence lately to answer that question in several jurisdictions.
Earlier this week Federal Senator Bill Heffernan, chairing a Senate Committee enquiring into an ATSB report into the Pel Air accident at Norfolk Island three years ago, rained abuse on Airservices manager Jason Harfield regarding what the senator saw as an oversight on the part of Airservices.
Such an abuse of power in a civil environment might be classed as harassment.
Politicians abusing other politicians is part of their game, however it is generally accepted by the majority of senators that they do not rain personal abuse upon public servants trying to do their job.
These hearings have taken on a decidedly nasty tone, most likely fuelled by evidence provided in camera by people who may have an axe to grind with the ATSB and CASA.
It is unfortunate that senators with little knowledge of modern investigative and safety practices seem to be trying to twist information to seek out issues to attack Government bodies.
Most people in the industry with open minds and relevant experience know the issues of fuel management and weather monitoring are critical safety issues for which the pilot carries primary responsibility.
The spectacle of senators searching for motives in public servants to support accusations from malcontents does nothing to enhance people’s view of politicians.
All that happened in this committee was politicians demonstrating their willingness to appear to be strong on a topic they have not researched, do not understand, and are willing to pursue as a witch hunt without determining who is at fault. Jason and Airservices did not deserve this treatment.
So, for all those people “in the industry with open minds and relevant experience”, are the FIS responsibilities and arrangements at Norfolk Island clearly and mutually understood between Australia New Zealand?
If not, who is responsible for creating that problem and who is responsible for fixing it?
(I’m sure the Senators will appreciate being accused of conducting a witch hunt.)
If not, who is responsible for creating that problem and who is responsible for fixing it?
(I’m sure the Senators will appreciate being accused of conducting a witch hunt.)
Gosh we've come a long way
A look at how expert investigators, managers, and the public respond to accidents lends support to [the] argument that there remains a strong tendency to focus on human failure, human fallibility, and person-centered, internal causes of accidents. Evidence of psychological phenomena such as the fundamental attribution error suggests that this sort of tendency is much broader, possibly affecting society or humanity as a whole.
… The problem is that even a knowledgeable and well meaning professional may succumb to some of the biases of human nature described above. Biases may have at least three specific effects.
First, the bias to view accidents as products of a linear chain of causation may lead investigators to identify human action as the sole proximal cause, then to investigate the causes of human action. This is acceptable, except when the accident did not have a single proximal cause but rather resulted from a combination of co-occurring chance and non-chance events. …
Second, the salience of human action, especially in retrospect, may obscure distal contributors to safety problems which may not appear to be as obvious. If so, limited resources will not be spent on investigating deeper and distal systemic causes remain undiscovered. …
Third, even when some erroneous or risky human action has prominently contributed to an accident, it is a challenge to overcome the tendency to attribute that accident to some characteristic of the worker. …
Other behavior-based approaches to safety management, however, recognize that human behavior has multiple causes and that changing behavior requires changing the whole system not just the person in it ….
… The problem is that even a knowledgeable and well meaning professional may succumb to some of the biases of human nature described above. Biases may have at least three specific effects.
First, the bias to view accidents as products of a linear chain of causation may lead investigators to identify human action as the sole proximal cause, then to investigate the causes of human action. This is acceptable, except when the accident did not have a single proximal cause but rather resulted from a combination of co-occurring chance and non-chance events. …
Second, the salience of human action, especially in retrospect, may obscure distal contributors to safety problems which may not appear to be as obvious. If so, limited resources will not be spent on investigating deeper and distal systemic causes remain undiscovered. …
Third, even when some erroneous or risky human action has prominently contributed to an accident, it is a challenge to overcome the tendency to attribute that accident to some characteristic of the worker. …
Other behavior-based approaches to safety management, however, recognize that human behavior has multiple causes and that changing behavior requires changing the whole system not just the person in it ….
Last edited by Creampuff; 24th Nov 2012 at 00:44.
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Creampuff - the psychology of the human bias was covered in both courses I took part in on Auditing and Investigations.
Interestingly, we concentrated a lot on what has become known as "Hindsight Bias", which was explained fully in the Columbia Disaster inquiry.
If anyone is interested look here
http://ergonomics.osu.edu/pdfs/Press%20Releases/Press%20Release%20Oct03-Creating%20Foresight.pdf
Interestingly, we concentrated a lot on what has become known as "Hindsight Bias", which was explained fully in the Columbia Disaster inquiry.
If anyone is interested look here
http://ergonomics.osu.edu/pdfs/Press%20Releases/Press%20Release%20Oct03-Creating%20Foresight.pdf
Last edited by blackhand; 24th Nov 2012 at 01:21. Reason: found a better reference
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Creampuff
Yes I am. Nolo contendere.
I suspect we are in heated agreement about "most" issues.
And yes your ultimate question does indeed REQUIRE an answer.
What is the number of Inquiries do you think we might need to get it, I think we might be up to total around six or so. I really hope the answer is not 42.
I do not, despite the earnest and sincere efforts here and the Senate, expect much will really change. There are too many competing events the most recent about union slush funds might in fact bring down the Government, if it doesn't, there are still too many more interesting circus events to entertain the proletariat.
It will take a high capacity smoking hole to get the necessary attention and will. You can then expect in the usual knee jerk overreaction for aviation in all it's form to be proscribed.
but I digress.
The CASA ATPL syllabus and examination contains all of the relevant legislation, practices, air leg, flight planning techniques and requirement, PNR, CP, CPDP and so on to enable a pilot who has a CPL with a minimum of 2000 hours flight experience and a Command Instrument Rating to exercise the privileges of operating a transport category aircraft with a MTOW => 5700kg.
The license does NOT proscribe its use other than under the ambit of a COM neither are the flight planning and weather resources forecast and actual denied him.
So we are not here discussing someone proverbially "wet behind the ears". Then there is the type rating.
The pilot simply by the holding of his license and a rating is supposed to be capable of conducting a flight legally and safely.
I would be interested in your view of what exactly the addition of the "carriage of passengers" regulatory matter of which we speak could, would or should have, relieved the pilot of his responsibilities in regard to exercising the privileges of this license using the knowledge imparted in order to obtain it.
Edited to add,
Ockham's razor is much used and abused here.
I am more of the view that Alexander the Greats' solution to dealing with the Gordian Knot is a superior method.
Yes I am. Nolo contendere.
I suspect we are in heated agreement about "most" issues.
And yes your ultimate question does indeed REQUIRE an answer.
What is the number of Inquiries do you think we might need to get it, I think we might be up to total around six or so. I really hope the answer is not 42.
I do not, despite the earnest and sincere efforts here and the Senate, expect much will really change. There are too many competing events the most recent about union slush funds might in fact bring down the Government, if it doesn't, there are still too many more interesting circus events to entertain the proletariat.
It will take a high capacity smoking hole to get the necessary attention and will. You can then expect in the usual knee jerk overreaction for aviation in all it's form to be proscribed.
but I digress.The CASA ATPL syllabus and examination contains all of the relevant legislation, practices, air leg, flight planning techniques and requirement, PNR, CP, CPDP and so on to enable a pilot who has a CPL with a minimum of 2000 hours flight experience and a Command Instrument Rating to exercise the privileges of operating a transport category aircraft with a MTOW => 5700kg.
The license does NOT proscribe its use other than under the ambit of a COM neither are the flight planning and weather resources forecast and actual denied him.
So we are not here discussing someone proverbially "wet behind the ears". Then there is the type rating.
The pilot simply by the holding of his license and a rating is supposed to be capable of conducting a flight legally and safely.
I would be interested in your view of what exactly the addition of the "carriage of passengers" regulatory matter of which we speak could, would or should have, relieved the pilot of his responsibilities in regard to exercising the privileges of this license using the knowledge imparted in order to obtain it.
Edited to add,
Ockham's razor is much used and abused here.
I am more of the view that Alexander the Greats' solution to dealing with the Gordian Knot is a superior method.
Last edited by gaunty; 24th Nov 2012 at 03:43.
Having now gone through the transcript of the 21/11 hearing what I find most troubling is this accepted shift in the ATSB methodology of their core role as the independent transport accident/incident investigator. This is perhaps best demonstrated in the following quote from the transcript:
This quote is significant as it could be almost perfectly type scripted for CASA. However in terms of the ATSB remit it is totally inappropriate, their scope of inquiry should also be questioning the appropriateness of the applicable legislation and whether ASA, CASA, AMSA etc has procedures and oversight that covers off on the associated risks of this particular operation. In other words the operation category shouldn’t be a factor when it comes to the ATSB scope of investigation in any accidents/incidents as serious as this one.
The narrowing of the scope of investigation and the non-issuance of relevant safety recommendations would also appear to be in direct conflict with the ATSB ‘Statement of Intent’ which is written with Ministerial oversight, see here: Statement of intent
Therefore this apparent change in policy by the ATSB must have been ultimately signed off and accepted by the Minister. The following quote from the transcript is significant in regards to this:
Which is coincidental with the change of government and a change of Minister.
That said I would suggest that the Senators be aware that CASA legal has a history, over a number of years, of blatant manipulation and obfuscation of the FOI Act it might be better if the committee request that ‘paper trail’ under the Parliamentary Inquiry disclosure laws. Because even this case appears to have an example of obfuscation under the FOI by CASA legal, see here:
http://www.casa.gov.au/wcmswr/_asset...-ef12-5471.pdf
This version of the SAR was in response to flight nurse Karen Casey’s FOI request. However apparently, from people that know, this is still not the full, unadulterated, original version of the SAR. Which is reported to have had an additional 30 odd pages.
It is also interesting to take a look at the regulator’s disclosure log page: Civil Aviation Safety Authority - Disclosure log
Down the page you will see this PDF file:
30 April 2012
EF12/1779
http://www.casa.gov.au/wcmswr/_asset.../ef-121779.pdf
If you can bear to take the time to download you will see that this file contains scanned documents of all AOC renewals/additions and associated FOI/AWI supporting documents (AOC Checklist Form 069) dating back to 1998 for Transair Pty Ltd.
I’m not sure who made the original FOI request but besides being very revealing of the inner workings of the flight ops and airworthiness inspectorate there is one very notable omission (that I could see) guess what AOC approval/addition is missing? Sorry time’s up…if you go to page 175 (Schedule 1 Part 3) you will see where Lockhart River was first added as an approved route/port.
However when you scroll down to the AWI/FOI 069 form that supports the LHR route/port addition you will find there is nothing, zero, zilch for the flight ops section of the 069 AOC checklist!
Now we could say that these two apparent omissions are just an aberration, an anomaly, as documents do get lost. However I have been made aware that this, call it the CASA omission factor, COF..COF..err COF is a very common complaint (yeah Creamy I know ‘hearsay evidence’) by people in the industry who have made similar FOI requests.
Having submitted several FOI requests with various other federal agencies. I have noted that if an agency agrees to release the requested documents (i.e. not in dispute) those released documents are either pristine full and complete or if there is a ‘lost’ or ‘exempt’ part to the document that will be annotated by a series of blank pages with the FOI reference displayed somewhere.
So perhaps, Creamy can probably help me out here, an additional QON could be asked of the Professor: Is this COF acceptable under the provisions of the FOI Act or is it possibly a breach of the Act?
Mr Dolan: We see a broader issue, which is: what is the support that is provided to flight crews en route in terms of assessing their situation, getting access to weather and other related information, applying that to the management of their fuel and so on? This is in a context where we saw in the AIP something that very clearly said that it is the responsibility of pilots to obtain information necessary to make operational decisions and that pilots will not automatically receive routine TAF information showing deteriorating weather conditions if they are en route to a location. That was the status quo with Airservices, with New Zealand and, as we understand, with Fiji.
This quote is significant as it could be almost perfectly type scripted for CASA. However in terms of the ATSB remit it is totally inappropriate, their scope of inquiry should also be questioning the appropriateness of the applicable legislation and whether ASA, CASA, AMSA etc has procedures and oversight that covers off on the associated risks of this particular operation. In other words the operation category shouldn’t be a factor when it comes to the ATSB scope of investigation in any accidents/incidents as serious as this one.
The narrowing of the scope of investigation and the non-issuance of relevant safety recommendations would also appear to be in direct conflict with the ATSB ‘Statement of Intent’ which is written with Ministerial oversight, see here: Statement of intent
Therefore this apparent change in policy by the ATSB must have been ultimately signed off and accepted by the Minister. The following quote from the transcript is significant in regards to this:
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 approach it has been about four years.
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 approach it has been about four years.
Kharon said: This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof.
That said I would suggest that the Senators be aware that CASA legal has a history, over a number of years, of blatant manipulation and obfuscation of the FOI Act it might be better if the committee request that ‘paper trail’ under the Parliamentary Inquiry disclosure laws. Because even this case appears to have an example of obfuscation under the FOI by CASA legal, see here:
http://www.casa.gov.au/wcmswr/_asset...-ef12-5471.pdf
This version of the SAR was in response to flight nurse Karen Casey’s FOI request. However apparently, from people that know, this is still not the full, unadulterated, original version of the SAR. Which is reported to have had an additional 30 odd pages.
It is also interesting to take a look at the regulator’s disclosure log page: Civil Aviation Safety Authority - Disclosure log
Down the page you will see this PDF file:
30 April 2012
EF12/1779
http://www.casa.gov.au/wcmswr/_asset.../ef-121779.pdf
If you can bear to take the time to download you will see that this file contains scanned documents of all AOC renewals/additions and associated FOI/AWI supporting documents (AOC Checklist Form 069) dating back to 1998 for Transair Pty Ltd.
I’m not sure who made the original FOI request but besides being very revealing of the inner workings of the flight ops and airworthiness inspectorate there is one very notable omission (that I could see) guess what AOC approval/addition is missing? Sorry time’s up…if you go to page 175 (Schedule 1 Part 3) you will see where Lockhart River was first added as an approved route/port.
However when you scroll down to the AWI/FOI 069 form that supports the LHR route/port addition you will find there is nothing, zero, zilch for the flight ops section of the 069 AOC checklist!
Now we could say that these two apparent omissions are just an aberration, an anomaly, as documents do get lost. However I have been made aware that this, call it the CASA omission factor, COF..COF..err COF is a very common complaint (yeah Creamy I know ‘hearsay evidence’) by people in the industry who have made similar FOI requests.
Having submitted several FOI requests with various other federal agencies. I have noted that if an agency agrees to release the requested documents (i.e. not in dispute) those released documents are either pristine full and complete or if there is a ‘lost’ or ‘exempt’ part to the document that will be annotated by a series of blank pages with the FOI reference displayed somewhere.
So perhaps, Creamy can probably help me out here, an additional QON could be asked of the Professor: Is this COF acceptable under the provisions of the FOI Act or is it possibly a breach of the Act?
These days you just collect a bunch of hearsay, jump to the obvious conclusion, and ignore or cease to continue to investigate anything that might be contrary to the obvious conclusion.
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Questions on notice.
Just spent a quiet hour reading the Prof. McMillan – Sen Xenophon passage of play on the 21st. I was just going to 'cherry pick' the questions on notice for future reference and let it sit. But, does anyone else get the feeling that Sen X probably knows the answers to the QON and just wants them on record, from the horses mouth, 'official like'?
It makes some sense; he was quite specific and no one from the panel seemed inclined to chime in until he was finished. The whole exercise seemed to be 'clinically' and carefully executed to get at the IC' s answers 'on record'. You could assume this was for future reference, rather than to scratch Sen X's curiosity bump. The passage seemed gentile and civilised but did I get a whiff of gunpowder on the breeze?
This whiff also creeps into the Dolan later effort once the almost verbatim McCormick style speech had cut no mustard. He seemed to realise that the blustering, 'muscular' stance adopted on entry was not going to work and the rhetoric degenerated almost into gibberish later in the piece. Notably after the FOI and 'paper trail' requests were eased into play, the language descends into an ungrammatical, almost confused state when put on the spot to "read into the Hansard record" (Nash - again). Sen Nash seemed quite determined a couple of times to drive a point home but then ease off after the statement she was seemingly looking for was made. Intriguing stuff, but there was no doubt that the committee wanted the middle level 'paper trail', in camera would do, but they do want it.
Perhaps this was not the tame, easyology session we imagined it to be. In combination the two sessions provide much food for thought, even some robust tautological speculation. Have the Senate team got onto the fast and loose methodology CASA legal have developed and perfected for extreme, tailor made uses of the provisions within the FOI Act? There certainly appears to be enough complaints and examples available for serious consideration.
Aye well; I'll save it for the Bar Room Barristers, should be a lively debate if nothing else.
PS - Creampuff – Agreed: sorry, did not intend to get into 'conspiracy', just joining up some dots, thinking aloud, if you like. So many small unnecessary omissions which, if they had been addressed would not be creating doubt but 'attaboys' for correcting safety issues in a timely open manner.
It makes some sense; he was quite specific and no one from the panel seemed inclined to chime in until he was finished. The whole exercise seemed to be 'clinically' and carefully executed to get at the IC' s answers 'on record'. You could assume this was for future reference, rather than to scratch Sen X's curiosity bump. The passage seemed gentile and civilised but did I get a whiff of gunpowder on the breeze?
This whiff also creeps into the Dolan later effort once the almost verbatim McCormick style speech had cut no mustard. He seemed to realise that the blustering, 'muscular' stance adopted on entry was not going to work and the rhetoric degenerated almost into gibberish later in the piece. Notably after the FOI and 'paper trail' requests were eased into play, the language descends into an ungrammatical, almost confused state when put on the spot to "read into the Hansard record" (Nash - again). Sen Nash seemed quite determined a couple of times to drive a point home but then ease off after the statement she was seemingly looking for was made. Intriguing stuff, but there was no doubt that the committee wanted the middle level 'paper trail', in camera would do, but they do want it.
Perhaps this was not the tame, easyology session we imagined it to be. In combination the two sessions provide much food for thought, even some robust tautological speculation. Have the Senate team got onto the fast and loose methodology CASA legal have developed and perfected for extreme, tailor made uses of the provisions within the FOI Act? There certainly appears to be enough complaints and examples available for serious consideration.
Aye well; I'll save it for the Bar Room Barristers, should be a lively debate if nothing else.
PS - Creampuff – Agreed: sorry, did not intend to get into 'conspiracy', just joining up some dots, thinking aloud, if you like. So many small unnecessary omissions which, if they had been addressed would not be creating doubt but 'attaboys' for correcting safety issues in a timely open manner.
Last edited by Kharon; 25th Nov 2012 at 02:20.
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Creampuff.
I hate questions framed in the negative.
Your post #930.
The prefix " un" to able in your question reverses the effect of my intention.
Must be confirmation bias or some other fancy term for not RTFQ properly.
My answer was meant to convey "yes I am able to entertain" and nolo contendre to that which you posit.
Kerist it's worse than a CASA examination question.
I hate questions framed in the negative.
Your post #930.
The prefix " un" to able in your question reverses the effect of my intention.
Must be confirmation bias or some other fancy term for not RTFQ properly.
My answer was meant to convey "yes I am able to entertain" and nolo contendre to that which you posit.
Kerist it's worse than a CASA examination question.
Creampuff, I think your razor is getting blunt. Okham's Razor tells us the simplest answer is probably correct and to avoid complicated reasoning.
[T]he psychology of the human bias was covered in both courses I took part in on Auditing and Investigations.
Creamy can probably help me out here, an additional QON could be asked of the Professor: Is this COF acceptable under the provisions of the FOI Act or is it possibly a breach of the Act?
Amended to add: understood gaunty
Last edited by Creampuff; 25th Nov 2012 at 02:55.
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Creampuff - Why did the pilot make the error?
Can I leave aside my cultural bias and give you a straight answer, probably not.
As you stated, this is the remit of ATSB, and if I may be so bold, Mr Dolan did not carry out the investigation nor did Big John carry out the CASA Audit.
Up until about half an hour before top of descent into NFI, there MAY have been several systemic failings, after this point, it seems to me PIC had sole responsibility for the aircraft ending up in the water at near Norfolk and not on the hard at his alternative.
Those that subscribe fully to the "swiss cheese" paradigm must realize PIC was responsible for the last three or more holes lining up.
Em tasol, mi les pinis
Your argument is patently flawed. If ‘systemic failings’ were indeed contributing factors to the decision to continue to rather than divert, all that followed after the decision to continue must be attributed, in part, to those ‘systemic failings’.
And just to be clear: Until I hear a replay of the CVR, I won’t be convinced that the decision to continue rather than divert, after transmission of the SPECI, was an error on the part of the PIC.
And just to be clear: Until I hear a replay of the CVR, I won’t be convinced that the decision to continue rather than divert, after transmission of the SPECI, was an error on the part of the PIC.