Senate Inquiry, Hearing Program 4th Nov 2011

[Lookleft]

Is the co - pilot in a relationship with someone?

A bit irrelevant Sunny.

Given the publicity surrounding this event and the poor standard of the report she probably doesn't want put herself in the firing line. If she contradicts the ATSB, CASA and the PIC then she is just going to bring a world of pain upon herself. If safety hasn't been enhanced by the publication of the report and the ATSB can't be bothered recovering the CVR/FDR then any public statements she makes is not going to make much of a difference. I think she is an F/O with Virgin so I don't blame her for just wanting to get on with her career without all the stress of going public.

[Lookleft]

Yes she should but I can understand why she hasn't. Remember the Senate hearing is into the investigation not the incident itself although the lines can be blurred. To suggest that she hasn't spoken publicly because she might be in a relationship (the relevance of which is beyond my comprehension) only serves to diminish Sunny's credibility not hers.

[Sarcs]

DCT given the reporting date is the 27th Feb I don’t believe there will be anymore public hearings, unless of course the committee seeks a further extension.

That said it is possible that the committee can request further witnesses to give evidence in a private (in camera) meeting, something that we won’t know about till after the event or when the Senate sits from the 5th Feb then any private meeting requests will be captured in the Senate Hansard.

Kharon good catch on the NTSB investigator’s manual, although very dry reading it is worth the time to read and there are some extremely relevant sections when comparing to the ATSB investigation process.

Trying to find the ATSB equivalent is a totally different matter, although it is listed here: Operational information
But it appears to be spread across multiple volumes and you also have to pay for the privilege to access, still the FF equivalent referred to several times in their Enforcement Manual as the ‘Investigators Manual’ is either a work of fiction or buried somewhere in Flying Fiend’s basement??

Anyway back to NTSB CVR/FDR and wreckage recovery priorities reference (‘Wreckage Recovery’ pg 57 and CVR/FDR pg 79, pg 155 onwards)….

As the NTSB investigator’s manual displays the retrieval, protection and analysis of the CVR/FDR is given maximum priority in the conduct of their investigation. I have no doubt the NTSB would have moved heaven and earth to retrieve the blackbox from VH-NGA and probably any other parts of the aircraft that they thought would be relevant to their investigation i.e. ‘no stone unturned’.

This extract from the NTSB manual is also of particular interest in regards to information that the FAA (not including the ATC section) are required to provide to the NTSB:

Federal Aviation Administration Information
(1) "Blue Ribbon" medical and pilot certificate records.
(2) Violation and other certificate actions on flightcrew and airline. Obtain certified
copies.
(3) Inspections performed on the airline during the previous 12 month period including base, ramp, en route, ground and flight training program, crew member; dispatcher records (including flight and rest), trip records, dispatch center/flight
following/flight/locating facility. Obtain certified copies.
(4) Latest regional inspection performed. Obtain a certified copy.
(5) Latest national inspection performed. Obtain a certified copy.
(6) Frequency of surveillance. Compare the number and types of inspections performed with regional and national inspections guidelines.
(7) Workload of POI.
(8) Background and qualifications of POI.
(9) Authorized and current staffing level of district office.
(10) Most recent pre-accident/incident flight inspection and post flight inspection results of pertinent en route and approach facilities/aids. Obtain certified copies.
(11) Most recent pre-accident/incident airways facility inspection and post inspection or pertinent en route and approach facilities/aids. Obtain certified copies

Talk about transparency and independent authority…begs the questions;

Q1/ If Fort Fumble were required to provide all of the above would we even be having this enquiry??
Q2/ If the ATSB had the same head of power as the NTSB and were operating to a similar investigator’s manual would the ATSB have produced such a flawed, defective ‘Final Report’ in the first place??

Certainly food for thought!

[Taildragger67]

44m?

Surely the RAN have divers who could easily go to 44m. Why not put it through the budget as a training exercise?

[Sunfish]

Blackhand and lefty, I made no assertion at all. You are the ones with the dirty minds.

Why has the co pilot not spoken? Perhaps because no one bothered to ask?. Or is there another reason? Would the co pilots evidence be relevant or not?

[JetA_OK]

I understand the co pilot spoke to everyone she was required to. This doesn't include 60 mins, 4 corners, PPrune or (much to his apparent disapproval) Sunfish

[4dogs]

In Camera

For Sarcs and all of the other dogs looking around and sniffing the ground, the truth is that you don't get to find out who gives evidence or what is said during "in camera" sessions if they choose not to give any public evidence. Part of the confidentiality is that no one other than the Committee and the Secretariat know what transpires. Parliamentary privilege is a very powerful thing and every person involved in such matters has a very clear understanding of that.

As for Sarcs' prediction: the Committee will not be put off by CASA being too busy to reappear last year. They can invite whoever they feel will add value to make an appearance - the witness decides on public/in camera. The reporting date will not be the controlling factor - a satisfactory explanation of the state of safety regulation will be the driver and I suspect the most unified of all RRAT Committee Inquiries of recent times will not be "whipped" into premature completion.

So what relevant questions do we want CASA to explain?

Stay Alive,

[Cactusjack]

Taildragger, top point! Fiddle the books, perform some smoke and mirror act. There is a dozen ways to skin the rabbit so to speak, bureaucracies are masters of it!! Maybe even sacrifice a months bonus and use that money to retrieve the boxes?

[Sarcs]

4dogs yep up with the Senate Committee processes and parliamentary privilege. Just making the point that if the Senate is sitting and the committee want to hold a private (in camera) or public meeting then they have to 'ask leave' to do so, therefore you can catch that request on Senate Hansard

Oh and you could be right the RRAT committee may require a further public hearing to question the DAS and various members of the GWM (FF), time will tell!

[Kharon]

Just an aside -

I have often wondered why in Australia we do not use the "military" more on SAR than we do. I am sure our RAN would welcome the opportunity to plan and execute (budgetary constraints acknowledged) "as part of 'hands on' training an exercise" to retrieve whatever could be found at Norfolk Island. The guys would love it and it would beat swimming about in Darling Harbour "pretending"; hands down. The RAAF pilots could use their 'nav' time executing a SAR mission and gain real life experience, with a purpose; the Reserves could do ground search (having a ball – uniform and toys).

We have a very good, probably bored military (all codes) infrastructure, paid for and available to fight: why not 'real' NVG practice at low level – but to find a lost aircraft: or, go to sea to 'rescue' trapped submariners (read OBR), RAAF pilots out on SAR. Crazy idea I know, but I'd bet a six pack the troops would be up for it and the trainers glad of it. Why waste the best of the best in a swimming pool (semmantic).

Anyway - Nuff said – I know wind correction angle not equivalent to drift. But it's a point.

[halfmanhalfbiscuit]

Feb could be interesting with the Hempel inquest due to report as well as this inquiry.

[Taildragger67]

Jack,

It's late in the day so I'm not sure if you're having a dig or not.

I think Kharon gets my point - one sees militaries from other nations getting involved in searches; the RAN and RAAF go after stranded yachties (amongst other tasks).

Recovering a CVR / FDR could be, if this thread is to be believed, something which actually does go to the national interest - aviation safety - and hence a reasonable task for the ADF.

My line about sticking it through the training budget is simply to say, as Kharon has, that if the Russell bean-counters wouldn't pass it as an operational cost, then maybe it could be seen as real-life training. Just as when Bullimore and Dubois were rescued and the then Defence Minister, Ian McLachlan, brushed aside questions of cost by saying it was excellent practical training.

Reply over, back to topic.

[JetA_OK]

Funnily enough, if the ADF had sent a team to Norfolk for a training mission they would have flown with ...... Pel-Air

[Sarcs]

HMHB in reference to your mentioning the Hempel inquest perhaps the ATSB could of utilised the RAN to raise the Yak??

Also relevant to the Hempel accident and from the NTSB investigator’s manual is a memo put out by the NTSB Director of the Office of Aviation Safety back in 1991, the subject being the “Implementation of Selective Criteria Policy”, here’s an extract from that memo:

A review of our investigative activity has revealed that although the overall number of accidents are down, our number of field investigations remains relatively constant. Of more significance is the finding that many of these field investigations involve types of accidents that historically and predictably have no safety impact. They very seldom result in anything other than the determination of probable cause.

Accidents that involve experimental, amateur built and aerial application aircraft fall in this category. Because the FAA is required to investigate these accidents to satisfy their obligations, we developed an agreement with them to delegate the investigations when their workload permits. This delegation process has not always been consistent in the number and types of accidents delegated nor in the quality and timeliness of the completed reports and a more uniform application of delegations is needed.

Therefore, in the future, no experimental, amateur built, or aerial application accident will be done as an NTSB field investigation unless there are unusual circumstances that the regional director feels justify the field investigation, and that action has been coordinated with either AS-1 or AS-2.

Although that sounds similar to the way the ATSB prioritise their investigations there is some very notable differences in their actual selective criteria list:

2. Selected emphasis areas:

a. Part 91 accidents with elements common to Part 121/135 operations (e.g., aircraft
typically used in Part 121/135 operations; Part 121/135 training flights, etc.).
b. All fatal general aviation accidents.*
c. Commercial passenger flight incidents with safety improvement potential.
d. Air traffic control incidents with safety improvement potential.
e. Aging aircraft.

*The Safety Board, through a letter of agreement with the FAA, delegates the investigation of all agricultural, home-built, and experimental category aircraft accidents to the FAA. However, for those cases in which the FAA does not accept a delegated accident, the Safety Board must perform the investigation.

Although I can’t imagine the ATSB ever delegating an investigation to CAsA it is apparent from the above that had the NTSB been notified of the Hempel accident and the FAA (FF) refused the delegation, then the NTSB would still be obliged to carry out the field investigation. And even if the FAA (FF) accepted the investigation delegation the NTSB still keeps an element of control or supervision over the investigation:

When an accident is delegated to the FAA, it will be the regional director's responsibility to make sure the delegated accidents meet minimum quality control and timeliness standards.

Which is very different to the Hempel investigation where the ATSB and CAsA totally wiped their hands of the matter.

Just like the CVR/FDR issue with Pel-Air the ATSB should have been obliged to salvage the wreckage. With the relevant history of prangs in the Yak (FOD jammed controls etc), I have no doubt that the NTSB would have recovered the wreck regardless of whether the investigation had been delegated to the FAA (or in the Hempel case the QPS Forensic Crash Unit)!

No as HMHB says it is going to be an interesting month and a half!

[Sarcs]

VH-NGA OBR 49er’d ?

Further to the non-recovery of the blackbox, section 49 of the TSI Act reads:

49 OBR ceasing to be an OBR under declaration of ATSB

(1) The ATSB may, by published notice, declare that a recording, or a
part of a recording, identified in the notice is not to be treated as an
OBR on and after a date specified in the notice.

(2) If the ATSB decides not to investigate the transport safety matter
to which an OBR relates, the ATSB must, by published notice, declare that the OBR is not to be treated as an OBR on and after a
date specified in the notice.

(3) If:
(a) the ATSB decides to investigate the transport safety matter to
which an OBR relates; and
(b) the ATSB is satisfied that any part of the OBR is not relevant
to the investigation; the ATSB must, by published notice, identify that part and declare that part is not to be treated as an OBR on and after a date specified
in the notice.

(4) The ATSB cannot revoke or vary a notice published under this
section.

(5) When an OBR, or part of an OBR, ceases to be an OBR because of
a notice published under this section, then any related OBR
information also ceases to be OBR information.

Q1/ Given Beaker’s decision to not recover the blackbox and that the Final Report has been published, have the ATSB effectively 49er’d any useful evidence contained on the OBR?

It would appear from the TSI that if the OBR has been 49er’d then even if the Pel-Air investigation was miraculously re-opened then two eyewitness statements would be regarded as inadmissible evidence. Which probably suits the likes of Fort Fumble and the operator but may not please the victims and the interested insurance companies.

Q2/ However could this also mean that any interested party can now recover the OBR devices or is the wreckage still effectively quarantined by the ATSB?

Q3/ What would be the legal implications if the wreck and OBRs have been written off by the ATSB and someone, say an insurance company or two, salvaged the wreck/OBR devices i.e. could the OBR evidence then be used in any legal action?

The more that is revealed, or rather not revealed, of this sordid tale the more the pile of pony pooh grows, as flight nurse Karen Casey said: “CASA & ATSB have a lot to answer for, dragging this on for selfish intent is criminal & at the least cruel to all on board. The coverup is surfacing and all will be revealed about the incompetencies of all parties involved.” One can only hope she is right and to quote her again they… “Just stop the B.S & tell the truth.”

[Kharon]

Here here.

Sometimes I sits and thinks – sometimes I just sit.

ATSB - Ben Sandilands – Plane Talking.

[Sarcs]

Another classic Ben Sandilands, hope the Senators are getting his stuff piped into them?

So Beaker’s mob prattles out this:Under reporting of occurrences

But in the enquiry environment Beaker wants us to believe his justification for decimating the once obligatory ‘Safety Recommendation’ is as stated in the following Beakerised policy:

From ATSB supplementary submission 2[1]:

Managing safety issues and actions

Traditionally, accident investigation agencies produce final reports and issue safety recommendations to other organisations or individuals, to encourage change in order to prevent a recurrence of an accident. Further, performance targets are often associated with the number of recommendations issued by investigation authorities. The focus of an ATSB investigation is on achieving safety outcomes; that is through the identification of the factors that increased risk, particularly those associated with ongoing/future risk (safety issues), such that action can be taken by relevant organisations to address the identified 'safety issue'. This does not in itself require the issuing of safety recommendations, although that is an option. Noting that safety recommendations are not enforceable, the issuing of a safety recommendation in itself may not achieve any
tangible safety benefit, if the target organisation elects not to accept and react to the recommendation.

In this regard, the ATSB prefers to encourage proactive safety actions that address the 'safety issues' identified in its reports. Other benefits of this approach are that the stakeholders are generally best placed to determine the most effective way to address any 'safety issues' and the publication of the safety actions that address an issue proactively should be viewed as a positive step that provides for timely safety action prior to the release of the report and a level of completeness when the final report is published. This approach is reflected in the difference that Australia has filed with respect to Annex 13 para 6.8.

The response to a safety recommendation is most often unlikely to be any different to the safety action reported by an organisation in response to an identified safety issue, but the latter is likely to be more proactive and timely. That is specifically the case with respect to the Norfolk Island investigation, where the responses to any formal safety recommendations to CASA and Pel-Air related to the two identified safety issues, are likely to be as per the safety action detailed in the report.

The ATSB is in the process of redeveloping its website to be 'safety issue' focused rather than 'recommendation' focussed. The point of importance is that the safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required.

The ATSB's Safety Investigation Information Management System (SliMS) provides tools for investigators to record and track safety issues and actions, including through the setting up of alerts to prompt periodic follow-up of progress with safety action where a safety issue is open and the safety actions are being monitored (the same process applies if a recommendation were issued). In addition, a standing agenda item is included in the quarterly Commission meetings to review safety issues and actions during the previous quarter, with particular focus on those that remain open.

The ATSB's Annual Plan and part of the ATSB's Key Performance Indicators
specifically relate to a measurement of safety action taken in response to safety issues; in the case of 'critical' safety issues, the target is for safety action to be taken by stakeholders 1 00% of the time, while for 'significant' safety issues, the target is 70%.

For the FY11 /12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.

(NB Carefully read this passage a couple of times and try to understand the Beaker logic, stuffed if I can!)

Hmm…clear as mud yet???

WTF? Beaker’s left hand appears not to know what his right hand is up to, although after reading this crap I think I’ve got a pretty good idea!

The “Managing safety issues and actions” extract also seems to conflict the importance the TSI Act places on the ‘Safety Recommendation’:

"25A Responses to reports of, or containing, safety recommendations
(1) This section applies if:
(a) the ATSB publishes a report under section 25 in relation to
an investigation; and
(b) the report is, or contains, a recommendation that a person,
unincorporated association, or an agency of the
Commonwealth or of a State or Territory, take safety action.
(2) The person, association or agency to whom the recommendation is
made must give a written response to the ATSB, within 90 days of
the report being published, that sets out:
(a) whether the person, association or agency accepts the recommendation (in whole or in part); and
(b) if the person, association or agency accepts the
recommendation (in whole or in part)—details of any action
that the person, association or agency proposes to take to
give effect to the recommendation; and
(c) if the person, association or agency does not accept the
recommendation (in whole or in part)—the reasons why the
person, association or agency does not accept the
recommendation (in whole or in part)."

Maybe the Beaker regime is breaching the TSI Act….what a joke!

[Kharon]

A Fifth column – perhaps.

A coffee and 5 minutes to mull over Ben's latest provokes some interesting thoughts; like I wonder if there is still a "real", old ATSB struggling to get out from under the pile of dross CASA have left them saddled with. The ATSB were always a well respected, world class operation and very few of the main players have changed in the engine room. Some of the 'old school' must be tearing their hair out, but I expect protecting the family rice bowl must come above professional pride and integrity. Whilst it's an understandable position, the aftertaste must be grim.

Perhaps the Senate could dig some of them out and find out exactly what happened with not only the Pel Air investigation but with a few of the other stinkers laying about, Hempel, Canley Vale etc. etc. etc. I believe permanent protection would be available under privilege; any future threats could be passed off as revenge for spilling the beans. QED.

A worrying thing is the time and money required to get 'proper' legal opinion on the 'legality' of the CASA operations with PA. Someone has shot from the hip again only this time, shot their foot off. The question as to whether due process under the Investigation manual and the TSI act was followed is worthy of some serious consideration. Clearly the outcome was pre defined, pre ordained by the gods and executed by the willing accomplice – no question there. Then the deeply hidden first agenda is revealed then the 'amazing' back flip, then the ATSB joining in. Who was the masked man with a smoking gun and only one foot? Bet a dollar he was not wearing a hood or a mask at the time.

Lots of lovely big fat legal issues right there, the legal fandango on the extremes of the law begs so many questions I doubt that simply grilling a few of the top dogs will divine the truth. We need to see managers, auditors, FOI and IIIA investigators, under oath giving their version of events. That would clear some of the deckchairs which cannot any longer support the arses, large and small stuck there.

Did I mention managers ?– I believe I did.

[my oleo is extended]

Mr Kharon, I believe you to be correct. The ATSB does have an inner core that are bursting to be break free of the Beakerology that has been inflected upon them in recent years. Those people can only do what they are permitted to do, even if it includes sitting by as the upper echelon put a red pen through their investigation reports and insist that they are diluted to worthless pieces of paper.

And I must agree that a higher level of inquiry that goes beyond the Senate is desperately needed. The answers are out there, but who wants to sacrifice their careers and the livelihood of their families in the pursuit of truth? Not many bold souls, and that is fair enough. A royal commission would see all stones overturned and an assortment of evidence providers brought to the fore, some willing and some by chain and hook.

I know that out there in aviation land will be an ATSB investigator who has kept his original notes, concerns, drafts and final report, before it was 'modified' by the upper echelon.
I know that out there somewhere are the auditors from the 'CASA Special Audit' of Pelair. They too would have transcript, evidence, and the draft version of their initial report.
I know that out there are the audit team who undertook the general audit of Pelair, they too would have copies of what was handed to their seniors and what actually made it into the mainstream.
These people are the keys to unlocking the 'mystique' of CASA and ATSBeakers actions in all of this. But they too would be held at the mercy of senior management, hence the need for a robust inquiry.

So again dear Senators, it's over to you. You hold the keys to the chest full of treasures, will you unlock it?

[Sarcs]

Top posts Oleo and "K"!

Oleo said:

I know that out there somewhere are the auditors from the 'CASA Special Audit' of Pelair. They too would have transcript, evidence, and the draft version of their initial report.

Oleo don't forget that a couple of those very same auditors were also tasked to help at least one designated CAA Part IIIA investigator conduct and contribute to the infamous, hidden investigation report titled CAIR 09/3.

A report that appeared to initially support the findings of the ‘Special Audit Team’ but then did an almost complete 180 by the time they got to their own findings and conclusions.

NB It would also appear; much like the ATSB A320 report, that the ATSB ‘Final Report’ pretty much mirrored the CAIR 09/3.

As FF is a recognised federal government investigation/enforcement agency they are obliged to conform to the ‘Australian Government Investigation Standard’. Therefore it should follow that the Pel-Air investigation team should have documented, managed, compiled evidence (chain of evidence etc) as per the AGIS 2011, see here:
http://www.ag.gov.au/RightsAndProtec...GIS%202011.pdf
Which I suggest Oleo could/should be made readily available for the good Senators to review?? It would be interesting to see if the FF IIIA investigator(s) have followed ‘due process’ in the conduct of the Pel-Air investigation…perhaps a few more required witnesses to give evidence, the list is growing!

As Mr. Buzzy would say…Bbzz..bbzzz..bbzz…or the Kelpie: “More to follow”!