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Senate Inquiry, Hearing Program 4th Nov 2011

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Senate Inquiry, Hearing Program 4th Nov 2011

Old 15th Feb 2013, 23:52
  #1041 (permalink)  
 
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"and perhaps highlights the angst that highly regarded ATOs have been feeling in recent times".

Sarcs,
no wonder given the BK ex baggage handlers perchance for pulling experienced ATO's briefs, even a highly respected ex CASA senior examiner of airmen ran afoul of the chamber pot.
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Old 16th Feb 2013, 01:45
  #1042 (permalink)  
 
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Old Akro, I agree with your comments, however CEO's in private enterprise do fit into the 'accountable person' classification. Unfortunately, and wrongly, Government people, such as the CASA, don't have to be accountable for their actions, pretty well no matter what. This is where the system breaks down. Until the rules of the game change and these people are made to be accountable for their actions nothing will change.

'K', agreed. The Chamber Pot has learned from other long term game players and survivors, and has most likely been working very hard on executing a series of manoeuvres with the intent of elevating himself into a deeper corner of the trough, however the game plan may have been revealed, and his chess strategy revealed?
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Old 16th Feb 2013, 08:45
  #1043 (permalink)  
 
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Internal ATSB email to Mr Dolan, cc Mr Sangston, dated 9 February 2010:
Quote:
… When the aircraft ditched, both the flight crew and the operator stopped their Westwind Aeromedical operations. CASA coached and guided the operator very well and they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pel-Air are now operating again. The same thing hasn’t happed to the flight crew. While they may not have been the ‘Aces of the base’, they were following the relevant procedure provided by both CASA and their operator. …

[Underlining in email]

Oh dear.
To follow on from Creamy’s post, which perhaps highlights the turning point where the ATSB’s investigation all went South, here is (hopefully if I've got it right??) the full and complete email from 'ATSB officer' (ps thanks Creamy) to Beaker and Sanger :






Now if you combine that full and frank 'ATSB officer' proclamation with the Chamber Pot review and bagging of certain members of his fellow BK Flight inspectorate, well maybe we should be writing a 'Safety Recommendation' that highlights a 'Critical Safety Issue' in the lack of proper oversight by FF of the Pel-Air operation.

After all as the 'ATSB officer' points out they'd effectively covered all the other systemic operational issues that related to this accident...

Last edited by Sarcs; 16th Feb 2013 at 09:54. Reason: stand corrected Creamy...hmm I shouldn't just assume!
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Old 16th Feb 2013, 09:20
  #1044 (permalink)  
 
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Not sure the person whose nickname you've stated was identified, in the tabled documents or in the course of the hearing, as the author of the email.

Should you be stating that nickname?
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Old 16th Feb 2013, 10:01
  #1045 (permalink)  
 
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Well...booger I..!

Gee, thanks Senate hearing...right out of the mouth of Jmac himself.!!
"...we are not a commercial regulator, we are a safety regulator"

Geezus, how many decades to wait for that admission?
Could be some interesting legal implications there.!

And as for X question re any CASA consideration to unwarranted expenses to a business...quite frankly CASA just doesnt give a rats arsK....safety regulator or otherwise.
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Old 16th Feb 2013, 11:07
  #1046 (permalink)  
 
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Creampuff, the interesting thing in that email trail is that the ATSB unnamed Investigator mentions the 'Reason cheese' approach, something that has been accepted as a form of best practise across investigative communities. Yet this must have disturbed the Beaker as he has made it abundantly clear that he operates from a much higher plain than Reason, hence his recent high level ramblings about things beyond the Reason scope! Considering that CASA's very own Associate DAS himself has been challenging the theories on 'Just Culture' in somewhat opposition to what his beloved ICAO promulgates, shows that these clowns have too much frickin time on their hands enabling them to challenge Newtons laws on gravity as well as everything else and they need to pull their heads in and do what they actually should be doing - Increasing the level of aviation safety in Australia, FFS.

I think everyone has had a gutful of these mad scientists challenging the laws of relativity and want some real aviation people placed in these roles who are actually able to define, improve, lead and better our industry rather than tearing it asunder.

I believe the boiling Chamber pot cauldron is yet to fully manifest itself and there is much more to the inner workings of these aviation bodies than has been revealed so far. The entire episode gets worse by the week, and the level of incompetence, obfuscation, ignorance and sheer stupidity is mind numbing.
The ATSBeaker changes its mind more than a pregnant bride, and CASA couldn't identify a root cause if one dropped on their heads and started defecating!
In regards to the Norfolk report, a bunch of high school graduate could have written a better piece of work and the fact that FF are still maintaining the old chestnut of 'it was all Dom's fault' is ample proof that immediate action must be taken to remove one of the root causes of Australian aviation safety being compared to Lebanon's! What's next, Kim Jong Un hired as a Consultant???

Last edited by my oleo is extended; 16th Feb 2013 at 11:14.
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Old 16th Feb 2013, 12:27
  #1047 (permalink)  
 
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The chambers report also raises concerns regarding resources awi and foi and audit schedule running late.

Jmac has addressed resources but it does look there was an issue there. I think he resisted in the inquiry. One senator chirped in something like things were bad when john took over.

I suppose the question is was casa resourcing an issue? The author of the chambers report seems to indicate it was.

Or is this a similar problem to what we have seen in financial regulation?

Just a thought. Could the Atsb now say as casa allegedly breached the mou and withheld information they could prove important to the investigation the existing report and investigation needs to be re opened?

Perhaps the senators could recommend with expert assistance from NTSB or AAIB.

Last edited by halfmanhalfbiscuit; 16th Feb 2013 at 16:03.
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Old 16th Feb 2013, 23:18
  #1048 (permalink)  
 
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Cause and effect.

The cause is hidden; the effect is visible to all. Ovid
Well, I've tried to fathom it, in a fair way as a reasonable man should, to determine the cause of the "The Chambers Report". I regret it will take a higher authority, time, money and some considerable effort to determine, accurately the reasons, motivation, purpose and beneficiaries of the document. We can, and probably will speculate for a while on that, in many cockpits, bars, cafe's and other places where aircrew meet.

Some of the worlds nicest folk have produced the most horrendous documents, usually in fiction, occasionally with a nod towards fact or even legend; but I wonder here, I truly do, at the true nature of this remarkable document.

The potential effects emanating from this badly drafted, weasel worded, self aggrandising, incompetent, amateurish report are truly remarkable. There arise from this document many questions which, for one I would like to have answered in the cold, sober light of day, by a competent, independent Judge in a court of law.

Consider:-

1) The DAS had this report for a while; if you were a Chief pilot or manager how would you respond to it?. Clearly, something is very wrong and should the report be tested and proven concise; then documented proof should be available to all of swift, executive action and cure.

2) I believe, the author of "The Chambers Report" has now managed three of the most significant, contentious incidents in the recent history of GA: Pel Air, Airtex and Skymaster. Each and every one has been rancorous, acrimonious, declared by industry to have been, very like "The Chambers Report" an indication of the fault lines, injustices and maladministration inflicted on an industry which can't and dare not challenge the local street bully.

Old Akro # 1077 – "and I would expect (have seen) guys dismissed or demoted for better answers than we've seen from Messer's McCormick & Jordan. Can you imagine a Chief Executive (or Chairman) not being able to answer equivalent questions in a shareholders meeting? It would be a scandal." etc.
As this is a 'public service' event, we need be a little more circumspect, however there should be a call made, and there is provision for the suspension of the author of "The Chambers Report", at least until such time as an investigation is complete and it establishes that the "Author" is, indeed, a fit and proper person, competent and qualified to wield the powers, bestowed by Parliament on a "Manager" in a highly visible, safety sensitive industry.

Problem: if the Pel Air debacle is openly re examined, then the motivation, directions, decisions made, actions taken in the other two cases (Airtex and Skymaster) manipulated and managed by the author of "The Chambers Report" must be suspect and are, in all probability, akin to the John Quadrio case and likely to be proven legally "unsafe".

Ah well, so much for idle speculation, time and evidence will no doubt provide the correct answers. I just wonder if the DAS and his willing accomplices realise how very easily avoidable this now public spectacle; this waste of tax payer time, money, credibility and effort could have been avoided. Is there time to affect a cure?

Hosea 8.7 - For they sow the wind, and they shall reap the whirlwind.
Change of pace -


Last edited by Kharon; 17th Feb 2013 at 00:38.
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Old 16th Feb 2013, 23:48
  #1049 (permalink)  
 
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So, basically, am I wrong in thinking that CASA and the ATSB are joined at the hip? The "independent safety investigation" service that ATSB was supposed to provide in the interest of safety - because aviation safety in itself was so important that it transcended mere regulatory matters of infringement and punishment, is now completely gone.

Furthermore, am I wrong in thinking that both entities will do anything and everything to maximise their own chances of organizational survival, including destroying or protecting any person or entity for no good reason whatsoever?

To put that another way, apparently anything that is communicated to ATSB, whether in confidence or not, will be routinely communicated by ATSB to CASA, together with enough information to identify the source. The confidential reporting service that is advertised is a sham.

Could I be forgiven for thinking that the correct answer to any question of the ATSB of anyone is now: "I refuse to answer on the grounds that I may incriminate myself."?

Last edited by Sunfish; 16th Feb 2013 at 23:49.
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Old 17th Feb 2013, 00:06
  #1050 (permalink)  
 
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correct !

Sunny.. 10 out of 10.
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Old 17th Feb 2013, 00:23
  #1051 (permalink)  
 
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"Could I be forgiven for thinking that the correct answer to any question of the ATSB of anyone is now: "I refuse to answer on the grounds that I may incriminate myself."?

Sunny,
given there are now well over a thousand aviation related regulations written in such a manner that even a person trained in law has trouble understanding, with about the same number soon to be added, it is now impossible for anyone to be 100% in compliance.
Every time you climb in an aircraft you become a criminal.
I think your quote above is a timely reminder to everyone.
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Old 17th Feb 2013, 07:35
  #1052 (permalink)  
 
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The MOU, Section 24 and other favourite fairy tales.

Story One: The tale of the Big Mack, the ‘Chamber Pot’ and ALIU (pronounced ‘a loo’).

The good Senators at last Friday’s public hearing focused very much on these sections of the ATSB-CASA MOU and for very good reason it would appear:
4.4.4 CASA agrees to assist the ATSB in relation to the provision of documents and other evidence or specialist participation concerning transport safety matters that the ATSB is investigating. Normally, the request will be made pursuant a Section 32 notice to ensure that information provided is protected as restricted information under Division 2 of Part 6 of the TSI Act. When a request for information is not directed to CASA by a Section 32 notice, CASA may request the issue of a notice to the Authority prior to the release of the requested information.

4.4.6 CASA agrees that if a CASA Officer is known to have information that could assist the ATSB in the performance of its investigative functions, CASA will undertake to advise the ATSB of the existence of the information.

4.4.10 CASA agrees that, whenever it conducts a parallel investigation into a transport safety matter the ATSB is also investigating, CASA will, subject to any legal or other applicable requirements, provide the ATSB with a copy of the CASA investigation report or other compilation of relevant details as soon as it is practicable to do so.
The DAS when questioned on whether he was aware of section 24 of the TSI Act said he wasn’t , which is quite risible when you consider that the title of the inquiry is “Aviation Accident Investigations” to which one would have thought has particular relevancy to the TSI Act and the MOU.
Section 24 (1) reads….
24 Offence to hinder etc. an investigation

(1) A person is guilty of an offence if:
(a) the person engages in conduct; and
(b) the person is reckless as to whether the conduct will
adversely affect an investigation:
(i) that is being conducted at that time; or
(ii) that could be conducted at a later time into an
immediately reportable matter; and
(c) the conduct has the result of adversely affecting such an
investigation (whether or not the investigation had
commenced at the time of the conduct); and
(d) the conduct is not authorised by the Chief Commissioner.
Penalty: Imprisonment for 12 months.”

Despite all the evidence to the contrary, at the hearing Beaker continued to argue that the SAR; and now the ‘Chamber review’; the FRMS Special Audit of Pel-Air; past audits; emails from ATSB officers etc…etc are still not or were ever relevant to the Bureau’s investigation into the Pel-Air ditching….I guess it is too late now for Beaker to start marching to a different drum!
Newsflash!
Ben's piece on Congress scrutiny of FAA further proof of 'Beaker's folly':
It is thus not encouraging to know that CASA here not only failed to do this with Transair (the Lockhart River disaster of 2005) or Pel-Air (the Norfolk Island ditching of 2009) but in the case of the latter improperly suppressed the ATSB from knowing that it had failed, leaving its chief commissioner Martin Dolan looking like a goose during a Senate committee hearing yesterday.
ps Worth a read because it highlights how the US political system keeps the FAA fully accountable and transparent:
FAA has a maybe worse problem than the 787 | Plane Talking

However the Senators now appear to be focusing on the legal implications in the conduct/misconduct of the Pel-Air accident investigation and the FF oversight/lack of oversight of the PA AOC.

So could there be trouble afoot for Big Mack his ‘Chamber Pot’ and/or his new ALOO? “Section 24 Offence to hinder etc. an investigation”…for starters








Reality Check! BM, CP, Mr Aliu here’s a recent comment from one of those deeply affected by this sordid tale:
  • Karen Casey
Posted February 16, 2013 at 10:57 am | Permalink

CASA, ATSB, Pel-Air. Shame, shame, shame. How dare there be people in positions that knowingly put the public at risk.

When I hear that this crash could have been prevented if more pro-active safety follow ups were insitu, my stomach churns. The hell myself and others on board have experienced in many forms, is too difficult to adequately express. The ditching was positively preventable had our trusted systems had honest, thorough scaffolding, starting at the top.

CASA audited Pel-Air in April 2007, they found the operator was not adhering to numerous rules. Audited again March 08, safety alert issued. No further audit follow up until after the ditching.

Then a dodgy ATSB report, the Chambers report sitting south under McCormick. How dare all involved shake our lives to the core…their turn to shake now. Lies always unravel. I hope this is the start of real change.
Pel-Air Senate sensation CASA hid key safety audit from ATSB | Plane Talking

Reality Check over! Now hurry along and scurry back to Flyingfiend's office…oh to be a fly on the wall!!



Last edited by Sarcs; 17th Feb 2013 at 10:40. Reason: Plane talking newsflash
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Old 17th Feb 2013, 12:04
  #1053 (permalink)  
 
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Sarcs, The 2008 senate report is worth a revisit.

http://www.aph.gov.au/binaries/senat...ort/report.pdf

There is quite a bit dealing with Byron's direction and concerns about effective regulation and the idea of self regulation. Ben is onto this in his article. The interesting bit is that Continental comment stating it is the FAA's responsibility to ensure standards. You get the held impression nobody wants to be accountable.

FAA has a maybe worse problem than the 787 | Plane Talking

I'm pondering whether flying fiend is now nervously awaiting that fax machine firing up with an incoming Friday afternoon fax?

Last edited by halfmanhalfbiscuit; 17th Feb 2013 at 19:22. Reason: added link to bens article
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Old 17th Feb 2013, 19:22
  #1054 (permalink)  
 
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I predict we are about to see a reorganisation of both CASA and ATSB.

That is the classic, bureaucratic, response to calls for change and improvement.

....and of course it will do nothing of the sort.

Or as Petronius put it in 66AD:

"We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganised.� I was to learn later in life that we tend to meet any new situation by reorganising: and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation."
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Old 17th Feb 2013, 20:38
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Sunny, not a bad call but I suggest fine tuning the old Ouija board. To reorganise you need wriggle room and there is none. Not for anyone; the Senate have but a tiny slice of one incident, there are at least a dozen similar cases known about, right now and a similar number yet to be revealed.

Remember this is just one event, think on: Jones, Johansson, Butson, Repacholi, Barrier, Hardy, Hempel all now 'suspect'. Quadrio, Airtex, Skymaster. All there and yet to be exposed and they will be, publicly if required. It would make a hell of a book.

The Senate ("Bless 'em") are only scratching the famous surface of one!; they stated that they cannot and dare not be seen as part of any form of cover up or "reorganisation" because should (gods forbid) there be a major event, the knock on effect would unseat the government.

There is an honourable and transparent way to resolve the issues, as they must. Happily, this time the Committee appear to have resolve, intelligence, integrity and technical understanding on their side.

I felt sorry for Nick Xenophon, banged up in Malaysia but the parallel was wonderful: he must now know exactly how the industry feels when confronting CASA, powerless, no appeal, no options. Just administratively graped. (There was a bunch of them).

Tempus fugit

Last edited by Kharon; 17th Feb 2013 at 20:56. Reason: More haste - again.
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Old 18th Feb 2013, 00:23
  #1056 (permalink)  
 
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Kharon
That is what happened after the Seaview episode, would be deja vu all over again.
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Old 18th Feb 2013, 00:53
  #1057 (permalink)  
 
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Sarcs, your post really seems to dig down to part of the root cause of the current issues - Person(s) who are out of their league, don't understand aviation cultures, systems and obligations. When you examine Section 24 of the TSI it does indeed appear that the 'potted one' is 'guilty as charged your honor'. However, we all know that these rules, laws and regulations are written containing loads of 'intent', and can be manipulated to any desired outcome at the whim of a politician or legal spin doctor. However, excluding this fact, it is very poor form that the DAS admits he is not aware of some or all of the requirements of the Act? Dry that one out and you can fertilise the pot plants!
Whether he is lying, or genuine, that isn't for me to judge, but either way it proves that he and his lieutenants are not 'capable to hold these official roles', and the same applies to Beaker.

Karen Casey hits the nail on the head. This malaise is just wrong wrong wrong. Issues of this nature and accidents and deaths date back to the 90's, and nothing ever changes (particularly the same spin doctors hiding in these organisations, who have been ingrained for decades). The comparison between Lockhart and Norfolk is incredible when examined holistically and the farce of blaming 'just the pilots' is removed. We have poor regulatory oversight by way of some very ordinary and lame audits undertaken, in some cases inspectors concerns are ignored, there is poor operational surveillance and there is a culture of regulatory cost cutting over and above safety. Nothing has changed, just go back and look at Seaview. There were regulatory concerns with that operator prior to and leading up to it having its AOC upgrade, then crash..

Some of the disturbing facts are as follows:

Accidents: Between 1975 - 2009, 10 serious accidents. All with fatalities except the Norfolk ditching.

Deaths: Death count from these 10 accidents = 102.

RPT: 4 of these flights were RPT.

Charter: 5 of these flights were Charter.

The Senators are doing a good job thus far. Senator Fawcett has a good grip on flight operations, Senators Heff and Nash are pushing the right buttons and Senator Xenophon, himself a Lawyer, seems to have 'Flyingfiends number'. The Senators are gradually narrowing down FF and ATSBeakers wriggle room (thanks 'K') dramatically.

From my travels nationally and internationally there is some robust discussions in quiet drinking holes and risqué entertainment venues and none of it is trending positively towards the hierarchy at CASA, ATSB and ASA. The Senators should be awarded full plenipotentiary powers to compliment the work they are achieving. These organisations are the furtherest supporters of egalitarianism this country has seen. These 'agent provocateues' have reached the end of their use by date and should be discarded so as to make way for some fresh produce.
This hegemony has to go..

Last edited by my oleo is extended; 18th Feb 2013 at 04:04. Reason: Final paragraph, using robust vocabulary that should excite Flyingfiend and friends!
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Old 18th Feb 2013, 04:04
  #1058 (permalink)  
 
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Essential reading.

Human Factors Pel Air - Special Audit Report.

PAIN believe the above document is worthy of serious, professional consideration. For those who have been unable to download the report from the Senate site the link above will provide a download for the document.

It is quite a long download (70,085 KB) and may take 5 or 6 minutes; but to any involved in the safety management of Australian aircraft, the 44 pages are a must read.

We remind you only to use the "Download Now" button at the top right hand corner of the page, avoid the advertisements and that downloads from the site are not tracked.

P4- a.k.a. Ferret.
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Old 18th Feb 2013, 04:40
  #1059 (permalink)  
 
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A witches cauldron boiling with potions, spells and 'mystique'

The special audit report is not a pretty one. Just to scratch the surface you have:

Poor fuel policy and practise.
Pilots apprehensive to formally record defects.
Operational control - The AOC exercises little, if any control over the operation of tasks once a task commences.
Poor pilot training.
Lack of FRMS
No DAMP conducted after incidents/accidents, and this one;
Broad organisational failures.

All of this uncovered, yet Mr Pot Plant and Mr White see no reason to pass this on to the ATSB?
All of this uncovered yet Mr Pot Plant sees no relevance between these organisational findings and the root cause of the accident (keep in mind CASA promulgate the holistic approach to investigations and look at the broader context of an Operator), Mr Pot Plant still keeps blaming Dom entirely?

It seems that the special audit leader, as well as people such as Mr Cook are (were) the only ones who understand true root cause and latent conditions because Mr Pot Plant, his executives and the Beaker are completely lost in transit!

I am also starting to wonder if Mr Chambers has been covertly setting up his own Star Chamber in which Mr Pot Plant was being set up to be the star attraction? Could we now see a reverse place with the Chamber Pot receiving a pineapple and Messr Marcolin getting paroled from projects and again regaining the Sydney throne?

To many possibilities, to much shenanigans and too many bobbing apples to choose from! I better grab a beer, popcorn and copy of the SPM and sit back to enjoy the next enthralment!! (Well, not until I have taken out the garbage and watered the pot plants!).
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Old 18th Feb 2013, 10:35
  #1060 (permalink)  
 
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A pox on the lot of them!

Unfortunately, like every Australian athlete, everyone at CAsA is tarred with the same brush. Too many lies, untruths, unanswered questions, obsfucation, wasted taxpayer money, stupidity or oncompetence, take your pick, and the conceptual indoctrination/ mentorism of untouchability.

CAsA need performance enhancing drugs. A fatal overdose by any measure.

Last edited by Frank Arouet; 18th Feb 2013 at 10:37.
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