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Senate Inquiry, Hearing Program 4th Nov 2011

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Senate Inquiry, Hearing Program 4th Nov 2011

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Old 16th Feb 2013, 22:48
  #1121 (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 22:49.
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Old 16th Feb 2013, 23:06
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correct !

Sunny.. 10 out of 10.
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Old 16th Feb 2013, 23:23
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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, 06:35
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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 09:40. Reason: Plane talking newsflash
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Old 17th Feb 2013, 11:04
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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 18:22. Reason: added link to bens article
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Old 17th Feb 2013, 18:22
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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, 19:38
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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 19:56. Reason: More haste - again.
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Old 17th Feb 2013, 23:23
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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 17th Feb 2013, 23:53
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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 03:04. Reason: Final paragraph, using robust vocabulary that should excite Flyingfiend and friends!
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Old 18th Feb 2013, 03:04
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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, 03:40
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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, 09:35
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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 09:37.
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Old 18th Feb 2013, 11:08
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Frank, if CASA took performance enhancing drugs their calf muscles would swell and the jackboots would no longer fit, so that's a bad idea.
Plus steroids will make you prone to outbursts of anger, and some of them already have anger management problems!

Be that as it may, L.Armstrong is looking for work! Come to think of it, as of next month so will the Pope be, and in September most of Joolia and friends also, so there is a couple of ideas for FF's new robust structure!
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Old 18th Feb 2013, 15:16
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casa atsb and the MOU

Just a quick read of the report on the FRMS [casa called it "shelfware"] and the letter by casa [below] leads one to a very dark place:



casa says: "We have added a dot point on FRMS requirements for time zone changes as this is a major omission from the manual."

and jmac says".......atsb would not have changed what they thought or the report....." Mr. Senator.

Well well well!!!!! Come on Mr. casa
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Old 18th Feb 2013, 19:56
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Well done.

Once again, the great team supporting the Senate Committee have proven their worth.

The Pel Air FRMS – Special audit – has been modified and is now a very user friendly 30 second download from either the Senate site or from the link below.

FRMS Special audit.

Only use the "Download Now" button in the top right corner, watch out for the adverts.

P1. a.k.a. P1.

Last edited by PAIN_NET; 18th Feb 2013 at 19:57.
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Old 18th Feb 2013, 21:38
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Reading between the lines of the special audit it seems clear, at least in my opinion, that the fatigue risk management system (FRMS) was considered "shelfware" to use CASAs term. It also appears that their fuel planning procedures weren't any better.

In other words, it was there to satisfy CASA that it existed - just like a Thousand other regulatory imposts across all of the economy, such as "anti discrimination' or "gender equity" policies. For that is what shelfware means. A sop to the regulator unless I am mistaken..

And to make matters worse CASA couldn't identify the FRMS as "shelfware" or the fuel planning practice deficiencies without a special and detailed audit.

So Mr. McCormick, what are you going to do about identifying all the other "shelfware" that is gathering dust in a Thousand Operations offices as we speak?


But wait, it gets worse..........

Only problem was that Fatigue matters. It kills pilots and passengers. It costs employers money to observe it. No one in management really wants it anyway, realising that the chances of accident on their watch are slight, so leave it to the next manager to sort out. As for pilots, they are in the Toxic "Double Bind" problem - damned if they do and damned if they don't.

Complain about fatigue = get a reputation as a whiner and kiss the company goodbye.

Don't complain = Make a fatigue related mistake and CASA will blame you and only you, just like the Head of CASA appears to have done.

And to top it off:

The only way out of the double bind problem that I know of, apart from quitting, is an appeal to the safety auditor in the form of a confidential report to the ATSB. But the ATSB has a memorandum of understanding with CASA that requires them to pass on information capable of identifying the complainant, and in any case CASA leaks like a sieve and has its own agenda in play.

What that means as far as I can tell, is that no pilot, PPL, CPL, whatever can put any trust in the integrity of Australian Air safety systems whatsoever because the outcome of even a well meaning and constructive communication with ATSB, let alone CASA, could be firing, blacklisting, criminal prosecution or loss of licence on the flimsiest pretext depending on the political wind blowing at the time.

We are indeed "criminals who havn't been caught yet".

So to ask a question: Why does Pel Air get off with a clean slate? How and why was the Pel AIr Chief Pilot hired by CASA? Why does Dominic James have to shoulder all the blame for what CASA now apparently agrees are systemic failures at Pel AIr?


....sorry for being Captain Obvious.

Last edited by Sunfish; 18th Feb 2013 at 21:50.
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Old 18th Feb 2013, 22:13
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The pot plant in the middle of the room

Sunfish, although your last 3 questions, as you put it, are obvious, they are quite crucial in this entire sordid mess. We are awaiting a clear and concise explanation from the CASA hierarchy. Although I don't think any reasonable answers will end up coming as these guys just don't get it.

In fact, to go out on a limb when you analyze Colgan against Norfolk there are some glaring and subtle comparisons. Yes I know, different countries, different aircraft and different circumstances and outcomes, but the big equaliser is Fatigue! Both organisations operated a fatigue inducing operation with no mitigation strategies in place. The more the 'potted one' opens his mouth the more ludicrous this situation gets. The Skull has proven he does not look at broad systemic issues, he is not capable of doing so. He is purely a stick and rudder left hand seat man, nothing else. This is the wrong type of leader to be leading an authority transition from the safety systems of the 70's, 80's and 90's. He should robustly exit the building taking the CASA Board and his 2 sidekicks with him, as a starting point.

The MOU with the ATSB is a farce. It's akin to the FBI having an MOU with the state troopers.
The ATSB has been the last bastion of trust, when all else fails you have one body you can confide in. All gone!
The Minister for Mascot, Sith Mrdak, the Boards and other 'intellectuals' involved in putting the 'agreement' in place should all receive an industry vote of no confidence for allowing the parlous condition that now exists to be 'acceptable'.
The MOU should be rescinded immediately as part of an ATSB and CASA gutting.

Last edited by my oleo is extended; 18th Feb 2013 at 22:23. Reason: Fatigued and need a rest. Went and potted some new plants!
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Old 18th Feb 2013, 22:34
  #1138 (permalink)  
 
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PelAir FRMS section 2.2

A bit more reading - Section 2.2



Worth a little comment??

Last edited by Up-into-the-air; 20th Feb 2013 at 02:49.
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Old 18th Feb 2013, 23:09
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UITA, what can one say?? The document speaks volumes all by itself!
Perhaps the Senators would like to ask the CASA to respond to this document??

I agree with this - If this is just a sample of one lack of oversight of an operator then what else is out there?
Hmmm. Me thinks Lockhart and a number of other accidents would have a similar lack of oversight attached to them - prior to, during and after an issue arose?
This is a disgrace. I guess it beggars the question of 'how safe are our skies really'? Don't bother answering. The proof is in the Senate.

'Reactive CASA skies for all'
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Old 19th Feb 2013, 06:34
  #1140 (permalink)  
 
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I was going to answer this post from blackie, but it's a wind up so I'll ignore it.

The skies are safe there being no aircraft to make them unsafe, but it's the poor poor little school kiddies that worry me having to look up all the time for falling space rocks.
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