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Senate Inquiry, Hearing Program 4th Nov 2011

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Senate Inquiry, Hearing Program 4th Nov 2011

Old 2nd Apr 2013, 15:12
  #1381 (permalink)  
 
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Devil What would the recorders have proven?

Love the focus on not recovering the recorders. However, the value in that decision is that it shows exactly what Beaker's mission at the ATSB is - get the bluddy budget under control - which, if you constrain the scope of the investigation to not look past the obvious, this accident exemplified in spades.

But I have to question what value the recorders would add to the investigation.

Firstly, what type of recorders were fitted and what were their capabilities?

Secondly, what was the serviceability state of the recorders, the sensors and the looms?

It might be very helpful for us armchair experts if someone familiar with the aircraft equipage and the maintenance status could fill in some of the knowledge gaps for us. Given that this outfit appears to have run in a familiar West Texas style of operations (minus most of the beef), what chance was there that anyone even cared about the serviceability state of the recorders? I also have little doubt that the minimum required standard of recorders is probably useless.

Certainly, it isn't a matter publicly explored by either CASA or the ATSB.
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Old 2nd Apr 2013, 17:50
  #1382 (permalink)  
 
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The report is due to publish end of April.

But I have to question what value the recorders would add to the investigation.

Certainly, it isn't a matter publicly explored by either CASA or the ATSB.
The report should be interesting with the ATSB being challenged under questioning to reopen the investigation. add in possibly breaching of both MOU and TSI act!

Love the focus on not recovering the recorders. However, the value in that decision is that it shows exactly what Beaker's mission at the ATSB is - get the bluddy budget under control - which, if you constrain the scope of the investigation to not look past the obvious, this accident exemplified in spades.
Could explain the 'who' approach and ignore the 'why'
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Old 2nd Apr 2013, 22:58
  #1383 (permalink)  
 
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PNM – you may have to go back to almost the beginning of this current (Pel Air) inquiry: about page 20 (ish). The OBR issues have been discussed at length and with some heat. There has been, recently, some in depth discussion related to all of your OBR questions, from pretty much every angle. But if you can find the time, it's worth a look back; you may well spot an optional extra overlooked, the kids have been a bit spoiled for choice.

But Oleo has the right of it -
# 1380 –"You wouldn't have seen such a ludicrous penny pinching decision and palpable decision made had the extremely qualified and dignified Alan Stray been running the place."
It sad when we have 'clerical', barely operationaly cognizant administrative types running 'safety departments', writing 'reports' and letters, drafting rules, making subjective interpretation of 'policy' and perverting the rules which affect the industry. Have a look at the disgusting Tiger episode if you want a short, accurate example. Yuk.....Have Singapore Inc. forgotten? - don't think so, not by a blurry long march.

One thing is absolutely certain though; the more research (drilling down) I do into the Chambers Report and the man who wrote it, the more convinced I am that the antics of the Bankstown office will not withstand independent scrutiny. The ghosts of too many enemies buried over the last few years haunt this episode. The question I ask is - can anyone believe anything this man has said, done or sworn to??; and not just on Pel Air.

Chambers on the stand? Oh yes please; but let me draft the questions, now that sir, would be fun.

Last edited by Kharon; 2nd Apr 2013 at 23:05. Reason: High heels - they're murder.
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Old 2nd Apr 2013, 23:45
  #1384 (permalink)  
 
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So many questions, so little time, and the conspirity theories grow and grow.

Were certain operators slated for shutdown regardless of audit result? Who descided and why?
Was a tactic to knock out key personell as NFAP persons the norm to avoid any form of review?
Was there proper control of the attack dogs in these events, illustrated by evidence of certain dubious characters being withdrawn from tribunals at the last minute for lack of credibility?
You could go on and on.
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Old 2nd Apr 2013, 23:47
  #1385 (permalink)  
 
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"....with troughuristic intention,"

Hey Princester to add to Kharon’s advice the CVR/FDR was a combined unit…..“The aircraft was equipped with a model FA2100 solid-state cockpit voice recorder (CVR) and a flight data recorder (FDR). Both units were installed in the aircraft’s tailcone” (from the final report).

Although it was generally accepted that the longer the recorders sat on the ocean floor the greater the probability of recorder degradation, however essentially the recorded information could still be retrieved (especially from the FDR as it is digitally recorded).

On the matter of what useful information could be extracted, perhaps Mr Brian Aherne’s supp submission (Sub_10_Aherne_Supplementary3[1].pdf) that deals with “Prejudice, Outcome Bias and Coercion” at paragraph 3 best summarises your query and also highlights how all the evidence was handled by the ATSB (CVR/FDR info highlighted in red):
3. Evidence:
a) Outcome Bias.
Email from Martin Dolan to ATSB Investigator and General Manager Investigations written 10 February 2010:

Thanks very much for this. My discussion yesterday with John McCormick gave me some confidence that CASA was looking for systemic answers and amenable to our approach. Since then CASA has changed its rhetoric and seems to be hardening its view that there has been a regulatory breach that needs to be addressed.

I think it would be helpful if you and other addresses could meet with me so that we agree the best way to manage our relationship with CASA in the course of this investigation.

Analysis:
It is very clear that the ATSB had decided on a systemic investigation approach but that simply because CASA changed its rhetoric the ATSB did too. This is evidence of a weak State safety investigator that allowed itself to be influenced by the regulator whose shortcomings may have been exposed in any systemic investigation.

b) Prejudice and Outcome Bias
Email: Wednesday 18 August 2010 From CASA Officer to Director of Aviation Safety and Deputy Director of Aviation Safety

Re: ALIU Accident report Norfolk Island ditching VH-NGA
The above referenced report is now complete………….I have discussed the report with the ATSB and there are no differences in the key areas which will eventually be published by them in their report. I have aligned the report with the submission made by …our Westwind FOI Subject matter expert in yesterday’s AAT meeting.

Analysis: For CASA to have confidence that there would be no differences from the key findings (made by CASA) in an ATSB report which was still two years away from being complete is strongly suggestive that a meeting of the minds had occurred and an outcome agreed. This is evidence of prejudice and outcome bias.

c) Lack of independence of the ATSB and its investigators
Email: 6 August 2012. ATSB officer to General Manager Investigations
…Many of my arguments that have been rejected have been ones where I have applied safety management methods and tolls and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead….To make useful comments on these matters relies on a belief in and use of contemporary safety management theories and methods. To me this was particularly evident when CASA’s Norfolk Island audit report came into our hands and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA’s findings not mine! When I have to rely on CASA’s opinion to persuade the ATSB how can I claim that the ATSB is independent when it investigates CASA?

Analysis: This shows that the ATSB undermined the independence of its investigator. It also shows that the ATSB is unduly influenced by CASA or it shows a crisis of confidence at the ATSB. Either way the ATSB is clearly not independent of CASA.

d) Breach of International Conventions
Australia is a signatory to article 37 of the Chicago Convention, ICAO, Part IV International Standards and Recommended Practices.

As such, three International Standards (International Standards are defined as 'shall', International conventions intend to foster standardisation, consistency and efficiency and when it comes to safety- shared learning) under Annex 13 have not been complied with, namely Annex 13, 5.4 which states:

"The accident investigation authority SHALL have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of Annex 13" Annex 13, 5.6 states:
"The investigator in charge shall have unhampered access to the wreckage and all relevant material, including flight recorders and ATS records, and shall have unrestricted control over it to ensure that a detailed examination can be made without delay by authorised personnel participating in the investigation".

However:
1) The Investigator in Charge was not given unhampered access to the relevant material of the "Chambers Report", the "UK CAA FRMS Study of the pilot" and the internal CASA survey results of its "Flying Operations Inspectors Survey" and the complete "FRMS" report by CASA officers.

2) The aircraft wreckage (evidence) was not recovered which meant that:
a) Crashworthiness data was not gathered. (Data as to how the impact forces were distributed, which load paths were critical, how energy was dissipated remain unknown and would have been useful information for future aircraft design.
b) Reasons for the survivability of the accident could not be determined. Seatbelt function, seat design, floor attachment points; cabin design; emergency exit design, stretcher design and placement.

3) The Flight Data Recorders and Cockpit Voice Recorders were not made available to the Investigator in Charge because of budget, not safety considerations. As a result the following data (evidence) is missing:
a) How much fuel was on board the aircraft? What were the fuel flow rates?
b) What were the actual winds and temperatures?
c) What was the navigation instrument accuracy? How accurately were the instrument approaches flown?
d) What altimeter settings were used by the crew? How accurate were the altimeters?
e) Which systems were operable / degraded /inoperable?
f) What decision making process was used by the crew?
g) What discussions were had regarding the viability of continuing the flight to Melbourne following a diversion to Noumea-this centres around flight and duty limitations.
h) What discussions were had regarding the costs of a diversion (fuel , navigation charges, landing charges, hotel and transport for passengers and crew)?
i) To what extent were the crew fatigued?
PNM said:
Given that this outfit appears to have run in a familiar West Texas style of operations (minus most of the beef), what chance was there that anyone even cared about the serviceability state of the recorders? I also have little doubt that the minimum required standard of recorders is probably useless.
Good point Princester however surely that fact alone (the serviceability of the CVR/FDR) was worth knowing, much like the u/s CVR in the Lockhart River Metro. At the least it would have meant more scrutiny would have occurred on the P/A maintenance organisation with a couple more RCAs etc chucked into the mix.

Anyway PNM hope that helps…now back to the ‘Chambers Report’ crucifixion!

Last edited by Sarcs; 3rd Apr 2013 at 00:42. Reason: "....Well secluded, we (finally) see all..."
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Old 3rd Apr 2013, 07:59
  #1386 (permalink)  
 
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Chorus: "Let's do the timewarp again..."

Geez OM bit sharp on the response there mate, it’s a pity that you didn’t spend the time to read the last half dozen pages of the thread might have made you realise how stupid your last post really was, or do I detect a certain animosity to Mr Aherne?? Oh well onwards and downwards and on to....

"Beyond all reason?"

From the written QONs for the 15/02/2013 hearing, Senator X asked:
12. Can you provide the committee with an outline of the 'beyond Reason' methodology the ATSB now applies to conduct its investigations and produce its reports?

ATSB response: The ATSB provided an outline of its analysis approach in its initial submission of 12 October 2012 (Sub03_ATSB, parts 2 and 3). It also provided additional information in response to question 32 of the questions on notice from 21 November 2012.
Okay so let’s jump on Lefty’s timewarp machine again…

Quote from my previous post:
Government response to recommendation 15…
Response

The Government supports this recommendation in-principle.

The ATSB already has a robust approach to the investigation and publication of human factor issues which was recognised in 2009 when the ATSB received an award from the International Society of Air Safety Investigators for its world-leading work in human factors.

An example of the ATSB’s continuing commitment and approach to investigations into human factors to help explain accidents and incidents is its research report: Evaluation of the Human Factors Analysis and Classification System as a Predictive Model released in December 2010.

Note: Here’s the link for that very valuable report, I believe once again, that the irony will not be lost on most reasonably intelligent people: http://www.atsb.gov.au/media/3536263/ar2008036.pdf
Besides the fact that the ISASI are now probably pondering whether they should be asking for that award to be returned…the chronology is interesting in terms of the mi..mi..mi Beaker’s repeated proclamations in this inquiry about how the bureau has gone ‘beyond Reason’.

So questions…

When did this fundamental change in the bureau investigative methodology actually happen?

Why was the minister not informed about this fundamental change to bureau operational methodology? given that his ministry’s response and by extension, the Minister to the last inquiry was issued November 2011 and the AR2008036 report December 2010??

Why weren’t the authors of AR2008036 informed of this change?
From that report (my bold):
1.1 Overview of HFACS
The Human Factors Analysis and Classification System is based on a sequential or chain-of-events theory of accident causation and was derived from Reason’s (1990) accident causation model (Wiegmann & Shappell, 2003). It was originally developed for use within the United States military, both to guide investigations when determining why an accident or incident occurred, and to analyse accident data (Shappell & Wiegmann, 2000). Since its development, the classification system has been used in a variety of military and civilian transport and occupational settings, including aviation, road, and rail transport (e.g. Federal Railroad Administration, 2005; Gaur, 2005; Li & Harris, 2005; Pape et al., 2001; Shappell, 2005), and has also been used by the medical, oil, and mining industries (Shappell, 2005).
Further question: Given the Norfolk Ditching investigation was well under way and everyone (except for Beaker), including the minister, Beaker’s research boffins and the Norfolk investigation team was conducting business on the old bureau ‘Reason Model’, is it then acceptable for Beaker to apply his new (Beakerised beyond all reason)methodology to the context of an active investigation? Or maybe everyone just missed Beaker's memo?

Sorry about the slight diversion...let's go back to the Chamberpot stoning shall we!

Last edited by Sarcs; 3rd Apr 2013 at 08:48. Reason: ..."Let's do the timewarp again.."
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Old 3rd Apr 2013, 11:15
  #1387 (permalink)  
 
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Message from Pink Floyd.

Breathe

Breathe, breathe in the air.
Don't be afraid to care.
Leave but don't leave me.
Look around and choose your own ground.

Long you live and high you fly
And smiles you'll give and tears you'll cry
And all you touch and all you see
Is all your life will ever be.

Run, rabbit run.
Dig that hole, forget the sun,
And when at last the work is done
Don't sit down it's time to dig another one.

For long you live and high you fly
But only if you ride the tide
And balanced on the biggest wave
You race towards an early grave.
I'm from the lighter side of the moon and would like to see the timbre of the thread continue.

"The meek shall inherit the World" (If that's OK with you mate)?

Last edited by Frank Arouet; 3rd Apr 2013 at 11:17. Reason: Orbit alignment.
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Old 3rd Apr 2013, 11:35
  #1388 (permalink)  
 
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Regulators around the world consider the Australian regulator a bit of a joke, now I guess our accident investigator as well, but I dont think they are laughing, this thread is a very serious reflection on just how incompetent and corrupt things have become in this country. If OM,s observations are an example of the establishments attitude god help us all.
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Old 3rd Apr 2013, 14:29
  #1389 (permalink)  
 
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So we have CASA and the ATSBeaker. Is there something in the water affecting the top management?
Firstly, the ATSB and Beaker. He somehow decides that the mi mi mi mi tried, tested and proven Reason Model is somehow flawed, outdated or second rate pony pooh and The Beaker has a more fluid method??
Then secondly, you have CASA and Twerp 3. He somehow thinks that ICAO's methodology on Just Culture is flawed (even though his beloved CASA promulgates it and enforces it) and that this concept is also lightly basted in pony pooh and he has a better methodology and he disagrees with some of the ICAO fundamentals of Just Culture??

What is Canberra feeding these numpties? Is there something in the air? Have these guys been anointed with aviation Holy Spirit from above and been commissioned by The Lord to go forth and preach a new safety message throughout the land?
Beaker said it himself, not one of the three commissioners has an aviation investigation background. CASA is no better, Twerp 1 and Twerp 2 are washed up and been away from the real tin for too long, particularly Twerp 2. And Twerp 3 has been a bureaucrat, lawyer and philosopher all his life so his experience in the real aviation world is negligible. Mixing with ICAO and people like Beaker doesn't give you real life experience.

You're damn right we are stuck in a time warp. No wait, we are in the Matrix. No no wait, it's Quantum Leap!!
No, sadly the oversight of the industry is palpable and the decision makers have proven themselves not capable of understanding the industry they regulate or investigate. The only possible solution to cure this cancer is a robust injection of Senator radium.

"Aviation, what aviation?"

Last edited by my oleo is extended; 3rd Apr 2013 at 14:33.
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Old 3rd Apr 2013, 15:30
  #1390 (permalink)  
 
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Had a few once again have we Oleo?? Hope for your sake you don't get DAMP tested tomorrow...
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Old 3rd Apr 2013, 16:03
  #1391 (permalink)  
 
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Regulators around the world consider the Australian regulator a bit of a joke
Thornbird,
That couldn't be true, surely, no less a person than Mr. McCormick, himself, has publicly stated that CASA is the envy of the world's regulators, or words to that meaning.
He wouldn't say that, if it wasn't true, would he???????
Tootle pip!!
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Old 3rd Apr 2013, 16:17
  #1392 (permalink)  
 
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Beaker said it himself, not one of the three commissioners has an aviation investigation background.
A quite alarming statement. But at least honest. Now, there are very good courses around the world and other bodies willing to offer support. Beaker could and should have done something.
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Old 3rd Apr 2013, 20:15
  #1393 (permalink)  
 
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MLE# 1392 –"Had a few once again have we Oleo?? Hope for your sake you don't get DAMP tested tomorrow..."
Well Oleo, there you have it, the games up: the tried, tested and fully approved "Psychic DAMP" conviction. I hear through the grapevine (get it) that it's yet another Bankstown generated safety innovation which apparently does away with all of that unpleasant detail, like proof and expensive testing. The only problem area being that it may take up to six months for the conviction to filter through to you, which can be inconvenient if you happen to be airborne at the time. Rumour (and it's only a pub rumour) has it that there is a very 'interesting' civil law suite in the offing which relates, in part to just this issue; can't wait for that transcript to hit PPRuNe, that should be fun.

Thanks MLE – keep the ammunition coming.......

Dear Half cut – apparently not applicable, protected species etc. etc Although, under the only whispered of in dark corners, rumoured BK special rules; apparently, a well placed "psychic" complaint works just fine. Metaphysics and all that; refer GWM handbook of Impredicativity.

Russell's paradox is a famous example of an impredicative construction, namely the set of all sets which do not contain themselves. The paradox is whether such a set contains itself or not — if it does then by definition it should not, and if it does not then by definition it should.

Last edited by Kharon; 3rd Apr 2013 at 21:18. Reason: Drift orbit realignment.
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Old 3rd Apr 2013, 20:45
  #1394 (permalink)  
 
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Kharon,

These random DAMP tests have they ever been done on a casa office or officers? After all they are safety sensitive positions.

Half man half cut.
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Old 3rd Apr 2013, 22:07
  #1395 (permalink)  
 
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Who fwamed Wodger...

HMHB:

These random DAMP tests have they ever been done on a casa office or officers? After all they are safety sensitive positions.
Apparently with Wodger the waskily wabbit (at least) you don’t have to worry about DAMP checks as he is allergic to beer and hard liquor. Although I’d be a bit concerned about him maintaining his class one as he’d only possibly need the fumes coming through from first class to set him off on some kind of epileptic episode…



Rumour is that this was filmed not long after Wodger wodgered DJ!

Oh well back to quartering Wodger for the wabbit stew simmering in the chamberpot!
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Old 3rd Apr 2013, 23:27
  #1396 (permalink)  
 
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Ills of society on the loose

Aargh yes VH-MLE, trolling once again? Usually it is Leadie or Sarcs that you are having a dig at, but that's ok, I have broad wings like your 182! I am happy to indulge your bitterness so feel free to keep posting and getting ignored

P.S Tell that Wiley Blackhand I said g'day

Now, enough of this tautological nonsense and back to the meat of this thread. Take it away Sarcs...........

Last edited by my oleo is extended; 4th Apr 2013 at 01:42. Reason: Time Warping with Dr Frank n Furter and the CASA German slap dance team
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Old 4th Apr 2013, 00:33
  #1397 (permalink)  
 
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Good question:-

OM #1386 – "3) The Flight Data Recorders and Cockpit Voice Recorders were not made available to the Investigator in Charge because of budget, not safety considerations. As a result the following data (evidence) is missing:

Q. a) How much fuel was on board the aircraft? What were the fuel flow rates?

A) Not enough.

Or: perhaps whether the things were working, or not. Now that would be nice to know.
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Old 4th Apr 2013, 01:25
  #1398 (permalink)  
 
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Kharon - Or: perhaps whether the things were working,
Do you mean the OBRs?

Last edited by owen meaney; 4th Apr 2013 at 01:28.
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Old 4th Apr 2013, 01:40
  #1399 (permalink)  
 
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Mr. McCormick, himself, has publicly stated that CASA is the envy of the world's regulators
Wayne Swan has called himself the world's best treasurer too!
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Old 4th Apr 2013, 01:47
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Big John is deluded. NZ, Singapore, FAA p#ss all over AUS.
If the Skull thinks that 24 years to rewrite the regs and $200 million dollars constitutes a world class regulator then he truly is off with the fairies in some fantasy land filled with potted plants, gold producing rainbows and silver lined chamber pots.
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