Senate Inquiry, Hearing Program 4th Nov 2011

[dogcharlietree]

Oh and dogcharlietree I don’t think the ferryman meant we should quite go that far back..off doing a Kelpie!

But if Pel-Air is a re-run of an old movie then I think it's very appropriate.
Does "pilot error" in both cases sound familiar?
Why let the FACTS get in the way of crucifying the pilot?

[my oleo is extended]

Frank, very astute observation. DCA days were tough but relatively fair. CAA was the commencement of the current regime. FF's issues go deep to the core. Most of the CEO/Directors have been idiots, with the occasional good one, but their tenures are short term. So you need to dig down deeper, bring to the surface the long termers who have been there 10, 20 or so years. They are the ones who have spent years manipulating, creating and building the beast we now see. And if you don't believe they can be influential then just look at the ATSBeaker. An organisation that went from top class to pony pooh in 5 short years under the direction of one person.

So we understand the concept of root cause don't we? Yes we do. So lets apply that very methodology to FF and ATSBeaker. Look at the causes, conditions, trends and facts and you find the answer. FF's power brokers and former faceless men who have risen through the ranks over one to two decades are individually worthy of closer Senator scrutiny. Same with the ATSbeaker, review their history, structure, senior people and the time frame from when they used to churn out quality work and had built up a good reputation to now, the past 5 years since the Head Beaker came onboard and turned the place into a mi mi mi
mess. Root Causes galore friends!

[Kharon]

DCT – You make an interesting point well worth a Sunday thought or two;

Q. Do I believe Rod was unilaterally crucified ? (A) Dunno, need to think it through.

The thing that pops into my head is the different attitude we all had back then. The difference is, back then BASI would be 'widely' believed and trusted as was CAA (or whatever). The general mindset in the day - would be one of 'reasonable doubt' and it would be tough to generate support for an argument that BASI got it wrong. This may well have been so in Rod's case; but, by and large BASI usually nailed an inquiry and were unlikely to be seen as 'glove puppets' for the authority. Please – I'm not saying for right or wrong; just saying 'the troops' would be more likely, on balance of probability, to 'believe' a BASI case then.

This is not the situation today –

Q. Do I believe DJ and JQ were unilaterally crucified ? (A) Absolutely, no doubt at all.

CASA and ATSB, looking at the inquiry evidence so far, appear as a shambollic mess, seemingly dedicated to presenting reports designed for CASA to push through the smoke and mirror factory, polish and spin for public acceptance, to ease the avoidance of civil action and fostering a 'Strictly No Liability' facade. They present with the appearance of relying on the extremes of law used only to suit their purpose, bluffing, denigrating or bullying all who would dare challenge the might of the self styled - government safety watchdogs, or lap dogs if you like, (anything other than honest working dogs).

This all is extraordinarily counter productive – once upon a time, with the odd grumble things could be accepted as 'kosher', but not anymore; even the outright villains get support. Any semblance of reasonable doubt provided against a CASA case after this little lot will have the judge seeking to avoid making an unsafe ruling. Why, because it is being demonstrated in Parliament, to my satisfaction, that CASA and ATSB can and will be 'economical' with the facts.

Did I tell you the one about the wabbits at the bottom of our garden?; no, later then, over a beer.

A favourite - for Sunday pleasure.

[dogcharlietree]

In Rod's report http://www.atsb.gov.au/media/24341/a...401043_001.pdf BASI mentions no less than 19 times the use of unapproved performance charts. They were in fact approved.
This had absolutely ZERO in contributing to the accident. There were other similar smoke screen/diversions.
The circumstances that led to this accident were;
1) Port engine failure caused by an incorrectly fitted thrust washer (see page 12 of the report).
2) Port propellor failed to fully feather (see page 15 of the report).
3) Incredible profile drag attributed to a very old airframe which degraded performance so much that continued flight was not a possibility.

Here is a link to the Dutch Dakota Assoc fatal DC3 accident that occurred with very similar circumstances. Very interesting to see what their accident investigation concluded.
dda

[Sarcs]

Mr Aherne's CASA rebuttal continued...

From page 19 of Brian Aherne’s Sub_10_Aherne_Supplementary1[1].pdf where he defends himself from CASA’s playing the man tactic is worth regurgitating :

5.10.4 This allegation indicates that Mr Aherne has little or no knowledge of the history involved. While he may be frustrated at what he perceives to be slow pace of regulatory reform, his unsubstantiated claims that certain individuals in CASA have wilfully obstructed the program are not tenable. Over the last three years, since the Standards Division was re-established, CASA staff have worked tirelessly to progress regulatory reform. It may be of interest to the Committee to know that elements of the aviation industry are now calling for CASA to slow the pace of change and in some cases stop it all together.

CASA assert in 5.10.4 that I have little or no knowledge of the history involved. See my extracts from the 2003 Cape Hillsboro accident report. That report speaks for itself.

I don’t call a 2001 decision to think about putting aerial ambulance operations into Aerial Work and determining over 8 years later not to, only to re-invigorate the idea again in 2012 for a 2014 intent as “Working Tirelessly”. If CASA do, then that is remarkable. (love it BA!)

Note: It might have been worth the author(s) of the CASA ATM (attack the man) to do a bit of research themselves as this statement… “It may be of interest to the Committee to know that elements of the aviation industry are now calling for CASA to slow the pace of change…” has been spruiked by the DAS in Senate Estimates before, here is just one example from the 16/10/2012 Senate Estimates Hansard:

Senator FAWCETT: I have a couple of questions following on from the white paper. The CASA regulatory reform program, which was forecast to be completed by 2011, is on page 69. What is the current status of that?

Mr J McCormick: We have in previous estimates discussed the priority issues and also coming out of the flying training inquiry of last year. The status of the white paper was that the regs would be made by that date but not implemented because obviously some of the regulations affect up to 800 organisations and it takes a considerable amount of time to do the industry training and practice to make sure that those regs enter into the industry without introducing undue risk into the industry at the same time. So we undertook to complete parts 42, 66, 145 and 147 to be made by the end of this year, as I reported at estimates in the past, and we are on track to complete those regulated parts in time.

At the moment we have maintenance regulation 145 for the small end of town, GA part 135, which is the current low capacity RPT area. They are out to consultation now. The operational regulations part 119 and 121, the high capacity RPT replacement regs, and 135 are interleaved with those maintenance regulations because of requirements for the Continuing Airworthiness Management Organisation, which is part 42. And we have generally taken the view that we do not want to make any of the regs when they are going to have a shelf life of longer than one year. We have had some calls from the industry to slow down the rate of the reg implementation program and we are cognisant of the fact that a considerable amount of training has to be done to make sure that those regs, particularly in the small end of town, are well and truly consulted with the industry so that we take on board their concerns and then we produce legislation that harmonises with existing parts 145 and 42 which we are in the process of rolling out and have been since June 2010.

It is also interesting to note that Bryan Aherne mentioning the 2003 Cape Hillsboro accident report has effectively taken us full circle on Senator Fawcett’s original question, yet to be properly answered, on ‘closing the loop’ back at the 23/05/2012 Senate Estimates, see this link to my post on the Hempel thread: 503

[Sunfish]

I am reminded of an old Army saying that encapsulated the modish operandi of many NCOs when dealing with officers:

"Bullshyte baffles brains".

And 99% of the time they were exactly right.

[thorn bird]

There was a suggestion in earlier posts that certain CASA individuals may have been in breach of the TSI act and that the DPP was examining prosecution.
I have read in other threads where the DPP has declined to prosecute perjury against CASA officers. How serious an offence has to be committed before the DPP WILL take action or can CASA get away with anything?

[Centaurus]

DCA days were tough but relatively fair

I would say you are looking at the past with rose-coloured glasses. The characters in those days could be just as arrogant and shifty as those accused of similar sins now. I remember after leaving the RAAF to join DCA (bad move in retrospect) and on my first day out of uniform being shown my dark and dingy little office in DCA HQ at Aviation House and told to sit down at my table, learn the ANO's and and keep my head down. Don't suggest anything. Don't try and change anything. Above all, don't make waves lest you bring down upon you the wrath of the very senior DCA public servants high in the top floor of the building and high on the food train.

[Frank Arouet]

"Bullshyte baffles brains".

Yes, "Tarus excreta conundrum cerebellum". A well used phrase and oft quoted in the Officers Mess as well. Be this as it may, I would prefer those DCA days to these CASA days.

[Sunfish]

Politically, it appears that the current Transport portfolio is designed to suit a Minister who needs to spend all his time on party matters. The most likely instructions to the Secretary being that waves are not to be made under any circumstances and nothing "courageaous" is to be attempted.

In support of that requirement, Mr. Beaker was placed in charge of the ATSB - the most obvious potential source of a Tsunami, with instructions to muzzle it.

CASA on the other hand has realised that the Minister couldn't give a rats backside for anything to do with aviation apart from the Chairmans lounge and a First class seat. They surmised that they can do what they like as long as they don't make waves. That means leave Qantas alone and strangle any operator who dares to upset the status quo.

That is what I get from reading between the lines of the Ministers instructions and the CASA/ATSB MOU. I suspect that the CASA/AsA MOU would reveal similar intent.

To put that another way; the Minister simply said "don't bother me about Aviation, I'm too busy" and to be fair, he is.

The subject will get no attention until there are Three smoking holes in the ground, and even then the terms of reference for the resulting Royal Commission will be perverted to preclude consideration of CASA, ATSB and AsA operations.

Civil Aviation - a sleepy administrative backwater.

[Kharon]

Of men, balls-

- and the playing with thereof. The mystique of air safety has a lot to answer for; this ball has, for many overs satisfactorily serviced the needs of the authority and has been cynically and ruthlessly hammered to death. We'll take the new ball now, thanks Ump.

I can't see that the Senate has any option but to call in the DPP and closely examine the events subsequent to the ditching. Even if it is only to eliminate the possibility that breaches of not only the TSI Act, but of the AN Act, Regulations and Orders on through to misleading the Senate were committed – by CASA; if only for self preservations sake. That aught to take care of the ball – but what of the men, how should we play them?

The current CASA outfit has demonstrated, when it suits, no mercy when it comes to playing the man; not just Davis, Aherne, Quinn, James, Quadrio etc. etc. there are many. Perhaps the DAS is misinformed as to whom exactly is, universally, perceived as the confused minority group. Hint; it ain't the industry.

CASA have not scrupled to 'bend' Acts, facts, statements and words to a sole purpose – has that not been self evident throughout the Pel Air inquiry? The 'authority' seemingly has not hesitated to reverse course from a full on doing over of Pel Air to a full blown "nothing to see – move on" report being generated, served up under the tattered remnants of the cloak of mystery. This is what they are so desperately arguing through the Senate inquiry. James ? a bone thrown to the rapacious wabbit – hells bells, Chambers should be fired, out of hand, simply for gross abuse of the English language, never mind the rest.

The 'system' is designed to allow for 'personalities'; as group, we tend to fix up a SOP or COM system glitch first (our end); dealing with 'offender's' for the most part, in house. It is a good system and has served well for many years. But for CASA, those days must be numbered, it's time; distasteful and unnatural as it is, to play the man. The systems when not abused work fine (ish), perhaps it's time for a few CASA operatives to have 'tea and biccy's with the CDPP, or someone's legal team under civil law, (up close and personal like).

Once we have the system working, maybe we can tackle the essentials: like why Hempel crashed, why DJ ran out of motion lotion. etc. etc..... Crikey, we may even get some educated, qualified recommendations about how to avoid such unpleasantness. But, as Grandpapa used to say – "if you want a rabbit pie, first, you must catch your rabbit."

[Dangly Bits]

Spot on Sunny.

[Thats what she said]

I must congratulate Kharon for not degenerating into an incomprehensible essay on characters from 1960's comedy shows. Your lucid and sage post above means much more to us 'general readers' than the confusing dissertations of past posts. Thank you.

[Frank Arouet]

Further to my last on the DCA days, (Dept Civil Aviation), most probably thought of them as over bearing twits just back from the war with nice facial hair. The thing was however they did have a measure of respect. Something the CASA lost years ago.

Not liking not being liked, they persue the stratagey of "the floggings will continue until morale improves".

Blokes like Bob Jarvis educated first and prosecuted as a last resort.

Prosecutions should be removed from the CASA duties and handed to the Federal Police if an audit is failed or a serious safety complaint is received.

CASA have proved incapable of a regulatory review. Until they get that right, they should stay after school until they get it right.

How can they prosecute laws when they can't make them in the first place?

[Lookleft]

I must congratulate Kharon for not degenerating into an incomprehensible
essay on characters from 1960's comedy shows. Your lucid and sage post above means much more to us 'general readers' than the confusing dissertations of past posts. Thank you.

I'll second that motion.

[halfmanhalfbiscuit]

Casa briefing March

Good news the casa briefing is out. Lots of useful advice including an article on fatigue. No mention of this inquiry though!

[Sarcs]

Referral for investigation!

Kharon said: I can't see that the Senate has any option but to call in the DPP and closely examine the events subsequent to the ditching.

Or the Senator’s can directly refer the matter to the AFP for investigation as that is inevitably what the CDPP would have to do anyway as they do not have investigatory powers. DJ (and probably many others by the sound of it?), besides taking civil action, can as a private citizen refer a brief to the CDPP for their consideration.

I would say on the balance of probabilities and all the solid documented and verified evidence brought forward by the inquiry so far, I believe any good prosecutor could mount a prosecution for proving numerous breaches of the TSI Act, the CAA Act, the Commonwealth Criminal Code Act by various parties within FF and dare I say the bureau. Note: It would also appear that there has been serious obfuscation/abuse of a parliamentary process.

However before there is a prosecution the CDPP need to task the AFP with conducting a full and comprehensive investigation (i.e. you can’t just skip a step or two like FF invariably do) as per the AFP charter and the HOCOLEA AGIS (2011).

One would have to say that the AFP’s task has been simplified by the work of the Senate RRAT committee inquiry’s gathered evidence so far, however perhaps some suggestions on where to start could be helpful??

Perhaps the first place the AFP should start is to take a look at the CASA Accident Investigation Report (CAIR 09/3) that FF released under the MOU and section 32 of the TSI Act. This would appear to be the script that FF wanted the bureau to run with. It is also apparent that the bureau acquiesced with this script by many statements made by Beaker and in various AQONs/Supp submissions throughout this inquiry. Here’s an example:

From Senator X’s question 4 (written QONs for the 15/02/2013 public hearing):
4. Did the ATSB think to obtain some independent analysis of fatigue levels from another investigation bureau/aviation authority? Were you aware that CASA asked the UK Civil Aviation Authority to analyse the fatigue levels of the crew?

ATSB response: The ATSB has several human factors specialists. During the course of investigation activities, the ATSB will on a case-by-case basis obtain information and advice from external specialists in a specific human factors area, such as fatigue, when provision of this advice is necessary or will enhance the ATSB’s understanding of an issue. With regard to this investigation, the ATSB did not obtain any independent analysis of fatigue levels, nor did it think it was necessary to do so.

The ATSB was not previously aware that the UK Civil Aviation Authority (CAA) had provided CASA with an analysis of the fatigue levels associated with the accident flight (which was provided in the email titled ‘Air Amb Supp’ from a UK CAA officer to a CASA officer on 11 December 2009). The ATSB notes that the analysis did not appear to warrant inclusion in CASA’s Accident Investigation Report.

Note: It is simply extraordinary that Beaker essentially shrugs his shoulders at the fact that FF chose to barely even acknowledge in their report the comprehensive FRMS Special Audit Report compiled by Ben Cook a human factors expert, excerpts from CAIR 09/3:

And this:


It would also appear that in the spirit of the MOU ‘parallel investigations’ that the bureau, maybe due to lack of resources, accepted the findings and evidence gathered by the FF investigative team and subsequently didn’t deem it necessary to explore the veracity of the FF CAIR 09/3 review/analysis of certain documented evidence. Perhaps the following highlights one example of this:

From the FF constructed history of taped transcript pg 7 of CAIR 09/3:

0801 UTC NADI ATC provides the aircraft with the METAR for YSNF issued at 0630 ZULU. This was then updated with an Auto SPECI for Norfolk issued at 0800 ZULU. Wind 290 at 08 Knots cloud overcast (OVC) at one thousand one hundred ft AGL, 21ºCand the dewpoint was 19º C and the QNH Norfolk 1012.

Then from the 4 corners transcript:

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.
DOMINIC JAMES: If I'd been told that there was cloud at 600 feet, even given the fact that I suspected the automatic system was overstating the weather at Norfolk, I would've gone to Fiji.

Note: This clearly shows that not only did the ATSB make a mistake but the CASA investigators neglected to include what the “0801 UTC NADI ATC” actually reported for the 0630 METAR, instead skipping to the 0800 Auto SPECI details.

Do we honestly believe that the bureau investigators, without FF involvement in this investigation, would have missed such an elementary and critical point on the erroneously transmitted 0630 METAR cloud base? Maybe the omission by the FF author of CAIR 09/3 was an honest mistake but it is something that remains outstanding and needs to be explored.

So maybe the AFP could start with CAIR 09/3 and ask why it appears the document has either been doctored or edited to suit some kind of self-interest direction from FF executive? And has this ultimately led to the integrity and veracity of the bureau’s investigation and report being severely compromised?

[Kharon]

On t'other hand.

Sarcs # 1330 –"Or the Senator’s can directly refer the matter to the AFP for investigation as that is inevitably what the CDPP would have to do anyway as they do not have investigatory powers."

Valid point: but why not cut out the middle man; is the question now one of law?. The AFP may well be great 'investigators" but are they the right folks to be deciding if ATSB is in breach of the TSI, or CASA flouted the Act?. There's some deuced tricky wriggling, giggling and plain old legal hanky-panky floating about the 'legalities' of the whole exercise. Perhaps CP could give us a steer.

The AFP could very easily, I should imagine define if a 'document has been interfered with, documents such as the CAIR 09/03 or the less obvious 'Chambers report". Was the CAIR 09/03 the song sheet for the investigation?; was the Chambers effort never to see the light of day? I believe the original has been manipulated, but was it before or after the FOI disclosed the thing? All passing strange.

The thing that really intrigues me is the why?, what's the motivation ??. At face value we have the heads of two separate government safety bodies, scampering about the place waving bits of suspect paper, ducking direct questions and playing at silly buggers with the Senate? They should have nothing to hide – simple exercise – simple solution. Pilot retrained, operator to fix procedures, CASA to fix up their end, increase oversight and a big tick when the job's done. Smiles all round, so why?; what has been a powerful enough force to motivate their bizarre actions? There may well not be a cover up, but it looks like a duck. There may well not have been some collusion, but it walks like a duck. There may well not have been some creative writing done, but it quacks.

Oh my goodness, how it quacks.

Always remember -

"We are not trying to entertain the critics. I'll take my chances with the public". Walt Disney.

[aroa]

Sarcs... re yr #1330

Yr comment re DJ and submitting a brief to the CDPP.

Have just been down that path, having been advised about 18 months ago that I could do so, since neither the AFP or QPS would deal.

Two investigations had found the CASA SAWIs should be dealt with by the AFP. A chat from CASA and a 'no deal'.

The document in exactly the same format as the CASA brief, but the obverse of their ****ty coin, having gathered my witness statements from folk who were in the investigations of ICC and Birrell contractor.

NONE from the CASA (non) "investigator" since he couldnt/didnt want to find anyone in my favour...funny that.
Dont upset CASAs pre -investigation punitive apple cart... ffs!!

My Brief did a quick round robin of offices, all in week...and the final suggestion is I refer to the AFP (Aarrgh...FFS!) and rejected because my gathering of statements doesn't constitute an "investigation"
Probably BS ....but just flick it on ..!

The CASA bum/"investigator" wasnt sworn in as a Part 111 until AFTER the event...so he was an individual as I was....and wasnt even doing his "job" properly either.

So just where does the individual go..???
OZ.. the Land of BUllsh*t Supreme. And Just Ar$e.

[Frank Arouet]

aroa old chap;

We must refrain from cryptic innuendo which may confuse those who come to PPRune for entertainment lest you be accused of degenerating the thread into an incomprehensible essay.

I know what you are on about but people either ignorant by wont, or lack of emotional attachment are deprived of amusement.

For instance AFP-QPS-SAWIS-ICC-Birell- ffs- Part 111 exemplify this.

Being cognizant of the need for many to stray not into a legal battle as depicted on the PPRune Header, and the well known fact that those who suffer the barbs of these cryptic analysis full well know they are the target, may I suggest we refer only to published data of which William Shakespear is a prime example.

Don't want to exploit the innocent old chap.