Senate Inquiry, Hearing Program 4th Nov 2011

[VH-MLE]

Lookleft,

You're spot on!!

[4dogs]

suggestion vs satire

Sarcs,

Although the concept of what Senator X suggests is in itself most disturbing, it would appear from the evidence presented thus far that this is effectively what is already happening and the bureau is no longer a fully independent transport investigator. Perhaps this is the underlying point that Senator X is making in asking this question??

I reckon there is a big gap between asking a satirical "elephant in the room" question and actually proposing a course of action.

If you go back to the Report of the Senate Rural Affairs and Transport References Committee into Pilot training and airline safety; and Consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 which was published in June 2011, you will see that Senator X was about protecting reporters from adverse action by providing whistleblowers protections consistent with the Just Culture principles. Nothing has changed in regard to his attitude, but the CASA-dominated ATSB has been shifting the ground all along with no fanfare or real debate.

So how disturbed are most pilots with the concept that reports that they make in the interests of improving safety are slid straight to CASA as unprotected self-incriminating evidence for administrative action?

Stay Alive

[scrubba]

revisiting a little history

just had a thought about that inquiry.

it was running about in the middle of the Pel-Air saga, so the evidence from CASA and the ATSB would have been given in the light of what they had already decided to do with the Pel-Air scenario.

i suddenly feel the need to revisit the evidence in light of what has now been revealed by the current inquiry...

[Sarcs]

4dogs and scrubba both good points that you make, especially the fact that Pel-Air was set in motion with an apparently pre-determined outcome by FF and the bureau while the previous Senate inquiry was still in play!

On the subject of Senator X still pushing the protected reporting and just culture barrow, I couldn't agree more and he has been consistent on that issue throughout this inquiry..you only need look at Q3 from the written QONs for the 28/02/13:

3. What access to incident reporting does the ATSB currently grant CASA?

o

What information in a report would usually be provided? Does this include personal or other identifying information?

ATSB response: Details of the information disclosed to CASA are provided on the ATSB’s website as follows:

Information disclosed to CASA
Oral and SMS report of Immediately Reportable Matters
Oral and SMS advice of the occurrence of immediately reportable matters (IRMs – accidents and serious incidents) are provided to CASA as soon as the ATSB is informed.

The advice may contain details such as operator names, registration numbers, times, dates and locations. The ATSB will try, where possible, to avoid directly identifying individuals.

Daily report

CASA is provided with a redacted daily report of all incidents entered into the ATSB database. The redacted summary is a generic description of the event notified.

Depending on the workload for data entry, this may be provided 1 to 3 weeks after the occurrence of the event. The notification will include aircraft registration, so that CASA has enough detail to gather its own information about the occurrence.

Aggregate summaries

An automated weekly transfer of summaries of information entered in the ATSB’s database during that week is provided to CASA. The aggregate summary does not include identifying information such as aircraft registration.

o

Does the ATSB provide any conditions on access to this information?

ATSB response: The information is provided with acknowledgement of CASA’s enforcement policy concerning the use of safety information.

The ATSB is not aware of any circumstance where notification information has been relied upon by CASA to take enforcement action other than where the ATSB requested assistance in an instance where a person provided false and misleading information.

o

Is the ATSB aware of any limitations CASA puts on using this

information? For example, could it be used to investigate an involved individual?

ATSB response: CASA may use the information supplied in an ATSB forwarded notification to inform itself of matters that require investigation by CASA so that CASA may obtain its own evidence where there is a need to take safety action.

Again I don't think the Senator is particularly interested in the answer. Other than the fact that it is just further spin from Beaker and by now no-one will ever believe the guy again as he has lost all credibility in the eyes of the Senators and the many observers/participants of this inquiry.

I also feel that Senator X and Senator Heffernan have never forgotten how the outcome and recommendations of the previous inquiry were basically ignored or subterfuged by the minister and DOIT. Hence the reason that the Senator's are using this inquiry as a chance to rectify past wrongs!

I also find it intriguing that the committee is still fielding submissions from the industry..take a look at submission 20 from the flying docs, it was submitted 19/03/2013...hmm now that is interesting??

Maybe the Senators are actually consulting with industry..maybe??..perhaps??

[halfmanhalfbiscuit]

Sarcs,
This is the page I think the ATSB QON was referring to:
Aviation Accident or Incident Notification

Aviation Accident or Incident Notification

However, what about REPCON's?
REPCON - Aviation Confidential Reporting Scheme

REPCON - Aviation Confidential Reporting Scheme

It states:
"REPCON may use the de-identified version of the report to issue an information-brief or alert bulletin to a person or organisation, including CASA, which is in a position to take safety action in response to the safety concern."

In the QON they state:

The advice may contain details such as operator names, registration numbers, times, dates and locations. The ATSB will try, where possible, to avoid directly identifying individuals.

Now if the REPCON should have been included as it states above. That statement could be at odds with the confidentiality required.

REPCON Aviation is established under the Air Navigation (Confidential Reporting) Regulations 2006 and allows any person who has an aviation safety concern to report it to the Australian Transport Safety Bureau (ATSB) confidentially. Personal information will not be disclosed unless permission is granted by the individual concerned. Only de-identified information will be used for safety action.

I seem to recall it was the REPCON system that some groups were concerned with and how information was not sufficiently de identified allowing the person(s) to be identified?

[thorn bird]

All of which says....do not talk to anybody without a lawyer's advise and preferrably present.
CASA has cut itself off from the industry and dragged the ATSB with it.
The corruption is palpable, both organisations have demonstrated they cannot be trusted. If its not already happening, how long before the brown paper bags over the counter Friday afternoon? Just look what happened in NSW when a blind eye was turned to corruption. How long before those at the bottom see how those at the top are getting away with it so they may just as well wade in and help themselves?

[Sunfish]

It now has to be assumed that anything the ATSB is told will be reported to CASA by the ATSB in sufficient detail to identify the pilot. Once the registration is known it is a simple matter to peruse the Maintenance release and in the case of a company or hired aircraft, the booking or task logs.

Even easier, CASA may request details of the flight plans of the aircraft concerned for the period under investigation from Air Services Australia which will identify the pilot. There are no end of methods that can be used to identify the pilot once the registration, or even perhaps simply the make, model, time and location are known.

Note: Yes I know you alll know that, but I'm hoping someone useful might read this.

Lookleft:

And who is the Shadow Minister? Why will they be any different to John Anderson and John Sharp (I think that's his name, the bloke who's on the board of Rex). The Regional Services portfolio usually goes to the NP leader who is also usually the Deputy PM. How much time or effort do you think will be put into aviation? Greg Searle was on the Senate Committee that looked at training and aviation and he was very alarmed after he heard some of the evidence. What influence did he have on the government's response to the final report?

At the risk of being long winded, this is how Government works.


1. Ministers are very very busy people. It is a hard job and Ministers have very little spare time - which is why they have public servants to do the detail work. Ministers and Governments make POLICY.

2. Ministers only operate from ADVICE which comes from a Public servant. That is why you constantly hear the words: "I am advised that....", "My advice is.......", "According to my advice......". The reason they operate by reference to advice is that they don't have the time or technical expertise to nut out a response to a particular issue. Doing something without a brief is highly dangerous because the Minister can't flick the blame onto a Public servant who advised him. .For example, the former NSW mines minister MacDonald is allegedly in trouble with the Corruption commission because he CANNOT produce a brief from the Public service recommending he grant Eddy Obied a mining lease.

3. The people who provide the advice are public servants who have the time and technical expertise to sort out:

(a) what the heck is going on?

(b) What should the Minister do about it? They do that by referring to the Governments policy.

(c) The Public Servant prepares a written BRIEF to the Minister asking him to DO SOMETHING.

4. The Brief to the Minister will be no more than Two A4 pages long, perhaps with supporting documentation such as a speech to deliver or a letter to someone to sign. The art of Brief writing is to get a succinct summary of the background, analysis and a recommendation onto no more than Two single sided A4 pages and preferably only One.

5. A Brief follows a set path. Say you write to the Minister, your letter will be opened by a Ministerial advisor. The letter gets sent to the Departmental Secretary who notes it and passes it on to the head of the section of the Department concerned. He sends it to the head of the sub section and so on until it arrives on the desk of the poor bugger who has to sort the matter out.

6 When the poor bugger sorts it out, he writes a Brief that goes up the same ladderr and each section head or department head initials the brief, meaning they approve it. A brief can go up and back down the approval chain many times before everyone judges it is exactly right. Finally the Department Secretary approves it and hands it to the Minister.

7. As I said earlier each brief is written with the objective of requesting that the Minister do something. Typical recommendations are:

"That you sign the attached letter" (to someone about something)

"That you note" ( because you are going to cop a parliamentary or media question about something, and you need to know these facts).

"That you approve something" (we want you to exercise your ministerial power under an Act of Parliament)

So when you "write to the Minister" about some bloke in CASA who had harsh words to you in Oodnadatta last week your letter is first catalogued, then passed right down the Departmental food chain to the very guy who spoke to you and he gets to write the Ministers reply. Now this is all a pain in the backside for everyone concerned because it makes unnecessary work.

As many people have found out, the Public service can be occasionally vindictive when the bona fides of their actions are called into question and they never forget. Your letter and the brief and response are on file forever and it will be pulled out and read the next time you request an approval for something, and of course it will influence the outcome.

In other words, you are expected by the Public service to cop it sweet and not to make waves. You may be branded a nutter or serial complainer and the Public service will exercise its revenge, perhaps years later.

Of course if Fifty unconnected people write to the Minister about the behaviour of a public servant on multiple occasions then action will be taken. On the other hand if a Public servant does something praiseworthy then write to the Minister because everyone from the Department Secretary down the food chain gets a big tick after their name and the letter goes on someones file as evidence of their good performance.

So back to the original question: Will a new Minister do something about CASA, ATSB and all? Short answer: NO. How could he when he has to take advice from the very people you are complaining about?

The only real threat to CASA and the current regime comes from the Department of Prime Minister and Cabinet who are the very dedicated public servants who keep the rest of the service in line. If there was a national scandal that attracted public interest (and lost votes) then the PM might act. If a sufficiently large, diverse and credible number of letters to the PM started appearing then the Department of PM &C might act. They are the only ones with sufficient authority, drive and intelligence to cut through the multiple defensive layers of legal and technical BS that have been built up around CASA for generations.

In case you are wondering, I had the priviledge of working in the public service for a few years and 99% of Public servants are hard working, intelligent, poorly paid and incorruptible people who have the best interest of the country to heart and do their best to make the unwieldy system we have built work. They taught me how to write a brief for which I am ever grateful.

[Kharon]

Physician , heal thyself.

Dolan- Hansard – 25/02/11. "We also believe that our existing confidential reporting system offers an additional mechanism for ensuring that safety information is not suppressed for fear of the consequences, and perhaps we need to put more effort into publicising that scheme to give it its full effect." My bold,

McCormick – Hansard – 25/02/11. "There could have been a view in the past that ATSB and CASA were perhaps not going in the same direction. We certainly are these days, but one of the direct outputs of that is that when the ATSB—bearing in mind the caveats as I have said are around their own transport safety and investigation act—becomes aware of an issue that is going to result in a recommendation to CASA to take action or to investigate something, they inform us of that and then we conduct a parallel investigation ourselves. My bold,

Seems to me, the sinister irony within these paragraphs could do with a briefing to someone. We can only hope someone appoints a Fawcett look alike competition winner as 'Junior Minister' for aviation.

[my oleo is extended]

Sunfish, you forgot one other small point when it comes to 'threat to the regime' - Two smoking holes. That is likely to 'change' the regime. Not the most desirable method for making change at CASA but this will probably be the most likely method.

[Sunfish]

Agreed Oleo, Two or Three smoking holes was what I was thinking when I wrote of a "national scandal" as a regime changing event.

[thorn bird]

Aint it sad that here we are almost wishing for an event that 99.999% of us strive to ensure never happens, happens.
Is this the only event that can affect reform in a moribond, self serving, corrupt organisation?.
Must this event occur before those sociopaths that infect its upper echelons are weeded out, the them and us culture that prevails consigned to the dustbin of failed policies enabling Industry and regulator to work together in a common goal of foster and promote not just safety, but the industry itself.

[Sarcs]

"Passing strange" volume two!

Kharon :

McCormick – Hansard – 25/02/11. "There could have been a view in the past that ATSB and CASA were perhaps not going in the same direction. We certainly are these days, but one of the direct outputs of that is that when the ATSB—bearing in mind the caveats as I have said are around their own transport safety and investigation act—becomes aware of an issue that is going to result in a recommendation to CASA to take action or to investigate something, they inform us of that and then we conduct a parallel investigation ourselves."

Yep there is sure some golden moments in that Hansard but there is even more irony, spin and obfuscation, given what we now know, in the QONs for the 25/02/11 public hearing.

Which begs so many questions that one really doesn’t know where to start …but I’ll give it a crack…

Firstly this statement from the DAS above… “becomes aware of an issue that is going to result in a recommendation to CASA to take action or to investigate something, they inform us of that and then we conduct a parallel investigation ourselves.”

And further backed up by the DAS here:

Senate Rural Affairs and Transport Committee
ANSWERS TO QUESTIONS ON NOTICE AND WRITTEN QUESTIONS
Pilot Training Inquiry 25 February 2011
1
Question No.: CASA 1
Division/Agency: Civil Aviation Safety Authority
Topic: ATSB/CASA investigations
Hansard Page/s: Written Question
Senator Xenophon asked:
When conducting a compliance investigation of an aviation event that is also subject to an ATSB investigation, how does CASA avoid any perception that it could potentially compromise the ATSB’s independence and potentially affecting the free flow of safety information to them?

Answer:
CASA and the ATSB have entered into a Memorandum of Understanding (MOU) that expressly provides for both organisations to avoid any impediments to each other’s functions.

The MOU is published on the ATSB website.

Ok got that?? We can now probably all agree that in context the Pel-Air Norfolk ditching was the first official test of the new MOU 2010 (i.e. ‘test case’) and a new détente between FF and the bureau (which I might add they failed miserably!).

So the ‘passing strange’ questions in light of the above statement and several AQONs from the 25/02/11 hearing..

• Why, given the statement above and the fact that the MOU had been in force for over a year, did FF instigate a ‘parallel investigation’ and ‘Special Audit’ almost immediately upon being notified of the accident by the ATSB? Surely this indicates a hidden sinister agenda and lack of trust by FF for the ATSB to make a preliminary assessment of the accident in an unbiased and independent manner?

Coming back to the DAS statement and Kharon’s highlights…“becomes aware of an issue that is going to result in a recommendation to CASA to take action or to investigate something...” in light of which it would be fair to assume that even 15 months after the Norfolk ditching that FF were still expecting (as you would according to the TSI Act and past bureau practice) to receive a ‘SR’ for the bureau’s significantly researched and notified ‘Critical Safety Issue’.

• So was this the reason why the ATSB investigation ground to a halt (especially given that an investigation of this stature would normally take 12 to 15 months to complete)? And was the inquiry the reason why the ‘CSI’ remained a ‘CSI’ and subsequently unaddressed by a ‘SR’ for over two and half years before being downgraded to ‘Minor’?

All ‘passing strange’ indeed?? Oh well off doing a Kelpie…

Note: The Senate Inquiry was referred to the Senate on the 30th September 2010… http://www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=rat_ctte/completed_inquiries/2010-13/pilots_2010/info.htm … which was some 3 months after FF sent their CAIR 09/3 to the ATSB and nearly 2 months after the ‘Chamber Report’ was sent to the DAS…the timeline here is very interesting??

[Kharon]

Metaphorical smoking holes are abundant – perhaps we could use these instead? The questions posed by Sarcs above leaves the 'ravelled sleeve of care' untended; it teases you with a notion that the delay on Pel Air was created for one express purpose: the back flip a must have been a required part of the deal to ensure adequate arse cover was available for the 2011 inquiry. Should this ever be proven not even 'he must not named', he hoodoo voodoo behind the scenes cannot hide from the wrath of the people who have had the Mickey Bliss taken for a number of years now.

Stick to your research Sarcs – develop that time line and all will become apparent in due course.

[my oleo is extended]

Sunfish, perhaps an even more eye opening scenario would be the loss of say VH-BBJ into a smoking hole? Maybe brought on by an unfortunate TIBA issue? Or caused by an A320 cadet with minimal hours climbing through BBJ's decent path with its warning systems U/S ? That would certainly awaken the sleeping Government from its comatose state. Unlikely scenarios I agree, but one that would inflict instant change especially if the 'system' was the cause. But imagine the Beaker and all his painful mi mi mi-ing and panicking about how to investigate the accident with a budget of just $500!

'Aviation, what aviation?"

[Sarcs]

4dogs and scrubba look what you’ve started!

Kharon:

Should this ever be proven not even 'he must not named', he hoodoo voodoo behind the scenes cannot hide from the wrath of the people who have had the Mickey Bliss taken for a number of years now.

I agree “K” much like the evil emperor of Star Wars fame who relies on his able Lieutenant Darth Vader to enforce the ways of the darkside so too is the influence of ‘he who must not be named’. Remember this is the man who believes that the MOU was designed for the convenience of FF to exploit and cover up their failings….

“I was very closely involved in the development of the MOU and the situation that preceded it. If I could just say something that might put some context for both Senator Fawcett's question and Mr McCormick's answer, it might help a bit. Firstly, the rationale for the new MOU was to create an environment in which, if I may put it this way, as much information as appropriate could be exchanged between the agencies. The motivating factor at the time had far less to do with any concerns on the part of the ATSB with information CASA was not providing to them but rather information that the ATSB in the past had not provided to CASA” (from 15/02/2013 AAI inquiry Hansard).

After all who do you think has been writing and proving all the AQONs, MOUs, DAS retraction letters, regs etc for all these years, certainly not the DAS or his predecessors??

Stick to your research Sarcs – develop that time line and all will become apparent in due course.

Okay that I can handle, as I’m really not much for conspiracies but there certainly is a chasm of dark unexplained murk and corruption mixed up in this lot.

So timeline.. 21st July 2010 ‘CAIR 09/3’ completed and presumably forwarded to the ATSB as per section 32 of the TSI Act. This report didn’t mention virtually anything about the FF deficiencies in oversight as highlighted by the SAR and the FRMS SAR. However 12 days later on the 1st August 2010 the ‘PELAIR-OVERSIGHT (“The Chambers”) REPORT’ is released to the DAS. Then to really throw a spanner amongst the works on the 30th September 2010 the Senate announces the ‘Pilot Training Inquiry’....

Kind of puts a new light on stuff that was stated and answered in that inquiry, here’s an example from the next paragraph down from Kharon’s earlier quote from the 25/02/2011 hansard (my blue thought bubbles):

Mr McCormick 25/02/2011 pg 115 – “Of course, we investigate for different reasons. I am certain—and I will speak slightly for Mr Dolan (DAS thought bubble: …so pay attention Mr Dolan as I have a message for you!)—he most probably said they do not appropriate blame or look for those sorts of issues.

We are not necessarily looking for someone to take action on (DAS thought bubble: …but we are actually doing that as it is all part of the smoke and mirrors to avert attention from our own failings in oversight and hence potential liability!), but we are looking more at what it means for the industry and what has happened here. Perhaps over a year ago, there was an unfortunate incident off Norfolk Island where an aeroplane was ditched. We actually started our activities and our action much sooner than we would have if we had not had that MOU in place (DAS thought bubble: …we now have the perfect mechanism in place to circumvent any unwanted interference and close scrutiny from the ATSB, whereas before the ATSB already had the jump on us).

We are moving to get to a result and an understanding much quicker while the ATSB naturally takes its due process (DAS thought bubble: …so Mr Dolan fair warning we need you to sign on the virtual dotted line and come across to the darkside and take up our mantra that it was all the pilot’s fault and there is.. “nothing to see here!”).”

Okay well back to my timeline and doing a Kelpie i.e. back in my box!

OK Sunny which acronyms are you having trouble with?? DAS= Director of Aviation Safety, FF= Fort Fumble, AQON= answer to question on notice, SAR= Special Audit Report, FRMS= fatigue risk management system, CAIR= CASA Accident Investigation Report, CSI= critical safety issue, SR= safety recommendation or maybe AAI= Aviation Accident Investigations (the name of the inquiry). Hope that helps??

[Sunfish]

For Gods sake don't use acronyms witout explaining them if you want anyone outsde the small circle that writes this stuff to read it and understand.

[my oleo is extended]

Actually Sunny it is YOU that has recently come up with a term that tickles my fancy - 'Twerp' I hadn't heard that term used for years mate, very old school but quite amusing, and it is also a much nicer term than what the youth of today let fly from their potty mouths, not to mention myself on rare occasions.
So I am thinking that the following is what I shall use for a week or so, just to test the waters;

Director Aviation Safety - Twerp 1
Assistant Director Aviation Safety - Twerp 2
Associate Director Aviation Safety - Twerp 3

"Aviation, what aviation?"

[Sunfish]

Oleo, I take your point. However there are Two things that do not help your case, both relate to the hope that a passing politician or journalist might read what has been written on some Pprune pages and decide to take the matter further.

1. The first is the habit of some pilots to revile both journalists for their aviation hyperbole ("the lazy journalists guide" etc.) and calling members of the travelling public "self loading freight" a derogatory term I detest. Both tend to form an impression that the pilot community is a bunch of self indulgent prima donnas, leading to the false conclusion that compliants by them about CASA may have no basis in fact.

2. The tendency to use acronyms without explaining them and not bothering to put the story into words others can understand.

The whole point of the story is that the ATSB was set up in the first place as an independent body, as are similar institutions all over the developed world, to paraphrase Mr. Dolan: because it is vital to the safety of the travelling public all over the world that any safety information must not be suppressed for fear of the consequences,"

However CASA and the ATSB established a Memorandum of Understanding (MOU) that now completely subverts the intent of not only Australias laws on the matter but Australias intenational obligations to the International Civil Aviation Organisation which is a big deal because non compliance prejudices the availability of international travel services to the Australian public.

The ATSB now transmits information to CASA that facilitates prosecution or administrative punishment against individual pilots and allegedly perverts its reports to make them supportive of CASAs preferred outcomes. This situation now guarantees that pilots will think twice before reporting anything to the ATSB at all - suppressing safety information.

I dare say AirServices Australia (AsA), the air traffic control provider, has an MOU that facilitates similar actions by CASA. Which is one reason why I'm fitting data logging equipment to my aircraft.

In my opinion. both CASA and ATSB have "drunk the Kool Aid" (referring to the forced suicide of the Jones cult) - meaning that they have perverted their operations in a manner that reduces the possibility of an adverse Aviation event being discovered and requiring the Minister to take either criticism or action, while at the same time assuming absolute responsibility for one should it occur.

To put that another way, by embarking on MOUs CASA ATSB and AsA have willingly entrapped themselves in "the double bind problem" at the invitation of the Minister who will no doubt wreak terrible justice on them after there is an accident and their failings are revealed and I have some sympathy for their hardworking and diligent staff for this reason..

The usual personal calculation made by people requested to enter this type of double bind is to take the pay and responsibility and hope like hell nothing happens during the term of their contract. This is what I was invited to do by Esso many years ago and I quit as a result. What Esso some years later did to its poor employees, some of who died in its Longford Gas Plant Explosion, validated my decision.

My guess would also be that a new Government would have no stomach for reform whatsoever.

That is the guts of the story that needs to be told in my opinion and I wish the good Senators luck.

[tail wheel]

”Aint it sad that here we are almost wishing for an event that 99.999% of us strive to ensure never happens, happens.”

Statistically and regardless of CASA incompetence, it is highly unlikely an Australian airline will be involved in a smoking crater event any time in the foreseeable future.

30, 40 or 50 years ago airline accidents around the world occurred relatively frequently. However this century and despite the dramatic increase in the world’s airline fleet size, airline accidents have fortunately become a rarity. Technological advancements have all but excluded the possibility of accidents such as occurred and the result of the Comet I fuselage and Lockheed Electra wing structural failures.

[Lookleft]

Very true TW but its not the technology thats killing people its the lack of basic flying skills and sound judgement that is the current problem. Look at AF447, AF in Toronto, Turkish Airlines in Amsterdam, Colgan, all the runway overruns occurring. It is the state of technology that have allowed the rule makers to reduce the experience levels worldwide, a problem that is only going to get worse over the next decade as the demand for air travel increases. Combined with older pilots leaving the system because age does indeed weary then the concern about the increased likelihood of a catastrophic accident is a valid one. Stats are fine as an interpretation of the past but I wouldn't be relying on them to forecast the future.

BTW Sunny thanks for your summary of the way Governments work. It highlights just how hamstrung by the system is the good work of the Senate .