Senate Inquiry, Hearing Program 4th Nov 2011

[Kharon]

Sunny, you are but as innocent and unworldly as a new born, we all know the blindingly obvious. The staff of anyone who willingly participates is a guilty as the one who ordered the actions, no sympathy from me, none at all. We pay for, and everyone who travels by bus, train, boat or air, expects probity. What we have here is the perversion of a system, nothing as simple and honest as backsheesh; and it has bugger all to do with aircraft ploughing into stationary objects. Nada -we had our white paper answer to that inquiry, didn't we. So alls well.

What we do have is an out of control safety department which can and does get away with the most outrageous manipulations, threats, intimidation, punishment and general embuggerance of the industry; deliberately, with malice and aforethought. Pel Air don't signify – it's a bagatelle; the real game is being played at deeper, darker level to expose the system, warts and all, (to borrow a phrase). Protect Hempel – OK. Crucify Quadrio – OK. Shut down Polar - OK. Protect Pel Air – OK. To name but a few of many. Enough with the bull**** already. Now-this Senate inquiry provides one, slim, fragile chance to correct at least some the iniquity, so-think on.

How about you do your homework and then tell us what you think it means? Then we can discuss it.

Steam off;

Sarcs - Don't much go for a conspiracy line either; but the Pel Air incident sure had the potential to upset the cosy relationship. Beaker's boys to do the 'technical' only and he saves a mint. CASA boys draw the conclusions to suit the "Strictly no Liability" policy; Yep - works just fine. Until the wheels come off that is.

If you can find the time I urge you to read the Canley Vale report – I mean read it; it's a sow's ear. The last part from about p 30 (ish) is an arse covering exercise of mammoth proportions; you may even spot some familiar language and grammatical gaffs. Even the technical analysis is suspect. When the Coroner reads that, signed off by ATSB as 'kosher' many awkward questions would potentially be avoided, the system works, just fine. Unless serious 'new' information is provided and accepted. Like..?..?..?..?..?.. But that is a battle yet to be fought, on another day.

Currently, I remain intrigued by the motive for the unfortunate 'Chambers' missive: is it still being touted as the 'cure' ?; does the DAS still robustly stand behind it ?; does the current atmosphere even allow for the thing to be dismissed, for what it is?. The ATSB and Ben Cook primary reports, supported by Aherne, certainly have more value, credibility and authority, yet they remain buried in a sea of fluff. Hard to tell – but, I agree Sarcs, the inconsiderate DJ certainly picked a hell of a time to run out of noise and then have the audacity to survive and the temerity have his very own Senate committee, asking awkward questions. Particularly of the potted, risible, Chambers Report.

Who's this Kharma bitch anyway ??

[Up-into-the-air]

casa, asa atsb and the SOE

Well noted Sunny:

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.

The real problem in this is the directions by the Minister to:

1. casa [By Instrument to the Board];
2. asa [By Instrument to the Board] and:
3. atsb [By a direction to the ATSB, directly by the Minister]

The three SOE [Statements of Expectations see: Statements of Expectations | Assistance to the Aviation Industry ] are along the following lines:

Statement of Expectations (SOE) outlines in a formal and public way, my expectations concerning the operations and performance of the Civil Aviation Safety Authority (CASA) from 1 July 2011 to 30 June 2013. This Statement of Expectations serves as a notice of strategic direction to CASA under section 12A of the Civil Aviation Act 1988 (the Act) and commences on 1 July 2011.

This is directly from the Minister and gets worse as you read on.

[Frank Arouet]

The whole point of the story is that the ATSB was set up in the first place as an independent body

This may seem strange given recent events but ATSB, CASA and Airservices were once all the one, The Department of Civil Aviation, (DCA).

It would be interesting to see how many people were employed in DCA of those days compared to the sum total of the three separate organisations we have today.

As one example, Licences were run by one Lady, (Mrs Giltrap from memory) and a staff of just a few. They handled all licences.

The aviation medical branch today probably has a cast of hundreds. I think there was one Doctor and some admin staff during the 60's.

I'm sure if they were burdened with the ASIC that would be attended to without the mess we have now.

We got free maps and amendment service as well.

DCA also looked after all engineering matters, registrations, home built aircraft, (the Cri Cri was one example), a really high quality crash comic without advertising and edited contributed to by experts.

I can remember booking night circuit time at Bankstown due to the number of aircraft flying and pilot licences have remained pretty static since the 60's to today.

It was normal for light aircraft to frequent Mascot/ Kingsford-Smith airport without charge. In fact there were no landing charges anywhere.

Everything was paid for from consolidated revenue.

I wouldn't object to a return to those days.

[Sarcs]

"Let's do the timewarp again.."

Can’t guarantee Frank that we can ever return to the good old days but maybe, just maybe we could right a few wrongs and help put the industry on a better more sustainable footing…so to the thread!

Lefty said:

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.

Lefty are you in a time warp or something? Your observations/opinions in the above post could have been plucked out of the thread for the previous ‘Pilot Training’ Senate Inquiry; I hope you were actively involved in that one too??

Using Lefty’s time machine and altering the historic chronology slightly so that the previous Senate Inquiry was called in early 2011 and the ATSB released their final report for AO-2009-072 within the normal timeframe for such an occurrence (basically on or around the same time)….well what would that have changed??

Ø To begin with this inquiry probably would never have happened because it would have been all revealed in the context of the last inquiry. It would also have meant that FF and the bureau would have been caught with their pants down, although I think it would have reflected more poorly on FF and the bureau could have come out smelling of roses.
Ø It would also have meant that the committee would have been given a perfect snapshot of the current system at work and would have focussed more attention on the General Aviation sector.
Ø It would have given more credence to several private individual submissions (and ironically Mr Lyon’s submission 18 from this inquiry), instead of getting lost in the airline ‘white noise’….

……….I’m sure people can think of many other things that such a change in history could have caused but unfortunately that isn’t the way it all transpired..oh well moving on!

Going back to Lefty’s time warp post where he mentions AF447, well again ironically that was included in the report and recommendations of that inquiry:

Recommendation 9

The committee recommends that the Civil Aviation Safety Authority (CASA), the Australian Transport Safety Bureau (ATSB) and Australian aviation operators review the final findings of France's Bureau of Investigation and Analysis into Air France 447, including consideration of how it may apply in the Australian context. Subject to those findings, the committee may seek the approval of the Senate to conduct a further hearing in relation to the matter.

And the government response:

Response


The Government supports this recommendation as it confirms current agency practice.

Australia’s independent safety regulatory and investigatory agencies, CASA and the ATSB, and industry, routinely examine the outcomes of accident investigations and consider their implications for the safety of Australian aircraft operations.

Both agencies are monitoring the French investigation into the accident of Air France Flight 447 and when the findings of the final report have been issued, which is expected next year, CASA and the ATSB will review any implications for Australian aviation.

So has this happened and if so are we going to be privy to the review information?? And are the Senators still keeping the option open of a further hearing to look into the AF447 investigation and findings?

There was also a further recommendation that has direct relevance to this inquiry in regards to human factors:

Recommendation 15

The committee recommends that the Australian Transport and Safety Bureau (ATSB) review its approach to the investigation and publication of human factors with a view to achieving a more robust and useful learning tool for the industry.

The Government response, also in light of this inquiry, has the potential to be very embarrassing for the minister and his motley crew:

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 and I believe again the irony, in relation to this inquiry, will not be lost on most reasonably intelligent people: http://www.atsb.gov.au/media/3536263/ar2008036.pdf

However I digress and I am in agreement with Kharon on this…“Now-this Senate inquiry provides one, slim, fragile chance to correct at least some the iniquity, so-think on…” and believe we as representatives of the industry can endeavour to help the Senators kick over the metaphorical rocks and obstructions placed to protect the axis of evil and dispel the myth of the ‘mystique of aviation’. If we don’t succeed we sure would have had a lot of fun trying!

So Kharon said:

Currently, I remain intrigued by the motive for the unfortunate 'Chambers' missive: is it still being touted as the 'cure' ?; does the DAS still robustly stand behind it ?; does the current atmosphere even allow for the thing to be dismissed, for what it is?. The ATSB and Ben Cook primary reports, supported by Aherne, certainly have more value, credibility and authority, yet they remain buried in a sea of fluff.

Agree “K” the ‘Chambers Report’ coupled with the self-serving CAIR 09/3 is the key here but the public portrayed airbrushed image in the ‘Pilot Training’ inquiry is a further piece of the puzzle…all very fascinating if it wasn’t so in your face and real!!

Off doing a Kelpie!

[scrubba]

can't apologise for an interest in history

hey Sarcs,

my vague recollection was that senator X was pushing for whistleblower protection to enhance reporting but the atsb was saying that there was no problem because they didn't just give the info to anyone! of course, that was a problem, because they had already embarked on giving CASA almost all of the information they received and CASA had already completed its enforcement actions by kicking DJ into touch while assisting Pel-Air in its voluntary recovery program.

what is being revealed now is what has actually been going on since 2009, including 3 good years of polishing that turd in the senate - now the obfuscation and misinformation is revealed

but when does plain lying turn into a conspiracy? your call

[AEROMEDIC]

[QUOTE]It was normal for light aircraft to frequent Mascot/ Kingsford-Smith airport without charge. In fact there were no landing charges anywhere.

Everything was paid for from consolidated revenue.

I wouldn't object to a return to those days./QUOTE]

They called it "cost recovery" and was a series of "one time fees".
The trouble with this was it created a trough for the managers and the feeding frenzy began.........

[Sunfish]

Tailwheel, I don't share your view that "technology has saved us" what technology has done is eliminated some forms of accident while creating new ones.

Examples? Air France 447 where it appears a pitot enabled air data computer failure completely embuggerised the flight director system and so confused the crew that they could not determin what corrective action should have been taken.

QF A380 that lost a chunk of its data bus and the systems that used it, to the point where only excellent aviation by a former schoolmate saved the ship.

Then there is the ongoing B787 lithium battery saga..

To quote Pogo: "we have met the enemy and he is us" we have created new and more elegant ways to screw up. I agree with you that the probability of accident is vanishingly small, but as Richard Feyneman pointed out it ain't zero.

One wonders if CASA feels, as the management of NASA did, that they can complacently keep going on their merry way because it can't happen here.

I still keep asking myself: what don't I know? I try and learn something new every flight......And now its time for me to find an instructor and go and get current again.

[Frank Arouet]

[quoteThey called it "cost recovery" and was a series of "one time fees".][/quote]

AEROMEDIC, cost recovery came into being in the '90's. Prior to that, we all paid air nav charges. A fuel levy came into the scheme of things just after, from memory.

Anyway, I've had the best years of aviation in Australia and I doubt any of you younger pilots will have or even see how good we had it then.

I sincerely wish you could.

[my oleo is extended]

Safety time warp

I agree with tail wheel that a fully fledged smoking hole incinerating 150+ pax would be of small odds. However I also believe, in a perverted sort of way that is one of our current problems. The lack of a giant smoking hole has enabled FF and the Fabulous Beaker Brothers to not just lose sight of the ball but the ball has never been in their field of play. Lockhart, Canley Vale, Pel Air have all been comedy caper affairs for the powers to be. If these accidents are a 'practise run' for the 'big one' then god help us.

At the end of the day we don't have a crystal ball, so maybe we won't have a major hull loss in the next 10 years. Then again, maybe we will. Either way, a decent safety regulator and a decent safety investigating body would surely go a long way to preventing what I foresee as the inevitable.
Am I wrong? I actually hope so, I hope this inquiry, this thread and the my thoughts about the state of this industry are all an over exaggeration, hysteria, the ramblings of one of society's ills, i hope i am trapped on some kind of time warp. If this is the case then so be it, I may be opinionated but I am humble, I will concede defeat and see out my days basking on the aft deck of the Styx houseboat awaiting the day when even the boats HAAMC has to cross over.

My motivation, ironic as it may sound, has only ever been 'safety', and for that I have my good reasons. My ramblings may be cryptic, my language 'colourful', and my disgust in corrupt bureaucracies unmeasurable, but I will eternally support every person, irrespective of their method, who continue to fight for change and 'realignment' of our piss poor regulatory agencies which have been hijacked by executive philosophers, wordsmiths, spin producing twerps and twerpettes.

P.S Seeing this is a rumour network I have heard that Flyingfiend is actually Dr Frankenfurter and Twerp 1, Twerp 2 and Twerp 3 are the masters of his stage show.
As Beaker would say "It's just a ministerial jump to the left, and a mi mi mi mi to the right, put your hands in a trough"......

"Aviation, what aviation?"

[VH-MLE]

Oleo,

Go and have another drink...

[Kharon]

Pete, our hero.

You will all notice how our hero, "Pete, the lonesome pot plant" foils a grab and smash mission.

Potted plants rule – right.

There is probably some obscure moral to the story – perhaps there is a serious requirement for - ; Nah, forget it. Oleo, I'll have another if you're off to the bar - rinse the taste of troll away. Cheers.

[Sarcs]

“It's astounding; Time is fleeting; Regulatory madness takes it’s toll..”

MOIE said: As Beaker would say "It's just a ministerial jump to the left, and a mi mi mi mi to the right, put your hands in a trough"......

Just had a vision of the Ferryman, gobbles and crew doing the timewarp aboard the housboat on the river Styx…hmm sort of fits I think!

“Anyway to the thread dear Watson”!

scrubba I too am a lover of history and research! Your, yet again, insightful post #1372 shows that you also do your homework:

my vague recollection was that senator X was pushing for whistleblower protection to enhance reporting but the atsb was saying that there was no problem because they didn't just give the info to anyone! of course, that was a problem, because they had already embarked on giving CASA almost all of the information they received and CASA had already completed its enforcement actions by kicking DJ into touch while assisting Pel-Air in its voluntary recovery program

Which makes me reflect back on this statement from the DAS (25/02/2011)…“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”…

Just surmising but I would say that the DAS was testing the waters to see if there was any interest in the Pel-Air ditching investigation. And because he had now had time to absorb the ugly implications if the ‘Chambers Report’ findings were to come out!

Also had to laugh at one of Senator X’s QONs and the hypocrisy of ‘he who must not be named’ answers in light of the Pelgate inquiry:

Topic: Operator resources
Hansard Page/s: Written Question
Senator Xenophon asked:
As a rule, our system of government gives significant leeway to operators to run their
businesses as they see fit. As regulators observing some of these operations, how do you:
a. Pick the threshold below which the system fails for lack of resources?
Answer:
There is no single specific threshold.

b. Assess whether some ambitious manager seeking to please his or her boss has
not just sown the seeds of future dysfunction or disaster?
Answer:
The assessment of key personnel, SMS and other regulatory requirements ensures CASA is satisfied that an operator fully understands their safety obligations. (yeah right..snigger, snigger)

c. Train your staff to make appropriate assessments?
Answer:
CASA inspectorate staff are required to complete core regulatory courses and ongoing
specialised regulatory training for their given discipline.

To be fair to the DAS and 'he who must not be named' it was a bit late to turn around and say..

"well actually one of our most trusted lieutenants has come up with a report that revealed we really dropped the ball with the oversight of the operator involved in the Norfolk Island ditching.

However because we commissioned that report we now have a clear insight and have manufactured a robust MAP (Management Action Plan for Sunny)specifically drawn up to address our deficiencies in surveillance and oversight of operators like Pel-Air..spin..polish the turd..etc.etc..blah..blah..blah"

...especially when you've already rogered the pilot and allocated that 89 million dollars extra funding to the GWM and potted plants retirement fund.

I mean FFS poor FF apparently didn't even have enough spare coin to help their poorer 'brothers in arms' fund the recovery of the CVR/FDR...
no I can understand where they were coming from...not!

[my oleo is extended]

"The Chambers report it's so dreamy, oh fantasy free me"

I mean FFS poor FF apparently didn't even have enough spare coin to help their poorer 'brothers in arms' fund the recovery of the CVR/FDR...

Perhaps if the VH registered aircraft had ditched near Montreal they would have spent the money to go over there and retrieve the 'beaker boxes'? There is always money from Montreal in the FF pot of money. Cha ching $$$

On a serious note (and with my bolding), from;
ParlInfo - Rural and Regional Affairs and Transport References Committee : 22/10/2012 : Aviation accident investigations

Senator FAWCETT: Do any of the commissioners have a background or qualification in aviation accident investigation?
Mr Dolan : I do not believe any of the three commissioners are qualified in aviation accident investigation. I have a reasonably significant background in aviation safety—air security and various other things—and a broader background in safety, including work health and safety and the systems approach to that. The other two commissioners have backgrounds in marine safety and rail safety.

And,

CHAIR: Mr Dolan, who made the decision not to recover the black box?
Mr Dolan : I did, Senator.

Could this be part of the broader systemic reason the ATSBeaker has become a complete farce? Yes, I think so. 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.
Sorry friends, the top echelon has to go. The cleaners at ATSBeaker headquarters could do a better job than mi mi mi Beaker and Co.

Also,

Agree “K” the ‘Chambers Report’ coupled with the self-serving CAIR 09/3 is the key here but the public portrayed airbrushed image in the ‘Pilot Training’ inquiry is a further piece of the puzzle…all very fascinating if it wasn’t so in your face and real!!

This is the plot shaper, the curve ball. I would like to see the Senators gently tug on this ball of yarn a little bit more. Lets see Herr Chambers take the stand and explain the 'mystique of the Chambers report' to the Senators in a little more detail. The 'who, how, where, when and why' as only the surface of this sore has been scraped.

Sarcs, I momentarily posted a Poohtube clip of Dr Frank N Furter however I removed it so as to not cause offence. Great movie however, and I can imagine Kharon dressed as the good Doctor (no, not Aleck) prancing around the deck of that beautiful sloop called the Styx Houseboat, enjoying the fresh air, the smell of Hades and the gentle swish of the river water lapping against both bow and stern as the boat slowly works its way towards 'The Circuit, Brisbane Airport'.

[Prince Niccolo M]

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.

[halfmanhalfbiscuit]

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'

[Kharon]

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.

[thorn bird]

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.

[Sarcs]

"....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!

[Sarcs]

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!

[Frank Arouet]

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)?