Senate Inquiry, Hearing Program 4th Nov 2011

[Kharon]

UN bail out.

Is the part where Oleo's appeal to a world body may well be needed?, on humanitarian grounds; an entire country penalised and an industry decimated because of one government administrative department which couldn't find a cat, in a cat house with a candle.

The whole episode has so many neat parallels and paradoxes. ICAO judge CASA as a being a very 'dodgy' operator, but being understanding of the economic hardship a downgrade causes, give them a chance to clean up their act; the quality of mercy etc.

CASA then proceed to arrogantly handle the chance offered with a smoke and mirrors dance routine, which fools no one. There is no user friendly AAT capable of overruling an inconvenient downgrade. It would indeed be ironic if the industry had to sponsor, fund and launch an appeal to a heavyweight body, in defence of the very authority which showed no integrity, granted no mercy and had not only decimated an industry, but dangerously compromised safety by failing to meet the expectations and requirements imposed by their ultimate 'authority'.

Someone should tell the CASA ostrich, the kids at ICAO and FAA can and do play rough, also mention that they are no where near dumb or dislocated from reality. They have special equipment which prevents dizziness on roundabouts and allows clarity of vision despite smoke and mirrors.

Think on – if there is a downgrade, the last straw being the complete cock up created by the CASA/ATSB/ Pel Air embarrassment, it will be industry doing the rescue. Are things that bad? well lets just wait for the next FAA/ICAO audit. Don't, not for one minute forget what's at stake, who is dealing the cards and the quality of players at the table. After the Pel Air debacle, CASA only have a few cards left, they'll have to bluff – again.

Perhaps ICAO will enshrine the "Chambers Report" as world best standard, it must have made a deep impression on them. I can see it all, Wodger v ICAO qualified heavy duty auditors, yup, that'll work, just fine. Quick twirl of the golden pen, fast skate around the ragged edges of some law bent to suit; then, off to the races for a nice day out. ...Brilliant.

Great post again Creamy; there is a lot more in the ICAO report but once again, the point driven home, beautifully.....

News flash - ICAO have lodged an application to join the National Misfits and Ills of Society Society. Proud to be a non profit, deluded, misguided, out of touch minority group...

[my oleo is extended]

Today's winning numbers are 16, 62........

The weighting of the ICAO audit report still rings in my ears: 16.62%
Imagine the audit score if it was done today?? An audit of CASA and all its rhetoric and high level waffle, ASA and Russell's $800 million dollar project and then bailing out of the burning kitchen into the arms of the contractors, and ATSBeaker with King Beaker, the budget conscious bureaucrat mi mi mi-ing in front of us ills of society!!

Oh my, it would be a tautological new audit, the findings would be the same pooh with a different gloss after being massaged by the same hands.

16.62% and dropping like the worlds economy!

[Sarcs]

Come in Spinner!

Creamy:

If that is the report to which Mr McCormick was referring when he said the major issue was that CASA did not have sufficient training in place for the inspectorate, I wonder whether he’s actually read all 98 pages.

Top marks there Creamy because that is exactly what I thought reading the transcript that went along with the QON from Senator Fawcett!

How could anyone make such a statement if they had actually read and deciphered the FAA audit recommendations? Or is it just that the DAS and his cronies really don’t care what the yanks found on behalf of ICAO?

I also think it is particularly interesting that Senator Fawcett asked the ICAO audit question of Fort Fumble at that particular time (12/02/2013), considering all the stunning publicly revealed revelations/evidence that was tabled/recorded at the AAI inquiry public hearing three days later (e.g. the ‘Chambers Report’ and the FRMS Special Audit Report).

After all (and as Creamy highlighted) most of the deficiencies of the bureau and FF brought to our attention in this inquiry were perfect causal examples of the risks of not properly addressing the non-compliances found in the FAA audit.

Kharon:
CASA then proceed to arrogantly handle the chance offered with a smoke and mirrors dance routine, which fools no one.

A most important point that you make Kharon and I might add that the evidence lately would suggest that not only are the RRAT Committee members no longer being 'fooled' but they also no longer trust the veracity and expert advice of FF and the bureau.

Why else would the committee be inviting, at this late stage, opinion/advice from two fully independent (not for profit) organisations that are highly regarded and have successfully survived long enviable histories (RFDS 85 years, FSF 66 years)?

We would also be naïve to believe that the committee also stopped there or that this hasn’t got the attention of the FAA/NTSB (and by default ICAO).

Shirley it wouldn’t be a stretch for the committee to sound out these organisations to garner further expert advice on how best to handle such a self-aggrandizing, outcome biased, politically manipulated investigation/Final report into the Norfolk ditching, plus all its subsequent implications to Australia air safety as a signatory to ICAO.

Hmm Oleo I think your onto something with those numbers 16, 62. I think you could add 17 and 25...might have to change my lotto numbers but in the meantime I'm doing a Kelpie!

[my oleo is extended]

BARS Room Barristers?

PAIN, I read through submission 21 and have to wonder out loud - Why?? Why would FSF submit a free plug for BARS, now?? Although I am absolutely not against the BARS process for some operators, BARS is not a solution for all operators. The need for an effective and robust audit program is essential, but BARS is not the 'be all and end all' tool that it is sold as. Any qualified decent auditor with either his own skill or experience along with a number of audit tools out there or even a LOSA style audit is much more effective than what FSF are flogging.

And personally I have found that FSF tend to kiss CAsA's ass just a little too often. BARS is a profit making tool. The Senate is not the place to advertise it. However, to be fair, if the system they flog does increase safety by even a mere fraction then that is a positive outcome. And to be honest any system or process that CASA can offer is usually incomplete, untested, buggerised or is a half arsed slapped together massaged turd.

I seriously do humbly apologise if I have offended any BARS lovers.
It's just that I have been under immense pressure to get the Styx houseboat mechanically sound by April15. We are expecting an ISO audit and Captain Kharon is too busy plotting a chart to get us to Canberra on time.
Also the deck is still covered in baby oil, a soiled twister mat, Bulgarian chocolate body sauce, Barry White CD's, an inflatable pot plant and empty Crownies so there is a lot o cleaning required before we can board new guests!

[halfmanhalfbiscuit]

ICAO auditor

There is a rumour that CASA had in their employment a trained and experienced ICAO auditor and that he was not asked to get involved either pre ICAO audit or post despite offering his expertise. Also that he left after about 2 years Of course only a rumour from one of the 'ills of society' etc.

30th April soon so the report could be out very soon!

[Kharon]

FSF Submission.

Oleo – I too was curious when I saw the FSF 'letter', particularly as I much prefer the IOSA system. However, this is probably not the forum for a 'deep and meaningful' on audit systems. I just wonder if the Senate is desperate for a solution; any solution to the deep dark morass CASA call an audit system (not what I'd call it; but.).

Both the BARS and IOSA systems have 'provenance' (for want of a better word) are internationally recognised and may be 'legally' defended. By that I mean to say, had Barrier for example, been a BARS compliant operation, CASA could not have cleaned them up as easily as they did; not that they could not, but it would have been more difficult and challenged the CASA mess openly.

Both systems help provide solutions to identified potential problem areas, are clearly defined and more importantly; the auditors are properly trained and qualified in the system. They are not a bunch of ex industry whatever's turned loose with some paperwork and a mission statement. Shades of FAA audit there me'thinks.

The FSF letter (IMO) is a yardstick of sorts for the Senate. Sen. Fawcett probably has forgotten more about 'audit' quality check lists systems than any CASA FO/ AWI ever knew or was taught. No doubt he is well aware that the current system of audit is only a favourite weapon of choice, reached for when there is a need; it is fluid, flexible and lethal. Some of the more disgusting aberrations used against operators have their roots in the dreaded CASA audit. What the CASA legal and not so legal creatures can spin from a minor infraction is truly mind blowing; whereas with a BARS/IOSA audit the operator knows what is required. Read some of the IOSA briefing material – makes life very simple. The IOSA system cannot easily be manipulated with 'malice and aforethought' to suit a predetermined outcome. I know a couple of companies which are audited about every six weeks on average (it's a rort, but same as insurance a necessary evil), by their clients and it's a no sweat, proactive process which can actually be of great value, improve efficiency and safety outcomes.

Anyway – I waffle. Point is the Senate seems to be isolating the problems surrounding CASA "audit". It's probably not the CASA systems per se, it's the way it is used. Same as the regs.; sure they are prescriptive and clumsy, but used in an honest fashion, they are 'do-able'; the problems start when they are misused to suit. Ask DJ or couple of the operators who have been the selected target of a carefully massaged 'bad' report card, you'll get an ear full.

Selah.

[Sarcs]

Lotto numbers and ARSE!

Auditing, rorting, safety enforcement (ARSE) and the houseboat syndicate lotto numbers?

Oleo:

The weighting of the ICAO audit report still rings in my ears: 16.62%
Imagine the audit score if it was done today??

Okay so we’ve got 16, 62 so far…but I’ve also come up with the numbers 17 and 25, why you may ask? Well 17.25 was the first registered Safety Trend Indicator score by FF of the Transair AOC, see here:

March 2000

CASA completed a safety trend indicator (STI) assessment of Transair. The STI revealed the following findings:
§ Key personnel experience
§ Procedure/process change
§ Organisation size change
§ Requests for corrective action (RCA)
§ Difficult operating conditions
§ Performance limit
§ Inadequate documentation
§ Inadequate processes in practice
§ Immature safety system
§ No corrective action system
The STI weighted score was 17.25. The CASA surveillance procedures indicated that a weighted score above 7 was classified as a ‘high risk’.

Passing strange indeed that this score never triggered a ‘Special Audit’, in fact the following years of system based FF auditing and surveillance of Transair netted scores of 15, 12, 12, and then surprise, surprise a 3.

So maybe we could be a bit wicked and pretend that the 16.62% was a FF Safety Trend Indicator score, which would suggest that FF is 9.62% over the threshold for a ‘high risk’ organisation. Coupled with the previous FAA NCN/RCAs issued and with point 3 (see below) more than adequately covered by this thread and the Senate inquiry, we could safely justify the FAA conducting a ‘Special Audit’ of Fort Fumble.Note: Probably even got more than enough evidence to present a ‘Show Cause’ case in the AAT at least.

4.2.4 Special Audits



A Special Audit may be planned when:

• An STI score indicates certificate/permission holder to be a high risk. Certificate/permission holders are prioritised according to their STI score
• Follow up Safety Alerts and RCAs indicate that the certificate/permission holder is a potential safety risk.
• Other information suggests the existence of an increased safety risk.

Note: Just curious but I wonder what the STI weighted score was for Pel-Air, Barrier, Airtex, Skymaster, Alligator, Hardys, Polar etc..etc??

Ok Oleo for our lotto numbers we’ve got 16, 26 (lotto numbers don’t go up to 62 so we’ll just reverse 62),17, 25, 15, 12, 3 and 7 for the sups.

Maybe we could get the Hoodoo Voodoo doc to deal his tarot cards to check our numbers as it obviously works for him…just a thought?

[Kharon]

The ARSE submission.

Oh!, Good shot Sarcs, well played Sir...... Tim Tams all around.

HMHE # 1469 – "There is a rumour that CASA had in their employment a trained and experienced ICAO auditor and that he was not asked to get involved either pre ICAO audit or post despite offering his expertise."

HMHB - refer Sarcs 1471 – You shall see Oh' half baked one, how expertise and qualifications pale to insignificance; you see how anyone can wiggle the numbers, as required to suit; so we can find some budgetary easing right there: experts, don't need no experts.... And anyway, we have Wodger – the weport wabbit to keep those pesky, irritating ICAO and FAA inspectors baffled; once you master the Montreal snake charming dance: you're in. None of these foreign upstarts are graduates of the approved school for plain and fancy legal tap dancing, so they'll swallow anything. No mate, sorry – no more experts need not apply, jobs done – good and proper. (Howzat for a split whatchumacallem ?; borrowed it from wodger).

Sarcs #1471 – "Probably even got more than enough evidence to present a ‘Show Cause’ case in the AAT at least."

Perfect, you have discovered the secret of how the universe was formed – you must be able to massage the numbers (as required) before entering the hallowed ground. The more massaged, the merrier and if you get lucky, he hoo doo voodoo will slaughter a chook, fish about in the entrails and give you a favourable outcome forecast. Great fun and; winners are grinners.....

[my oleo is extended]

Numbers, chicken guts and Auditing

Sarcs, Kharon. I must be honest, your last 2 posts did bring me great amusement and robust chuckles. I believe that the hoodoo cauldron is simmering as we speak and it's weekly brew of magic potions, elusive tricks, deceptive flavour and thick mass will be shared around shortly. The FAA, ICAO and the Minister have been drinking from the magic cauldron for years (and apparently the potion not only blinds you from aviation truths and reality, it cures 'brewers droop' and 'private part rashes').
But do not be fooled, the cauldron does not contain the same niceties as the trough, so I am sure that once all and sundry have been fed their weekly cauldron brew (or chamber pot brew??) there will be a refreshing trough close by to wash down the taste.

Halfmanhalfauditor, interesting 'rumour'. I am actually surprised that any qualified or skilled auditor works for CASA (Barrier, Airtek, Pel Air, Transair all underwent the 'CAsA audit process and look what happened). But if said auditor did exist it is no surprise he was not involved in the audit process because to have an audit background this person, may we call him 'Mr 1662'?, would have actual operational, frontline aviation and audit experience. Now the skills of Mr 1662 may be good on paper and in practise but those skills are irrelevant to senior management. The skills they require for such a project are skills in spinning, polishing, bluffing and deflection, hence Mr 1662 not being invited to assist.

Now speaking of lotto, has any external body such as the NTSB conducted an independent audit of our very own ATsBeaker in the past year or two?
Being the numbers man that mi mi mi Beaker is I was wondering whether a weighting score pertaining to just the Beaker boys exists somewhere?

Anyway, much food for thought. Now lets relax a little, sit back and enjoy a relaxing ATsBeaker ballad;

You Tube

[my oleo is extended]

ATSB Hypocrisy - Does the left aileron know what the right aileron is doing??

So, switching some focus back to the Pel Air ditching and the ATsBeakers involvement, I have studiously pondered over some additional robust safety methodology, papers and assorted ditties. Anyway I re-read something espoused by one Julian Walsh, manager and minion at ATsBeaker, you know mi mi mi King Beakers footstool. Anyway, the following is from Jules;

http://www.asasi.org/papers/2008/Ope...an%20Walsh.pdf

Now this was 2008, before poor Jules was 'Beakerised' and became another government bureaucrat rather than safety leader.
He spoke at ISASI, and incredibly during his opening tautology he promulgates some of the following statements;

1) Jules commends Dr Warren for his work in, get this, CVR and FDR introduction! (page 2). That is gold! To think that Norfolk was round the corner and he and Beaker Snr would shortly hold a different view of the importance of CVR/FDR's. (Beaker would not approve today). And incidentally no mention of sacrificing good investigation processes over penny pinching budgets.

2) Jules praises the Reason Model (page 2). Again, something that Beaker Snr doesn't particularly embrace. Oh dear, again, King Beaker would turn in his trough if he heard Jules say that today!

3) Lockhart accident. Jules criticises the Lockhart investigation timeframe of 2 years (page 5). More gold! Again, around the corner was Pel Air. How long was that investigation again? Oh my, King Beaker obviously mi mi mi mi promotes the more protracted style investigation?

All this raises more questions about the ATsBeaker's direction, ability and management does it not?
What on earth has been put into Canberra's water supply?
What would Pete the pot plant say about all this?
Will the Senators probe a little deeper into this hypocritical misaligned mob of societies ill's?

Sarcs, more lotto numbers for you - 20, 08.

[Sunfish]

From Mr. Walshs paper:

To prevent conflicts of interest, the Air Safety Investigation Branch reported directly to the Director General of Civil Aviation, rather than through the departmental chain of command. In practice, however, this arrangement could not always completely refute perceptions that the Department was ‘investigating itself’. This was particularly so where one branch within the Department came under scrutiny for its part in the development of an accident or an air safety incident.

The formation of the Bureau of Air Safety Investigation (BASI), in May 1982, as an operationally independent entity linked to the Commonwealth Department of Aviation reporting directly to the Minister of Aviation and operationally entirely separate from the regulatory functions of the Department, was a major change in the way air safety investigation and, particularly air accident investigations were conducted and administered. It is interesting to note that with the creation of BASI, there was in one sense a return to the situation that existed prior to 1938. The separation between air investigator and regulator was furthered with the creation of the separate regulator, the Civil Aviation Authority in 1988.

....And now you have precisely the same rotten situation of " collaboration" between CASA and ATSB that stinks to high heaven again thanks to the Minister and his Department Secretary!!!! CASA and ATSB MUST be at arms length for the sake of safety. The Pel Air accident demonstrates why.

[Sunfish]

From Walshs paper:

The principles of independence and the protection of sensitive safety information in the interests of future safety have been firmly protected. These are considered non-negotiable ingredients for a successful safety investigation agency. These principles have been bolstered with the introduction of the Transport Safety Investigation Act 2003 after nearly two years of consultation.

That principle is Now totally destroyed by a "memorandum of understanding" between ATSB and CASA such that no pilot in their right mind will talk to either.

[PAIN_NET]

In light of posts #1474-1476, PAIN would like to draw your attention to the following links that seem to be at odds with Mr Dolan’s ‘beyond all reason’ philosophy to the future of aviation accident investigation in Australia.
http://www2.zippyshare.com/v/59437133/file.html
NB PAIN notes that AR-2008-036 was released by the ATSB research team in December 2010 and was later referred to by the Department of Infrastructure and Transport in November 2011 as part of the Departments response to the Senate Inquiry into Pilot Training.
http://www2.zippyshare.com/v/75090409/file.html
NB PAIN believes Mr Christie last gave this presentation on behalf of the ATSB on the 04/09/2012.

Link: http://www.aacm.gov.mo/aigworkshop/www/programme.php
NB Mr Christie was a previous employee of the CASA until mid 2010. Mr Christie was also involved, as a Human Factors expert, in the Special Audit of Pel-Air in December 2009.

Usual precautions - Zippyshare file – "Download Now" button only.

Cheers

P2 aka BP “the quiet achiever”.

[Kharon]

Slight thread drift -mea culpa

I cribbed this from - Piers Ackerman's - web site this morning. It's from a Margaret Thatcher speech made in Australia; I thought it germane.

“Common to all collectivist theories is the presumption that ‘social justice’ is more equitable than justice to the individual; that the ‘social wage’ is more desirable than the income a man or woman earns, and spends or saves; that ‘classes’ matter more than people; above all, that ‘collective rights’ are more important than the rights of the individual citizen,” she said.

Thatcher demolished the concept of “collective rights” and used as her example the Soviet Union, where, she said, more than anywhere else, the collectivist dogma had - in the name of the “people” - made the state the owner and manager of all the means of production, distribution and exchange.

And the result?

“Far from abolishing poverty, socialism has kept the vast majority of the Soviet people miles behind the western world in standards of living and quality of life,” Thatcher said.

“Instead of ‘superior productivity’ based on workers’ control, its state-owned industries and collectivised farms are steadily falling further and further behind those of the west. Socialist ‘realism’ has meant neither artists nor writers have been free to express their own ideas. Anything that conflicts with the collectivist mystique is feared, and is condemned and banned.

“Note, too, this further perversity. The ‘condemning’, and the ‘banning’ are all done in the name of ‘the people’. Thus, the People’s Courts, the Public Prosecutors, the state-controlled industries are presented to us as organs of ‘collective’ democracy.”

“Freedom,” said Thatcher, “is our most precious possession. To defend it and maintain it is no passive task, but requires continuous vigilance and resolve. Let it never be said the dedication of those who love freedom is less than the determination of those who would destroy it.”

Ah well, back to my knitting.

[my oleo is extended]

Oh Kharon , what a beautifully worded statement from the now deceased 'Iron Tablet'. Perhaps the hoodoo voodoo of Canberra will take this speech, add a dash of PhD lingo to it and then present it at some seminar in Canada or Europe? After all, the 'Iron Tablet' did smash the maritime union and some in power in Canberra are smashing and trashing our once grand aviation industry.

Alas, enough tomfoolery, back to the thread. In the meantime I shall make myself a strong black, read some of the latest antics of industry in the weekly ATsB summary and amuse myself by again analysing how CASA and BAC are both pretty much rooted and how they have a common link within their Board membership!

[Sarcs]

The Captain Bligh syndrome maybe?

Okay back on thread…reference Oleo’s post ‘ATSB Hypocrisy - Does the left aileron know what the right aileron is doing??’

Maybe there’s some serious ‘black magic’ going on here?

So let’s get this straight first we have the ‘Investigator in Charge’ (withBeaker initially in full support of his IIC’s concerns) railing against FF’s apparent 180 take on their approach to the Norfolk ditching investigation; FF “we’re now solely blaming the pilot (outcome bias) and we’ve massaged all our evidence to reflect this…”.

Then Beaker has a ‘mind flip’ and comes out batting for the other team…meanwhile the other team’s two recognised Human Factors experts BC and MC decide to jump ship. BC goes to the ADF and MC to the ATSB.

Clear as mud so far, I think??

Ok so then we back up a bit and in 2008 the ATSB commission several experts in the field of human factors (Authors: Inglis, M., Smithson, M. J., Cheng, K., Stanton, D. R., Godley, S. T.) to conduct research into the ‘Human Factors Analysis and Classification System as a predictive model’. This HFACS uses its ‘baseline’ methodology on the ‘Reason Model’:

The Human Factors Analysis and Classification System (HFACS) is a hierarchical taxonomy that describes the human factors that contribute to an aviation accident or incident that is based on a chain of events theory of accident causation and was derived from Reason’s (1990) accident model.

Ar2008036 is finally published in December 2010 and is lorded by the Minister and his department in November 2011 as a benchmark of Human Factors research excellence by the ATSB.

Meanwhile if we jump on lefty’s TWM again and back up a little and reflect on Oleo’s post…“Jules praises the Reason Model (page 2). Again, something that Beaker Snr doesn't particularly embrace. Oh dear, again, King Beaker would turn in his trough if he heard Jules say that today!”

Hmm passing strange that?? JW, now Beaker’s left hand man, seems to have had a frontal lobotomy or maybe a Hoodoo Voodoo doll is manipulating him?

Then finally if we fast forward again to October 2012 and we get Beaker’s “Beyond all Reason” spin given to the Senators and yet only a month before MC gives a presentation that of all things features a block of Swiss cheese on page five:


So did all these bureau ‘Human Factors’ experts, the Minister and DOIT just miss the Beaker ‘beyond all reason’ memo? Or maybe the Hoodoo Voodoo doc just run out of dolls? Either way could there be a mutiny on the ‘HMAS Muppet’ brewing?

Enough of the Beaker bashing for a while, it would appear he is nearly at the end of the plank and in with the sharks…I’m off doing a Kelpie!

[halfmanhalfbiscuit]

Probably reading this book.

Who Moved My Cheese: An Amazing Way to Deal with Change in Your Work and in Your Life:Amazon:Books

Who Moved My Cheese: An Amazing Way to Deal with Change in Your Work and in Your Life:Amazon:Books

[scrubba]

Hope the Indonesians don't ask the ATSB for help with the Lion air investigation

I wonder if the ATSB has already sent the draft report "Lion Air ditching due to pilot error" to the Indonesian authorities in anticipation of being asked to assist in the investigation...

[halfmanhalfbiscuit]

Scrubba,

This could be an interesting one as casa did have a team in Indonesia.

I'm guessing Boeing will be looking for FAA and NTSB support. Good news is no fatalities being reported.

AFP: Plane misses Bali runway and lands in sea

The Pel Air situation and whether casa and Atsb help is requested or offered could be interesting.

There is a thread running on this crash
http://www.pprune.org/rumours-news/5...down-bali.html

[my oleo is extended]

Poor old 737, its a crying shame to see a couple of month old plane sitting in the drink with a broken back!

Now here is the irony. CASA, ASA and ATSBeaker have been sending inspectors, investigators and specialists to Indonesia to assist them since 2008. Around $30 million spent to date.
Lion have been trying to get permission to fly to Australia for a few years, wonder what effect if any that has on FF's decision makers?

Anyway, we will find out if Beaker allows his people to get involved as the draft accident report won't be published for 3 years, the Lion 737 landed in a few inches of water so the black boxes won't be retrieved and then the final completed report will contain lots of tautological nonsense and a heap of mi mi mi-ing!

"Safe skies aren't Indon skies"