Senate Inquiry, Hearing Program 4th Nov 2011

[halfmanhalfbiscuit]

Rural and Regional Affairs and Transport
Agriculture, Fisheries & Forestry: Monday 27 May and Tuesday 28 May 2013
Infrastructure and Transport: Wednesday 29 May 2013
Regional Australia, Local Government, Arts & Sport: Thursday 30 May 2013

Estimates daily programs ? Parliament of Australia

Looks like after the senate inquiry report?

Oh, there is a seminar in Melbourne on design and manufacturing around the 23rd & 24th May too. Busy month!

[Creampuff]

Ziggy: I support your cause, absolutely. Anything I’m arguing about is trivial nonsense in the context of what you went through and continue to go through. If I'm distracting in any way from the achievement of your cause, that is not intended and I apologise if that's how it seems.

The name “Investigations Manual” is apt to confuse. It’s not about ‘looking into’ aviation stuff generally. It’s about very specific kinds of investigations, by very specific people, for very specific purposes. It’s almost certain that the circumstances of the ditching of NGA did not require an investigation of that kind, by those people for those purposes.

[Up-into-the-air]

On Topic

Heare's the latest:

Interim report: Inquiry into Aviation Accident Investigations

30 April 2013
© Commonwealth of Australia 2013
View the report as a single document - (PDF 33KB)
INTERIM REPORT On 13 September 2012, the Senate agreed that the following matters be referred to the Rural and Regional Affairs and Transport References Committee for inquiry and report by 29 November 2012:

(a) the findings of the Australian Transport Safety Bureau into the ditching of VH-NGA Westwind II, operated by Pel-Air Aviation Pty Ltd, in the ocean near Norfolk Island airport on 18 November 2009;
(b) the nature of, and protocols involved in, communications between agencies and directly interested parties in an aviation accident investigation and the reporting process;
(c) the mechanisms in place to ensure recommendations from aviation accident investigations are implemented in a timely manner; and
(d) any related matters.

The current reporting date is 30 April 2013.
The committee intends to present the final report by Thursday, 23 May 2013 which would allow it to fully consider the evidence and conclude its deliberations.

[Sarcs]

"27 vs 458"

Kharon:

Someone mentioned that the 12th is "estimates' day : that's a Saturday, (unless booze and old age have addled the marbles) can anyone assist.....

“K” had corrected my previous 12th date for the next RRAT Estimates see here: #1640

Cheers UITA you must have been on hols mate, as I had also provided a html link for the interim report back at #1616.

Just doing a comparison on surveillance procedures documentation/guidelines to our ‘brothers in arms’ across the ‘dutch’…..hmmm think I rather be an FOI/AWI in Nzud…

NZ Surveillance Policy (27 pages)
vs
OZ Surveillance Manual (458 pages)

Also noticed that the Oz SM has done away with the controversial STI now called a SRI which is used to establish the Systems Risk Profile of individual AOC/Approval holders etc:

3.8.1 System Risk Profile (SRP)
The SRP is a table of the most recent mitigated risk results for all assessed risks for an individual authorisation holder with full details of the risk assessments displayed in Sky Sentinel. When conducting an assessment of an authorisation holder, particular attention must be given to the composition of the SRP. The SRP provides a direct insight into an authorisation holder's ability to manage its systems risks.

The SRP is also represented as a numeric/colour indicator, the System Risk Indicator (SRI). The SRI shows the level of assessed mitigated risk (Extreme/High/Medium/Low) and is calculated from the ten most poorly controlled systems risks from all assessed risks in the SRP. It is displayed on the Authorisation Holder Assessment (AHA) page in Sky Sentinel as well as in other review pages.

The SRI score should be interpreted as follows:

• A red (Extreme Risk) SRI score indicates that considerable and significant system risk issues exist within the authorisation holder's systems demanding close attention

• An orange (High Risk) SRI score indicates that a number of system risks within the authorisation holder's systems are being poorly managed and require attention in the medium term

• A yellow (Medium Risk) SRI score indicates that, for the most part, the authorisation holder has control over its system risks

• A green (Low Risk) SRI score indicates that the authorisation holder has effective control over its system risks.

It would also appear that there is no longer any provision for the conduct of a ‘Special Audit’ (or if there is I can’t find it??). Which is interesting in context of this inquiry and the SAR/FRMS Special Audit??

Of course the NZud (much like the US, Singapore, UK etc..etc) system also doesn’t need to worry about EMs or IMs as enforcement and investigation isn’t part of their remit i.e. that’s the Ministry of Justice’s problem not the CAA. This leaves the equivalent of FF’s ‘Legislative Drafting Branch’ to carry out the more important task of amending the regs/Act to ensure it keeps up with the times in an ever-evolving world of aviation….makes sense to me!

[halfmanhalfbiscuit]

Sarcs,

The differing page numbers say a lot. 458 pages suggest a very prescriptive procedure?

The views for this thread are getting close to 375k. Looks like 400k is possible.

[my oleo is extended]

Let us read "CAsA Chronicle 2007" Ref: Shelfware Bruce

Here is a snippet from the CAsA Chronicles, specifically "CAsA Chronicle 2007", Ref: Shelfware Bruce.
There are many many chronicles in existence, along with philes galore. I have bolded the bits that I like, I am sure Frank will have a chuckle as well.
I just wonder if ESSO's replacement at the end of year will also put out some puff piece pony pooh such as this when he/she first arrives? Time is a good measuring stick of effectiveness, go back 20 years and there is more of this folly out there - winsome words, salient statements and succint papers, even a smattering of Wodger euphemisms and casting couch commentary!

Link below to the original bollocks:

Civil Aviation Safety Authority - Building the new CASA - a check of the scorecard

Building the new CASA – a check of the scorecard

Aviation Law Association of Australia and New Zealand
Avalon, March
2007

Regulatory Development

First some background. To put it bluntly, CASA and its predecessors had a long and not so proud history of rule writing. There had been a number of regulatory re-write initiatives over the last decade or so, and each has failed to reach fruition, for a variety of reasons. There was another such re-write in train when I joined CASA at the end of 2003. In this case, after a few years of mixed progress a major effort had been made to fast-track the bulk of the program.

Unfortunately, the effort to get it done in the required time-frame had increased the risk that the quality of the rules that were emerging would be compromised, that the goal of ‘Safety Through Clarity’ would not be met and that the new rules were less to do with safety outcomes and more
to do with control or prescription.

I also had doubts as to the quality of the consultation that had taken place. So, as some of you are aware, one of the first things I did after
arriving at CASA was to issue a series of directives which effectively put ‘on hold’ the so-called ‘operational’ package of the new regulations, pending a review to be undertaken by the Standards Consultative Committee, a body whose members are drawn largely from industry to advise CASA on regulatory issues.

This was likely to be the last chance we had to get the rules right and I made no apology for slowing the process, and even suspending it, until we could get it right.

The new guiding principles were for regulations which were to
be:
· Based on known or likely safety risks
· Drafted to specify the safety outcome required, rather than detailed requirements to achieve that outcome
· Within a two tier framework – the Civil Aviation Act, and the Civil Aviation Safety Regulations, supported by advisory and guidance material where needed.

In short, I wanted to get our regulations back to where they needed to be, and with a clear safety focus.

Also, I am interested in safety outcomes, not necessarily in the way those outcomes may be reached, which can be many and varied. This is the
approach adopted by the European Aviation Safety Agency, and I will refer further to that in a moment. The prospect of having the flexibility to meet the requirements by a means of one’s own choice appealed to some, but the concept was not universally embraced, as many in our industry like to be told what to do, literally ‘doing it by the book’. Such people are catered for in that the new style regulations will be supported by an advisory method of compliance. In other words, if you adopt this method you will satisfy the regulatory requirement (and satisfy CASA). But if you have a better process, one that works better for your organisation and achieves the desired outcome, then we will be happy to check it out, and if we agree it works, approve it as an acceptable means of compliance.

Implementation of the new guiding principles was established through Directive 16 of 2004 and were given support by the establishment of a new set of review bodies, the Regulatory Advisory Panels or RAPs, in addition to existing consultative arrangements. Membership is a mix of CASA and industry representatives, plus a representative from the Department of Transport and Regional Services. The distinguished Chair of this meeting [James Kimpton] is also the chair of two RAPs.

The need for new regulations to meet the new guiding principles initially slowed the regulatory development process, but there is no question that better and more effective safety focused rules have been the result.

Bruce
Byron AM
Chief Executive Officer
31 January 2007

Oh Bwuce, CAsA and its predecessors?? Some of them are still there today, 2013!

[LeadSled]

Sunfish,
I can confirm the case of "Vic", and it is recent (as CASA timescales go) and ongoing.

About six months elapsed between the episode of meeting the FOI and the "immediate threat to aviation safety" being acted upon.

Tootle pip!!

[Ziggychick]

What a Mess

Hi Y'all,

After reading, hearing and deducting some very important information. It is clear the management of our Aviation Industry is in trouble.
A quick comparison:
As a Registered Nurse in Intensive Care, a pre-hospital nurse for the V8 Supercars and other Motor sport events and as an Intensive Care Flight Nurse and Nurse educator I can give an accurate account of the problems within our health system and the need for change.
The need for change is necessary, as it can cause suffering to those wanting.
A typical ward nurse ratio is 1:6, Intensive Care 1:1 Flight Nurse 1:1.
Our ratio for harm is lessened thanks to change, there is still plenty to be done though.
My point being, that at any given time a pilot could have from 1 -400 peoples lives in their hands. Surely this would compel our Minister (especially the attention and current SI happening) to hear their voices. But it is a sad state that Speak no truth, Hear no truth and See no truth are monkeys sitting on their branch. A branch I would like to see fall as many of you I'd imagine would like to happen too.
If the Medical field can recognise and make change over time, same with aviation, maybe too long. Then why are C&A so protected. I know it's called politics, but there has to be more??
To every problem there is a solution.
Just a thought: I questioned the fellow I'm emailing at the FAA and I have pondered this to him:
The FAA visited Canberra twelve days after NGA ditched. Not much heard or a mention that I can recall. I would think that a visit from the FAA 12 post serious incident would raise some questions.
A non-technical rant, but good to get it out

[my oleo is extended]

Nurse Betty vs The Establishment, top stuff!

Ziggy, welcome to the 'mystique of aviation'! The longer you work in the industry the more the mystique intrigues you! Keep up your good surgical work on that ailing patient CAsA. Yes, it is an industry in which those bestowed with the responsibility to ensure safety is upheld and exceeded prefer to concentrate on watering pot plants, ignoring internal reporting processes, spinning, evading, building ergonomic field offices (complete with worm farms) and stalling on implementing workable safe regulations.

An astute and interesting 'industry fellow' once told me this about aviation safety - "It's all a game, a very serious game, but all a game". I didn't subscribe to that view, still don't, but its true. To those charged with maintaining and ensuring, dare I say 'safe skies', it is all a game, a game of odds, a game of chance. They know that in Australia large passenger jets won't simply start dropping from the heavens, so they spin the wheel, knowing that number 13 rarely comes up. As Sunny would say "it's not until there are 3 smoking holes, then action will be taken". Unless of course there is enough tautological nonsense taking place to awaken the ICAO and FAA from their deep slumber. I believe those beasts may be stirring from hybernation, but whether they awaken fully in time is itself another 'mystery' yet to be played out perhaps?

Remember, the issues don't lay just with CAsA. The ATSBeaker is a basket case ( at least they used to be a decent outfit once upon a time), and ASA aren't out of the woods yet. All three portfolios have been plagued by mismanagement, ego driven narcissists, inept leaders and sociopaths.
Ziggy, its as if at some point in time somebody collected as much hospital waste as they could (pus, faecal matter, gangrenous organs and rancid stomach bile) stirred it around in a giant chamber pot, tipped it out and said 'Arise Australian aviation oversight'!
We will have to wait with baited breath and watertight fuselage until April 30 to see if our good trusted friends in the Senate have the power to insert a cataclysmic sized pineapple up the CAsA's empennage or whether the Senators are given the Gonski and shut down, mission terminated, celebrations cancelled.

Either way one thing won't change, Mr ESSO has little fuel left in the tank and he will soon run empty.

P.S I am intrigued with the similarities between CAsA and hospitals as both contain bed pans and chamber pots, both collect waste and both require constant cleaning to prevent disease spreading!

P.S.S Ziggy, I can't but help wonder if the governments health bureaucracy also spends copious amounts of taxpayer money on overseas jollies, executive bonuses and Hospital pot plant maintenance while people are dying and wards remain dormant and sealed up? Nah, don't answer, I think I have worked it out!

'Safe skies are ones embracing Ziggys crusade "

[halfmanhalfbiscuit]

We will have to wait with baited breath and watertight fuselage until April 30 to see if our good trusted friends in the Senate have the power to insert a cataclysmic sized pineapple up the CAsA's empennage or whether the Senators are given the Gonski and shut down, mission terminated, celebrations cancelled

Remember 30 April was deferred to 21 May. Casa wants Hansard corrected. Was to were - or whatever.

[Sunfish]

Do the Hansard corrections suggest that CASA is trying to prolong the process with a view to ensuring the report sinks in pre election fun and games?

How long should that take and what would be its effect on the report timeline?

Would the Minister, CASA and ATSB be given a draft copy of the report and asked for comment? That is the usual way of letting people know what is coming and allowing them time to act in advance to limit any damage.

[my oleo is extended]

Biscuit, I stand corrected, appreciate that. So many dates, so many extensions, for a moment I was working off a CAsA calendar!

Sunny, you are very correct. They would most certainly be aware of what the report contains. My thoughts were similar to yours, some stalling would enable them to quickly apply a couple more coats of quick dry rapid polish to the turd, water the pot plants, make sure the Skulls comcar is fully fuelled, have one or two last Montreal trips, do some shredding and check that the superannuation is in order.
With that in mind the two weeks prior to May 21 (2013? ) should see some movement on the CAsA chess board one would think? So far all is quiet on ze Western front, and we are inside that 2 week zone until the report is released.
I am sure the Execs, the bloated Board and Sith Mrdak are quite busy about now.

[Ziggychick]

Bit Strange

Checked out Senate interim report and the date for release is May 23rd. What is interesting is that McSkull introduced a new FRMS policy effective from April 30th. How convenient to implement subject matter that was of great importance in the Senate, prior to the release. Who's talking to who. Is there such a thing as fair justice? Or is the circle of lies unbreakable?

[Greedy]

Ziggychick,
Unfortunately I think the web of deception and cover up in this industry is almost inpenetrable. Your reference to your profession reminded me of something that concerns me. It frightens me when I see Medical organisations stating they are looking to the aviation industry for safety management solutions. I think you have already discovered what a façade aviation systems can be.
For example I work at REX. I am tested every three months for my knowledge of legislation, ability to fill in maintenance forms, and competence to fly. Yet the very person (Chief Pilot) who is responsible for that testing has encouraged me and others to break the law and fly aircraft back to maintenance bases when they have been unserviceable.

I have complained both internally and externally. Doing so has only provoked retaliation and cover up from Rex and CASA. The REX board wrote a threatening letter and backed the Chief Pilot.

The explanation for this I think is in the very thin profit margins in this business. Operating costs are high and any call to improve things is immediately assessed by its effect on the bottom line. While they can get away with things they will.

It must have been a terrifying experience that night and I can understand your wish to hold CASA to account for their lack of oversight. I fear they are masters at cover up so it may be a longer road than just this present inquiry. I and many others support your endeavour. Good Luck.

Greedy

[Ziggychick]

REX/Pel-Air...Interesting

Thanks for that Greedy. I am surprised that you work for REX considering Pel-Air are part of them. Your concerns are valid and I am aware of the board for the company.
Funny thing, I was in the elevator loft on my way to see Warren Truss at Parliament House, and there was John Sharpe with a whole lot of , what looked like brochures. He said he saw Warren Truss the day before then he had the audacity to ask how I was. Have not heard a peep from Pel-Scare since the ditch. I gave him no answer and went into the other elevator.
The coldness towards the human side of this incident is freezing.

Anyhow, after seeing the audits of P/A from 2007, 2008 and the "special" CASA audit, the only conclusion I can come to is they operate on a superficial level, just skimming the surface of safety to save the almighty dollar. Quite disgraceful. I feel for you, you're obviously a concerned pilot working in a company that have serious issues that CASA and the ATSB have turned their head away from. I wish you well in your career and hope you can elevate into a robust, safety conscious employer.
Regarding healthcare...a whole new sight would be needed for that old chestnut

[Ziggychick]

Bangin on again...

Just a quickie, responding to greedy.
I can recall CRM being used in trauma situations, and this worked very well. Apart from that, I can't recall any other aviation implementations.
In saying that I needed to learn quite a bit when flying as a nurse (HUET etc)
Grateful for that one when we hit the drink
Your ex-chief pilot (for Pel-Air) at the time of the incident, now works as an Investigator for CASA at Bankstown...what the??
I wonder how one obtains membership to the kiss my butt club (KMB) to enhance their career.

[UnderneathTheRadar]

ATSB performance survey

Here's your chance fellas (and fellettes)

http://www.atsb.gov.au/newsroom/news...ms/survey.aspx

[thorn bird]

Just had a look at the survey. Is this one that attracts 50 penalty points for not responding to, or for providing answers contrary to the "Dear Leaders" expectations?
Looking down list of questions I think any five year old could very quickly narrow down the respondents identity with a reasonable degree of accuracy.
Everyone should be aware by now that whatever goes to the ATSB also goes to CAsA. Beware the ides of May.

[Greedy]

Ziggy,
The examples I can recall concerned doctors and some hospitals implementing safety reporting systems that are similar to aviation ones.
These systems are designed to identify risk and implement mitigating circumstances. In aviation the mitigators usually must not cost much.

You nailed it in your last post with the KMB. In this aviation business it pays to be in the KMB club.

Having any opinion that differs from your superiors is dangerous. To express it career suicide and possibly a strict liability offence to be prosecuted by CASA. But you have to laugh at some of the contortions CASA and others go through to try to justify their positions.

Greedy

[my oleo is extended]

Meep

A survey of mammoth pony pooh proportions. That's 8 minutes you will never get back. I agree with thorn bird, what an absolute crock. A bunch of mi mi mi with little substance, and all info will likely be shared with their loving bride CAsA.

They should have added one last survey question -
What famous personality does Chief Beaker look the most like? Is it;
A) Beaker from the muppets
B) Daniel Sterne from the movie Home Alone
C) Sheamus from WWE

Some strong contenders in my book

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