Senate Inquiry, Hearing Program 4th Nov 2011

[thorn bird]

Algae,
could you let us know just who's reg's Australia's are aligned with?? is our regulator so arrogant that they consider themselves the only people who knows anything about aviation, therefore we don't have to be compatible with anyone, they should align with us .
I have operated just about everywhere in the world and my perception is that it is a whole lot less stressful than Australia and in many jurisdiction's
a hell of a lot safer and a hell of a lot cheaper.
Interesting that Singapore manages reg reform which is 100% ICAO compliant, NZ almost complies, unlike QANTAS which seems to be going down the gurgler, The industry in Singapore and NZ seems to be doing very well.
Can you tell us what the quarter billion or so dollars we have spent to date on reg reform has bought us? other than incompatibility with the rest of the world, incomprehensible gobbledygook for rules which have done nothing to enhance safety, in fact quite the opposite.

[Up-into-the-air]

casa and the effect on commercial operations

Here Here!!!! [Hear Hear!!]

[my oleo is extended]

Algie bloom??

Algie, you are a naughty boy poking fun at Kharon.
Kharon asked me to pass this on to you;

Dear Algie,

I am currently busy making repairs to the Styx houseboat with Gobbles and Minnie, so I can't respond to your request for my résumé as there is no Internet, faxes or wifi available on the boat.
As for your question relating to nicknames and code books I do not have access to such material at the moment. I believe Sarcs may be able to help you with that as I left a 'regulations code book', complete with a pooh deciphering tool, at his place last week when we started our own project to re-write the regs. I also left a 'Minister for Mascot' code book there as well, and it is good for decoding exactly what the Minister is saying through all that froth, spray and lickspittle when he speaks. Sarcs also has my 'Davinci code book' and a code book that deciphers the meaning of 'PNG voodoo in aviation, a regulators handbook'. So you can borrow that one also when I return.

As for nicknames, I do use a couple of different ones for my bar room barrister mates and a couple of the old timers that I buy my horse feed from, otherwise let me explain them for you:
ICAO - International Charter of Air Operators
CASA - Civil Aviation Safety Authority
ATSB - Australian Transportation Safety Bureau,

Lots of love,
'K'

[Kharon]

The Ego has landed.

Well now; lets have a look and see what the tides of fate have fetched up on the banks of the Styx. "Gobbles – put that flamin' chain saw away. No you cannot feed it to the pets yet". "Minnie, sweetie, (sotto voce) let go the nice man, yes, yes: later maybe; we shall see"..... Hmmm, an ego? or an inferiority complex?. How shall we decide?

In primus, the creature must decide if it is drunk or not.

Algie – "by the amount of red I've had before reading or the amount of red you had before writing".

There seems to some small confusion in it's mind. Now then, seeing as I am sober and 'druther chew my leg off than drink red wine, we must determine (still being good natured) if the child is confused. Fail – this, whilst not 'good', is forgivable; so, the test must become complex. Let us ask some questions:- Now then, we note that you cite 192 members states in ICAO, this is accepted as reasonable -

Algie: Australia is not alone in sticking to its rights to be the final arbiter of what goes on here: Article 1: Every state has complete and exclusive sovereignty over airspace above its territory

.
No argument- but then you fail to mention that the tattooing, whilst admirable, only reflects a protection of 'sovereign' rites on airspace: but fails to mention the number of States which lodge exemptions against Annexe 13; who has the most lodged, who's are the most complex; and, more to the point, who's appear to almost exempt Australia (whilst technically compliant) from compliance with ICAO Annexe 13? Not a good look; no way to kick off a street fight (bluff and bluster just define bullies and by default cowards). Fail.

Secundus.

Algie - Can you PM me a code-book of names, nick-names issues, places etc please?

This statement is not good form in round one; it implies a lack of inside knowledge, a shortage of wit, a dearth of humour, all forgivable except the work has been done and a little time spent reading would have explained many of the 'mysteries' you seem to be grappling with. Now that's just plain idle and smacks of "mummy help me" , which is an unforgivable. Fail.

Algie - Also a few lines of your resume so I can see if, when I do finally understand what you're on about, I'll know whether you actually do know what you're talking about.

A pause for thought here: the breathtaking arrogance, mind numbing complacencey and the purblind assumption that provided Algie can count the nuts in the stew, well it's all good. Bollocks. Actually, bollocks in spades – re doubled. Fail.

Tell you what Algie, you show me yours and I'll show you mine. There are not many rules in a street fight, but you my sunshine seem to have found how to break 'em all. Cool.

Oh, and your Mother too – best wishes etc.....

Nah. let him go Gobbles: put him down Minnie; honestly - you get home and then this. Who found it, eh? Who?. "Fetch me a pint of good honest, old fashioned Ale Minnie, there's a good lass".

[Algie]

Ah Kharon

You know not do you.... except that you have of course read Don Quixote as well as the Goon Show scripts.

As for having to read all your earlier posts in order to understand your later posts......bit of a complex there have we? needing to be noticed?

Best wishes

Algie

[Sunfish]

You should have humoured him Algie....... How are things at the Circuit?

[Algie]

I was humouring him. And sadly. given my fondness for Qld, I'm not within several time zones of the Circuit. And don't expect to be.

Anyway. My quota of time for feeling anything about Kharon's sheltered workshop and outpourings is all used up. I just thought it might be nice to know more of someone who seems by his own testimony to be as uniformly right on all CASA issues as CASA is wrong

May allocate some more time to reading Kharons work next year. Right now the AFL season is taking up a lot of my thinking time.

Best wishes

A

[Sarcs]

Ditching to ditching..

Oh well after that brief interlude...

As I stated in this post; http://www.pprune.org/7725153-post7.html ….all roads lead back to LHR and it is extraordinary how many similarities there are between the PA ditching investigation, flawed ‘Final Report’, FF surveillance/oversight (or lack there of!) and the LHR accident. The major difference is that the ‘safety watchdog’ under Beaker have now cashed in their chips and are no longer in the game….god help us!

From the ‘Chambers Report’, the ‘FRMS Special Audit Report’ and indeed the ‘SAR’ it would now appear that Fort Fumble has not addressed any of the highlighted deficiencies of its adopted ‘systems based auditing’ and ‘risk based surveillance program’ that were publically documented in the ATSB LHR ‘Final Report’ and in the Coroner’s report.

The angst, animosity and total open warfare between the bureau and FF was first made public knowledge in the course of the LHR Coroner’s inquest. However I believe there was several instances where the bureau had been critical of the new surveillance procedures adopted by FF at the turn of the century.

The one that stands out is the ditching fatal accident of PA-32-300 VH-MAR and the subsequent safety recommendation R20040042 that was generated from that investigation; which read…“The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review their Safety Trend Indicator process, including with a view to developing a methodology to assist in objectively assessing potential at-risk organisations. That should include formal ‘triggers’ that enable the consistent prediction of the requirement for additional surveillance until Civil Aviation Safety Regulations Part 119 takes full effect”…

Recommendation R20040042

If you read the response text you will see that FF got particularly defensive of their new fandangle surveillance system.

After Hamilton Island there was the Toowoomba C90 EFATO SRs (R20040064-R20040069) that were further critical of FF’s surveillance procedures…then there was Lockhart…


Reference pg 44 Coroner’s report (my bold and comments):

As detailed earlier, CASA became aware of a number of deficiencies in the operations of Transair in about 1998 and 1999. Those deficiencies gave rise to a concern that Mr Wright, as CEO, Chief Pilot, Head of Checking and Training and line pilot was “stretched a bit thin”.

Steps were then taken in early 2000 to address those concerns by requiring Transair to appoint a maintenance controller, safety manager and re-organise the structure of Transair’s organisation. I have highlighted earlier the considerable delay that occurred before these organisational deficiencies were addressed and the suboptimal manner in which some key positions were filled. CASA sought to “keep the pressure on” so to speak, by refusing to at first accept the nominee for deputy chief pilot. It was not so assiduous with the equally important role of safety manager.

Thereafter, CASA conducted various scheduled audits and ramp checks in accordance with its Surveillance Procedures Manual. None of the audits identified any problems associated with the duration or quality of endorsement training, frequency of proficiency checks or whether appropriately authorised pilots were conducting such checks. * (pel-air similarity)

It may be suggested that having regard to the concerns that CASA raised with Transair in 2000 concerning the work load of the Chief Pilot as the head of the check and training organisation of Transair, inadequacy of Transair’s “systems of corporate management control and communications” and the need for “a comprehensive safety system within the organisation”, CASA should have been minded to ensure that Transair was strictly complying with its own operations manual and had an effective program of recurrent training in place.

The extent of CASA’s assessment of Transair is well documented and highlights a number of inconsistencies between CASA’s oversight of Transair and its regulatory policies and surveillance guidelines. It seems CASA’s surveillance did not detect that some of the line and base checks had been undertaken by pilots not approved to do this, and that training stipulated in Transair’s operations manual had not been delivered. *(pel-air similarity) It is also apparent that audits of other operations run by Transair, notably the Big Sky Express, did not detect breaches of various aspects of the AOC. Nor did there seem to be much continuity of effort from one audit to the next, and some audits were done with very few resources (often only one inspector) and very little time spent. * (so what has changed??)

CASA’s task was made more difficult by its inability to develop an adequate risk assessment tool for targeting its audit and surveillance activities. When the agency switched to systems auditing in about 2000 an advance that apparently marks it as a leader in aviation safety and warranting commendation it attempted to apply a safety trend indicator system that failed and was abandoned * (but was it abandoned?). Because systems auditing was so new, the guidance the agency could give to its inspectors was minimal. *(comes back to the ATSB’s previous criticisms of the system auditing and risk based surveillance system)

Further, I accept the ATSB’s conclusion that even if CASA had fully met its own requirements, there is insufficient evidence to conclude that it would have detected and corrected the fundamental problems with Transair’s operations. *(again the similarity to Pel-Air is embarrassing!)
Another area of concern relates to CASA’s processes for assessing risks associated with applications by air operators to vary their AOC to add new routes. Such applications required CASA field officers to apply the guidelines and provisions of a particular manual of air operator’s certification. In the case of Transair this involved considering the operator’s request, in 2001, to add Bamaga as its first mainland Australia regular public transport route (from Cairns), and subsequently in 2004 to seek the addition of Lockhart River.

In neither case did CASA require the operator to conduct a comprehensive or structured risk assessment of the proposed change. In particular, no such assessment was required in relation to Transair’s operating procedures, pilot experience or level of training, the rostering practices of Transair in relation to pilots who would be flying the routes involved and the pilot resources available to Transair. In short, it was not part of CASA’s processes to require Transair to undertake a formal risk assessment or make out a safety case for the inclusion of Lockhart River as a new port although it did require Transair to revise performance charts. *(again the similarities to PA are embarrassing i.e. CASA BK weren’t aware of many of the routes that PA was flying internationally)

I find that senior CASA management failed to provide sufficient guidance to its staff to enable them to fully and effectively evaluate risk management issues associated with Transair’s application to add Lockhart River to its air operator’s certificate as an interim port on the Cairns – Bamaga route. That guidance may have been as straight forward as requiring Transair to engage an independent specialist to conduct an assessment of, and provide a report on, all safety issues that were pertinent to the operation proposed. *(good job Barnesy pity he dropped the ball..but that man Harvey wouldn't have helped!)

Hmm..food for thought: Q/ Given what has (so far) been revealed in the Senate inquiry and if god forbid there had of been a fatality, the question that should be asked is whether Coroner Barnes’ summation would look out of place in the subsequent Coroner’s report into the Norfolk ditching??

NB A bit sharp to react there blackie..err No Hoper..err Owen corrected..and I will ignore the RPT vs Airwork comment because it is only relevant to the 'scoping' and risk matrix of an individual AOC or were you saying that Barnesy got it right with LHR??? Now back to the naughty corner...

[owen meaney]

Transair (Tropic Air) were operating low level RPT, Pel air was Operating Aerial Work Ambulance.
Transair had coroners inquiry due to death, PelAir no one died, no coroners inquiry.
You are comparing apples and wombats.
Algie may be right, it's the Red Wine.

[Up-into-the-air]

atsb, casa and the coroners courts

Real lucky Owen then.

Transair had coroners inquiry due to death, PelAir no one died, no coroners inquiry.

I am sure that Nurse Casey, the patient, the Doctor and the husband would be happy with your comment or the action of the atsb or casa in the Norfolk Island matter.

From a post on avweb:

Nurse Karen Casey says it all:

Karen Casey
Posted February 16, 2013 at 10:57 am | PERMALINK
CASA, ATSB, Pel-Air.

Shame, shame, shame.

How dare there be people in positions that knowingly put the public at risk. When I hear that this crash could have been prevented if more pro-active safety follow ups were insitu, my stomach churns. The hell myself and others on board have experienced in many forms, is too difficult to adequately express. The ditching was positively preventable had our trusted systems had honest, thorough scaffolding, starting at the top. CASA audited Pel-Air in April 2007, they found the operator was not adhering to numerous rules. Audited again March 08, safety alert issued. No further audit follow up until after the ditching. Then a dodgy ATSB report, the Chambers report sitting south under McCormick. How dare all involved shake our lives to the core…their turn to shake now.

Lies always unravel. I hope this is the start of real change.

[Creampuff]

Owen

It seems to me the comparison is a valid one. I think we can reasonably assume that had the Pel Air incident ended in tragedy, the Coroner’s findings would have been broadly the same as those in Transair. Patently inadequate regulatory interaction or intervention.

[my oleo is extended]

Putz's

Owen you really don't get it do you? Blind Freddy (sorry PAIN) can see they were different accidents with different outcomes. You need to stop doing a CASA/ ATSBeaker and skimming the surface, put on a miners lamp and dig deep son, below the weeds, the earths crust and into the mantle. That is where a whole new world opens up to ones eyes!

The similarities (again, forget life vs death outcomes) is a systemic issue with the operator, and worse, a lack of regulatory surveillance, risk management on behalf of the regulator, and a lack of regulatory action over matters they did know. Throw in the mix a lack of skilled Inspectors in FNQ, tick n flick audit methodology and complete laziness and you have a causal factor.
Take your James Reason model and as one of the defences add in 'efficient proactive quality regulatory oversight'. Now lets see if all the cheesy holes still come together in one linear trajectory or does the line bounce of a robust piece of defence and hey, an accident is prevented? Sound too simplistic? Damn straight it is.
The families of the Lockhart victims were dudded, pure and simple. The issue won't go away and nor should it until justice is served and the entire saga is properly addressed. Norfolk stinks of Lockhart. It's time for the CASA to search below the icebergs tip. Is it that frigging hard?

And Algie and Co, you will hate this stretch, but go look at the Dryden Ontario crash, which I may add was the catalyst for Canada and ICAO's promulgation and implementation of the holy SMS. No, the Fokker didn't ditch in water nor did it impact a mountain side, but it had all the workings and causal factors similar in nature to Lockhart and Norfolk. You bet, operator issues (many) and of no surprise, Regulator incompetence. Unlike the CASA, Transport Canada was force fed (and correctly so) one helluva poo sandwich, and they changed the system. It still isn't perfect, but they accepted their partial cause and leapt forward, unlike the prehistoric dinosaurs spinning our industry into a bottomless pit of decay.
It is beyond comprehension that on odd occasions CASA will ping an operator for not providing a root cause, not digging down deep into the heart of a problem, yet in the case of Norfolk all parties are willing to undertake a 20 second investigation and say 'its all Dom's fault'!

At least the Senators are looking outside the box, they have sniffed out the blood trail and know that it is leading to a giant smoking hole. I just hope they can engage change before our worst nightmare is realised.
I really hope the FAA don't come back and jam a giant pineapple up Australia's klacker but I fear that the longer this baloney continues the more likely it is that our sphincters will get reamed.
And Dear Anthony, don't worry about our industry, that's ok, you just bury your head in the sand down at Rooty Hill (saw Rodney Rude live there a couple of times, almost as funny as Beaker at the Senate) and you just keep making pony poo comments about BNE's runway construction to deflect the real pressing issues...

'Safe skies used to be Australian skies'

[owen meaney]

Take your James Reason model and as one of the defences

Well I am no expert,like some posting, but I understand Reason is a model for finding cause of accident not prevention of same.

yet in the case of Norfolk all parties are willing to undertake a 20 second investigation and say 'its all Dom's fault'!

The 4 corners program said nearly three years for the ATSB investigation, or did I understand incorrectly?

[my oleo is extended]

Owenology...

Owen,
In regards to the Reason model, if you use it to identify the cause of an accident you can take those lessons or causes and apply them to future activities to prevent a repeat. So the Reason model can act as a method of prevention. Anyway, I'm not in the business of teaching, discussing, arguing or bantering with you publicly. It has the potential to be fun, but the lesson would be painful for you....perhaps someone else would enjoy a robust joust with you?

Anyway, you go back to 4 Corners and come up with your own conclusion. Obviously the 'real experts' over there can assist you in your quest.

[owen meaney]

My Oleo
Why should a discussion about aircraft stuff become painful?
I am interested by stander.

[mightyauster]

The 4 corners program said nearly three years for the ATSB investigation, or did I understand incorrectly?

Owen, you just don't get it!
The whole point of this thread has been that the ATSB has dragged their heels for three years to produce a half ar5ed report, hence the Senate Inquiry. It causes me great distress to see CASA and the ATSB disappearing down the toilet this way and successive Governments have done little or nothing about it. Aviation is dying a very slow death in Australia as a result of apathy, inaction and in some cases, down right corruption on the part of the failed government ministers.

[Kharon]

MA- Horses to water. etc.

Peter Boyd Manager, Compliance Practices & Procedures .

This new approach to surveillance has the goal of encouraging airlines to take responsibility for their own safety management systems while maintaining CASA's monitoring and evaluation of compliance.

We are in the midst of a fundamental change in the Authority's approach to the safety surveillance of the aviation industry. This is being undertaken in conjunction with a major review of the Civil Aviation Regulations.

The Compliance Division comprises approximately 350 staff located in offices throughout Australia and is tasked with the compliance and enforcement functions for the Authority, functions which are designed to ensure that operators comply with the Regulations.

At the same time, studies into the causes of airline accidents were beginning to conclude that a significant proportion of aviation accidents could be contributed to system deficiencies within organisations (the so-called "organisational accident"), whereas, in the past, they may have been simply attributed to pilot error.

The FAA has embarked on a program to increase their airline operators' safety through an emphasis on operator management systems and a surveillance structure based on these systems. Other Civil Aviation Authorities have also launched similar initiatives.

After the mid 1990s and in line with the global developments, CASA had started to introduce a system audit approach to surveillance. Quality system audit techniques were taught in training courses and attempts were made to integrate these techniques into the surveillance system, but there tended to be a widespread belief that the quality systems and the system approach was all very interesting, but where did it fit in with my real job?

In early 1999 the Australian National Audit Office carried out an audit of CASA's surveillance and enforcement activities. The audit report is a matter of public record and pointed to a number of shortcomings with the surveillance system, including a serious shortfall in meeting the inspection targets set by the system.

Clearly, changes had to be made in the system of surveillance of the aviation industry.

"To encourage and achieve industry development of management responsibility and effective safety management processes whilst efficiently monitoring and evaluating industry compliance." (my bold).

In short – we will take no responsibility at all, but; you stuff it up and the roof will fall in. Brother Sarcs # 1230 has drawn your attention to the progressive undermining of the ATSB, the corruption of a holistic 'shared' approach to effective safety management and the monumental cynical disregard for Coronial recommendations. Even the Barnes (LHR) notion of cooperation was corrupted to develop the MOU (one of the very few CR ever 'adapted'). So, we devolve into a system where a policy of "strictly no liability" becomes the robustly supported mantra. Slide around ICAO, slip past FAA, take ten or so years to obliterate Coronial recommendations, manipulate the system to ensure total "plausible, legally defined deniability".

P7-(TOM) recently offered a sneak read of a PAIN draft report on this one subject which chronologically defines the decline and failure of the ''adopted' system, it runs to some 40 pages just to address

{"Fort Fumble has not addressed any of the highlighted deficiencies of its adopted ‘systems based auditing’ and ‘risk based surveillance program’ that were publicly documented in the ATSB LHR ‘Final Report’ and in the Coroner’s report"} Sarcs.

There are three pages related to differences in the training of CASA 'auditors' to the real deal IOSA Auditors used by civilised countries like Singapore and India. Tick and flick – right out.

Once you start to join the dots, even in a small way a very ugly picture emerges. Sarcs is to be commended for condensing many days of research into a short article; which just about defines one small part of the multi headed monster CASA has become. Perhaps this Senate Inquiry will pave the way for an in depth analysis of just how well the current system has been corrupted to suit everyone except the survivors and victims. Lockhart River, like the ghost of Banquo haunts the feast.

[flying-spike]

Challenge accepted Oleo

Owen you really need to a little more research. The Reason model is used to discover the trajectory of an accident or incident through the absence or failure of defences that should have prevented it. Once these are identified then the job at hand is to bolster and sometimes place those defences to prevent similar accidents or incidents from reoccurring.

Dig a little deeper to our regulator's actions over the last 20 or so years. Trumpeting their achievements in recognising the need for employing specialist inspectors to conduct through audits and investigations then white-anting them by not putting their specialist skills and expertise into practice, not promoting them to positions where they can influence change and frustrating them out of a job, thus allowing the system to revert to where it was 20 years ago and maintaining the status quo.

Come to think of it, the Coles theme song should be adopted by CASA because they are hell bent on keeping the quality of its service as a regulator "Down, Down, Deeper and Downer".

Only a root and branch removal of this gnarled old weed will bring any improvement to the regulation of the aviation industry in this country.

[Kharon]

10 for effort.

Good try Spike – wasted wind; but a bloody good effort. To keep it simple, just keep digging on the Pel Air patch. The Bankstown boys under their fearless leader have left a trail a mile wide which provides a perfect "snapshot" of exactly what occurs within that one small circus.

It's not too big a stretch to see how that rot has infected the whole system. Back flip directives, secret weports (which turned out to be a back fire of monumental proportions), hidden agenda, hidden reports, legally covered footprints through the yellow snow, more breaches of the TSI Act and associated than can be counted; ATSB roped into (or happily colluding?) in the mess. All delivered to the Senate in Parliament in a pink beribboned container full of rubbish, containing some hidden gems. This performance is ably supported by carefully scripted denials, polished to a fare thee well, to be repeated at every opportunity.

Superb cast with just the right mixture of arrogance and contempt for the hapless punters to admire. A wise man once said it's bloody near impossible to stuff a wet noodle up a tiger's arse, but this lot don't seem to take advice easily; much better at dishing it out. Perhaps the tiger has finally paid attention.

[my oleo is extended]

A conga line of suckholes

Nice fluffy Compliance statement from Boyd. Hope his 350 compliance staff do a netter job than his ASOP group! Now that was one disgraceful mess that could do with a Line of robust Senate questioning.

Lets be robustly honest, FF Managers and persons of influence who have been there 10+ years should walk the green mile. Some of them are up to around 15 to 20 years, and we know what happens in a dictatorship, the longer the dictator has influence the more he sets up and creates his own system, to a point where he wields so much influence and power he simply can't be removed by natural means.

Spike, CASA don't promote people based on actual skill. If they did, those skilled people would be generating additional work for the Regulator, and that is a no no. They promote people who can play the system, people with masters degrees in smoke and mirrors. Anybody who can last up to 20 years in a role and achieve absolutely nothing is not good for the business.

The same shenanigans at FF are being repeated at ATSBeaker and ASA.

For all the Screaming Skulls faults, and my goodness there are many, Herr Skull isn't the sole root cause. You need to look closely at his minions, management team, the Board, advisors, enemies and even supporters, and possibly his cigar suppliers. Look at the big big picture. The dross is not confined to one pot plant, it covers the entire Forrest.

Now go forth my brethren - Kharon and Sarcs, and cut down the tallest tree in the Forrest, with......a herring! (Sorry Algie and Owen, more silly nicknames and coded speech, oops)

'Safe skies are Boyds skies????'