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Senate Inquiry, Hearing Program 4th Nov 2011

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Senate Inquiry, Hearing Program 4th Nov 2011

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Old 15th May 2013, 14:00
  #1841 (permalink)  
 
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Ah Algie and look left posting again. Are you in canberra or bris? This blame the pilot seems very at odds with modern thinking? The ills the ilks and the deluded have a common interest.

It's not just about 'who' but 'why'. Focus on the target said a lot.

Anyway, the report should be out next week. It'll be interesting.

Two approaches to the problem of human fallibility exist: the person and the system approaches

The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness

The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects

High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure
396,000 hits. Could be 400,000 views by the weekend? That is a lot of views for pprune.

Last edited by halfmanhalfbiscuit; 15th May 2013 at 16:20. Reason: Elephant in room
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Old 15th May 2013, 15:43
  #1842 (permalink)  
 
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Alfie and look left, you are dead wrong. Every time I go near an aircraft I am thinking, " what don't I know?" More than once the answer has been " plenty" because no training system is perfect.

Your suggestion that " he should have known" is unhelpful. The question is why he didn't know.

... Speaking as one who has been on the wrong end of that same situation, luckily only at the expense of my wallet.
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Old 15th May 2013, 19:19
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Sunfish you are of course right. My little post was a comment, not the definitive summary of the issue.

It is at the core of the issue to ask why the crew (and in particular PIC) didn't know better, why he was not supoorted better by a quality dispatch function and how it could be that this shortcoming in the crew and company capabilities was unknown to his company management and why CASA hadn't identified that his company was capable of not knowing these things.

I think what I was trying to say, and a few others too along the way....is that the ability of a pilot(s) to address other options while they are still available is not some esoteric skill set, known to a few...it goes to the very basics of single engine-flying...."Always have a paddock available".

Anyway, I stand willing to learn...I make the point again that this threads in-jokes, code-words and slang, and meandering sarcasm don't help me learn and quite probably present more than a little opacity to other truth-seekers too. I have known and disdained managers who practiced such styles and fear that Kharon etc, in their vehement ramblings may have become part of the problem, not part of the solution.
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Old 15th May 2013, 19:57
  #1844 (permalink)  
 
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(Groan!!) sotto voce – not the Dom Dun it argument, again. It may have been valid at one time and may even be used in ground school as a training lecture, but it is not what the inquiry is about now, is it?

There is some real interest in the events afterwards. The regulator micro managing toward a predetermined outcome, the use of the MOU to suit, the dilution of safety recommendation, the absolutely dreadful standard of the ATSB report, the bollocks, bluff and bluster used to defend the 'status quo'. It's quite a list without mentioning the perceived and alleged breaches of protocol, prescription, policy and regulation by various agencies. We will try hard not mention the fairly public international embarrassment caused not by a pilot who ran out noise, but by the spectacle presented within our own Parliament.
See Phelan –CASA must answer.

A snapshot of the ills being foisted on society may be derived from the shameful AMROBA meeting; all there in spades, redoubled. Each area of concern denigrated in true draconian, table thumping style. The awful parody of the EASA regulations, strained through FF no liability policy, expert interested parties being force fed; and, the real possibility of retribution lurking in the shadows for the w@n#e$s, daring to speak. What's at the end, more administration, more cost, more loop holes to use against anyone who needs it; and for what?, an improved system. Bollocks.
See Phelan - Preaching to the unconverted.

At least James has had the backbone to own up, admit the error and taken his licks like a man. No bitching, backbiting or 'not my fault' whining. The rest of the shambles could take a leaf from his book. The FF and Beaker crowd of poncesses could also 'harden up', admit the errors and sort the bloody mess out instead of scuttling about trying to find a rock to hide under. "Mi Mi Mi" should be changed to "Not Mi -Not Mi - Not Mi"......

Steam off....Coffee – cigar – feet up.

Now, to sit back and enjoy the erudite comments of those who have a wider, more understanding view: the narrative commentary of true experts who can, with a single sentence and a hearty Hi Ho Silver resolve all the issues. But, then again, I may just saddle up and spend the day quietly, with the elephants. At least their belching and farting is soothing and somewhat amusing. Smart animals – elephants. ....

Ben Sandilands – Elephant supremo – Lion Air Bali.

Selah.

Last edited by Kharon; 15th May 2013 at 20:29.
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Old 15th May 2013, 22:40
  #1845 (permalink)  
 
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“All paths lead to Rome!”

Whoa kicked over the hornet’s nest with that last post, however what I think it highlights is that everyone is entitled to his and her opinion and we all have different paths to follow on the way to retribution…

…PNM makes a good point on the Annex 19 implementation phases as outlined on page 76 of the SMM, headed ‘3.4 SSP IMPLEMENTATION - PHASED APPROACH’. Which could effectively mean it may be many years before full implementation of the SSP proper. However that doesn’t mean that a State can subvert the planning processes in the meantime…

…Lefty has been nothing but consistent with his concern that the crew of NGA were not entirely blameless and shouldn’t be given a pardon in all this…

…The pessimists (of which Lefty has shown allegiance) have a point as well…i.e. “we’ve seen all this before..Senate inquiries, industry outrage etc..etc but yet nothing changes. Why should this be any different?”

I could go on but the major point is that people are generally concerned enough (approaching 400k reads), albeit for various motivations, to keep reading, absorbing and staying involved with monitoring this thread, and indeed the Senate inquiry itself.

Overall this concern manifests itself as a very real concern for the state of aviation safety in Oz and will this?..could this?…possibly be the final straw, the panacea, the nirvana that finally brings it all to a head?

We all live in hope and we all follow different paths to Rome, the main thing is that we all finally arrive at the same destination in one piece!

Top catch “K”! And top timing Ben!

Ben’s article is so relevant that it is worth regurgitating in whole:
Lion Air Bali crash reports damns airline’s safety

The captain of the brand new Lion Air 737-800 that crashed into the sea near Denpasar’s airport in April took control of the jet at an altitude of 150 feet after the junior pilot repeatedly complained he could not see the runway, according to a preliminary report by Indonesia’s air safety authority.

The captain then attempted a ‘go around’ from an altitude of only 20 feet, moments before the flight hit the water within wading distance of the sea wall at the end of the runway, seriously injuring four of the 108 people on board the jet.

The National Transportation Safety Committee in Jakarta recommended Lion Air “review the policy and procedures regarding the risk associated with changeover of control at critical altitudes or critical time”.

It added the fast-growing airline should also “ensure the pilots are properly trained” on this subject.

In a Reuters report Lion Air’s co-founder Rusdi Kirana said he would respect the outcome of the investigation, but voiced dismay at the interim recommendations which were directed solely at the airline.
“If our pilots make mistakes we are not scared to admit it, but we are not happy just blaming the pilots without proof,” he said.
“It is important not to give people the impression that we don’t have proper procedures. We take safety seriously, we are a profitable airline and we are not going to limit our budget on training and maintenance.”

The interim report, which is available in English, is a model of no nonsense clarity and factual detail. It points to the decision of another flight that experienced the sudden onset of the rainy conditions on approach to Denpasar to go around shortly after Lion Air’s on-time but not-at-airport water landing.

The Indonesian report shames the ATSB’s efforts in relation to the ditching of an air ambulance near Norfolk Island in 2009, in which it issued a report which failed to reference grave deficiencies in the safety standards of operator Pel-Air at the time, or question the failed oversight of CASA, and loaded all the blame onto its pilot.
List the ironies in that lot…sheesh where do you start?

Ok I will kick it off…

Perhaps we should remember that the ATSB preliminary report into the ditching of VH-NGA was pitched in a similar vain, see ‘here’. It wasn’t till after the release of that report that everything went south…don’t think that’s going to happen in the Lion Air case do you?

There’s more much more! Meanwhile I’m outta here..

Thanks Lefty I was aware of that...you've just pointed out another irony i.e. the Indons have been mentored by the now 'old school' ATSB/BASI and it looks like they've learnt their lessons well, no 'beyond all reason' for them!

Last edited by Sarcs; 15th May 2013 at 23:39. Reason: Even pessimists live in hope!
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Old 15th May 2013, 23:24
  #1846 (permalink)  
 
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Lefty has been nothing but consistent with his concern that the
crew of NGA were not entirely blameless and shouldn’t be given a pardon in all this
Thanks Sarcs, you seem to be the only one who actually read what I wrote rather than jump to conclusions.

Ah Algie and look left posting again. Are you in canberra or bris? This blame the pilot seems very at odds with modern thinking? The ills the ilks and the deluded have a common interest.
The ultimate comeback. If you are not following the herd you must be from CASA. As for modern thinking have a look at Just Culture. The thinking that the pilot is never at fault is just as out dated.

Your suggestion that " he should have known" is unhelpful. The question is why he didn't know.
Sunny thats not what I am saying at all. What I am saying is that when the crew realised that they were committed to Norfolk (and they were not the only people responsible for that) then all the subsequent decisions were the crew's responsibility and that includes not informing the rescue services where they were actually located.

Sarcs you might be interested to know that Alan Stray spent a lot of time in Indonesia helping them to develop their investigation capabilities. I think we are starting to see the benefits of that assistance.

Last edited by Lookleft; 15th May 2013 at 23:26. Reason: Seems to be de rigeur to add another comment after editing.
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Old 16th May 2013, 00:38
  #1847 (permalink)  
 
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Ll, I will ask again, what was the copilot doing? Why is she not only blameless, but invisible?
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Old 16th May 2013, 01:40
  #1848 (permalink)  
 
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Ll, I will ask again, what was the copilot doing? Why is she not only
blameless, but invisible?
A valid question Sunny but one which seems destined to be never answered unless the CVR is recovered and is functioning. She could shed a lot of light on the decision making process but by staying silent she has let DJ carry the can for all the decisions that were made.
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Old 16th May 2013, 03:24
  #1849 (permalink)  
 
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Indonesia powers ahead while Australia declines. WTF??

Very interesting Sandilands article.
Of interest is that Stray, a very very capable and skilled man was rogered by the ATSBeaker's head cronies and power seeking bean counters. So in turn he spends almost 3 years travelling to Indonesia courtesy of the Australian government assistance program funding - teaching, training, mentoring and fixing their woeful investigation outfit. In fact he does such a good job that you have the recent Lion Air investigation report, a testament to Indonesia's increased and improved ability and to Alan's work (and yes, the tall man is highly regarded and respected up there).
But keep one thing in mind - While Alan was away helping to fix Indonesia, Australia slipped way way backwards under the stewardship of that fool Beaker an his minion Jules Verne! So you do the math, where does the real muscle, skill and fortitude of our ATSB rest? Not with the peckerheads currently running the outfit in Australia. It's unbelievable really, one of our key asserts, Big Al, building capacity in Indonesia while a bunch of bureaucrats in Aus push us back 30 years, yet all of this is funded by the one Australian government????
To add further to this, my source relays to me that CAsA also had a couple of good people working up there alongside Alan and others, and that is the reason why a number of Indonesian carriers were removed from the EU blacklist, yet incredibly those inspectors were also rogered, just like Alan, and all of these individuals have apparent disappeared (sort of) from the Aus government payroll.

And you are telling me that the system isn't sick? (Or should I say 'Ill' or 'ilk' instead of sick?)
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Old 16th May 2013, 07:32
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At least James has had the backbone to own up, admit the error and taken his licks like a man. No bitching, backbiting or 'not my fault' whining.

Is this satire?
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Old 16th May 2013, 07:36
  #1851 (permalink)  
 
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Copilot and CVR

All these answers and more are to be found on the CVR. In a known location and only 45 m deep.

Odd ATSB didn't want the CVR. If there was a bank robbery and the Police did not wish to view the CCTV footage as part of their investigation, you would regard that as odd.

This accident nearly killed 6 people. It was just luck it didn't. Lucky to survive a ditching at night on an open ocean in fog. It could even have come down to the warmer water temperature in November compared to July. So it was just luck ATSB were not investigating a fatal accident.

This means the investigation should have been conducted as if 6 people were dead. And that means getting the CVR.

All very odd.
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Old 16th May 2013, 07:47
  #1852 (permalink)  
 
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Long time lurker of this interesting topic.
The satirical take on ATSB and CASA is most amusing.
Is there an index or tabulated data to help an outsider decipher the cryptic comments.

FONC
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Old 16th May 2013, 08:51
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“Very odd” is a very kind description.

Other descriptions that spring to my mind are less kind.
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Old 16th May 2013, 11:56
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Creampuff, I like you in a perverse sort of way.

A lot like some of my odd friends.

As a matter of fact, I believe many of my friends are odd, but they are only pilots and engineers. I think I even have an odd, (as in one or two), ATCO.

Reminds me of a story, post Munich Olympics, when a bus driver taking athletes to the village determined to call everyone 'green' to prevent racial disharmony, then announced all you dark green 's get to the back of the bus.

Like I said, I like you in a perverse sort of way.
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Old 16th May 2013, 13:41
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FONC welcome party

FONC, welcome to the 'house of ill repute', hosted by the ills of society. Lurking is ok, but sounds like something CAsA do, perhaps you are a Regulator? Anyway, feel free to lurk, however exercise caution as the naked greco roman wrestling contests and pee pee measuring disputes can at times distract one from the absolute issue here - aviation safety.
Frank just mentioned Germany and 'perverse' in his post, so add 'lurking' and we could have a theme developing? Then again add those items to say a book of magic spells and 900kg of elephant dung and you have the monthly CAsA RRG meeting (risk review group)!!
As for cryptic comments, I didn't realise there were any? For me this is simply every day normal goings on, seriously!

CAsA and ATSBeaker satire? If you want to see amusing then you should see them in their Friday casual clothing - RM Williams belts, Hawaiin shirts, cheesecloth singlets, jackboots, leather chaps and aviator sunglasses!

Anyway, must go now. Gobbles has asked me to put together FONC's welcome pack which contains some robust items apparently so keep an eye out for your mail, you should receive it on the 23rd, from Canberra, express delivery by either Styx Houseboat Couriers or The Pineapple Express!

Last edited by my oleo is extended; 16th May 2013 at 13:43.
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Old 16th May 2013, 13:56
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Oleo , CAsA and ATSBeaker satire? If you want to see amusing then you should see them in their Friday casual clothing - RM Williams belts, Hawaiin shirts, cheesecloth singlets, jackboots, leather chaps and aviator sunglasses!
Available from Brisbane DFO. While your there pop in to villa and hut or cofffee club for a coffee too. Note: Dress code not suitable for Canberra.
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Old 16th May 2013, 19:38
  #1857 (permalink)  
 
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Call me names if you like, but I wonder if the lack of any visibility of the NGA co pilot in all this is somehow connected with the ATSB's refusal to retrieve the CVR.

My sporting dive limit is 42 metres, but the professionals go way deeper.

I suspect that there is something very embarrassing to the ATSB, CASA and perhaps other powers that is on that CVR.

I'm bringing this up because I have seen a lot of treachery and very strange things in my business career. I learned the hard way that truth is stranger than fiction, and I suspect that what is on that CVR might reinforce that belief.
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Old 16th May 2013, 19:46
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Irony in Indonesian fires?

Reading through Oleo's 1755 and thinking 'good one'; then Creamy chimes in and cracked me up. Still smiling, enjoying the purity of a well timed one liner. Choccy frog awarded.......

FONC – most of the 'cryptic' stuff is home grown and more shorthand than cryptic. Much of the so called insider stuff can be deciphered from the posts. For example, Slats used the phrase 'very odd', which is completely acceptable, but 'passing strange' is more commonly used. Index ref:- One day, some clown in a cheap suit read out a risible diatribe, denigrating a respected 'ills of society' (that's us, the Senate Committee and anyone else who won't go Hawaiian) member. The phrase 'We find it passing strange' was picked up and became legend, it does speak volumes and perfectly describes a mind set, but you need to have read Hansard to twig . The rest is pretty much bog standard Mickey Bliss, as and when the muse descends.

Sponsored by the Subliminal Message Society. (Don't read us, we'll read you).

Last edited by Kharon; 16th May 2013 at 19:47. Reason: Styx courier service - you ring we bring.
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Old 16th May 2013, 22:30
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Hello oleo
Thanks for the welcome. Now reading the senate submissions. Cannot see any statement from the copilot, is there one?
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Old 16th May 2013, 23:12
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Someone referred to a statement to the committee by a CASA executive to the effect that CASA don't hold files on pilots.

What then does this reference in the AIP p157 gen 2.2 - 5 mean?

Aviation Reference Number (ARN): A unique six-digit number used to identifyaclientwhoconductsbusinesswithCASA. WhenCASAreceivesan application for a new licence, certificate, or other service, an ARN is established and all subsequent transactions for the client are recorded against that ARN. In addition to being a client number, the ARN may also be the licence or certificate number. The ARN should be quoted in all correspondence with CASA or with Airservices Publications Unit.

Last edited by Sunfish; 16th May 2013 at 23:14.
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