Norfolk Island Ditching ATSB Report - ?
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Experience is a concept that seems to be thrown around without definition. Airline flying is not Corporate flying, Corporate flying is not Australian GA flying. The australian flying experience/culture is vastly different to a lot of the world. The application of domestic operational paradigms to international operations...well, you can be the judge...
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A section of the ATSB report that caught my attention was page 13 just after the PIC 's details.It refers to " post endorsement training". This I think refers to "line" training.
It states that the ATSB could not confirm the content of any Flight plan, CP or PNR training that the crew may have received.
This is of course typical of the training in all companies I have had experience of.The typical Line Training document itself is just a list of subject areas that are eventually signed off without any reference anywhere to the content of that training. It could be signed off by a person who only asked if the trainee knew what a PNR or a Flight Plan was ! On the other extreme a person my be requested to complete ATPL like questions relevent to the operation. The really stupid thing is that no one knows !
This is all part of the basic problem with airline aviation training. It is mostly conducted after endorsement on normal revenue line operations with the airline not providing trainer time or resources other than a few minutes extra pre and post flight.A proper training system would have the airline providing time and resources to complete the training tasks alocated. This costs money, of course, so it is completely unacceptable.
Greedy
It states that the ATSB could not confirm the content of any Flight plan, CP or PNR training that the crew may have received.
This is of course typical of the training in all companies I have had experience of.The typical Line Training document itself is just a list of subject areas that are eventually signed off without any reference anywhere to the content of that training. It could be signed off by a person who only asked if the trainee knew what a PNR or a Flight Plan was ! On the other extreme a person my be requested to complete ATPL like questions relevent to the operation. The really stupid thing is that no one knows !
This is all part of the basic problem with airline aviation training. It is mostly conducted after endorsement on normal revenue line operations with the airline not providing trainer time or resources other than a few minutes extra pre and post flight.A proper training system would have the airline providing time and resources to complete the training tasks alocated. This costs money, of course, so it is completely unacceptable.
Greedy
500lbs per unanswered Q's (or phone call)
"Look, Ive chatted with the doc and the patient is stable and if we wait six hours we can make the fight in daylight,"
Or
" I picked up extra fuel in Samoa even though the plan didnt need it"
Or
"I haven't got Internet so can you run and file my plan, my fax number at reception is xxxxxx. I'll talk to you at Ted-90mins"
Or
"I've got no way of running a plan here, can you run it?
Or
"I went via Fiji even though I had fuel for Norfolk "
Or
" I picked up extra fuel in Samoa even though the plan didnt need it"
Or
"I haven't got Internet so can you run and file my plan, my fax number at reception is xxxxxx. I'll talk to you at Ted-90mins"
Or
"I've got no way of running a plan here, can you run it?
Or
"I went via Fiji even though I had fuel for Norfolk "
I never got a "please explain" phone call, because that was the smart thing to do. All costs were passed onto Careflight anyway, so it made no difference in the end.
Unfortunately, there was a lot of "that's how we always do it" going on at Pelair, but that doesn't mean you have to do it that way.
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This is one of the issues- the PiCs lack of experience. At 3500 TT the PiC only just met the requirements for a job at Pel-Air as a First Officer 20 years ago.
It is all relative and it seems to me that Australia has always been spoilt for so many pilots available compared to Asia where for example 250 hour TT first officers are second in command of wide-bodied jet transports.
Last edited by sheppey; 18th Sep 2012 at 07:33.
Pony express delivery from Gen GA Skull to F Troop seen by brave when rider not looking...
Bluecoat chief orders troops to tell him about any strategies being planned by Gen WT Gollum and his army reserve to beat the indians.
Bluecoat chief only one who can say go ahead.
Bluecoat chief orders troops to tell him about any strategies being planned by Gen WT Gollum and his army reserve to beat the indians.
Bluecoat chief only one who can say go ahead.
Caught a rumour that the Ginger Ninja's 'Carbon Cops' have noted excessive power use eminating from Fort Fumble, seems the wagons have been circled and the 'Ghost Who Walks' has been seen stumbling around the battlements at 0200 muttering.."back in my day I'd put a code red on these insubordinate, undisciplined, GA riff raff!"
"Thru the centuries...the nemesis of evildoers everywhere...he works alone...The Phantom!"
"I am known by many names...."
"The Ghost Who Walks will never die...."
Well we will have to see if the prophecy is true....
Last edited by Sarcs; 18th Sep 2012 at 12:09.
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Kharon - I would agree if it were not for the many questions concerning CASA influence over operational management, AAT hearings, Coronial findings, ATSB reporting
It is difficult to imagine CASA having influence over ATSB and AAT outcomes. The Senate Inquiry called by Mr Xenephone may be able to find if this is true or not.
'Ghost Who Walks'
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But I am guessing the industry does not wish for micro management of organisations-or am I wrong?
What's with the "goat who walks comment", is someone a member of a society or organisation that you don't like? I would tread carefully here as I have been threatened by such an organisation of great wealth and influence.
I'm thinking of becoming a KIWI or a Gay/ Black/ minority group to set the standard.
Seriously.
Well, well, well....sure is quiet on pprune lately, hopefully everyone is busy writing up their submissions for the upcoming Senate Inquiry well here's a bit of goss that may help fire up the neurons:
And hey this is not an isolated case of a substandard, ulterior motive ATSB 'Final Report'...hmm it's just one that has grabbed a certain amount of mainstream media and public interest!
ps Don't know if I'm really taken by the new format at Crikey!
New evidence that the ATSB Pel-Air crash report is flawed | Plane Talking
From Planetalking Sep 23, 2012 4:05PM:
Earlier today an article about rumors that the ATSB final report into the Pel-Air ditching was being withdrawn or revised was denied by a Ministerial spokesperson.
But in the course of this an explanation of the RVSM or reduced vertical separation minima was provided, and is published below:
Nowhere in the report is RVSM even mentioned. It is very obvious in the ATSB report that the there is a place in the narrative where the words reduced vertical separation minima ought to have appeared.
Why didn’t they appear? Could it be that the report avoided or expunged this term so as to avoid alerting the curious reader to the fact that the Pel-Air jet which routinely used this non-RVSM airspace was not equipped to use it as a matter of course?
Might that have then caused the curious to turn to the standard operating procedures quoted by the ATSB and discover that there is no contingency written into them for a need to exit RVSM airspace, and that the fuel burn figures pointed to by the ATSB have even less relevance to the situation the pilot was put in by the operator that CASA so woefully failed to supervise?
This illustrates why this report is so bad. It is designed to steer the reader away from asking questions that would embarrass the operator, or from asking further questions about the quality of its oversight by CASA.
The ATSB has already been caught out publishing incorrect information about the meteorological information provided to the pilot, which was picked up in the 4 Corners report and dealt with there.
Its inability or reluctance to even mention RVSM or the certification of the pilot to land at Noumea in the event of a diversion is telling.
This report is going to be examined in minute detail in the Nick Xenophon instigated Senate committee hearings into it and related matters.
It is reasonable to anticipate that the operational history of Pel-Air medical repositioning flights in this part of the Pacific, including diversions to Noumea which caused friction with its civil aviation authority because of the level of equipment present on its aircraft will be discussed under parliamentary privilege.
Indeed there is a real prospect that the hearings will carry out the job that the ATSB either failed to do, or was unable to bring itself to do because of the adverse effects that may have eventuated for Pel-Air.
Earlier today an article about rumors that the ATSB final report into the Pel-Air ditching was being withdrawn or revised was denied by a Ministerial spokesperson.
But in the course of this an explanation of the RVSM or reduced vertical separation minima was provided, and is published below:
· Non-RVSM-equipped ambulance aircraft can be cleared by NZ ATC into RVSM airspace, should traffic allow and the necessary altitude ‘buffers’ be available.
· In this case the aircraft had been cleared by ATC to cruise within NZ/Pacific RVSM airspace, at FL350.
· After initially being cleared by ATC at FL350, the aircraft was instructed to descend to FL270 due crossing traffic. Being conscious of the increased fuel burn at the lower altitude of FL270, the crew requested and was subsequently re-cleared by ATC to climb to FL390. This was maintained until descent into Norfolk Island. Once at FL390, the crew reassessed their fuel remaining and set a lower thrust setting to satisfy themselves that they had sufficient to complete the flight with the necessary reserves intact.
This is further evidence as to how this ATSB report is a disgrace.· In this case the aircraft had been cleared by ATC to cruise within NZ/Pacific RVSM airspace, at FL350.
· After initially being cleared by ATC at FL350, the aircraft was instructed to descend to FL270 due crossing traffic. Being conscious of the increased fuel burn at the lower altitude of FL270, the crew requested and was subsequently re-cleared by ATC to climb to FL390. This was maintained until descent into Norfolk Island. Once at FL390, the crew reassessed their fuel remaining and set a lower thrust setting to satisfy themselves that they had sufficient to complete the flight with the necessary reserves intact.
Nowhere in the report is RVSM even mentioned. It is very obvious in the ATSB report that the there is a place in the narrative where the words reduced vertical separation minima ought to have appeared.
Why didn’t they appear? Could it be that the report avoided or expunged this term so as to avoid alerting the curious reader to the fact that the Pel-Air jet which routinely used this non-RVSM airspace was not equipped to use it as a matter of course?
Might that have then caused the curious to turn to the standard operating procedures quoted by the ATSB and discover that there is no contingency written into them for a need to exit RVSM airspace, and that the fuel burn figures pointed to by the ATSB have even less relevance to the situation the pilot was put in by the operator that CASA so woefully failed to supervise?
This illustrates why this report is so bad. It is designed to steer the reader away from asking questions that would embarrass the operator, or from asking further questions about the quality of its oversight by CASA.
The ATSB has already been caught out publishing incorrect information about the meteorological information provided to the pilot, which was picked up in the 4 Corners report and dealt with there.
Its inability or reluctance to even mention RVSM or the certification of the pilot to land at Noumea in the event of a diversion is telling.
This report is going to be examined in minute detail in the Nick Xenophon instigated Senate committee hearings into it and related matters.
It is reasonable to anticipate that the operational history of Pel-Air medical repositioning flights in this part of the Pacific, including diversions to Noumea which caused friction with its civil aviation authority because of the level of equipment present on its aircraft will be discussed under parliamentary privilege.
Indeed there is a real prospect that the hearings will carry out the job that the ATSB either failed to do, or was unable to bring itself to do because of the adverse effects that may have eventuated for Pel-Air.
And hey this is not an isolated case of a substandard, ulterior motive ATSB 'Final Report'...hmm it's just one that has grabbed a certain amount of mainstream media and public interest!
ps Don't know if I'm really taken by the new format at Crikey!
New evidence that the ATSB Pel-Air crash report is flawed | Plane Talking
Last edited by Sarcs; 23rd Sep 2012 at 12:17. Reason: Ben's Sunday arvo piece!
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Still bits missing
One might also ask why the CVR and FDR were not recovered. These may have given valuable evidence either way in the investigation. Or is it the fear that they may have countered what was already a foregone conclusion?
Wasn't Mark Vaille on the board of Rex too?
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There is no love lost between Rex and Albo. Rex have pretty publically declared which side of politics they support.
http://rex.com.au/MediaRelease/Files...irservices.pdf
http://rex.com.au/MediaRelease/Files...nt%20Taxes.pdf
I don't think the current Fed Govt would do any favours for Rex. They would do favours for themselves though and make sure there were no embarrassing stories for Albo to answer.
http://rex.com.au/MediaRelease/Files...irservices.pdf
http://rex.com.au/MediaRelease/Files...nt%20Taxes.pdf
I don't think the current Fed Govt would do any favours for Rex. They would do favours for themselves though and make sure there were no embarrassing stories for Albo to answer.
Last edited by Lester Burnham; 24th Sep 2012 at 04:30.
Horatio, owen and Falling Leaf I believe in bureaucratic speak that would be called 'regulatory capture', where the big end of town seeks to find political and regulatory favour with government regulating agencies.
Back in 2008 "RC" got the FAA in a spot of bother when they were dobbed in by a couple of whistleblowers, see here from Wikipedia:
Regulatory capture - Wikipedia, the free encyclopedia
"Culture of coziness"! Not sure if for any amount of regulatory or political favour I'd want to get cozy with the likes of "Voodoo Doctor" or the "Ghost Who Walks!"
Back in 2008 "RC" got the FAA in a spot of bother when they were dobbed in by a couple of whistleblowers, see here from Wikipedia:
Federal Aviation Administration (FAA)
The Federal Aviation Administration has a dual-mandate both to promote aviation and to regulate its safety. A report by the Department of Transportation that found FAA managers had allowed Southwest Airlines to fly 46 airplanes in 2006 and 2007 that were overdue for safety inspections, ignoring concerns raised by inspectors. Audits of other airlines resulted in two airlines grounding hundreds of planes, causing thousands of flight cancellations.[29]
The House Transportation and Infrastructure Committee investigated the matter after two FAA whistleblowers, inspectors Charalambe "Bobby" Boutris and Douglas E. Peters, contacted them. Boutris said he attempted to ground Southwest after finding cracks in the fuselage, but was prevented by supervisors he said were friendly with the airline.[30]
The committee subsequently held hearings in April 2008. James Oberstar, former chairman of the committee said its investigation uncovered a pattern of regulatory abuse and widespread regulatory lapses, allowing 117 aircraft to be operated commercially although not in compliance with FAA safety rules.[30]
Oberstar said there was a "culture of coziness" between senior FAA officials and the airlines and "a systematic breakdown" in the FAA's culture that resulted in "malfeasance, bordering on corruption."[30]
On July 22, 2008, a bill was unanimously approved in the House to tighten regulations concerning airplane maintenance procedures, including the establishment of a whistleblower office and a two-year "cooling off" period that FAA inspectors or supervisors of inspectors must wait before they can work for those they regulated.[29]
The bill also required rotation of principal maintenance inspectors and stipulated that the word "customer" properly applies to the flying public, not those entities regulated by the FAA. The FAA was directed to stop calling airlines its "customers".[29][note 2]
Southwest was eventually fined $10.2 million for failing to inspect older planes for cracks, according to a 2004 FAA directive.[31]
In September 2009, the FAA administrator issued a directive mandating that the agency use the term "customers" only to refer to the flying public.[32] Prior to the deregulation of the US air industry, the Civil Aeronautics Board served to maintain an oligopoly of US airlines.[33][34]
In a June 2010 article on regulatory capture, the FAA was cited as an example of "old-style" regulatory capture, "in which the airline industry openly dictates to its regulators its governing rules, arranging for not only beneficial regulation but placing key people to head these regulators."[35]
The Federal Aviation Administration has a dual-mandate both to promote aviation and to regulate its safety. A report by the Department of Transportation that found FAA managers had allowed Southwest Airlines to fly 46 airplanes in 2006 and 2007 that were overdue for safety inspections, ignoring concerns raised by inspectors. Audits of other airlines resulted in two airlines grounding hundreds of planes, causing thousands of flight cancellations.[29]
The House Transportation and Infrastructure Committee investigated the matter after two FAA whistleblowers, inspectors Charalambe "Bobby" Boutris and Douglas E. Peters, contacted them. Boutris said he attempted to ground Southwest after finding cracks in the fuselage, but was prevented by supervisors he said were friendly with the airline.[30]
The committee subsequently held hearings in April 2008. James Oberstar, former chairman of the committee said its investigation uncovered a pattern of regulatory abuse and widespread regulatory lapses, allowing 117 aircraft to be operated commercially although not in compliance with FAA safety rules.[30]
Oberstar said there was a "culture of coziness" between senior FAA officials and the airlines and "a systematic breakdown" in the FAA's culture that resulted in "malfeasance, bordering on corruption."[30]
On July 22, 2008, a bill was unanimously approved in the House to tighten regulations concerning airplane maintenance procedures, including the establishment of a whistleblower office and a two-year "cooling off" period that FAA inspectors or supervisors of inspectors must wait before they can work for those they regulated.[29]
The bill also required rotation of principal maintenance inspectors and stipulated that the word "customer" properly applies to the flying public, not those entities regulated by the FAA. The FAA was directed to stop calling airlines its "customers".[29][note 2]
Southwest was eventually fined $10.2 million for failing to inspect older planes for cracks, according to a 2004 FAA directive.[31]
In September 2009, the FAA administrator issued a directive mandating that the agency use the term "customers" only to refer to the flying public.[32] Prior to the deregulation of the US air industry, the Civil Aeronautics Board served to maintain an oligopoly of US airlines.[33][34]
In a June 2010 article on regulatory capture, the FAA was cited as an example of "old-style" regulatory capture, "in which the airline industry openly dictates to its regulators its governing rules, arranging for not only beneficial regulation but placing key people to head these regulators."[35]
"Culture of coziness"! Not sure if for any amount of regulatory or political favour I'd want to get cozy with the likes of "Voodoo Doctor" or the "Ghost Who Walks!"
Last edited by Sarcs; 24th Sep 2012 at 04:44.
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LIttle Bighorn That Blackhand...he one dumb whiteman.
@ Sarcs- that is a scarey thought, the penultimate in collusion.
Last edited by blackhand; 24th Sep 2012 at 07:33.
Update to the update!
Planetalking sure is firing up about all this:
Oh there is some awful murky waters loaded with pony pooh to navigate before we get to the guts of all this me thinks...scratching my sore noggin!
Yeah Blackie and I forgot to mention the 'Beaker from the Bureau'....hmm that would be a.. on cozying upto that numbnut!
*Publication of this post has produced a categorical denial from a Ministerial spokesperson that the ATSB report in question is being replaced or amended.
Of course those who read this post will become aware that this is not the real issue, which is the disgraceful quality of the report that the ATSB issued.
There are rumors circulating that the ATSB final report into the Pel-Air medical evacuation flight ditching near Norfolk Island in November 2009 is to be withdrawn and replaced with a new report.
The Minister for Infrastructure and Transport, Anthony Albanese’s media officers have not responded to a query about the validity or otherwise of this rumor since Saturday morning.
If the rumors are true, it will an heroic admission of exceedingly serious failures on the part of the ATSB, the air safety investigator, and reflect very adversely on CASA, the air safety regulator.
It would also follow from such an admission that both bodies would undergo some serious changes in management and conduct in order to restore Australia’s reputation as a level one state in terms of air safety administration.
If however the rumors are untrue, or there is instead a ‘final’ final report being prepared, which will attempt to repair the damage to process and institutional reputation done by the ‘no longer final’ final report, as well as to the captain of the flight, both bodies will struggle to regain credibility and respect from many stakeholders in aviation in Australia, as well as in the eyes of peer organisations, including ICAO and the FAA.
One way of analyzing the performance of the ATSB and CASA in relation to Pel-Air is to look at how the final report was constructed to load almost the entire blame for the accident on the captain for having inadequately fueled the small Westwind jet for first stage of its medical retrieval flight which was from Apia to Norfolk Island, where it was to refuel and continue to Melbourne, carrying the two pilots, two passengers and two medical professionals.
But even though the ATSB quoted at length Pel-Air’s operating manual for the flight, including the fuel calculations based on its flying at an optimal altitude, it fails to mention anywhere that the jet had not been upgraded to allow it to fly through much of the oceanic airspace it was to traverse at such altitudes under the rules applying to reduced vertical separation minima or RVSM.
Nor could the jet legally plan for or make a fuel diversion to Noumea as it encountered stronger than expected headwinds and higher fuel use because of the RVSM issue because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.
Neither of these critical matters are mentioned anywhere in the report. But they were raised with the investigating officers. The significance of both matters could not fail to be apparent to CASA or the ATSB, making inescapable a conclusion that both bodies were averse to making detrimental findings about the operator and had thus unjustly and deliberately focused all of their negative findings on the pilot.
For the two most important bodies in the public administration of aviation safety in Australia to conduct themselves in this manner is grossly improper.
The captain, Dominic James, was being directed by an airline CASA failed to properly regulate, to fly an oceanic route according to a fuel rule that CASA ought never to have approved, according to standard operating procedures for an altitude unavailable for much of the distance because it wasn’t RVSM equipped, and had not been trained to the regulatory standard required to use New Caledonia airspace in the event a diversion to Noumea, which some have criticised him for not using.
Much of the context for this is made lay friendly by the ABC TV 4 Corners report into the crash. But on its website, under background documents at the above link, 4 Corners also posts a CASA audit of Pel-Air which took place, as had been scheduled before the crash, shortly after the crash.
This audit found multiple serious safety deficiencies in Pel-Air’s operations at the time of the crash. Yet in its previous audit of Pel-Air CASA didn’t find much at all, leaving viewers to wonder whether the operator suffered a precipitous decline in standards in that period, which would surely have required an immediate grounding Tiger style, in the interests of public safety, or whether CASA audits are fundamentally useless before the fact.
The 4 Corner’s program site also hosts uncut videos of interviews with CASA’s director of safety, John McCormick, and the chief commissioner of the ATSB, Martin Dolan. Both interviews are shocking reflections on the processes and attitudes at these vital aviation authorities.
Dolan’s performance is more than 18 minutes of severely compromised testimony, in that he seems utterly unwilling to even acknowledge that CASA found more than 20 safety deficiencies were in effect at Pel-Air at the time of the crash or that they had anything to do with the accident.
Dolan and McCormick are well aware, and on the public record as being aware, that it is the airline or the operator that is ultimately responsible for the flight standards that are delivered to, or upon, the public.
This concept of airline or operator responsibility is the foundation stone of air safety regulation in the developed world. It has been trashed in Australia by this disgraceful ATSB report into the Pel-Air crash.
The performance of CASA and the ATSB in particular has been exposed as severely and dangerously deficient by the Pel-Air report and its aftermath.
One way or another, and without delay, these deficiencies must be remedied.
Of course those who read this post will become aware that this is not the real issue, which is the disgraceful quality of the report that the ATSB issued.
There are rumors circulating that the ATSB final report into the Pel-Air medical evacuation flight ditching near Norfolk Island in November 2009 is to be withdrawn and replaced with a new report.
The Minister for Infrastructure and Transport, Anthony Albanese’s media officers have not responded to a query about the validity or otherwise of this rumor since Saturday morning.
If the rumors are true, it will an heroic admission of exceedingly serious failures on the part of the ATSB, the air safety investigator, and reflect very adversely on CASA, the air safety regulator.
It would also follow from such an admission that both bodies would undergo some serious changes in management and conduct in order to restore Australia’s reputation as a level one state in terms of air safety administration.
If however the rumors are untrue, or there is instead a ‘final’ final report being prepared, which will attempt to repair the damage to process and institutional reputation done by the ‘no longer final’ final report, as well as to the captain of the flight, both bodies will struggle to regain credibility and respect from many stakeholders in aviation in Australia, as well as in the eyes of peer organisations, including ICAO and the FAA.
One way of analyzing the performance of the ATSB and CASA in relation to Pel-Air is to look at how the final report was constructed to load almost the entire blame for the accident on the captain for having inadequately fueled the small Westwind jet for first stage of its medical retrieval flight which was from Apia to Norfolk Island, where it was to refuel and continue to Melbourne, carrying the two pilots, two passengers and two medical professionals.
But even though the ATSB quoted at length Pel-Air’s operating manual for the flight, including the fuel calculations based on its flying at an optimal altitude, it fails to mention anywhere that the jet had not been upgraded to allow it to fly through much of the oceanic airspace it was to traverse at such altitudes under the rules applying to reduced vertical separation minima or RVSM.
Nor could the jet legally plan for or make a fuel diversion to Noumea as it encountered stronger than expected headwinds and higher fuel use because of the RVSM issue because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.
Neither of these critical matters are mentioned anywhere in the report. But they were raised with the investigating officers. The significance of both matters could not fail to be apparent to CASA or the ATSB, making inescapable a conclusion that both bodies were averse to making detrimental findings about the operator and had thus unjustly and deliberately focused all of their negative findings on the pilot.
For the two most important bodies in the public administration of aviation safety in Australia to conduct themselves in this manner is grossly improper.
The captain, Dominic James, was being directed by an airline CASA failed to properly regulate, to fly an oceanic route according to a fuel rule that CASA ought never to have approved, according to standard operating procedures for an altitude unavailable for much of the distance because it wasn’t RVSM equipped, and had not been trained to the regulatory standard required to use New Caledonia airspace in the event a diversion to Noumea, which some have criticised him for not using.
Much of the context for this is made lay friendly by the ABC TV 4 Corners report into the crash. But on its website, under background documents at the above link, 4 Corners also posts a CASA audit of Pel-Air which took place, as had been scheduled before the crash, shortly after the crash.
This audit found multiple serious safety deficiencies in Pel-Air’s operations at the time of the crash. Yet in its previous audit of Pel-Air CASA didn’t find much at all, leaving viewers to wonder whether the operator suffered a precipitous decline in standards in that period, which would surely have required an immediate grounding Tiger style, in the interests of public safety, or whether CASA audits are fundamentally useless before the fact.
The 4 Corner’s program site also hosts uncut videos of interviews with CASA’s director of safety, John McCormick, and the chief commissioner of the ATSB, Martin Dolan. Both interviews are shocking reflections on the processes and attitudes at these vital aviation authorities.
Dolan’s performance is more than 18 minutes of severely compromised testimony, in that he seems utterly unwilling to even acknowledge that CASA found more than 20 safety deficiencies were in effect at Pel-Air at the time of the crash or that they had anything to do with the accident.
Dolan and McCormick are well aware, and on the public record as being aware, that it is the airline or the operator that is ultimately responsible for the flight standards that are delivered to, or upon, the public.
This concept of airline or operator responsibility is the foundation stone of air safety regulation in the developed world. It has been trashed in Australia by this disgraceful ATSB report into the Pel-Air crash.
The performance of CASA and the ATSB in particular has been exposed as severely and dangerously deficient by the Pel-Air report and its aftermath.
One way or another, and without delay, these deficiencies must be remedied.
Yeah Blackie and I forgot to mention the 'Beaker from the Bureau'....hmm that would be a..
on cozying upto that numbnut!
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What really concerns me Sarcs is how the incompetence displayed by Dolan in his 18 minutes of 'severely compromised' testimony succeeded only in:
a) totally trashing the reputation of BASI/ATSB that took years and years to establish; and
b) making him THE hot favourite for the 2012 Darwin Awards.
If Dolan's performance during that interview didn't amount to misleading that idiot Albanese (the Minister), then I'll go he!
Little Bighorn...I think you probably need to give Blackhand the benefit of the doubt after post#392. Not so Albanese, Dolan and McF*ckwit...that trio are beyond all doubt (individually and collectively) dumber than dogsh1t.
Bring on the inquiry.
a) totally trashing the reputation of BASI/ATSB that took years and years to establish; and
b) making him THE hot favourite for the 2012 Darwin Awards.
If Dolan's performance during that interview didn't amount to misleading that idiot Albanese (the Minister), then I'll go he!
Little Bighorn...I think you probably need to give Blackhand the benefit of the doubt after post#392. Not so Albanese, Dolan and McF*ckwit...that trio are beyond all doubt (individually and collectively) dumber than dogsh1t.
Bring on the inquiry.
The CASA document at this link is interesting: http://atcvantage.com/docs/CASA_sms-ceo.pdf
In the context of the discussion in this thread, the opening paras seem particularly relevant:
And later:
In the context of the discussion in this thread, the opening paras seem particularly relevant:
For the CEO of a business that operates through an Air Operators
Certificate (AOC) - that is an airline or charter business - the legal obligations for managing safety are up front in Section 28BE of the Civil Aviation Act
1988. It’s probably worth quoting the key provisions here:
Section 28BE
Duty to exercise care and diligence
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of it’s directors must also take steps specified in subsection (1).
There are some useful observations to make about these obligations. Firstly, the issue of duty of care is quite clear and places the ultimate responsibility for safety with the operator. Secondly, it is the ‘holder’ of an AOC who carries that responsibility. The vast majority of AOC’s are held by corporate legal entities (a company), so CASA places the practical responsibility on the office holders or ‘key personnel’ of the company as listed in subsection 28 (3) of the Act. The CEO is at the top of the list of those key personnel. So although day-to-day responsibility may be delegated to other officers, should a serious safety issue develop CASA’s main port of call will be the CEO. The third point to note is that the scope of that duty of care is very broad. ‘Every activity covered by the AOC’ and ‘everything done in connection with such an activity’ includes everything from flying the plane and maintaining it to loading, training, dangerous goods management and so on.
Subsection (2) highlights the responsibility that each director of a company operating under an AOC carries for safety. A CEO will in most cases also be a director of the company, and if CASA needed to approach non-executive directors to resolve a safety issue, that in itself would be a sign of potentially serious concern.
Certificate (AOC) - that is an airline or charter business - the legal obligations for managing safety are up front in Section 28BE of the Civil Aviation Act
1988. It’s probably worth quoting the key provisions here:
Section 28BE
Duty to exercise care and diligence
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of it’s directors must also take steps specified in subsection (1).
There are some useful observations to make about these obligations. Firstly, the issue of duty of care is quite clear and places the ultimate responsibility for safety with the operator. Secondly, it is the ‘holder’ of an AOC who carries that responsibility. The vast majority of AOC’s are held by corporate legal entities (a company), so CASA places the practical responsibility on the office holders or ‘key personnel’ of the company as listed in subsection 28 (3) of the Act. The CEO is at the top of the list of those key personnel. So although day-to-day responsibility may be delegated to other officers, should a serious safety issue develop CASA’s main port of call will be the CEO. The third point to note is that the scope of that duty of care is very broad. ‘Every activity covered by the AOC’ and ‘everything done in connection with such an activity’ includes everything from flying the plane and maintaining it to loading, training, dangerous goods management and so on.
Subsection (2) highlights the responsibility that each director of a company operating under an AOC carries for safety. A CEO will in most cases also be a director of the company, and if CASA needed to approach non-executive directors to resolve a safety issue, that in itself would be a sign of potentially serious concern.
Although analysis over the years has highlighted the dominance of human factors involving technical people in accidents, it is clear that organizational factors in many cases play a major part. Organisational factors are clearly the responsibility of management in the broadest sense, not necessarily just technical management such as a chief pilot. Indeed, in many cases technical managers, even at a senior level, may need the support of more broadly focused managers, including the CEO, to see the system problems and identify system fixes.
…
But by far the biggest problem (present in well over 80% of accidents) is the human factor—where despite our best efforts, individuals make errors or deliberately engage in unsafe conduct. In managing safety, we must accept that what we are actually doing is carefully identifying risks and putting in place appropriate mitigators to prevent those risks resulting in accidents. Assessments of risks must cover the full spectrum associated with staff, hardware, software and the environment.
…
Safety management involves judgement, assessing priorities and making decisions. These are all elements of management in its more general sense.
And that’s what a CEO does—manage.
…
Provided the end result is acceptable, the approach gives industry the flexibility to run their business as they see fit—because that’s where the ultimate duty of care for managing safety sits. The consequence of a less prescriptive regulatory environment is a greater need for the business, particularly the CEO, to manage safety.
…
But by far the biggest problem (present in well over 80% of accidents) is the human factor—where despite our best efforts, individuals make errors or deliberately engage in unsafe conduct. In managing safety, we must accept that what we are actually doing is carefully identifying risks and putting in place appropriate mitigators to prevent those risks resulting in accidents. Assessments of risks must cover the full spectrum associated with staff, hardware, software and the environment.
…
Safety management involves judgement, assessing priorities and making decisions. These are all elements of management in its more general sense.
And that’s what a CEO does—manage.
…
Provided the end result is acceptable, the approach gives industry the flexibility to run their business as they see fit—because that’s where the ultimate duty of care for managing safety sits. The consequence of a less prescriptive regulatory environment is a greater need for the business, particularly the CEO, to manage safety.
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... because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.