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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 23rd May 2013, 23:43
  #601 (permalink)  
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Oh dear Aunty does not know the difference between a WWII and a Learjet.
Maybe they could request, on PPRuNe, input from an ex-corporate pilot.
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Old 24th May 2013, 06:05
  #602 (permalink)  
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Air safety agencies have 'full backing' despite report on Norfolk Island crash

This is what it has come to. Complete incompetence backed up by more complete incompetence

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Old 28th May 2013, 01:33
  #603 (permalink)  
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Updating thread with latest from AvWeb:

Australian Senate: Norfolk Island Crash Investigation Could Lead To Criminal Probe

In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia's Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air's operation that directly contributed to the accident. CASA's action, says the Senate report, may have violated Australia's Transport Safety Investigations Act. "It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation," said Sen. David Fawcett.

The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island en route from Samoa with a critical but stable patient. The Westwind's ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight's captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. En route, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB's accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.

Following the ATSB's findings, James challenged some of the investigator's findings but his queries were dismissed by the ATSB. The Australian Senate took up James' case last year and its probe revealed widespread flaws in the ATSB's investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that "unequivocally concluded … that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies." Yet no mention of this report appeared in the ATSB's findings blaming the pilot. "In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies," the Senate report said.

Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. "This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That's why I think we need an inspector general of aviation," Sen. Nick Xenophone told Australia's ABC News. "This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB," he added.

The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB's chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. "CASA's internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses' evidence that they did not think surveillance was adequate, when CASA's own internal investigations indicate that CASA's oversight was inadequate," the report said.
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Old 31st May 2013, 00:43
  #604 (permalink)  
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Australian Safety Regulator and investigator down in flames

While there is a significant thread already running in the Pacific sector, it seems to me that this news item has wider implications.

A recent Australian senate review has found that both the Regulator (CASA) and the Safety Investigator (ATSB) have significant issues to address. The inquiry, into the handling of information by CASA and the ATSB and reporting by ATSB of a ditching off Norfolk Island of a Pel-Air Westwind on a medevac flight, as well as the way in which senior bureaucrats handled themselves appears at:

Senate Committees ? Parliament of Australia

While the Pilot was deemed at fault for running out of fuel by both ATSB and CASA, the Senate report makes a big issue of the fact that both CASA and ATSB sought to blame ONLY the pilot, ignoring systemic organisational failures in the their own agencies.

It makes interesting reading, particularly for those that think that mishandling a cover-up only compounds the origininal stuff up.

Last edited by Seabreeze; 31st May 2013 at 02:40.
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Old 20th Nov 2013, 02:13
  #605 (permalink)  
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My head hurts.

I think these guys have a clever and advanced for of QCAS, just like TCAS but for questions. And it is highly effective.

And lots of arse covering by Dr Aleck as well.

Senator X must be a very patient man......I would have gone postal during that exchange.
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Old 20th Nov 2013, 02:52
  #606 (permalink)  
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Can't wait to see episode 2, .

That's the best attempt I've ever seen at avoiding a bunch of questions.

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Old 22nd Nov 2013, 18:29
  #607 (permalink)  
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Sea Air for all.

RW # 601 "My confidence in our aviation safety regulators and accident investigation body CASA, the Civil Aviation Safety body and the ATSB have been shaken to the core," he said.
Karen Casey was injured in the crash and says the report must be acted on.
"The truth has finally been revealed," she said."
"SB# 606 "It makes interesting reading, particularly for those that think that mishandling a cover-up only compounds the original stuff up."
Reading the Hansard script, I'm surprised that CASA has not issued another press release; this time saying Karen Casey was at fault as she failed to demonstrate robust compliance with the CASA rules; failed to attend a survival at sea course and breached 20.11, they'll probably prosecute. Nothing CASA do you see can possibly be wrong, nothing. Except not only have they screwed the pooch, they buggered up the cover up and then; got caught 'at it'. Arrogance + incompetence = AFP investigation ?.....

Last edited by Kharon; 22nd Nov 2013 at 19:46. Reason: Stuffed up the sarcasm - Mea culpa....
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Old 22nd Nov 2013, 19:33
  #608 (permalink)  
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Why would she be at fault Kharon? She was only a passenger.
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Old 22nd Nov 2013, 19:47
  #609 (permalink)  
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Sorry Morno – sarcasm is the lowest form of wit. I have rephrased. It was early, between first and second coffee....
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Old 22nd Nov 2013, 21:45
  #610 (permalink)  
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Right, gotcha. Did sense maybe a touch of sarcasm after I'd replied earlier.

In that case, I agree, .
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Old 20th Jan 2015, 02:26
  #611 (permalink)  
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The Skygods are bored??

Apparently the regular Skygod readers had become bored with the Merged: Senate Inquiry thread & therefore the powers to be have decided to shut it down... Now this was despite the thread being currently the most popular on page one (active) of the ANZ&P forum and from my estimates (if the counter had been working) would have surpassed 800k views in recent days... Oh well PPRuNe is entitled to do what they must do...

However in the interest of some continuity and without upsetting (hopefully) the Skygods or the mods and as the PelAir insanity is really a GA issue the BRB (and some members of the IOS) have asked me to continue the Senate thread here...so here goes (big breath..) the last page of the 2nd infamous Senate Inquiry thread...

#2681 - Mooted messages?
#2684 - Episode 316: Beaker's spin recycle machine.
#2685 - The Dolan prophesy.
#2686 - Episode 317: The lone muppet mission.
#2687 - What is that awful smell?

There is a definite odour of cynicism toward Australian involvement in the MH 370 affair creeping into the international press, previously only visible on Bloggs. The bloggers caught on early and responded cynically to the Dolan involvement. I wonder what they will make of it once Pel-Air becomes the international yardstick against which any ATSB involvement, no matter how far removed, will be measured in the future.

The steaming pile Muscles McComic and Doolally Doolan have left behind for the rest to clean up will take a while to shift. Even when it's moved away the stench will linger despite the best deodorising efforts of the Word Weasels, spin doctors and the like. No matter, ATSB will investigate the ATSB, a clean sheet will be provided and all will be well once more. It's a first class move as CASA gets to slither off the hook and out the back door – once again.

Then children, you shall see a lengthy queue forming around the block of all the regulators in the known world patiently waiting to buy their signed, Senate supported copy of Part 61 and the Beyond All Reason method of air crash investigations.

Absolutely stellar Australia; just ducking wonderful.
... ..........

#2688 - Feeling the PAIN!
Absolutely stellar Australia; just ducking wonderful.
Exactly Ferryman what an embarrassing smear on the good people at the coalface that were initially involved with the surface search; & now with the underwater deep sea search; not to mention the huge waste of taxpayer funded resources if it all ends up for nought, especially if it comes out that we have either been misled or are in collusion with the Malaysians...

If that were to transpire then indeed the parallels with the PelAir cover-up would be complete...

While on the subject of the PelAir debacle I noticed the following has been posted courtesy of Australian Flying online - ATSB to feel PAIN over Pel-Air Investigation
A confidential group known as the Professional Aviators Investigative Network (PAIN) has raised concerns over the ATSB review of the Pel-Air ditching report.

Late last year, the ATSB agreed to review the report into the 2009 ditching of a Pel-Air aeromedical flight at Norfolk Island, after a Canadian review highlighted anomalies with the investigation report.

In a submission to the Senate Standing Committee on Rural and Regional Affairs and Transport (RRAT) written in December, the group has criticised the ATSB's decision to use one of their own people to lead the review.

"... the ATSB [has] elected to utilise Dr Michael Walker of the ATSB to lead the investigation," the PAIN submission points out. "We believe that to be effective, any investigation should be conducted independently and not involve ATSB, the commissioners or staff if only to preclude any suspicion of 'internal' influence or external bias being raised."

PAIN is also concerned that the terms of reference announced by General Manager Aviation Safety Investigations IanSangston do not go far enough.

"The terms of reference cited by Mr Sangston are narrow and only mention the 'report' itself. Whilst the industry acknowledges that the report was substandard, there is little doubt that the investigators conducted their work with integrity and within the prescribed guidelines. Indeed, the early stages of the ATSB report were exemplary and clearly directed toward serious safety recommendations being made.

"We believe little will be gained by utilising scarce resources re-investigating the original ATSB investigative 'reports'."

Instead, PAIN points the finger of blame for the original Pel-Air investigation report squarely at the both CASA and the ATSB and hints at deeper issues.

"Our greatest concern is that a deliberate, calculated manipulation of the national aviation safety system was attempted. It is not a 'one off' aberration. We firmly believe that the subsequent actions of both the Civil Aviation Safety Authority (CASA) and the ATSB were proven, by the AAI [RRAT inquiry] committee, to grossly pervert the conclusions of the ATSB investigation to suit a clearly predetermined outcome, thus denying industry valuable, safety related knowledge and information.

"It is the process by which these subsequent events occurred which demands an independent investigation conducted transparently in public. We believe the Senate Committee is the right reporting and oversight platform for that investigation. The committee Senators are well briefed, informed and have a firm, current understanding of what transpired during the events subsequent to the Pel-Air aircraft ditching off Norfolk Island.

"Further, the Estimates committee is very clearly 'awake' to the machinations of the various aviation oversight bodies and will not easily be misled or confounded by 'technical' issues.

"We submit that any other form of investigation will not withstand the scrutiny of industry experts; as the initial premise is fatally flawed
Well done PAIN... Hmm...perhaps more IOS members should follow the PAIN initiative??

I'll be back...
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Old 20th Jan 2015, 09:33
  #612 (permalink)  
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Sarcs, it would seem that you have caused a measure of discomfort for some of those who reside in Can'tberra! Good work son. It's nice to see that some people still have a measure of testicular fortitude so keep up the good work, whether that be on ******* or some other avenue
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Old 20th Jan 2015, 09:39
  #613 (permalink)  
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Well done Sarcs,

I was disappointed to see the senate thread locked, maybe things were getting too close to the truth.

Only conclusion I can come to for shutting such a popular thread is someone got paid or someone got threatened, even money on both the way things are currently in Australia.

Aint censorship a wondrous thing, someone definitely is not a Charlie!
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Old 20th Jan 2015, 17:20
  #614 (permalink)  
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I am intrigued that the Board of Pel Airs Owners appear to include as Directors:

(1) A former Aviation Minister.

(2) A current member of the Administrative Appeals Tribunal.

I am also intrigued that Pel AIrs owners appear to have allegedly made massive political donations to both sides of Federal politics shortly after the Pel Air ditching and have never done so on this scale before or since.


I am also intrigued that the report on the Pel Air ditching has been acknowledged as one sided and unfair in that it apparently glossed over the failings of Pel Air management and that CASA and ATSB cooperated in the " fitting up" of the pilot as solely responsible for the incident. Exactly why the ATSB and CASA chose to do this is still a mystery to me.

I am also intrigued that the person who allegedly high level managed the production of the report is also apparently involved in the management of the Senate forced "review" of it - which could hardly be called "independent" by any standards I am aware of.

Could I perhaps be forgiven for wondering if there might be linkages of some sort between all these matters or are they purely coincidental?

If these matters had occurred at a State Level in perhaps Queensland or NSW, would those States Independent Commissions against corruption be interested in casting an eye over them?

...Or am I reading too much into this?

Last edited by Sunfish; 20th Jan 2015 at 17:38.
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Old 20th Jan 2015, 18:14
  #615 (permalink)  
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Not passing strange – business as usual.

Ah but Sunny you have at least had the benefit of a master class on how the Australian 'system' works. A five year effort, a Senate inquiry and recommendations, a parliamentary review and recommendations, followed by a peer review and recommendations. You can easily define the first class results of and benefits from all the time, trouble, effort and money invested. Has aviation been given a new lease of life, hope for the future, fighting off investors and generally doing just fine? No. you get the Senate thread discussing these matters shut down and dead silence from the government. Impressive I'd call it, not too shabby an effort at all; from the other team. No matter, we shall always have Be-a-Cur.

Speaking of the Norfolk debacle (as we must) I hear a whisper that the Pel-Air defence team have subpoenaed the children and family of flight nurse Karen Casey as witness; if this is true, then it begs the question why? What possible information or benefit can 'the family' provide to the team defending Pel-Air related to the event?, again, if true, it reeks of the sewer. Perhaps I shall find a seat in the gallery and see for myself what is happening; I shall sit with Mick and Dominic, beer and Pizza afterwards?, sounds great.

Round of applause, well done all..
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Old 20th Jan 2015, 19:50
  #616 (permalink)  
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Thanks to all those who have posted here.
It's a fascinating thread and I'm hoping we hear some
more inside information.

When accidents happen and the operators go Oh $hit,
we have a problem, they seems to be normal for any and all
influences to be pulled to first cover it up, two divert attention,
keep it covered by all means and throw in more diversions.

It's a no brainer that that there was a long list of criminal negligence
from the pilot to the investigation.

It boggles the brain that he could go to a fickle weather location,
pass the point of no return without checking the weather, knowing
that if the wx turned bad, he and his passengers would have little
chance of survival.

Criminal Negligence is such a narrowly framed charge that it excludes dam near anything that a reasonable person would assume is covered but its not.

It begs a review of the CAS alternate requirements which are very different to that in other countries.

It will be interesting reading the inside scoops on this story.
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Old 20th Jan 2015, 20:53
  #617 (permalink)  
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"I hear a whisper that the Pel-Air defence team have subpoenaed the children and family of flight nurse Karen Casey as witness; if this is true, then it begs the question why?"

Just to confirm that lawyers are bottom feeding scumbags is all Kharon.

Or maybe they are using the Singapore Inc. method of silencing dissent.

Sue them for liable until their money runs out, or terrorise their children in the witness box until they give up.

Pel Air, what a piece of work!
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Old 20th Jan 2015, 23:44
  #618 (permalink)  
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More on the political donations here -

Pel-Air, party donations, air safety! Just a brain fade? | Plane Talking
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Old 22nd Jan 2015, 04:25
  #619 (permalink)  
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The donations have raised additional question marks because Rex has repeatedly described industry as being in crisis, stating it was “beyond crisis”, and highlighting the “graveyard” of collapsed rivals in its last annual report.
From OakApe's link
I don't see the link between the donation and being concerned about the industry
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Old 22nd Jan 2015, 05:23
  #620 (permalink)  
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Oh by Crikey??

Guess who now controls the Senate...

Why Nick Xenophon is our most powerful man

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