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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 1st Feb 2015, 06:37
  #681 (permalink)  
 
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Can anyone post an image of the ATSB PHd who is doing the review? If it is who I think it is...
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Old 1st Feb 2015, 07:08
  #682 (permalink)  
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Ziggychick; Hang in there!

And more power to you!
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Old 1st Feb 2015, 07:42
  #683 (permalink)  
 
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Wink

Horatio...

Can anyone post an image of the ATSB PHd who is doing the review? If it is who I think it is...
Check your PMs.

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Old 1st Feb 2015, 08:52
  #684 (permalink)  
 
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Angry Dr Michael Walker

Thanks Siuya

I posted this earlier but deleted it in case I had my Dr Michael Walkers wrong.

Dr Michael Walker has a strong and emotional interest in the PelAir report, and he displayed this in front of about 200 people at the 2012 AAvPA symposium at Manly.

Martin Dolan had just spent the better part of an hour talking about Organisational safety factors and how the ATSB firmly believed in following the thread of causation all the way back to find the true cause of the accident.

After crapping on about "long before I became an ashen-faced thin-lipped beauracrat" for an hour he gave us the opportunity for questions. I had to ask:- something along the lines of

"The Aviation Industry has greeted the PelAir report with disdain and disbelief, and many are questioning its findings. Given your obvious belief in Organisational factors contributing to aviation safety, how do you defend the fact that the Pel Air report ignores all the organisational factors?"

Mr Dolan said that he would allow one of the team to answer that.

The man sitting directly in front of me stood up, trembling with rage and indignation. Thanks to the photo sentto me by SIUYA, I can now be sure it was Dr Michael Walker.

He proceeded to defend the report's findings and the ATSB's integrity with surprising venom.

His exact words escape me now, but sometimes it is clear to you that a person's venom and defensiveness stems from a guilty conscience. as I sat, buffetted by his abuse, I formed that opinion and I was not alone. Of the 200 people in the room, most if not all were psychologists or at least formally schooled in human behaviour.

Afterwards I was approached by 2 ATSB personnel and they both told me that the report had not reflected the original findings AND that there was some significant anger and frustration with the findings as they had been published.

I have probably posted this story earlier in this thread or on another thread on this topic, but to have Dr Michael Walker conduct the ATSB's review on this report given his obvious close relationship to Dolan an his emotional investment in the original report STINKS TO HIGH HEAVEN.

Last edited by Horatio Leafblower; 1st Feb 2015 at 20:40.
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Old 1st Feb 2015, 10:28
  #685 (permalink)  
 
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Leafie…….and you are surprised?

Add this to a long list of ATSB reports that stink and have a lingering smell of collusion with the regulator and the regulator stooping to activities that are either illegal or should be, in order to pervert the course of justice.

They are thick as thieves at times. We all know it. Just the government refuses to acknowledge it let alone act.

Most of us in the industry could name three or more. It should be no surprise. I can think of three of the highest profile ones without trying and possibly a fourth and fifth. No doubt some folk could rack up double digits

You and I both know a guy who should conduct the review, a fellow who is very qualified to investigate at the appropriate level. Maybe he should get a gig? What do you reckon? You know who I mean. And I know he silently watches these threads too.
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Old 1st Feb 2015, 10:33
  #686 (permalink)  
 
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I can think of a lot of people mate but I presume the bloke you refer to is no goose?
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Old 1st Feb 2015, 11:19
  #687 (permalink)  
 
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I reckon you are onto him. He is not a good looking chap (not as camera friendly as you are ) , but not a goose either

Knows a few things about aviation too I believe …….which would be a rather refreshing change to investigations.
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Old 1st Feb 2015, 12:01
  #688 (permalink)  
 
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No mate i think a coroner might be appropriate... nobody died but that is pure luck.

Last edited by Horatio Leafblower; 1st Feb 2015 at 18:49.
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Old 1st Feb 2015, 20:16
  #689 (permalink)  
 
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Memory of an elephant - MKII

Horatio: "...I have probably posted this story earlier in this thread or on another thread on this topic, but to have Dr Michael Walker conduct the ATSB's review on this report given his obvious close relationship to Dolan an his emotional investment in the original report STINKS TO HIGH HEAVEN..."

Totally agree with your sentiments HL - however my memory dims on when you may have posted such a twiddle.. Could you perhaps jog your memory a little more or point me in the right direction to where I may track down a transcript of this occasion...

Here are some links to the now banished (not forgotten) 2nd Senate Thread that took up the CV and the huge COI in the bureau (under Dolan)in re-investigating it's own abysmal PelAir Final Report:

Theorists vs realists
Not sure I'll be personally voicing an opinion on the Doc on here anytime soon but the first indications are not entirely promising - apparently the following image was attributable to Doc Johnny:



(my brain hurts just looking at that theoretical Doc masterpiece.) -

Please...please Miniscule bring back 'Reason' & Alan Stray (or his look-a-like). And Miniscule while we are at it please pay attention to the excellent advice/response freely provided by AIPA in regards to ASRR recommendation 5...:
Quote:

Recommendation 5
5. The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience.

AIPA strongly agrees with this recommendation. However, despite the Government and the ASRR Panel rejecting the Senate Inquiry recommendation that the Chief Commissioner should have that experience and noting the multimodal role of the ATSB, our full support remains with the Senate recommendation.

AIPA rejects the Panel’s view that aviation expertise provided by a part-time Commissioner is sufficient. Our view is that aviation is by far the most complex of the transport modes and the related operational expertise is more easily applied across the other modes.

AIPA also notes the Panel’s view that the Pel-Air investigation and report were an aberration in terms of how the ATSB should be viewed. In light of the material presented to the Senate Inquiry, such a conclusion appears charitable at best. {Spot on AIPA...love it..}

Kharon:- "...It's bad enough that Dolan and McComic created the unsightly aberration, worse that they attempted to deny ownership of it; but to allow Dolan control of the investigation for a second time beggars belief. The absence of an Indonesian invitation says it all really..."

Totally agree "K" but after reading the following from the Canuck press it maybe a Godsent that we're not invited to the slugfest...: AirAsia Flight QZ8501: Indonesia's aviation safety practices under fire
Quote:
Memory of an elephant.
However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...

From 3.5 Report preparation (November 2010 to March 2012) of TSBC report:
Quote:
At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.

They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.
But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...

However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):
Quote:
1.17 Organisational and management information
The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.

Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-

1.17 .1 Fuel Policy and Practice
• Inadequate fuel policy for Westwind operations.
• Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
• No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
• No alternate requirements specified for remote area and Remote Island operations.
• The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
• Criteria to obtain weather updates not specified in Operations Manual.
• Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
• No consideration of loss of pressurisation and an engine failure.

1.17 .2 Operational Control
• No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
• Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
• The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
• In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.

• Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.

1.17.3 Training
• Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
• Inadequate documentation of training programs.
• No formal training for international operations.
• Inadequate training records for pilot endorsement and progression.
• Inadequate records of remedial training.
• Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
• No mentoring program for First Officer to Command.
• Deficiencies in training records identified.

1.17 .4 Fatigue Management
• Over-reliance on FAID as the primary fatigue decision making tool.
• Inadequate adherence to FRMS policy and procedures.
• Excessive periods of 24/7 stand by.
• Lack of FRMS policy regarding fatigue management for multiple time zone changes.
• Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).

1.17 .5 Drug and Alcohol Management
• Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.

These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.
Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture... Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5(PDF 6032KB)...

The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..

18Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)
Quote:
Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA?


How indeed??
Hmm...interesting I noticed this from Eddie at the bottom of that page...:
Look Left Quote:
but overlooked the simple fact that if the go-around was conducted according to the manual (pressing the TOGA buttons) then it probably would not have happened.
I agree Look Left, the simple fact that an error occured in the cockpit in spite of correct organisational checks and balances(SMS), is overlooked.
The blind adherence to the James Reason model can lead to interesting results when there is either an accidental or wilful violation.
Oh & by the way top stuff Soteria & Creampuff...got the intel Sot's and the subtleties Creamy...

Ps For Ziggychick good luck today & stare the buggers down...on the subject here is one from the BK chronicles - The Seaview disaster: conscience, culture and complicity - oh memories...
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Old 1st Feb 2015, 23:13
  #690 (permalink)  
 
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So why do some state that the Sydney Office oversighted PelAir yet Sarcs info from the ATSB state that the Bankstown Office oversighted PelAir? IMHO the closer parallel to Seaview is Lockhart River, dodgy operator, dodgy oversight unsuspecting fare paying passengers thinking they are getting on an RPT operation.
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Old 2nd Feb 2015, 04:23
  #691 (permalink)  
 
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FYI only – No guarantees.

Sunfish - Slats is on the money, timing matters. I would appreciate help in constructing the exact timeline because I think there is something here that stinks to high heaven.
18 November
2009: Ditching 3 NM south-west of Norfolk Island Aerodrome,

18 November
2009 ATSB notified of accident and ATSB subsequently notify CASA. The ATSB decide to carry out an investigation and CASA decide to run a parallel investigation, which was initiated on 19 November. Pel-Air voluntarily suspend their Westwind operation.

26 November 2009: CASA initiate a ‘Special Audit’ which was conducted between the 26/11/2009- 15/12/2009 at the Pel-Air Bases in Sydney, Adelaide and Nowra.

7 December
2009: Audit team meet with Pel-Air management to discuss a number of deficiencies within the Westwind Operation. This was backed up by correspondence from CASA on 9/12/2009.

16 December 2009 CASA accept the Pel-Air ‘Management Action Plan’ which consisted of three phases.

18 December 2009 Pel-Air successfully completed Phase 1 items and were able to recommence domestic operations.

23-24 December 2009: CASA overseeing FOI of Pel-Air Eric Demarco issues 14 RCA and a number of AO. The RCA needed to be acquitted by 28/01/2010.

24 December 2009 Pel-Air successfully completed Phase 2 items and were able to recommence international operations.

8 January
2010 CASA issue 7 more RCA and several more AO, not signed by team members - Roger Chambers the Audit Coordinator signature appears on all.

3 February
2010 Video conference meeting between the ATSB and CASA to discuss critical safety issue.

12 February 2010 Mr R White ALIU Manager contacts Mr Michael Watson the ATSB ‘investigator in charge’ (IIC) to request a supporting letter that described the critical safety issue.

26 February 2010 Mr Sangston Director of Aviation Safety Investigations writes to Mr White addressing the critical safety issue with the requested supporting documentation.

20 March
2010 CASA internal e-mail that highlighted a 50:50 split within the CASA inspectorate on when to divert to an alternate.

26 March
2010 Mr White and CASA initial response to critical safety issue.

15 June
2010 ATSB receive e-mail from Pel-Air detailing actions taken in response to CASA Special Audit.

21 July
2010 CAIR 09/3 completed.

13 January
2012 ATSB issue preliminary report AO-2009-072.

26 March 2012 Mr Sangston approves Final Report draft release to the directly involved parties (DIP) for comment on its factual accuracy. Comments were requested from DIP by 23 April 2012.

4 July
2012 The ATSB requested a copy of the CASA special audit report under a section 32 notice. A copy of the report was received on 9 July 2012.

16 August
2012 ATSB Commission approve s25 release of Final Report AO-2009-072 and officially reclassify the ‘safety issue’ to minor.

30 August 2012 ATSB Final Report AO-2009-072 released.
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Old 2nd Feb 2015, 07:08
  #692 (permalink)  
 
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Newspaper report on court hearing today

Doctor David Helm and nurse Karen Casey sue for damages over CareFlight crash
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Old 2nd Feb 2015, 08:28
  #693 (permalink)  
 
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I can't stand it anymore, I have to speak up. 37 pages of dribble. What ever happened to the concept of PIC...the C meaning Command. One of my first instructors, a WW2 vet, said to me as a 16 year old. " Boy, No damn checklist, ops manual, SOPS, regulations etc" replaces the 2 lbs of grey matter between your ears.

Dispatching to a remote island with only a non precision approach, at night.

An island that is known by anyone with a SPL for changeable weather,

Not carrying every last drop of fuel the tanks can carry.

Poor route selection in the first place, could have gone to Noumea instead, precision approach there.

Not getting a minute by minute update on the weather en route, especially when the weather was worse that forecast on the outbound trip.

Being told the cloud is OVC or BKN at 200agl prior to TOD, yet still chancing an approach. Knowing that to make an approach is likely to paint yourself into a corner with not enough fuel to divert.

Can a patient really be that sick to open up all the above risk factors. Could they not have waited 3 hrs so they had daylight to help with the approach?

You can have all the fancy safety systems, flow charts, ops manuals etc etc and oversight you like. None of this over rules sound judgment and common sense.
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Old 2nd Feb 2015, 08:32
  #694 (permalink)  
 
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sorry nomorecatering but your judgement is hardly that of Solomon

while what your instructor said way back then will always be spot on advice, it is not right to attempt to deliver summary justice
in a complex case like this

It's akin in a way to those diehards over Mount Erebus and Captain Jim Collins who will never admit
to the truth that an always super cautious, highly competent pilot entered a trap not of his own making

It can do your head in having to listen to 'the expert' in the bar telling everyone how "Joe Blow, he busted minimums -
end of story".
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Old 2nd Feb 2015, 09:42
  #695 (permalink)  
 
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Nomorecatering, what you say is true - up to a point.

The truth is that DJ exercised poor judgement that night. No one disputes that, including DJ himself.

Equally however, the environment is designed to have multiple lines of defence. The PIC is always the last line of defence as you make clear. But hopefully the PIC is flying for a safe operator, and that operator is kept safe by appropriate regulatory oversight.

Unfortunately these "earlier" lines of defence both failed, leaving DJ horribly exposed to bad judgement and bad luck. The operator and regulator also contributed to the outcome that night. Unlike DJ however, then have sought to minimise their hand in this. And it is disturbing to many that the purported independent investigator seems complicit in this.


FYI, Noumea wasn't an option that night. The operator had been barred from New Caledonia for the previous 12 months because the plane was not fitted with latest generation TCAS as required under French (EU) regulations. So the only ILS runway in that part of the world was off limits. Ironically the operator had just finished putting TCAS into the aircraft, but the pilots had allegedly not been trained in its operation.

Similarly they didn't have RVSM. It has been speculated the reason why full fuel was not uplifted at Apia was the requirement to climb above RVSM airspace upon departure.

Thats how marginal the whole thing was.
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Old 2nd Feb 2015, 10:05
  #696 (permalink)  
 
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Nomorecatering

You don't know, for sure, what weather information was transmitted to and understood by the crew.

What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.

All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP.
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Old 2nd Feb 2015, 11:26
  #697 (permalink)  
 
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Folks, remember that while CASA and PelAir are equally responsible, and my mind swings on what %age that is, in the James Reason model the pilot and his training are the last lines of defence.

Has anyone else here watched the excellent Ansett training video analysing the B743 oops in Sydney. It started with the planned start up date, and folk sticking to it, external contractors pulling the rug out and then all manner of sloppy systemic issues, culminating in the crew being set up and subsequently poorly performing. It was almost a comedy of errors except I am sure nobody thought it was funny.

I am beating myself up for a small error made the other day, no biggie but in my mind I cary the can. 100% me.

In this case there are three parties who have almost equal shares. DJ deserves the whipping he gave himself and the industry has. The sad thing is the other two managed to duck and weave. Then there is the aftermath and the ATSB. Another round of dodgyness involving three parties, two carried over from the original event We know who.

But what happens with them? That is the disgusting part. History repeats. As the gobble dock used to say…tic tock…..
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Old 2nd Feb 2015, 17:49
  #698 (permalink)  
 
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Creampuff

You don't know, for sure, what weather information was transmitted to and understood by the crew.

What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.

All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP.
To answer that question the CVR would go a long way! Just because it was transmitted doesn't mean it was received on board NGA. It has always concerned me that the CVR/FDR were not recovered. Beyond all Reason!!!
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Old 2nd Feb 2015, 21:02
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Getting someone who fits that criteria will be a bit difficult Fantome especially as point 6 contradicts point 1. If someone like that does exist it would make an interesting read but given the lack of public interest in the story unlikely to be a best seller.
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Old 2nd Feb 2015, 21:56
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halfmanhalfbiscuit
Quote:
Creampuff

You don't know, for sure, what weather information was transmitted to and understood by the crew.

What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.

All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP.
To answer that question the CVR would go a long way! Just because it was transmitted doesn't mean it was received on board NGA. It has always concerned me that the CVR/FDR were not recovered. Beyond all Reason!!!
A concern shared by many me thinks.

Perhaps there was a very specific reason.
"There is no evidence your honour".

Consider this "hypothetical".

Suppose, just suppose, hypothetically, that "the investigation authorities (plural)" reaches a certain point, very early on, where they realise, that knowing whether or not NGA got the Nandi info, was cruicial to whether or not they could shaft DJ fully, with the met as the trump card and the fuel as backup, without DJ having a "met based defence".

After all, logic says, if he got the Nandi info, then yes, we have got him cold. Shaft to the max.

But, if he did not get the Nandi info, or if what was received was not entirely readable and understandable, it is not so conclusive, it might not be so easy to shaft him on that. It might leave him some wiggle room on appeal, so we have to do him on the fuel.

Further suppose, just suppose, that "the investigation authorities (plural)", realise that there are only two ways DJ may (or worse - if he gets a good lawyer) wriggle out.
The transmit tape from Nandi and the receive tape from NGA - and of course - subsequent discussion in NGA.
So, two holes to plug.

Suppose, just suppose, that for now, we just leave the box where it is, and make it known, very hush-hush like, in diplomatic circles, that it would be "really helpfull" if a little island nation "declined" to supply their tapes. Given the nature of things - much bigger things - certainly do-able.

Further suppose, just suppose, that, having received advice of such willingness to decline, "the investigation authorities (plural)" now know that only the box could save DJ, so they "concoct" a "rationalle" - beyond all Reason, to "let it rest in peace".

Then, DJ is "done like a dinner" and "the investigation authorities (plural)" slip out into the shadows - and away - scott free.

Eventually, post shafting, DJ and others, like a couple of blokes in a bloody big house with a grass roof, can be given the stock bullshit, fully aware, that they are safe from being implicated in any way, safe in the knowledge that if it ever went to the land of the legal eagles, their defence would be simple - "There is no evidence your honour".

Back to reality.

Question. Can a court demand that a box be retreived ?
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