Norfolk Island Ditching ATSB Report - ?
Years ago, I learned one thing to my cost after an incident at Alice Springs where an Ansett 727 and a DCA F27 were involved. The F27 captain was more or less hung out to dry on the evidence of an ATC transcript. A clerk did the transcription from the tape to paper but wrote what he thought was said on the ATC tape. In fact he guessed what was said and wrote it down.
For example the request by the F27 pilot "Request Airways clearance" while at the holding point at Alice Springs, was transcribed as "Are we clear" There were several similar mistakes by the transcriber which changed the whole context of the event. Moral of the story is that those involved in such incidents should ensure they are permitted to listen to the tapes themselves and not blindly accept the transcribed version.
For example the request by the F27 pilot "Request Airways clearance" while at the holding point at Alice Springs, was transcribed as "Are we clear" There were several similar mistakes by the transcriber which changed the whole context of the event. Moral of the story is that those involved in such incidents should ensure they are permitted to listen to the tapes themselves and not blindly accept the transcribed version.
In the ATSB's original report into the ditching of NGA there were, at the very least:
(A) patent errors in what was represented as a transcription of the transmissions to NGA, or
(B) disclosures of patent errors and omissions from transmissions to NGA.
(A) patent errors in what was represented as a transcription of the transmissions to NGA, or
(B) disclosures of patent errors and omissions from transmissions to NGA.
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AND:
(C) Failure to send atsb the Chamber's report by casa, which was highly derogatory of the operations of PelAir [and ultimately REX];
(D) Obfuscated Senate inquiry by atsb for a lengthy period of time [will be attributed to staff cutting and MH370, no doubt]
(C) Failure to send atsb the Chamber's report by casa, which was highly derogatory of the operations of PelAir [and ultimately REX];
(D) Obfuscated Senate inquiry by atsb for a lengthy period of time [will be attributed to staff cutting and MH370, no doubt]
Last edited by advo-cate; 2nd Oct 2016 at 00:10. Reason: Layout
The ATSB transcripts of ATC recordings differ between the draft & final reports of the Bankstown Mojave accident. Which really raises questions about the ATSB preparedness to change transcripts to suit the conclusion they want. Transcripts are no longer evident in recent ATSB reports that i have read. They seem to instead to adopting isolated quotes from a transcript.
The ATSB transcripts of ATC recordings differ between the draft & final reports of the Bankstown Mojave accident. Which really raises questions about the ATSB preparedness to change transcripts to suit the conclusion they want. Transcripts are no longer evident in recent ATSB reports that i have read. They seem to instead to adopting isolated quotes from a transcript.
Last edited by Lead Balloon; 6th Oct 2016 at 08:02.
Updated: 13 October 2016
The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen. However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry. The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.
"In the first part of 2017" Lets see, New Years day, Australia day, Good Friday or Queens Birthday weekend? Justice delayed is justice denied. The ATSB seems to me to be as corrupt as CASA.
I doubt it will happen at all. Mr Hood's nauseating praise of his predecessor indicates Mr Hood's primary job is to perpetuate the facade of ATSB competence and capacity patched up by his predecessor.
Unless and until I hear the actual content of NGA's CVR and tapes of transmissions to it from the ground, I will believe not a single syllable of what is represented as a "transcript" of what NGA's crew heard.
Unless and until I hear the actual content of NGA's CVR and tapes of transmissions to it from the ground, I will believe not a single syllable of what is represented as a "transcript" of what NGA's crew heard.
It looks like the list from the April update:
that the ATSB is finally focusing on the organisational issues which were MIA from the original report. If they had done the job properly in the first place they wouldn't have to tie up resources doing it again now. I will be surprised if they do a 180 on their original findings as the hole they dug for themselves is a very deep one.
That analysis is focusing on:
- pre-flight planning and fuel management procedures and practices
- in-flight fuel management and related decision-making procedures and practices
- fatigue management procedures and practices
- flight crew check and training
- the operator’s oversight of its flight operations activities
- provision of weather and other flight information to flight crews
- cabin safety and survival factors
- regulatory oversight of activities such as those listed above
The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process,
Updated: 21 November 2016
Reopened investigation into 2009 aircraft ditching near Norfolk Island
The investigation team is now finalising the draft report and has started an internal review process. Once the internal review is completed, the report will be handed to the ATSB Commission for their consideration and approval. The ATSB will then provide the draft report to directly involved parties for their comment and feedback. Given the broad-ranging and complex nature of the investigation, and the size of the report, the draft report is now expected to be released to directly involved parties in early 2017.
The investigation process has required a cycle of continuing review of the evidence and the acquisition of new evidence as knowledge gaps and new lines of enquiry have been identified. Further, the ATSB has not sought to confine the scope of the reopened Norfolk Island investigation in the way that it normally would to manage its overall investigation outputs recognising the interests of all parties involved, as well as the Senate Inquiry and the Canadian Transportation Safety Board review of the original ATSB investigation.
A significant amount of detail is required to explain the findings, which are based on a rigorous application of the ATSB’s analysis methodology. To date, the investigation team has acquired and analysed an extensive range of evidence as part of the new investigation. This includes:
The ATSB recognises the importance of being able to demonstrate that the reopened investigation addresses identified areas for improvement with the original investigation. Given the size of the report and the complexity of many of the issues, it is difficult to predict how long the draft review and final report processes will take, although it is likely to extend beyond those typical of more routine investigations/reports. After the draft report review process is complete, the ATSB should have a better understanding of a more specific likely timing for the release of the final report.
The investigation team is now finalising the draft report and has started an internal review process. Once the internal review is completed, the report will be handed to the ATSB Commission for their consideration and approval. The ATSB will then provide the draft report to directly involved parties for their comment and feedback. Given the broad-ranging and complex nature of the investigation, and the size of the report, the draft report is now expected to be released to directly involved parties in early 2017.
The investigation process has required a cycle of continuing review of the evidence and the acquisition of new evidence as knowledge gaps and new lines of enquiry have been identified. Further, the ATSB has not sought to confine the scope of the reopened Norfolk Island investigation in the way that it normally would to manage its overall investigation outputs recognising the interests of all parties involved, as well as the Senate Inquiry and the Canadian Transportation Safety Board review of the original ATSB investigation.
A significant amount of detail is required to explain the findings, which are based on a rigorous application of the ATSB’s analysis methodology. To date, the investigation team has acquired and analysed an extensive range of evidence as part of the new investigation. This includes:
- reviewing evidence from the ATSB’s original investigation, and obtaining and reviewing evidence from CASA’s investigation of the accident, CASA’s special audit conducted soon after the accident
- recovering and analysing data from the aircraft’s flight recorders
- re-interviewing the flight crew and medical crew from the accident flight, and conducting over 30 additional interviews, including with 14 Pel-Air Westwind pilots, eight other Pel-Air personnel and six CASA personnel
- obtaining and analysing wind and temperature data, and integrating this information with Flight Data Recorder data, Cockpit Voice Recorder data, Air Traffic Control data, flight crew interviews and refuelling records to provide the best estimate of the aircraft’s fuel status during the accident flight
- obtaining and analysing 8 years of Westwind flight records from the operator’s fleet to examine fuel management aspects for different types of flights, particularly flights to remote aerodromes and air ambulance flights. This also involved obtaining and analysing meteorological information and other information for several flights
- obtaining and reviewing a substantial amount of documentation from the operator, including documentation from the operator’s safety management group meetings, selected samples of incident/hazard/fatigue reports, audit reports, flight crew training records for 18 Westwind pilots, and duty periods for all Westwind pilots for the 6 months prior to the accident
- obtaining and reviewing 10 years of CASA documentation associated with the operator’s Air Operator Certificates
- reviewing documentation from the air traffic services’ providers in Fiji and New Zealand about their policies and procedures for the provision of flight information, and how these were applied during the accident flight. Information was also obtained and analysed regarding how operations in Reduced Vertical Separation Minimum airspace were conducted.
The ATSB recognises the importance of being able to demonstrate that the reopened investigation addresses identified areas for improvement with the original investigation. Given the size of the report and the complexity of many of the issues, it is difficult to predict how long the draft review and final report processes will take, although it is likely to extend beyond those typical of more routine investigations/reports. After the draft report review process is complete, the ATSB should have a better understanding of a more specific likely timing for the release of the final report.
it's now clear to me what is going to happen.
Pel Air or its successors is going to be wound up reorganised or sold before the final report is released.
it then becomes impossible to attach blame to any organisation, thing or person.
The technical term for this in organisational behaviour studies is "diffusion of responsibility".
the final report, far from being a damning document, will consist of nothing but motherhood statements and "who coulda knowns". Domenic James will still be left hanging out to dry.
Pel Air or its successors is going to be wound up reorganised or sold before the final report is released.
it then becomes impossible to attach blame to any organisation, thing or person.
The technical term for this in organisational behaviour studies is "diffusion of responsibility".
the final report, far from being a damning document, will consist of nothing but motherhood statements and "who coulda knowns". Domenic James will still be left hanging out to dry.
You're off with the fairies, Sunfiish.
Even assuming the new report makes the durr-obvious finding that the operator's systems and procedures contributed to the accident, that's a finding about the operator and its circumstances over 7 years ago. All of that was tidied up, quick smart, 7 years ago.
Even assuming the new report makes the durr-obvious finding that the operator's systems and procedures contributed to the accident, that's a finding about the operator and its circumstances over 7 years ago. All of that was tidied up, quick smart, 7 years ago.
We're getting a new report because everybody found out that the first report was a quick and dirty hatchet job to tidy up some very inconvenient political problems.
The new report will be another attempt to explain what happened, and why, seven years ago. So even if the report deals objectively and factually with the systemic issues within the operator, the regulator, the air navigation service providers and the meteorological forecasters that contributed to the accident, those are all circumstances that prevailed seven years ago.
You don't seriously think that the new report will contain any material that could justify some kind of legal or regulatory or administration action within or against or by any organisation or person involved, seven years later?
The new report will be another attempt to explain what happened, and why, seven years ago. So even if the report deals objectively and factually with the systemic issues within the operator, the regulator, the air navigation service providers and the meteorological forecasters that contributed to the accident, those are all circumstances that prevailed seven years ago.
You don't seriously think that the new report will contain any material that could justify some kind of legal or regulatory or administration action within or against or by any organisation or person involved, seven years later?
Do we have a "Statute of limitations" as in the USA, in Australia?...
But I could be wrong.
I'd be interested to hear your theories about who could take action against whom, for what, now.
Do we have a "Statute of limitations" as in the USA, in Australia?
I seem to recall that in the USA it was seven years.
Coincidence?
I seem to recall that in the USA it was seven years.
Coincidence?