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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 22nd Jan 2015, 05:58
  #701 (permalink)  
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Most interesting reading Sarcs. A bit depressing too.

One can only get the impression that there is a powerful and offensive stench emanating from ATSB and indeed CASA in general.

I'm beginning to wonder if either organisation can be saved without some very ruthless intervention from the Government. Of course the first thing would be to remove Warren Truss from the portfolio as Minister.

Can anyone suggest someone suitable?

Just a thought; I wonder how a certain Senator Xenophon would go?
There are precedents for an Independent being elevated to a Ministry.
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Old 22nd Jan 2015, 07:01
  #702 (permalink)  
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A different version of "follow the money"?.
 
Old 22nd Jan 2015, 07:14
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Isn't John Sharp the National Party Treasurer or is that somebody else
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Old 22nd Jan 2015, 10:08
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Sharp = National National Treasurer

Yes Megle, that is the case. Posted that information a few weeks ago.
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Old 22nd Jan 2015, 11:32
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I am only going to drop one hint on the following item, and the reason being that I believe if too much detail is put out there then another thread will be locked by some individuals being leaned upon by an ever nervous Government.

I propose that Karen Caseys lawyers need to try accessing information stored (or now deleted) from CASA's TRIM files that relate to potential fuel uplift issues including aircraft not carrying enough holding fuel for the routes being traveled. You know, the same sort of routes operated by aircraft operators (some of which may have ditched an aircraft). Who knows, one may find that one or two of FF's actually decent FOI's had concerns (and evidence) of insufficient fuel uplift on a continuous basis, for several years before the Norfolk ditching!! It's just a thought, after all this is just a rumour network. I even once heard a rumour that there was a certain 727 freight operator up North also doing similar shenanigans with fuel Again all rumour of course, and rumours are highly appropriate for this website apparently.
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Old 22nd Jan 2015, 17:24
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UITA, sure, understand what Ben is reporting, just saying - that particular paragraph doesn't support his argument.

Soteria, when I read the Pel Air ATSB report I noted the several "insufficient" fuel uplifts that had been recorded, including capt James', and weren't pursued further.

According to the Chief Pilot here, the pilot fuel planning was remiss, and is not related to the Operators lack of fuel policy.
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Old 22nd Jan 2015, 19:02
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Sandilands:
Truss appears to have drifted off into la-la land by allowing the ATSB to appoint one of its own, Dr Michael Walker, to lead the investigation into its own fiercely denied errors.
Seems this blogger Sandilands missed the mark somewhat.

The renewed ATSB investigation is not investigating the ATSB's errors in the original investigation, that has already been by the Senate committee and the TSBC. What the ATSB has done is reopen the Norfolk Island ditching investigation with a fresh team of investigators.

I don't put much credence in Sandilands' ramblings. He boasted back in December that Martin Dolan would be replaced the next day, and that hasn't happened. Why should anyone believe his drivel?
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Old 22nd Jan 2015, 20:17
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A rambling sidebar.

Sidebar:
I don't put much credence in Sandilands' ramblings. He boasted back in December that Martin Dolan would be replaced the next day, and that hasn't happened. Why should anyone believe his drivel?
Boasted did he?? Well let's take a look at that article and see if you are right...
A replacement for the ATSB chief commissioner Martin Dolan is expected to be announced by the deputy PM and Minister for Infrastructure and Regional Development, Warren Truss, no later than Monday.

At the moment the prime, but unconfirmed person being mentioned for the role in industry circles is Chris Manning, a former Qantas chief pilot also noted for being a safety consultant who guided Tiger Airways toward to the required compliance with Australia’s safety regulations after its grounding by CASA in 2011.

Captain Manning has been a high profile critic of defence handling of air traffic control procedures at shared civil military airports such as Williamtown (Newcastle) and Darwin. He was, at the behest of Qantas, a voice of caution and concern over the use of common radio frequency self separation procedures at busy airports when AirServices Australia had insufficient staff to meet its ATC obligations.

However in his response to the Aviation Safety Regulation Review to parliament last week, the Minister, in accepting almost all of the recommendations, also said an additional commissioner with aviation technical experience would be appointed to the ATSB or Australian Transport Safety Bureau. Captain Manning’s career would make him a strong contender for either appointment, but nothing has been officially confirmed.

The only thing that is certain at this stage is that Mr Dolan is being replaced. In the aftermath of the Transportation Safety Board of Canada’s peer review of the ATSB’s procedures and methodologies in arriving at its controversial and much criticised findings concerning the 2009 Pel-Air ditching near Norfolk Island it is clear that Mr Dolan’s position as chief commissioner is untenable.

While the anodyne version of that quite detailed peer review is that it found that errors had been made by the ATSB the actual document details a shambles in the management of the investigation, and failures to properly collect and assess information.

The ATSB’s accident report was however defended by the current secretary of the department of Infrastructure and Regional Development, Mike Mrdak, and Mr Dolan. A Senate committee that inquired into the conduct of the ATSB (and CASA) in relation to the production of the report unanimously expressed dissatisfaction with Mr Dolan’s testimony.

The committee included coalition senators Bill Heffernan, its chair, and David Fawcett, as well as independent Senator Nick Xenophon, who not only pursued a range of issues in the two aviation authorities, but helped bring to light previously undisclosed documents related to a confidential Pel-Air audit in CASA and associated matters.

Those disclosures reflected adversely on CASA and the ATSB.

The inability of the ATSB under Dolan to adequately and convincingly deal with a relatively minor accident set off a festering controversy that brought the safety investigator and CASA, the regulator, into disrepute. That episode may be coming to an end, but the task of rebuilding respect and ensuring the best safety outcomes in both bodies remains.
There certainly is not much boasting going on in that lot...please explain your accusation? Ben may have been in error but he did confirm in the comments and in this article - Reopened Pel-Air inquiry could be on slippery slope to ruin -that he had it from very good advice (source):
Nevertheless, the Minister acted, and on 6 December, based on very, very good advice, Plane Talking reported that a replacement for the chief commissioner of the ATSB, Martin Dolan, would be announced, and some serious work on the matters identified in the TSBC report would occur.

That appointment hasn’t yet occurred, and the report in Plane Talking is either wrong or premature. Since then Plane Talking has seen correspondence which would suggest to a reasonable reader that a determined effort to frustrate what might be the Minister’s best intentions (or not) is underway.

It seems like the iron clad rule of life in public administration in Australia, that it takes precedence over the elected executive branch, and will run right over the top of injured or damaged parties without any concern other than keeping Ministers compliant, and administrative decisions untouched, is being pursued with determination.
Sidebar it seems you are in the know yourself mate, please pray tell??

"...Seems this blogger Sandilands missed the mark somewhat.

The renewed ATSB investigation is not investigating the ATSB's errors in the original investigation, that has already been by the Senate committee and the TSBC. What the ATSB has done is reopen the Norfolk Island ditching investigation with a fresh team of investigators..."


But in this case I think you may have missed the mark a little yourself...

Take a look here at part of the Sanga email missive.. - "Caesar judging Caesar??" - & this from the official missive:




Still pissed no further comment...
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Old 22nd Jan 2015, 22:00
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Two quick questions:
1. When does a paid "journalist" become a "blogger" what qualifications do you need, and can it be a two way journey. Is it a promotion and do you get more money?


Eddie Dean:
2. Fuel availability at diversion destinations may well have been denied due to commercial factors but the diversion could always be planned which may have put undue pressure on the pilot knowing his job was on the line if he took this line. This could have been going on for some time historically and with different pilots and operators.
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Old 23rd Jan 2015, 00:53
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Sarcs: There certainly is not much boasting going on in that lot...please explain your accusation? Ben may have been in error but he did confirm in the comments and in this article - Reopened Pel-Air inquiry could be on slippery slope to ruin -that he had it from very good advice (source)
I confess "boasted" was over the top. "Reported" would have been a more accurate word. In any event, he got bad information from his source.

Sarcs: Sidebar it seems you are in the know yourself mate, please pray tell??
My perspective comes from a lot of research that commenced when the ATSB announced the TSBC review. I was surprised an agency like the ATSB could screw things up so badly, and I became curious. I had never heard of Pel-Air before that.

I studied the ATSB report, the 4 Corners show and interviews with Dolan and McCormick, Sandilands' reporting and commentary, the Australian Senate report and submissions, the CASA Chambers Report, the CASA accident investigation report, the CASA special audit report, the ASRR report, the TSBC report, and of course several threads on PPRuNe. There is lots of material out there to get informed about this.
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Old 23rd Jan 2015, 01:49
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I suspect that Karen's lawsuit will be settled out of court very shortly.

The risks for Rex if it doesn't settle include:

- The potential for the media to pick up on the donations story.

- Political fallout for all the political parties.

- Potentially an ASIC investigation of Rex and possibly a NSW ICAC reference.

- Further publicity about the state of CASA and ATSB.

- and finally, A lawsuit by Dominic James on the basis of being denied procedural fairness and natural justice possibly by CASA, Rex and ATSB in collusion.
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Old 24th Jan 2015, 03:34
  #712 (permalink)  
 
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Will part of the re-opened investigation be on the new evidence that will be provided by the CVR / FDR which the Senate committee said needed to be recovered immediately? Or did they conveniently get left on the ocean floor?
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Old 24th Jan 2015, 10:23
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Jamair,

The answers and discussion are well covered in the now closed senate inquiry thread.

But guess where they are?
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Old 24th Jan 2015, 23:57
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If the ATSB want to be seen to be unbiased in its own re-evaluation of the report then recovering the CVR/FDR would be a necessary first step. If they don't recover them then the result will be strangely, the same as the first investigation.
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Old 27th Jan 2015, 07:56
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PelAir, CASA, and ATSB - the movie

Someone suggested this saga could be the basis for a future Australian movie. To assist any scriptwriters out there, I offer the following:

1. There was a routine CASA audit of PelAir scheduled for October 2007. This had to be re-scheduled as the organisation could not provide sufficient paperwork to allow this 2007 audit to proceed.

2. The re-scheduled audit took place in March 2008. This audit was damning, finding multiple defects. Among the most serious was that the training records of 20 pilots were seriously deficient (for example, 80% of these records contained no evidence of training in emergency procedures). There were numerous other deficiencies - the full report is in the public domain. Most seriously of all, the company conceded its pilots had not been trained in fatigue management as required - this caused CASA to issue an immediate “Safety Alert” requiring the company to immediately cease operating under its existing fatigue management policy until this training was undertaken.

3. During the period 2008 – 2009, the existing PelAir Chief Pilot (Wally Myer) was replaced by John Wickham. However Wally was left in charge of international westwind operations, and carried the title of “Westwind standards manager.” Although no longer the CP, Wally was ultimately responsible for westwind international operations – as stated by CASA in the 2009 audit. Presumably CASA duly gave written authorization for these normal responsibilities of the CP to be delegated to Wally.

4. The crash happened in November 2009 - 18 months after the March 2008 audit. Extremely lucky that all 6 survived the initial impact. Lucky the patient was not on life support and could survive a prolonged swim. Lucky the water temperature was reasonably warm, and it wasn’t winter. Lucky there wasn't a shark about. Lucky the local fisherman found them given they ditched in an unexpected location and did not issue a Mayday. Lucky lucky, lucky.

5. Following the crash, CASA conducted a special audit in November - December 2009. This was much more in depth than the routine March 2008 audit. What had been wrong in March 2008 was still wrong. Furthermore, additional serious problems came to light. This audit found fault with the pilot, fault with PelAir, and fault with CASA itself. The report is truly shocking - this too is in the public domain. But it nearly wasn’t.

6. CASA apparently should have handed this special audit over to ATSB. However CASA did not do so. It is not 100% clear why. Perhaps CASA was concerned its oversight following the 2008 audit could have been seen to be deficient. There may have been international factors also. By a strange coincidence, at exactly this time the FAA were over in Australia deciding whether to downgrade Australia to Level 2 status - among other consequences, this downgrade would have terminated existing code-share arrangements between Aust and US airlines, and would also have precluded Qantas and V Australia gaining approval for new routes into USA.

Wikileaks: Australia failed US FAA air safety audit in 2009 | Plane Talking

Although Australia avoided being downgraded in 2010, there are persistent rumors the FAA have been watching subsequent events unfold and are not impressed. Time will tell.

7. By early 2010, PelAir had presumably digested the CASA special audit and must have realized it had a huge problem. They presumably decided the medevac business was finished - it would take a lot of time and money to rectify all the issues identified, and it probably didn’t make commercial sense to pursue this. In addition to all the deficiencies, the jet they crashed at Norfolk (NGA) was the only one capable of operating into Noumea. Regardless of the reason, PelAir exited the medevac business in 2010.

8. The ATSB released its report in 2012 after much delay. In fairness, they were distracted by QF32. The final report put most of the blame on the pilot, made some mild criticism of PelAir, and there was little if any criticism of CASA’s oversight over PelAir. It was almost as though ATSB had not seen the CASA special audit. And astonishingly, it appears they had not. One particular oddity of the ATSB investigation was that the ATSB did not seek to recover the CVR and FDR – from a known location only 40 metres deep. It has been suggested the local fisherman were ready to drag the jet to shallower water to facilitate the recovery. Despite this, Dolan stated this decision was made on the grounds of cost and safety, and also there would be nothing to be learned from the recorders anyway. In which case why bother having recorders - it seems a bit like the Police not bothering to obtain the security video from a bank following an armed robbery.

9. There was a significant outcry over the ATSB report. The pilot admitted he had made his share of mistakes that night, but pointed out (quite correctly) that he was not the only one. And then we had the 4 Corners report - someone had leaked the CASA 2009 special audit, and further that CASA had not forwarded this audit to ATSB.

10. In the later half of 2012, Rex (parent company of PelAir) made several large donations to political parties – Labor, Liberal, and National. Rex has apparently not made such donations before or since. Presumably 2012 was a good year for Rex.

Vague minister, generous airline, Pel-Air issues mount up | Plane Talking

11. The outcry over the ATSB report led to a bipartisan Senate inquiry in 2013. The key outcomes of the Senate report were:

a) CASA was caught not providing the special audit to the ATSB. This caused the committee to refer the Director of CASA (McCormick) to the Australian Federal Police for possible breach of legislation. McCormick subsequently did not seek to renew his appointment as Director.

An Issue of Leadership

b) The Senate stated it had no confidence in the ATSB report, and had lost confidence in the ATSB Commissioner (Dolan). Dolan himself conceded he was "not proud" of the ATSB report into Norfolk. The Senate was also infuriated with Dolan playing games with different versions of the regulations pertaining to the recovery of the recorders. Under the regulations in force at the time, the ATSB should have obtained the recorders.

Damning Senate report on ATSB, CASA Pel-Air failings | Plane Talking

c) The Senate called for the ATSB report to be scrapped, and for a new investigation to be held. Starting with the retrieval of the recorders from the plane.

12. Inexplicably, the Minister did not accept the recommendations of the bipartisan Senate inquiry.

13. Instead, due to concerns about the quality of the ATSB report and the process by which ATSB had produced this report, it was agreed that the Canadian TSB be asked to conduct an independent external benchmarking investigation of ATSB and its methodology. This was done under very narrow terms of reference. The release of the Canadian report was repeatedly delayed – there was apparently a process of the report going back and forth between Canadian TSB and ATSB. The Canadian report was released in December 2013. It was highly critical of the ATSB investigation and final report.

Damning review of ATSB Pel-Air investigation released | Plane Talking

14. So ATSB was not proud of its own report. The Senate committee was highly critical of the report. And the Canadian TSB was critical of the report. It seemed the Minister was finally spurred into action. He announced the investigation would be re-opened. There are suggestions the recorders will be recovered this time. And the Minister also announced the forthcoming appointment of a new Commissioner at the ATSB – specifically one with aviation experience.

ATSB 'asked to consider' re-opening Pel-Air crash inquiry | Plane Talking

ATSB told second rate not good enough in Pel-Air inquiry | Plane Talking

15. During the inquiry, the Senators expressed their concern to CASA that many people giving evidence were nervous about possible repercussions from CASA. They went so far as to remind CASA that all evidence heard was subject to Parliamentary Privilege. The latest twist in this long tale is the Senate has referred the possible intimidation of witnesses to the Committee of Privileges. We will have to see where this goes.

Intimidation motion concerning Pel-Air raised in Senate | Plane Talking


The legal action by the nurse is now imminent, and so there are a few more scenes to be added. But it would indeed seem a good basis for a movie.

Last edited by slats11; 27th Jan 2015 at 12:55. Reason: typo
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Old 27th Jan 2015, 08:33
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Slats,

A great precis of the story so far - thank you
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Old 27th Jan 2015, 08:40
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Slats you perhaps should have mentioned the absolutely despicable act of Pel Airs scumbag lawyers to intimidate the flight nurse by issuing subpoena's to her children, dragging them into court to be grilled in the witness box by some rabid QC.


My god where are the mainstream press in all this??? has Pel Air bought them off as well??
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Old 27th Jan 2015, 09:53
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slats that is a brilliant summary of the whole sorry saga. No tangents, no twists no hyperbole.
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Old 27th Jan 2015, 11:28
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Gone with the Westwind

That script for that scene is waiting to be written Thorn.

Wonder if we should call the movie "Gone with the Westwind." Because plenty of things seem to have gone down with NGA. The recorders. Honor and integrity.

Last edited by slats11; 27th Jan 2015 at 12:42.
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Old 27th Jan 2015, 18:02
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I think we need a timeline....

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.



The ATSB report was released 30 August 2012, The report had previously been released to directly interested parties (DIP) on 21 August 2012.

The Rex donation to the Labor Party was made 1 July 2012.

The Rex donations to the Liberal and Country parties were made 1 November 2012

Donor - Annual Returns

The senate report is here:

http://www.aph.gov.au/~/media/wopapu...rt/report.ashx


So our timeline starts with:

1 July 2012 - Rex donates $250,000 to Labor party.

1 August 2012 - ATSB receives damning Chambers report, ATSB (Dolan) refuses to change report in light of Chambers findings..

30 August 2012 - ATSB Report published.

22 October 2012 - DAS McCormick defends CASA guidance and regulation as "adequate" to Senate RRAT committee. He continued to blame the pilot.

1 November 2012- Rex donates to Liberal and Country parties.

Lets move forward and back and look at what happened when... Please help.
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