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ATSB to be reviewed by Canadian TSB

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ATSB to be reviewed by Canadian TSB

Old 2nd Aug 2013, 02:32
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ATSB to be reviewed by Canadian TSB

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Old 2nd Aug 2013, 02:43
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Australian Transport Safety Bureau commissioner Martin Dolan announced on Friday his agency's methodology and processes will be assessed by Canada's Transportation Safety Board (TSB).
Nothing more than a desk audit. Investigating the politics of ATSB / CASA / commercial & political operators, appear not to be in the terms of reference. I am willing to stand corrected (and amazed!), but I think my bet will be safe that methodology and processes will be within "international best practice" guidelines. Sure, there will be a few grammatical & spelling errors in some of the policy & procedures manuals, and these will be noted in the extensive report.

Sir Humphry would be impressed, never call an an inquiry unless you already know the outcome. Nothing to see here, move along.
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Old 2nd Aug 2013, 02:54
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Ben's report seems somewhat sharper when it comes to this.

ATSB processes to be independenty reviewed | Plane Talking

The TSB will, it is to be hoped, consider the evidence tendered to that Senate inquiry by the chief commissioner of the ATSB which lead to the committee devoting an entire chapter of their report to their dissatisfaction with his testimony.
At the end it still looks like the ATSB might get pineappled. Can only hope so.

Whether the very bad smell created by the conduct of the ATSB and CASA in relation to the Pel-Air investigation can be removed by the independent and external review by the TSB remains to be seen.
The ATSB statement makes no direct mention of Pel-Air, and doesn’t disclose any response to the recommendations of the Senate committee that was so dismissive of the worth of Dolan’s testimony.
Those recommendations included, in short, the ATSB re-opening the crash inquiry and doing its job fully and diligently.
The TSB’s report will be published.
It isn’t know whether that publication will be preceded by the ATSB reviewing the final draft and having an opportunity to change it.
For the the sake of an external and independent review, it is to be hoped that this will not be the case, lest its independence and externality be cast into doubt.
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Old 2nd Aug 2013, 03:52
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It's a con job. Beaker has his head on the line so he commissions an overview of his organisation by the Canadians. The scope of the review will be very very limited, and is a smokescreen. The maples will indeed look at Beakers 'beyond reason' methodology under the guise of 'best practise'.
Now not surprisingly 'best practise' is the key here, as it is not prescriptive nor is it quantifiable or measurable! The Maples will walk away saying something like 'ATSBeaker do indeed employ best practise. They do things differently down under but it is commensurate with their environment'. Beaker will be on fire and an endless stream of mi mi mi mi will fill the halls of Canberra.

Perhaps the Maples will request a copy of Beakers methodology over the Pel Air investigation to see if that was 'best practise'? In reality it probably was - failure to retrieve the wreck saved him precious budget money and it prevented a fully accurate investigation to be completed, that would have had serious implications for the government and CAsA! So yes indeed, it was best practise for Dolans ass to do what he did.

Who is paying for this 'working group of Canadians'? Is it coming from Beakers budget or the Canadians? Either way I am sure some working groups will come out of this little smokescreen and the end report will see some bipartisan collaborative workshops hosted in downtown Montreal.

Last edited by 004wercras; 2nd Aug 2013 at 03:54.
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Old 2nd Aug 2013, 03:54
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Creamy's dreaded lettuce leaf – strikes again.

Nice bunch of folk the Canucks; happy memories of long cool drinks with short round goalkeepers before, during and after matches. Ice hockey goal keepers are the Canadian equivalent of our rugby hookers, purpose built (by the same company did the harbour bridge) to fulfil a tough role in a hard game. Will they bring their best game - I wonder?

I note Ben Sandilands has done a short piece on the proposed ATSB independent review (sorry madam, no audits this week). He also hints that the "process and procedures" will be 'scrutinised'. It's a pretty safe bet that end of the equation will be squeaky clean; but will the TSB dig deep and see if those policies, procedures and protocols are being executed correctly?. Will they dare to look beneath the shiny bright mudguard of the "beyond all reason" model ? Perhaps we should start sending accurate data to the TSB; a file 3 inches thick explaining just what is wrong; then, if the TSB do not wish to examine the rust under the mudguard we can make it all very, very public. The tar sticks where the brush touches.

I like the Canadians; I just wonder if they have any idea, at all, exactly what horrors are hidden under the skirts of Lockhart, Whyalla, Norfolk, Canley Vale and the other twenty or so abominations foisted on an undefended industry. There are after all only 87 outstanding similar reports....

I wonder who's paying for all this?, I wonder at the timing ?, (all blame the last Gumermint) but mostly I wonder how the ICAO states and the Senate can let Pel Air slip away without a word said and then happily countenance a user friendly "review" of process of procedure; we know the process is there FCOL; we don't know why they abused it; or why they cuddled up to the Sleepy Hollow men and become a proven safety liability and embarrassment?. More like revue than review, unless they go for boiler plate 'rear view'.

Yup move on, nothing of any value to see here.

Old Akro - If you take the ATSB budget and divide by the number of reports (air, sea & land) the average reports costs more than $200,000. Surely even McKinsey & Co would be cheaper and faster.

Last edited by Kharon; 2nd Aug 2013 at 03:59. Reason: When rape is imminent, relax and enjoy it. Who's shout is it anyway? – Click.
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Old 2nd Aug 2013, 09:16
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Bit like the report on staffing the Canadian ATC mob did on ASA, lol
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Old 2nd Aug 2013, 12:13
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Lets hope the TSB are smart enough to test the documented processes with the process in practice with such case studies as Pel Air.

Last edited by halfmanhalfbiscuit; 2nd Aug 2013 at 12:13.
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Old 2nd Aug 2013, 12:32
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ASN article cuts down the mi..mi..mi wriggle room

Biccy other independent and external (read foreign) aviation commentators believe that the TSB will have no other choice but to review the Pelgate investigation and Senate report:
The TSB’s review stems from a recommendation made by the Australian Senate Committee on Aviation Accident Investigations in May 2013. The committee was initiated in the wake of an accident involving the ditching of a medical evacuation IAI Westwind jet in November 2009.

The Committee stated in their final report amongst others that parts of the ATSB investigation process [of the Westwind jet accident] lacked transparency, objectivity and due process.
Beaker maybe still in denial but no one else is apparently...

'Canadian safety investigators to review and compare Australian ATSB processes'
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Old 2nd Aug 2013, 13:18
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Sarcs, surely the TSB will be smart enough not to damage their credibility here? Always a danger the NTSB will look at the TSB look at the ATSB.

I guess that is where the clever terms of reference come in.
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Old 5th Aug 2013, 20:50
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Honeymoon salad – Lettuce alone.

We still have the TSB visit to look forward to. Fresh from Willyleaks:- Terms of reference and agenda.

1000 – 1015. Meet and greet team fiasco in the 5 star lobby. Complimentary vomit bags are provided.

1030 - 1130. A selection of teas and biccy's served in the smoking room, to allow pre selection of your favourite playboy bunny competition candidate.

1130 – 1200. Inspection of world class work station, points awarded for spotting out of alignment paper clips and blunt pencils.

1200 – 1230 Con-Car transport to a 5 star restaurant, delays may occur due a shortage of Con-fuel, taxi vouchers will be provided. N.B. There is a 10 page travel warning guide provided in your delegate "Welcome package", you are cautioned not to leave your Con-vehicle, lest the Ills of Society are following on push bikes carrying eggs and chanting rude slogans. One size fits all rubber protection equipment has been provided for your comfort and safety.

1300 – 1500. Lunch; during which a talk on "Disconnected Writing" will be presented by the doyen of structured reports, on special release from our flagship regulatory body. Please note, due to a stress related condition and the "Bunny" theme of this seminar, we ask guests not to make derogatory remarks about the speakers choice of the "male" version bunny costume; the ears are an essential part of the recovery process for this outstanding visionary.

1530 – 1600. Con-Car transport to secluded marina (safety rules apply) where a harbour booze cruise will be provided, terminating at the Luna Park jetty. We ask participants to avoid overt fondling of the topless crew, we is a very PC outfit; we are always careful not to have our guests pictures taken by long lens vigilantes from the IOS, so squeeze discreetly to ensure plausible deniability.

1730 – 1930. A guided tour of our world famous, multi million Smoke and Mirrors facility will be conducted by the Sleepy Hollow spin squad. Time permitting a glimpse into the top secret Snakes and Ladders room may be possible, provided the courier bringing the signed permission from Marickville is not egged by the IOS.

1930 – Return to your 5 star suite followed by a Romanesque themed dinner party, featuring food prepared by the stars of My Kitchen Rules, served by your pre selected playboy bunny. Con-Cars will be available for those wishing to visit various places of interest after dinner.

The Commonwealth expects a fully detailed report to be provided by 1800 the following day, robustly exposing any small flaw detected during our rigorous and exhaustive tour of the great Australian protocols and procedures. Please ensure your invoice in not marked below the current standard consultant charge rate of AUD$ 200 per hour, plus OOP expenses.

Now, we know it's an onerous task but; try to have a nice day Y'all.

Willyleak sponsored by the IOS Salubrious Brotherhood of Whitewash Wallah's Inc.

Last edited by Kharon; 5th Aug 2013 at 20:56. Reason: Taking scuba diving lessons - perhaps
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Old 7th Aug 2013, 10:45
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After the Beaker has entertained the Maples as per Kharons previous detailed post, and he has mi mi mi mi'd them to death, perhaps the Canadian guests could be scheduled some R&R at Chateau le Nash? Maybe a day spent in the office with this fine lady, pot plant Pete and Nick, Sterle and Fawcett? At least that way the Maples could be provided with a much more transparent overview of how the Fabulous Beaker Brothers actually operate?

After that they could review the work on Canley Vale to date, of course fully review the Pel Air joke and then take a trip back a couple of years to the Lockhart investigation?
I am sure that if the Maples did just the above they would find that they need to station a permanent workforce in Australia just to sift through the 5 years worth of Beaker mi mi mi?
Please please bring back Alan Stray
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Old 7th Aug 2013, 23:13
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I think you will find Alan is busy enough in retirement consulting on safety investigation to be at all interested in going back to the ATSB. BTW Alan was at the ATSB during the Lockhart investigation so what part of that report requires another look? From what I saw of it, it was the last time the ATSB took a cricket bat to CASA's façade of being an effective regulator. It was the coronial into that accident that led to the MOU because the coroner thought that the ATSB and CASA should be able to work together. We all know where that ended up.
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Old 8th Aug 2013, 05:09
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Lockhart revisited by TSB..good idea!

Lefty suggest you take a look at the following link in regards to LHR:

ef-121779 pdf

That rather large FOI released pdf was recently updated because someone noticed that there were missing pages and consequently made a complaint to the Information Commissioner. This led to FF having to do a further search for said missing docs. Then through a typically convoluted process three missing pages miraculously turned up (wonders will never cease!) and now have been appended to the original ef-121779 pdf. {Note: I might add that this was done without any explanation/apology or with a re-issue of the original document on the FF FOI disclosure log with an amended date...sneaky buggers!} {Note 2: You can view when the PDF was appended by going into properties etc}

So what were the missing pages?

Ok go to PDF page 181-183 or FOI numbers (written in the top rh corner) 565-563. You will see that these pages relate to the Flight Ops section (069 Checklist) of the Transair port approval for LHR and was dated 01/10/04.

Now if you scroll back up to PDF page 174 you will see the official FF AOC variation for the addition of LHR as an approved RPT port dated the 05 October 2004. {Note:That would have to be close to a world record for FF to process a port approval variation to an RPT AOC, especially to a topographically challenged, potentially high risk port such as LHR!}

Now you will be asking..."what does that have to do with the ATSB investigation??" Well if you scroll through the many and varied variations/additions and keep at the back of your mind how long these changes etc would normally take to administer and be properly approved by FF you will see that there is a systemic pattern of rubber stamping going on. And in the case of the ATSB surely when they were reviewing the Transair AOC (see appendix H) they should have seen this in the context of their investigation...I mean even a layman can see what was going on FFS!

Q/ Wonder if they even bothered to do a proper proving flight??

ps I also suggest the DN Brasilia crash report should be added to the TSB bucket list.

Last edited by Sarcs; 8th Aug 2013 at 05:48.
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Old 8th Aug 2013, 05:52
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There are some other interesting aspects of that Checklist.

The “Operational Manual Rev” entry says “AMENDED 29/09/04”. Wouldn't Ops Manual changes usually be made a little further in advance than that?

The “Training and Checking Manual Rev” entry has ditto marks under the word “UNCHANGED”. No changes to the T&C manual when a new RPT port is added? Is that usual?
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Old 8th Aug 2013, 07:56
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Organisational influences – CASA

An Air Operator’s Certificate (AOC) holder had a clearly defined responsibility

under the Civil Aviation Act 1988 to ensure the safety of its operations. The

regulator, CASA, also had defined responsibilities for oversighting the activities of an AOC holder, through the processes of approving AOC variations and other permissions, as well as conducting surveillance of the activities of the operator.

AOC approval and surveillance processes will always have constraints in their

ability to detect problems. There is restricted time available for these activities.

Regulatory surveillance is also a sampling exercise, and cannot examine every

aspect of an operator’s activities, nor identify all the limitations associated with

these activities. In addition, to a large extent AOC approval and surveillance

processes have to focus on regulatory requirements, which provide legal checks

and a minimum standard of safety, rather than safety management processes that

can exceed these minimum standards.

Despite these constraints, CASA still had significant interaction with Transair,

through the conduct of scheduled audits and a series of approval activities, as well

as other activities such as the assessment of a complaint from a company pilot. As

a result of these interactions (most notably its audits), CASA identified areas for

improvement in Transair’s procedures and practices, primarily in the area of

maintenance control. However, it did not detect fundamental problems associated

with the Transair’s management of RPT flight operations, such as the problems

with pilot training, pilot checking, supervision of line flight operations, standard

operating procedures, operations manual format useability, organisational structure,

risk management processes and demonstrated management commitment to safety

outlined in Sections 2.6 and 2.7.

Given the significance of the problems within Transair, and the amount of

interaction CASA had with the operator, it is reasonable to conclude that some of

these problems should have been detected by CASA. In considering the reasons

why these problems with Transair were not detected, the investigation identified

safety factors in the following areas:

consistency of oversight activities with CASA policies, procedures and


– 225 –

guidance for evaluating management systems;

risk assessments for changes in operations;

regulatory requirements for safety management systems;

guidance for evaluating the useability of operations manuals; and

processes for assessing an operator’s risk profile.

In addition, limitations were identified with CASA’s processes for validating

instrument approaches.

The relationship between these factors and other factors identified during the

investigation is shown in Figure 46.

2.8.1 Consistency of oversight activities with CASA policies,

procedures and guidelines

There were instances where CASA’s oversight of Transair did not appear to be

consistent with CASA’s own requirements and guidelines.

The initial approval for Transair to conduct RPT (cargo) operations in

October 1999 did not appear to be subject to a full evaluation process

consistent with CASA’s AOC Manual. More specifically, proving flights

and port inspections were not completed before the approval of operations.

Transair’s application to add the Inverell – Brisbane route to its AOC was

recommended for approval by the Brisbane airline office on 7 April 2004.

However, on 8 April, the airworthiness inspector who had assessed the

application recommended that the approval not be processed until Transair

demonstrated that it had adequate maintenance control in place. The AOC

was issued on 8 April by a delegate in Canberra, and no information

addressing the airworthiness inspector’s concerns was recorded on file.

The extent to which the delegate in Canberra had been made aware of the

airworthiness concerns could not be determined.

The first systems-based audit in December 1999 identified several

significant management problems. Transair provided undertakings to

address these problems, yet there was no explicit monitoring of Transair’s

implementation of the agreed improvements. In addition, there was no

recorded evidence that CASA completed the activities it proposed to do,

such as ensuring that Transair submitted weekly progress reports and

conducting a special audit 90 days after the agreement.

After Transair recommenced RPT operations in September 2001, CASA

generally conducted scheduled audits about every 6 months, in accordance

with CASA’s specified schedule for airline operations. However, the

August 2002 audit primarily focussed on Transair’s helicopter charter

operations. Therefore, there was a period of 15 months between November

2001 and February 2003 when minimal auditing of the operator’s RPT

passenger operations was conducted.

Sarcs that's just a small sample from the actual report of the CASA deficiencies that the ATSB reported on. If you read the whole report there is no doubt that there is no "Pelair" style disregard for the regulator's role in oversighting the operation. In this instance there was more to it than just the sloppy CASA paperwork. The report is 265 A4 pages long and that's before you get to the Appendices. If you are looking for examples of ATSB reports that are superficial and don't provide a lot of detail then Lockhart River is not one of them.

As for the Brasilia the ATSB had already recommended that such MBS be done in a simulator and CASA had already mandated it. I think that's how the system is supposed to work. Its unfortunate that this flight was conducted at all but what further improvement in safety can be made if the ATSB has already recommended that such flights should be done in a simulator?
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Old 8th Aug 2013, 23:04
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One thing that intrigued me concerning the extract of the Lockhart River report was the reference to a CASA interaction with Transair to assess a complaint made by a pilot.
Can anyone enlighten us as to what this was?

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Old 9th Aug 2013, 04:06
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Lefty Read the report and you can see casa's pawprints all over it and in a similar fashion to PelAir
Sorry UITA you and I must be reading different reports. I remember when the LHR report was released that CASA was incensed by its findings insisting that they were not in the cockpit with the PIC and he alone was responsible for the accident. The coroner noted the animosity between the two agencies so that alone suggests that CASA did not have any input into LHR that they had at pelair. As mentioned before Alan Stray was still at the ATSB when LHR occurred and there would be no possible chance that he would be letting CASA anywhere near one of his reports.

Greedy are you referring to the extract Sarcs provided or the extract from the report? I can't see what you are referring to.
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Old 9th Aug 2013, 08:56
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Your post (no 15) second para in.
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Old 9th Aug 2013, 10:36
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Thanks Greedy I can see what you are referring to but I'm not sure of the specifics. The report is a very big report and it could be mentioned in the body of the report. Interesting to compare the CASA response to a pilot complaint at Barrier Aviation to a complaint at Transair though.
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Old 10th Aug 2013, 00:09
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LHR thread drift cont:

Lefty believe it or not I too have read and analysed the LHR report and Coroner's report several times. I totally agree with you about the LHR ATSB report being full and comprehensive, as it should have been considering the over 20 million dollars of taxpayers money it took to complete. I also agree the report does not hold back in it's criticism of CAsA's oversight of Transair, however the passages you quote also highlight what was the primary focus of the investigative team in regards to reviewing the Transair/CAsA relationship/management of the AOC i.e. the audit process and surveillance.

There is, as you point out Lefty, one example of the ATsB questioning an AOC variation approval process, where an AWI refused to approve the Brisbane to Inverell route approval on the grounds of inadequate (in his opinion) Company Maintenance Control (PDF page 154-156 of ef-121779 pdf). {Note: IMO this example was probably highlighted because it is the only instance (that I can see) in all the variations where an AWI or FOI has voiced a concern about the applied for variation/addition to the AOC}

But the one really crucial AOC variation, in light of the accident, that should have been heavily scrutinised was the port approval for LHR...so why wasn't it?

Was it maybe because the LHR port approval wasn't redflagged by a AWI or FOI (like the example above) and so didn't draw the attention of the ATSB investigators?

Or was it because the ATSB primary focus was on the CAsA audit/surveillance processes of Transair and not so much the AOC variations/additions?

Anyway enough of the thread drift here is a TSB you tube video that perhaps highlights their priorities in regards to OBRs (be it for trains):[YOUTUBE]

And in regards to accident/incident investigation methodology and subsequent safety actions/recommendations, perhaps the recently released report into a Beaver amphib crash (with additional links) highlights how the Canucks go about it :


Watchlist issue identified in May 2012 floatplane accident near Peachland, British Columbia

Aviation Recommendation A12-01

Aviation Recommendation A12-02

As I said earlier there is a lot we could learn from the TSB Canada!
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