CASA, Coroner's Courts and the Ombudsman
 

Here's the latest investigation into casa, this time by the Ombudsman, with a report released on 15th April 2015.

There's a bit to wade through if you go to the above.

A couple of extracts point to the general drift though -

THE aviation watchdog has been chastised for failing to respond to past coronial recommendations. (from 'The Australian')

COMMONWEALTH Ombudsman Colin Neave says the Civil Aviation Safety Authority needs to lift its game.

Mr Neave made eight recommendations in a report released on Wednesday, including improved links between CASA and state and territory coroners offices, as well as annual reporting on the progress of implementing recommendations.

Between 2009-2013, 153 people died in 120 general aviation crashes...

from Ombudsman's website -
Ombudsman says CASA needs to be more transparent

A report released today by the Commonwealth Ombudsman says the Civil Aviation Safety Authority (CASA) needs to be more publicly accountable in responding to coronial recommendations.

“Between 2009 and 2013, 153 people in Australia died in 120 general aviation aircraft accidents,” Commonwealth Ombudsman Colin Neave said.

“Many of these accidents were the subject of coronial inquests, which perform an important function in publicly examining questions around public safety and making recommendations aimed at preventing similar deaths in the future.

“Yet a lack of public response or visible action by CASA to these inquests made it difficult for the public – and other coroners considering similar matters – to establish whether CASA had considered or acted on the coroners’ recommendations.”
Mr Neave said his report made eight recommendations.


and a comment from Jim Davis, longtime commercial pilot and writer

"The old guard at CASA remains in place with no changes to senior management foreshadowed and no changes to the CASA board leadership until 30 June 2015. Most of the Aviation Safety Regulation Review ( ASRR) recommendations relate to CASA and will need CASA’s active involvement and support to implement them. It defies logic to have the management team that created the problems highlighted by the ASRR report to be charged with fixing those very same problems."

I'll refrain from commenting on the regulator - don't really know enough about their workings and plan to keep it that way, however I do know a bit about the coroners and believe there is a nasty case of the god complex doing the rounds there. If those muppets had their way, no-one would approach an aircraft unless they had completed a state approved hazard reduction course, were dressed in head to toe nomex and wearing a $1,000 approved helmet.

You forgot the hi-viz vest.

Perhaps CASA did not respond because the Coroners recommendations demonstrate that they are pig ignorant about aviation matters and their recommendations are costly, inefficient, pointless and do nothing useful to improve safety?

Lockhart River Inquest.
Counsel Assisting the Coroner: Mr Ian Harvey QC
Assisting Mr Harvey: Mr Robert Collins

http://www.pprune.org/7134194-post54.html

Casa needs a royal commission. End of story.

Awi,s with vicious vindictive actions need to be placed on notice that they may be sued and sacked for their actions.

Malicious grounding of aircraft , workshop approvals for minute infractions should not be accepted from these public servants.


A full independent complaints department not in any way part of casa is required.

They take you to court loose but still win. As you then have no chance of redeeming your legal costs.

The coroner in the Lockhart River inquest, Mr Michael Barnes, on the face of it, produced what appeared to many close observers of the process, a reasonable summation of the causes. Without inviting a rehash of the multitude of detailed dissections of every aspect preceding and following that accident, what Mr Barnes had to say about animosity between CASA and ATSB is no less relevant today, where ATSB's role has undergone substantial undermining. Coroner bashing, rather than the reasoned analysis of their perceived failings, does little to serve the interests of our readership and the interests of seeking better outcomes, dare I say.

Interaction between the ATSB and CASA

Finally, I wish to return to the concerns
I expressed earlier about the working relationship

between CASA and the ATSB. In this and previous

inquests I
have detected a degree of animosity that
I consider inimical to a productive,
collaborative focus on air safety. CASA’s
submissions in this inquest suggest that there
was a danger of the ATSB's recommendations

being ignored and I continue
to detect a defensive and less than
fulsome response to some of them.

I am aware that others in the aviation
industry share these concerns,
although I anticipate the CEOs of
the two agencies will disavow them.

And what gets done about the apparent, or seemingly apparent collusion between CASA and ATSB to cover someones butt/s?

Two other striking resemblance's to collusion come to mind.

One swallow does not a Summer make - or something to that effect.

I have no particular issue with what Coroner Barnes produced in the Lockhart River matter, howver the fact remains that the ratio of dung to diamonds rests firmly in the former camp when it comes to coronial recommendations, particularly when aviation is involved. If that is perceived as coroner bashing, then I plead guilty m'lud.

CASA vs the ATSB, there is certainly the appearance of a need to shine a bright light on things, but I am firmly of the opinion that the coroners are not qualified to aim that light.

yr right..
 

You are so very right. :ok:

The WHOLE industry should be loudly beating the ROYAL COMMISSION drum.:ok: And sending that message to ALL politicians.:ok:

Forget Denmark, there is so much rotten in the state of CAsA ONLY a ROYAL COMMISSION can let it all hang out...and maybe, just maybe,.. positive changes will be made so an industry so vital to this wide brown land can fly on :ok:...and not be ground down into the dust by an overload of bureaurats and convoluted, impractical "safety" bull****.:mad:

2c
And more to spend.

Folks,
Do you mean ANOTHER Royal Commission into CASA.

If you look at the record, CASA and its predecessors have been the most "inquired into" Commonwealth body since Federation.

I don't remember the numbers, but it was close to one per annum, whether it be some form of Parliamentary inquiry, or a Royal Commission, of which there have been quite a few. The "Morris" inquiry was the longest running of any Parliamentary inquiry since Federation.

The amazing thing is that they have all been like water of a duck's back, as far as reform (as we would understand it) is concerned, and has all too often provided at springboard for CASA or its predecessors to introduce yet further restrictive policies/regulations. I know of no case where a Coroner's criticism of CASA or its predecessors has resulted in any changes that the aviation community would regard as beneficial.

A good example is the, in my opinion, quite deliberate misrepresentation of the findings of the Seaview Royal Commission, which, all these years later, you about to see in Part 121/135, and you are already seeing in CASA imposed restrictions by way of Operations Manual. Part 135 is going to be a bigger disaster for GA than Part 61.

AOC "regulation" was elevated from regulations to provisions of the Act, as a result of a Royal Commission, it is/was this that has enabled CAA/CASA to extend the requirement for an AOC way beyond the original intent for an AOC, and to be completely inflexible about the ever expanding requirements for an AOC.

For CASA to be "forced" to implement every recommendation of an inquest would make aviation regulation an even bigger disaster area than it already is.

Again, an example is Mull in Victoria, if the recommendations were carried out, it would eliminate Experimental Amateur Built aircraft, one of the few bright spots in light GA.

Tootle pip!!

I've got to agree with LeadSled (:bored:) on this one. Laymen (including Royal Commissioners) simply don't understand the industry, so they turn to 'professionals' for advice. And where do the 'professionals' come from? Why the Civil Aviation Safety Authority of course!

The framework within which this discussion is happening is a manifestation of the problem: governments have abdicated responsbility to the regulator.

Every sector says coroners "don't understand".

Coroners may, if they wish, make a recommendation that, in the interests of safety, all aircraft be fitted with at least 5 engines.

The decision whether to implement that recommendation is not, or at least should not be in a functioning representative democracy, the regulator's. The decision should be the government's.

That's because all decisions about where to set regulatory standards are, ultimately, political decisions. That's because all decisions about where to set regulatory standards should require an assessment of all the risks and benefits to society, and decisions about what benefits are not worth the corresponding risks.

Regulators are not competent to do that, because regulators are not competent to assess or know all the potential risks and benefits to society of various levels at which standards could be set. All that regulators are competent to do is decide that one standard may result in higher levels of safey and cost than another, within the closed system of the sector being regulated.

CASA, for example, doesn't know or care about whether setting higher standards for, for example, aerial ambulance operations will result in an overall dis-benefit to society as a consequence of more deaths on the road or lack of treatment for people who would otherwise have been medivac'ed.

But governments these days want everything to be 'win/win', and don't want to take responsibility for any decision that might be electorally unpopular. Best to leave that to ever-keen to please patsies who are rewarded handsomely for appearing to be responsible.

The organ grinders have let the monkey loose.

Enter Sandman
 

Interesting thread. Now there is a nightmare of epic proportions which covers all aspects of scary: CASA, Seaview, Lockhart, Harvey and Collins. Christ I won't be able to sleep for a month now!!!

Creamie . . . Your last post is not exactly a haunting bugle blast. It reads a little like a preamble to a lengthy thesis, in which there may or may not be reference to Machiavelli and "The Prince". The framing of sensible rules for the guidance of those who need to know and abide by set limits within the society, or the airspace, in which they function, is these days a multi-layered task.

It is the compounding complexity of the acts, the statutes, the orders, and by-laws, that tend to do in the head of your average layman.
For every daily activity, of whatever kind, it would be so much simpler if there were straightforward, clearly written codes of conduct.
'The Rules of the Air' need not require a brace of shopping trollies to be trundled into court. Or be a necessary part of a student's study library.


Indeed, as you say, the organ-grinders are now monkeyless . . .
As of old, the monkeys have set themselves up line abreast, ears, eyes and mouths all stopped.

They see no point at all , anymore, in saying that the law is an ass.

And so....
 

..if a Royal Commission or Judicial Inquiry isnt the answer...then what are we left with.?
Civil disobedience?
Revolution ?
Burning of the CB Reichstag.? :ok:

Something has to give....

maybe after the next coroners report on this just past fatality, the coroner may just have enough sense to make one very simple and easy to enforce ruling of mandatory fitting of EPIRBS. May not stop people dieing but will speed up the search and recovery process.

We'll what I find strange is the amount of input from people that are not even commercially involved in aviation. Then complain about changes to an AD that they don't understand makes me wonder how we got to where we are now.

When we have awi, and foi,s being police , prosecuter , jury, judge and executioner with no recourse we are doomed.
When they ground and aircraft for a missing decal on the outside or wing walk that may interrupt airflow over a wing or how about a aircraft that has manufactures improvements fitted when being manufactured. Being on aust rego over 30 years then being asked for it's details even though the M/M s# says it what it is .

Face it they lie and cheat and they do it in court. However some of us still have wins over them.

"mandatory fitting of EPIRBS"

EPIRBS are for the marine environment.

Aviation ELT's are covered in CAR 252A

No need to worry a coroner

Tipsy

@ Sunfish

I'm not sure thats right. It is always difficult contesting the independent referee. Most people hold the Coroner in fairly high regard precisely because of the independence. The Coronial process is sometimes let down by the standard of the various "subject matter experts." Perhaps the industry needs to consider the need for some experts outside CASA & ATSB.

@ Fantome

Telling words indeed given what was to happen with PelAir at Norfolk Island.

Fencehopper,
With the very greatest of respect, you should get your facts straight !!!

If, by EPIRBS, you mean handheld or portable devices, a locator beacon is already mandatory for flight over 50 nm. They have had an excellent in-service record.

If you mean permanently mounted crash locator beacons, forget it, they are a complete waste of time and money, with a greater than 95% failure rate in actual crash scenarios, or 100% if in the water, or there is a serious post crash fire.

The source for my statement ---- examination of the Australian crash record in the 1990's, resulting in the regulations being changed to not mandate such a useless device.

This was confirmed by the statistics that underpinned the CASA post implementation review of the current regulations.

Tootle pip!!

I am interested to read this study - do you have a link?

What is the rate of activation of PLBs in actual crash situations? Stuff I have read suggests that PLBs also have issues e.g. they can't be reached after the crash, are also destroyed by fire, or there is nobody able to activate them.

I am most interested in crashes where there is a survivor - what is the rate of ELT activation in those cases? There were a couple of cases I found where the ELT failed to activate, a PLB was carried but the survivors were unable to activate it - so these are not really conclusive.

If the ELT fails to activate due to crash damage but there are no survivors I guess thats just the nature of the forces involved. Obviously a PLB is also unlikley to be activated in that case.

andrewr

The idea is that in the event of of a catastrophic crash (non survivable) the ELT/PLB is a moot point.

However, if you are in a bad situation such as S/E engine failure the first thing you do is point it to the best place you can, put the PLB on and perhaps stuff it in your shirt.

If the forced landing is survivable the PLB will certainly survive.

Have you ever activated a PLB, or read the instructions for activating one? It's not as simple as pushing a button. They are designed to make accidental activation difficult, not for fast and easy activation.

I know someone who had an engine failure and activated his PLB on instruction frm ATC. He described reading the instructions and working out how to extend the antenna and activate the ELT while setting up for the forced landing. This didn't sound ideal to me.

Also, a number have inbuilt strobes. A strobe inside your shirt (or even just in the cockpit) every 3 seconds probably won't help your forced landing.

I carry a PLB, but I do not expect to activate it in the air. I also have an ELT. If I have time to activate something in the air, it will be the ELT via the switch on the panel. On the ground, I will activate the PLB if able.

https://www.atsb.gov.au/media/412662...-128_final.pdf

I'm a firm believer that if you are carrying a PLB that it is carried on your person (typically they have a facility to be carried on your belt) and that you are familiar with the process to activate them. The ones that I am currently familiar with can be activated with one hand.

"Data from the ATSB database show that ELTs function as intended in about 40 to 60 percent of accidents in which their activation was expected."

"ELT activations have been directly responsible for saving an average of four lives per year."

Not a complete waste of time and money, if you are one of those 4.

Please, please (please) don’t start lobbying for a return to mandatory fitment of ELTs to GA aircraft. :ugh:

The battle was hard fought, and won, on the basis of objective data, not strongly-held opinions.*sigh*

How many pilot/pax lives have been saved through PLB activations, which lives would not have been saved if the pilot/pax had no PLB and instead been in aircraft fitted with an ELT?

Do you realise how many PLB activations there are on average each day in Australia, and how many lives are saved on average each day in Australia, as a consequence of PLB activations?

Next we’ll have ATSB resuscitating its campaign to have FDRs fitted to light aircraft. “It is very difficult to know what went wrong during the flight, because the aircraft was not fitted with a flight data recording device,” an ATSB spokesperson said [dropping a not-so-gentle hint]. (They went very quiet on that campaign, post the ditching of NGA...)

None of these ELT/PLB/EPIRB devices works perfectly in all circumstances. In the circumstances in which all of them are least likely to work – or to stop working - chances are there’s no one in trouble. Everyone’s probably dead.

If you want to increase the reliability of fitted ELTs so that the bodies and the airframe can be located more quickly and therefore less expensively, you’re going to have to increase ELT system crashworthiness, lots, and that will take money, lots. However, so far as I am aware, there is no plan to change the ELT system fitted to B777s or other heavy metal, notwithstanding the many, many, many millions spent so far on trying to find MH370.

I'm just interested to see the data. I didn't mean to lobby for mandatory fitment, just the middle ground between mandatory fitment and a waste of time and money.

If ELTs do sometimes save lives, talking someone out of fitting one might cost them their life. How much is a life worth? Mine is worth enough to me that I will pay the price for an ELT, on the remote chance that it might save me one day.

No idea. How many aircraft crashes are there per day in Australia, and how many lives are saved due to PLBs? As I said I am interested to see the data.

You are free to fly only in aircraft to which an ELT is fitted.

You are also free to carry a PLB whenever you fly.

Do you carry a defribulator when you fly? It could save a life. And what is life worth?

Satellite phone?

At least two turbine engines?

The trouble with the 'what is a life worth' argument is that no matter what you are doing, there's almost always something more that you could be doing that might make you and your pax safer and might make your and your pax' chances of survival greater. But always at a cost. And as Dick Smith says, you only get the safety that you can afford.

That's why people still die in accidents involving aircraft built to the highest standards, crews trained and tested to the highest standards, air traffic control systems built to the highest standards and operated by air traffic controllers trained to the highest standards, in and out of airports built and equipped to the highest standards.

That's why the response to the Germanwings incident is not to make a regulation requiring that all 2 pilot aircraft have at least 3 pilots assigned for each flight, to ensure that there are always at least 2 qualified pilots on the flight deck when one of the pilots needs to visit the toilet. Someone's decided that even though it's easy to do, the consequent cost is not justified by the risk, even if it could save lives. That someone has decided what is a life is worth. That decision is actually made many times, every day.

I should never have mentioned what is a life worth. My point was that mine is worth enough to me that I fit an ELT to my aircraft. Everyone is free to make their own decision on that one.

But I'm still looking for data to support the contention that my ELT is a complete waste of money.

"But I'm still looking for data to support the contention that my ELT is a complete waste of money."
You are free to protect yourself and your pax by having an ELT, if you so wish. I prefer to have a PLB on my belt that I can better monitor for serviceability. And yes, I do know how to activate it.

So go forth and look, ar. Presumably you wouldn't be silly enough to make a decision until you've found and digested the data.

The answer to your implied question depends upon what you would choose to do with the money that you would otherwise spend on fitting an ELT.

If, for example, the aircraft you fly doesn't have an all-cylinder engine monitor, or it has one but you don't have a clue what it's telling you or what to do about what it's telling you, the best bang for your safety buck would be to fit an all-cylinder engine monitor, learn what it's telling you and learn what to do about what it's telling you.

If, as another example, you're prone to scud-running in bad weather, the best bang for your safety buck would be to pay a mate to tie you up each time you have an irresistable urge to go scud-running in bad weather.

Why not be safer and just fit two ELTs?

I didn't mean to imply any questions or start a debate on engine monitors. My only question is the explicit one:
Where can I find this data about the (lack of) effectiveness of ELTs?

I searched, all I found was an ATSB study which found they activate in 40-60% of accidents where they would be expected to activate and save an average of 4 lives per year (I am slightly skepical)

Just fit 2 ELTs and you'll be fine. :ok:

andrewr,

Why not also buy sufficient PLB's for all on board your aircraft? And give your pax a safety briefing on their operation before going flying? All wear them on belts. Modern 406 MHz PLB's are rather inexpensive and importantly have modern technology batteries. That helps to make them very reliable. By all means fit an ELT (or two!) to your aircraft. That's if you genuinely believe that to be good value for your money spent on safety.

Andrewr,
A previous post already tells you where you can get the information that proves --- yes, proves, that fixed ELT are a waste if time and money, especially money.

Remember, the initial push for fixed ELT came from the US, but not from FAA, but from Congress, as a result of a loss (a single loss) in Alaska, and extravagant claims about fixed ELT.

Nowhere was a fixed ELT ever cost/benefit justified.

The "politics" of the fixed ELT saga in AU was somewhat different, remember, when a bad idea takes root in CASA (or its predecessors) it is very hard to kill. It became a straight head to head battle between the GA sector and CASA -- where several individuals in CASA made it very clear they didn't care how much it cost, or whether they worked of not, but they were not going to have their "authority" questioned or challenged by "the industry".

Where have we seen that more recently???

In mid-1990s, CAA/CASA came up with an unbelievable safety case, unbelievable because it was not very good fiction --- but they refused to make the data "on which they relied" public, out of "sensitivity" to the reactions of relatives of those who died.

No problem, in those days, BASI did not work hand in glove with CAA/CASA, and AOPA got all the data.

I don't remember the exact numbers now, but there were about 30+ accidents, where CAA/CASA claimed a fixed ELT would have saved lives.

On examining every one, AOPA found that six of the "aircraft" were boats, and not flying boats. Interestingly, it was a boat that made a very good case for the "portable ELT" --- the successful rescue of Tony Bullimore by the RAN in Arctic waters --- his fixed rescue beacon failed, it was his portable that was detected.

AOPA found yet another case of the good old "shifting the decimal point" trick, which showed that about 3.5% of aircraft went into the water, where ELT are 100% useless, the real figure was 35%.

In one hilarious case, a light aircraft force landed in the main street of a small Victorian country town, coming to a halt right in front of the police station. With a straight face, it was claimed that a fixed ELT would have helped to find the aircraft faster --- if the pilot remembered to turn it on before he exited an undamaged aircraft, and headed to the pub for a calming beer.

The bottom line, in some 5 or 6 cases a fixed ELT may have worked, but in each case a PLB would have also worked. The really sad cases were several which were survivable, but the fixed ELT failed, and the one or more survivors died after some days of injuries or exposure or both. One of these sad cases was, in fact, the example used by CAA/CASA in all the publicity for fixed ELT --- on detailed examination, the aircraft had been fitted with a fixed ELT, it didn't work, a portable and two young lives would have been saved.

AOPA also dug up a number of cases of airline crashes (Airbus routinely fitted fixed ELT to their products, next to the Flight Recorder and the Voice Recorder) and in not one case, even when the tail survived largely intact, in none of the cases did the fixed ELT work.

The fixed ELT failure modes are completely predictable, no useful signal is broadcast, because the aerial of aerial cable is disrupted in the crash sequence.

AOPA research with Civil Air Patrol in USA found the same results, where all aircraft had a fixed ELT --- rare was the case that a fixed ELT broadcast a signal.

As already posted, CASA did a post implementation study, as required by the legislation, about six years later, the results were the same, there was only one case were a downed aircraft transmitted a detectable signal, and that was only detected flying right over the top, after the aircraft had been found ---- as usual, the box worked, but the aerial/cable was stuffed, but if you were close enough (1000 ft overhead) a weak signal was detected.

So, the result ---- a 95% or greater failure rate in the real world.

All the AOPA research results were published in the AOPA magazines of the day, old copies can be found at the AOPA office, CASA should have archived copies of the post implementation review.

Tootle pip!!

PS1: Occasionally, something good comes out of Australia --- which played the major roll in changing the specifications for a PLB that would talk to the new satellites, most significantly changing the temperature range specified, that made a "commodity priced" PLB possible.

The original specifications never even envisaged a PLB, and required the battery to work at -70C or so --- Australia successfully argued that was not relevant to a PLB, as a human body could not survive that temperature.

Creampuff has already told you about the results, PLBs are now far more widely used tha ever, their contribution to saving of lives is immense.

PS2: I would not take ATSB figures at face value, unless I investigated each claim, particularly due to the loose definitional usage of ELT/EPIRB/PLB. There are not too many GA aircraft with a fixed ELT.

From the most recent Annual Report of the Australian Maritime Safety Authority (here: Annual Reports - Australian Maritime Safety Authority (AMSA) ): I’d also commend this advice from AMSA’s website (here: Aviation search and rescue education - Australian Maritime Safety Authority (AMSA) ):

andrewr loading up your aircraft with bumf to allow you to be rescued quicker is the dumbest idea I have ever heard in aviation.
what competent people do is maintain the aircraft so that it doesn't fail in the first place.

what you are actually saying in your posts is that you have no confidence in the maintenance of your aircraft.
recognise that that is the problem and attend to it.

that is such wonderful advice from people who have no real clue.
Bill Bell actually ditched an aircraft in the pacific when a ferry flight hit higher winds than ever expected.
He found that you only had available to you the stuff that was in your pockets.
he had all the gear on board and the aircraft floated. he repeatedly dived into the aircraft and couldn't locate a single item of his emergency gear.

far better to attend to your aircraft maintenance competently (illegally if needed) and never put yourself in the situation.
W8.

So how many people were rescued in rescues you coordinated in 2014, W8? Round hundreds will do.

If it's fewer than 4,600, I'm not sure you have the expertise to express an opinion that's better informed than AMSA's.That's why they invented pocket sized PLBs.

Anyone who doesn't fly with a 406MHZ GPS-equipped and AMSA-registered PLB in his or her pocket is as silly as someone who assumes that a perfectly maintained piece of machinery can never fail.