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Volume 2 –Senate Thread top posts 19/11/2012-15/02/2013

#722 I can understand your frustrations JS but personally I think there were some golden moments in the ASA appearance, which was best summed up in Ben's blog, see here:Pel-Air hearing stunned by ATSB safety cop-out | Plane Talking I have to agree with you JS it was a very insipid performance from the ASA exec

management Here's an example where the new CEO very much stepped into the breach:

Quote:

Ms Staib: The first thing I would say is that I am not concerned about how Airservices has dealt with this particular matter. The whole point is— CHAIR: Is that because it is not in your jurisdiction? Ms Staib: It is because we have followed our area of responsibility. CHAIR: That is right. Exactly. It is not in your jurisdiction to have what does not worry you? Ms Staib: Not in the way that this particular incident was handled. What it has brought out in my mind—appearing here before you—is that there is room for improvement in managing the cross-boundary areas of the different jurisdictions, because inevitably it is very difficult to see the line drawn on a map in the air. CHAIR: Surely, in normal human workings, this is—with your permission Senator Xenophon—a fundamental flaw in that the weather was not conveyed in New Zealand airspace by the Bureau of Meteorology in New Zealand. Everyone knows that. The guy—even if you were the most mediocre pilot, like I used to be—would know to divert to somewhere like Noumea with ILS. That did not happen, because he did not get the information, and the outcome was catastrophic, to say the least. Surely, it is not one of those things where, like Senator Fawcett said: 'Don't look over the boundary. You mightn't like what you see.' For God's sake, why wouldn't you have been up CASA and up ATSB and up everyone else, like I intend to be, over this? It is obviously a flaw and obviously bureaucracies tend to protect themselves and put up a shell—'Don't ask, don't tell. That wasn't our responsibility' and 'Don't look over the fence.' For God's sake, what is going on?

A very big learning curve for the new ASA CEO. Still she'd better get used to dealing with

hostile Senators, after all that is definitely part of Ms Staib's remit!!

The BOM part of this morning's event was very civilized in comparison... And you can find the Hansard PDF here: http://parlinfo.aph.gov.au/parlInfo/...pplication/pdf

#729 Sunny no disrespect intended but last time I looked this is a professional pilot's forum. Although gobbles has an extreme case of descriptive, colourful language that maybe sometimes be hard to follow there is no denying the simple message that he is conveying. And it is one that you and many others on this site totally agree with i.e. the current numbnuts heading up Fort Fumble, ASA and the bureau no longer have the mandate of the industry. These incompetents are screwing over a once proud industry that is fast becoming the laughing stock of the civilized world.

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If you need any further evidence of the crats attitude to the industry that is filling their troughs to brimming look no further than this:

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John McCormick thanks staff. Meanwhile, CASA Director John McCormick has thanked his staff for their input into the Senate process while also firing a vigorous shot across the bows at his organisation’s critics. We publish an extract because we’d hate to be labelled part of the “uninformed minority.” We recently appeared at a sitting of the Senate Rural and Regional Affairs and Transport Reference’s Committee Inquiry into the ‘PEL-AIR’ ditching report and ‘other matters’. I wish to pass on my personal thanks for the outstanding effort everyone made to meet the

requests of the Senate Committee inquiring into the PEL-AIR ditching report. I fully appreciate the time and effort that was required and on behalf of everyone else at CASA, thank you and well done! That sort of spirit is very humbling to me. As for these Inquiries themselves, they are an important part of Westminster Democracy in this country and, as such, are not events to be feared or avoided. I personally welcome the opportunity to present CASA’s positions at any venue. However, do not be dismayed by our vocal but largely uninformed minority of critics; they are symptomatic of other ills in society. I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material. I look forward to assisting the Committee conclude its investigations. At the completion of this Inquiry there is a report produced. That report becomes a ‘Report of Parliament’ and will be forwarded, by established process, to the Minister for his consideration.

This is why so many people in the industry feel so disenfranchised with the aviation safety authorities...and if you need an interpreter for gobbles passionate rants (which secretly we

all love!) please PM me with a.. "what was it he just said!"

#731 Intertextuality

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"I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material".

It is unfortunate the facts were not examined and honestly reported before burning up a whole lot staff time on an inquiry which should never have occurred in modern, first world aviation. Considering the last 38 minute 'philibluster' never even got within bulls roar of 'fact', you could be forgiven for thinking that CASA time was wasted. Will it be the facts from the deluded, misguided, social miscreants that spoil the Montréal sojourn? Will the delusional ICAO believe the 'facts' presented in Hansard? Will the 'facts and circumstances' CASA style withstand the scrutiny of expert ICAO analysis? Does the scourge of the 49'ers care?

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That report becomes a ‘Report of Parliament’ and will be forwarded, by established process, to the Minister for his consideration".

Nope, he actually believes the minister will, once again wave a magic wand and turn all of the 'facts' into soft white paper; this assumes of course that the minister will still be the go

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to man in times of trouble. Perhaps this journey to Canada is to allow time for the willing accomplices to get their resignations in, before the axe falls; perhaps not. I hope not, there's nothing I like better than roast pork for Christmas.

#732

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[D]o not be dismayed by our vocal but largely uninformed minority of critics; they are

symptomatic of other ills in society. I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material.

Presumably, then, the members of the Senate Committee who have already gone on record as being critical of CASA in this matter are among the “largely uninformed minority”. And BTW: Most of CASA’s evidence to the Committee is merely opinion and hearsay. Nothing wrong with that, mind you. But CASA might remind itself about that Pot/Kettle metaphor.

#735

Errrrm, Senator Heffernan is the Chair of the Rural and Regional Affairs and Transport References Committee. (Senator Searle is the Deputy Chair. Those positions are reversed in the Rural and Regional Affairs and Transport Legislation Committee.) I agree that Senator Heffernan does get a bit flamboyant and tiring. However, the climate of this inquiry is substantially different from other inquiries in which he is involved. In this one he is far from being alone in his disbelief of, and occasional open contempt for, some of the witnesses to the inquiry. During this inquiry there have been occasions on which the entirety of the Committee has openly scoffed in disbelief at the evidence being given. #739 Creamy,

One for an incisive mind... Mr Hobson tells Senator X that the airspace over Norfolk Island belongs to NZ and that there is no Australian airspace there. But I remember that the Chicago Convention embodies a fundamental principle:

PART I.—AIR NAVIGATION CHAPTER I.—GENERAL PRINCIPLES AND APPLICATION OF THE CONVENTION. Article 1. Sovereignty. The contracting States recognize that every State has complete and exclusive

sovereignty over the airspace above its territory. Article 2. Territory. For the purposes of this Convention the territory of a State shall be deemed to be the land areas and territorial waters adjacent thereto under the sovereignty, suzerainty, protection or mandate of such State.

So I wonder how this is managed? Given that the aviation law that applies to operations at Norfolk (Lord Howe, Christmas and

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Cocos) Island is undeniably Australian rather than that of the managing agency of the Oceanic Airspace, it seems likely that there is indeed some form of international agreement that deals with the transition of applicable law between Australia and, in this case, NZ. Anyone know which government agency would negotiate and act as custodian of such an agreement? Apparently it is not Airservices! Stay Alive,

#740

Gawd 4dogs - too complicated for my tiny mind. The external territories of Australia include the Norfolk Island Territory, which in turn also includes the 12nm territorial sea surrounding it and the airspace above. But …The Norfolk Island Territory is a ‘self-governing’ territory and, unless the Commonwealth chooses to legislate over the top of it, the Legislative Assembly of the territory makes laws for that territory. However …There appears to be no Norfolk Island Territory law about airspace (have some fun, here: Norfolk Island Government Information), but the Commonwealth Airspace Act 2007 and the Commonwealth Civil Aviation Act 1988 are each expressed to extend to “all external Territories” (see s 6 of each Act). Further, Australian citizens operating Australian registered aircraft are bound by Australian law, wherever they are, to the extent the Australian law is intended to apply to them where they may be. This seems to help answer the question as to what rules Australian pilots may be obliged to comply with and where. But …I don’t know whether it helps to answer the question as to what services must be provided, by whom, to aircraft in ‘international airspace’ – that is, airspace other than that above the territory of a sovereign state – or to what standard. There’s a hell of a lot of ‘international airspace’ out there. I have NFI about the potential

sources of legal obligations to provide air traffic services within it. Hopefully the consequences of the Senate inquiry may include some improved clarity about

who’s responsible for what, and to what standard. #747 To get back to the matter at hand and atsb's supplementary report:

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This is the absolute ostrich in the sand routine and surely Gobbles pineapple reward

extraordinaire!! AND from a submission to the Green paper, notes:

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Re The ATSB and the Transport Safety Investigation Amendment Bill: “The legislation also gives the ATSB new powers to compel agencies and operators within the aviation industry to respond to its formal recommendations within 90 days, giving the public greater confidence that the lessons from past accidents will be acted upon in a timely manner.”

#749 Sosij sizzl

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To suggest that Airservices is culpable for another ICAO State's procedures and should be informing them of their shortcomings is pure farce.

I think I have mentioned that rather than being farce, Airservices is quite entitled to point out other State's shortcomings, and is quite entitled to require airspace over Australian sovereign territory be operated in any manner Australia sees fit. If you are armed with that information, Airservices Duty of Care comes into play. Whilst Heffernan used insulting language, his point was entirely germane. He is quite right in that it appears AsA's attitude (via Harfield) is that "It isn't our airspace, so it's not our business". That attitude may not be good enough, especially in a venue such as the Coroners Court- let alone a Senate hearing. It is Australian territory, delegated to another provider. It's probable that that fact has just been overlooked, but can no longer (and nor should it) be ignored. #750 Don't be so lazy. ICAO Doc 7300 Part 1 Air Navigation GENERAL PRINCIPLES AND APPLICATION OF THE CONVENTION Article 1 Sovereignty The contracting States recognize that every State has complete and exclusive sovereignty over the airspace above its territory. There's a good start. #754

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Quote:

Senator STERLE: Colleagues, I understand the frustration and I am experiencing it too. But, with the greatest respect, yelling at the officers from the department is not called for. Chair, I think Senator Xenophon, rather than putting the question on notice, should put his questions to the officers now while we have the opportunity.

Hear, hear. But - there was a marked difference between the treatment of the BoM and ASA. In part, perhaps this was due to the BoM being very aware of 'public' comment on their services; if Uncle Bill's BBQ, the local cricket match or someone's wedding is 'rain interrupted', they catch the unfair abuse. Their system for dealing with perceived 'errors' is presented to the committee as mature, functioning and active. Essentially, BoM said that they independently of outside advice checked to make certain that any possible 'error' was investigated, addressed and action taken. Pro active safety management – easy, and off the hook. The lack of a similar system for ASA seems to have provoked the committee. There appears to be an identified 'fault line'; and, if that fault line had been addressed early in the piece (2000 days ago), then perhaps the heat in the kitchen would have been reduced. A Simple statement to the committee – "we have identified the fault line and taken the following steps to rectify it" – would have deflected the frustration. The committee could then throw their support behind curing any problem between jurisdictions at government level if required. Had this been presented as proactive safety management instead of the usual 'party line' it would have scored points. But, alas – Hansard tells a very different tale. The fury and frustration with the agencies concerned is apparent; perhaps 'El Jefe' was OTT, but could that not be excused as being completely "over" listening to another carefully scripted alibi. If you read the Hansard Fawcett, Xenophon and a couple of the others were in just as dangerous a frame of mind as Heff; but played the 'good cop' very well.

#755

Gee sure is lively on here this morning! It's officially official the Senate Inquiry reporting date has been extended:

Rural and Regional Affairs and Transport References Committee Reporting Date Senator McEWEN (South Australia—Government Whip in the Senate) (16:07): At the request of Senator Heffernan, I move: That the time for the presentation of the report of the Rural and Regional Affairs and Transport References Committee on aviation accident investigation be extended to 27 February 2013. Question agreed to.

Oh and for those who are interested, it seems there are quite a few, here's the live link for this arvo's theatre: Rural and Regional Affairs and Transport References Committe Aviation accident investigations 21 Nov

#762

Popcorn and beer ready to go.

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TD67 # 863 " In that case, it would probably be the transport ministry which has the responsibility to seek and ensure compliance".

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From Hansard – my spacing. There is an excellent post on the DGA Norfolk ditching page which I highly recommend.: QSK # 603.

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Senator STERLE: I am interested too. You did say, Mr Harfield, that you would do that if there was a recommendation from ATSB? Would you say that? Mr Harfield: I think we need to put a couple of things into context. You have CASA, which is the air safety regulator that provides the rules and procedures we abide by. We are there air traffic service provider. We provide services based on the rules and regulations that are set by CASA, so we apply the rules as set. When another air traffic service provider has a particular issue, we have discussions with that service provider about the issues that we see. We are surrounded by 11 different flight information regions. We are in constant contact with our neighbouring air navigation service providers. At the end of the day, we can talk about those particular issues but they also work under the jurisdiction of their safety regulator and apply the rules that their safety regulator deems. The fact is, this would be a matter for the civil aviation authority of New Zealand. Senator XENOPHON: Please do, and regarding New Zealand as well. Regarding the Australian Aeronautical Information Publication, is the text provided to Airservices by CASA or do you control all of the editorial resources? Mr Harfield: I will hand that to Mr Hobson to answer that particular question. Mr Hobson: Regarding the content of the AIP, in terms of the text and the language used, in the main the author is CASA and Airservices is the publisher. Senator XENOPHON: So you have to rely on what CASA provides to you? Mr Hobson: That is correct. Senator XENOPHON: Who is responsible for ensuring that material, which requires some sort of mandatory action, is properly based on a legal instrument and with an appropriate head of power? Mr Hobson: The author, CASA. Senator FAWCETT: You have highlighted a couple of times, and I completely understand, that you implement regulations that are made by CASA in many instances. If in your review of an incident you believe that there should be a change in the regulation so that you can implement it differently, do you make a recommendation to CASA that they look at that? Mr Harfield: Yes, we do. We advise CASA and say, 'We picked up this particular risk associated with an incident. These are the actions that we have taken to mitigate that particular risk, but from a systemic point of view we would look at changing the regulations or the standards that underpin the regulations. We think that needs to be addressed to ensure that there is a systemic fix being made.' Senator FAWCETT: Do you have a similar tracking system within Airservices to say, 'We have made five or however many recommendations to track if, when and how they are either closed out or still open'? Mr Harfield: We would be able to advise which recommendations have come up and that we have passed on to, for example, CASA for further work and where that would be at.

Monday, 19 November 2012 Senate Page 11 RURAL AND REGIONAL AFFAIRS AND TRANSPORT REFERENCES COMMITTEE

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#765

It doesn’t seem to me to be a vexed issue, at least in so far as Norfolk Island and its associated territorial airspace are concerned: Airservices Australia is responsible for ‘Australian-administered airspace’, and that includes Norfolk Island and its associated airspace (as defined). Airservices Australia might choose to discharge that responsibility by entering an agreement with someone else, but it’s up to Airservices Australia to ensure the agreement results in the appropriate levels of service in ‘Australian-administered airspace’ as defined in the Airservices Act. For completeness’ sake, I copy QSK?’s post in another thread:

Quote:

I think the responsibility for providing the FIS for YSNF "fell through the cracks" between the Australian and NZ civil aviation agencies when the Norfolk Island FSU closed. And the NZ AIP references would appear to imply that NZ still thinks the FIS responsibility for Norfolk Island lies with Australia. As you would be aware, prior to its closure in the '90s, the NF FSU used to hold the FIS responsibility for advising aircraft on NF weather during its hours of operation even though it was located within the Auckland Oceanic FIR. Outside of the FSU's hours of operation, the FIS responsibility reverted to the Sydney FSC and subsequently to the BN FSC when the Sydney FSC was closed. My understanding is that the FIS responsibility was totally transferred to the BN FSC when the Norfolk Island FSU was finally decommissioned. I'm proposing the view, that the issue of Norfolk Island FIS responsibility may have been overlooked by Airservices/CASA/CAANZ/Airways either when the FSU closed or with the subsequent institutional changes implemented by Australia (i.e the integration of ATC/FS functions) as well as the change to the Flightwatch "self help concept" in lieu of the directed FIS. It's this issue that requires investigation and comment on by the ATSB and, if necessary, be the subject of a safety recommendation so that the appropriate MoU/LoA remedial action, as you have proposed, is implemented between the Australian and NZ agencies so that we don't have a repeat of this situation again in the future.

If anyone can identify any flaw in QSK?’s reasoning, I’d be interested to hear about it. However, I say again, that none of this appears to answer the question as to who is responsible for providing what services to whom, and to what standard, in ‘international’ airspace.

#768

Hi again Sosij Sizzl I watched the lot and read the lot. Let’s assume the parliament and its committees do not exist. Let’s also assume your daughter was in the stretcher and your brother was the pilot of the Westwind in question. Are you seriously able to come to the conclusion that no systemic issues within the management of the AOC holder’s operations, or within the ATS system, or within the rules about this kind operation, contributed to this accident? Seriously? Are you seriously able to come to the conclusion that the experience of the survivors, in relation to the effectiveness and operation of the emergency procedures and emergency equipment, provides no information that is relevant or of concern to the other people who

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(to this day) are carried on aircraft with those procedures and that emergency equipment? Seriously? #769

Ben sums up this arvo's theatre best!

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Pel-Air inquiry to get critical CASA-ATSB attitude adjustment documents Ben Sandilands | Nov 21, 2012 9:01PM | EMAIL | PRINT A late session by the Senate committee inquiry into the Pel-Air crash report hears ATSB say it was focused on pilot errors not violations of the rules by the operator, and sees a perceived insulting email about them from CASA head John McCormick. The Senate committee inquiring into the final report the ATSB issued on 30 August about the 2009 Pel-Air medical charter ditching of a Westwind jet near Norfolk Island last night asked the safety investigator to provide full correspondence as to how CASA the safety regulator persuaded it to change its mind about the seriousness of the safety issues the crash raised. The chief commissioner of the ATSB, Martin Dolan has previously told the committee that the safety investigator had originally come to the view that there were ‘intolerable’ safety risks arising for the circumstances leading up to the crash, but in consultation with CASA had downgraded its assessment to ‘broadly acceptable’. The general manager aviation safety investigations at the ATSB, Ian Sangston, after being pressed to answer a line of questioning by the chair Senator Bill Heffernan, confirmed that the evidence on which the investigation reached its initial conclusion didn’t change, but its view of its seriousness did. In the first of a series of unpublished drafts of the final report circulated to affected parties about 23 March this year the ATSB view was that the crash was very serious. But when the final version of the final report was released in August the safety risks it raised were described as ‘broadly acceptable’ and all of the material blame for the crash was attributed to the captain of the flight Dominic James. The jet was flying from Apia to Melbourne via Norfolk Island when it was first banished from cruising at its fuel optimum altitude because it wasn’t equipped to maintain safe separation from crossing traffic, and having passed the point at which it could have diverted to Noumea, it made four missed approaches to the island in poor weather and was then ditched by the pilot immediately before the remaining fuel in its tanks was exhausted. The six people on board were able to escape from the sinking jet and were fortuitously rescued by a boat from Norfolk Island. In his testimony Dolan also acknowledged that the pilot community was divided as to whether James was correct in proceeding to the island, unaware of an amended weather forecast that warned that conditions had deteriorated to below the required minimum conditions, or should have diverted on a mandatory basis. He would not be drawn about an email between two senior people in CASA management in which one says that there was legal risk for the regulator in a situation where its Flight Operations Inspectors were divided as to whether James should have diverted or continued, and that this uncertainty which the regulator had left unresolved for years was ‘untidy’ and potentially embarrassing. Under questioning by Senator Nick Xenophon, Dolan, said he hadn’t asked until 4 July this

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year for the special audit of Pel-Air conducted by CASA shortly after the accident, which found the operator in breach of more than 30 safety rules and variously deficient or unsafe in its lack of fuel planning policies for its Westwind fleet at the time of the crash. In subsequent answers Dolan declined to confirm that he had actually read the document, even though he had insisted elsewhere on the public record that it was irrelevant to the ATSB inquiry. He could not explain why something he hadn’t read could be ‘irrelevant’ but described the focus of the ATSB investigation as being into ‘errors’ while the audit report, which was the business of CASA was about ‘violations’. Dolan agreed to find out the date at which the chief pilot for Pel-Air at the time CASA found its Pel-Air fleet operations to be critically unsafe or in breach of important safety regulations was recruited to the regulator but according to earlier testimony by the Director of Safety at CASA, John McCormick, to have played no role in the ‘consultations’ in which CASA persuaded the ATSB that the intolerable situation at the charter operator was in fact acceptable. Dolan evaded a concise answer as to whether or not it was the responsibility New Zealand Airways, which provides air traffic control for most of the route flown by the Westwind jet from Apia to the sea near Norfolk Island, to ensure that it informed the pilot of the deterioration in the forecast weather for its intended arrival. Senator Xenophon told Dolan that the committee had information that the weather warning, which would almost have certainly made James divert to Noumea when he was in a position to do so, was not passed on to the pilot. However as disclosed in a hearing this Monday, AirServices Australia sat on its hands unaware of this issue of weather warnings not being passed on to an Australian jet approaching an Australian airport because it was awaiting a safety recommendation in the ATSB final report. That same hearing heard that the ATSB had suddenly decided to stop ‘overusing’ safety recommendations and had made none in the case of Pel-Air, a change in policy not announced by the Minister, and unknown to AirServices Australia, until this information was dropped on Monday. Dolan also agreed that had the pilot of the flight, Dominic James, fully fuelled the Westwind before its departure from Apia, it would have been too heavy to have climbed to an altitude above the region of airspace the NZ control asked it to vacate as it wasn’t equipped to remain in its optimum altitude band while modern better instrumented aircraft were in the same airspace. He agreed to release the entire paper trail generated by the ‘consultations’ between CASA and the independent air safety investigator which lead to its changing its assessment of the risks revealed by the Pel-Air flight. Dolan was excused from answering a question as to whether he agreed with assessments made CASA’s current director of safety, John McCormick, in an email considered by some members of the Senate committee to be personally insulting. That email as received by at least two Senators is published below: We recently appeared at a sitting of the Senate Rural and Regional Affairs and Transport Reference’s Committee Inquiry into the ‘PEL-AIR’ ditching report and ‘other matters’. I wish to pass on my personal thanks for the outstanding effort everyone made to meet the requests of the Senate Committee inquiring into the PEL-AIR ditching report. I fully

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appreciate the time and effort that was required and on behalf of everyone else at CASA, thank you and well done! That sort of spirit is very humbling to me.

As for these Inquiries themselves, they are an important part of Westminster Democracy in this country and, as such, are not events to be feared or avoided. I personally welcome the

opportunity to present CASA’s positions at any venue. However, do not be dismayed by our vocal but largely uninformed minority of critics; they are symptomatic of other ills in society. I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material. I look forward to assisting the Committee conclude its investigations. At the completion of this Inquiry there is a report produced. That report becomes a ‘Report of Parliament’ and will be forwarded, by established process, to the Minister for his consideration. Comment. The McCormick email, like the ATSB final report, and its failure to deal openly and in detail with the systemic failings of CASA and Pel-Air, brings the administration of air safety in Australia into disrepute.

Wonder how Ben feels about being called a "tendentious blogger" as per that FOI e-mail PAIN put out? Pel-Air inquiry to get critical CASA-ATSB crash documents | Plane Talking

#771

To anyone not following the nuances very closely, your posts, along with some of the rubbish at the inquiry, read as though Australia did not promulgate the weather change at Norfolk which is simply not true.

At no time have I said that, or even hinted at it. I really don't know how you get that interpretation.

My point has been that Heffernan appears to be having a go at Harfield in this latest hearing, not about what the rules were or who was responsible for what, he is having a go at him for

having done absolutely nothing to fix it. To the good senators, it looks like CASA hasn't done their job, the ATSB - god knows what they are doing- they seem a bit lost about what their job is, AsA is saying "it isn't our responsibility" and the senators are getting a bit frustrated/exasperated. All these bureaucrats sitting around going "it's not our fault" and conveniently running lines that end with it being no-ones fault (except the pilots, of course), and them not having to actually do anything differently in future.

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If you think it can legitimately be done outside your own borders then please enlighten us all (that sounds sarcastic, but I genuinely would like to know).

OK, Norfolk is Australia. That's step 1. Accept that Norfolk is Australia, just like SY. Australia is getting someone else to do the airspace management at Norfolk. This happens by agreement, thru ICAO. Australia can ask to change the agreement to put in place FIS (hazard alerting) or whatever else Australia decides wants to happen at/inbound to Norfolk, to Australian standards (if that is currently not the case) with NZ, and then NZ to Fiji, or whomsoever else is required.

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If NZ politely declines to amend the agreement, Australia can lodge a dispute with ICAO, who can force agreement upon NZ, or Australia could even petition to take management of the airspace back (including an appropriate area around Norfolk to facilitate services). ICAO has a resolution system which can do that. In reality, most countries agree on such things without having resolution forced upon them.

States are voluntarily part of ICAO, but that membership infers rights on ICAO. In practical terms, I'm sure Australia does not want to take over a big section of oceanic airspace- it costs money! These days, the way things are done is to put the onus on operators eg. Australia could require (thru normal air regs) the PIC of an operation inbound to Norfolk to calculate a PNR and obtain updated wx from Norfolk/sat phone/HF briefing/whatever at 30 mins prior to PNR. Doing so means your landing fee is $100, not doing so means it is $10,000. Or it could be an offence (and I don't want to start an argument about whether an offence can be committed over the high seas). But there are lots of ways to skin that cat. Anyway, before we get too far off track- things can be done, and it appears no-one is doing them, nor has any intention of doing them.

#776 I am grimly amused by those who presume to know the precise terms of the weather information actually heard by the crew in flight. Not the words transmitted from the ground: the words actually heard by the crew in flight. Someone said someone transmitted some words. Therefore all of those words were heard by the crew. Therefore the crew failed to correctly assimilate the information they had. Now that’s solid gold “hearsay and tautological rubbish”. #778 Depends on what court we’re in and for what purpose the transcript is being adduced. But let’s apply Occam’s Razor and assume it’s admissible and incontrovertible evidence that the precise words in the transcript were transmitted, at the time and on the frequency stated in the transcript. It does not follow that those precise words were heard by the crew. Anybody with any experience in radio voice communications – especially HF voice communications – knows how easy it is to misunderstand, or not hear at all, some of those communications. That’s why there’s a phonetic alphabet. That’s why there are standard transmission formats and phrases. That’s why the standard phrases include: “say again”, “speak slower” and “words twice”. There is only one person who can give first hand evidence of what the PIC heard. And the 'blame the pilot' crowd might want to entertain the possibility that what the pilot actually

heard supported his decision, and he didn't know what he didn't know.

#781 Some of you are still banging on about fault and who was most at fault for this accident, please remember that currently the ATSB Final Report puts the blame solely at the feet of Dominic James. The Senate inquiry isn't about whose fault this accident was it is more about what appears to be an extremely substandard Final Report put out by the ATSB some three years after the event. The 'blame game' and, as Ferris clearly highlights below, those that are trying to escape scrutiny or ownership of any blame has come about as a consequence of the inquiry:

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Quote:

ferris: My point has been that Heffernan appears to be having a go at Harfield in this latest hearing, not about what the rules were or who was responsible for what, he is having a go at him for having done absolutely nothing to fix it. To the good senators, it looks like CASA hasn't done their job, the ATSB - god knows what they are doing- they seem a bit lost about what their job is, AsA is saying "it isn't our responsibility" and the senators are getting a bit frustrated/exasperated. All these bureaucrats sitting around going "it's not our fault" and conveniently running lines that end with it being no-ones fault (except the pilots, of course), and them not having to actually do anything differently in future.

You can continue to play the 'blame game' or you can question how it is that such an important safety agency (the ATSB) can deem that this flawed, deficient final report is an acceptable "safety document" to publish and be disseminated worldwide. #782

Quote:

The PIC is the PIC and carries the considerable responsibilities of the privileges of his/her license. Whether Private, Aerial Work, Charter, RPT notwithstanding regulation is not relevant. The passengers and the crew deserve the same duty of care.

Not so fast, we have heard this before and it isn't necessarily true. The problem is known as The double bind problem" and it is well known and frequently deadly, as it almost was in this case. A double bind exists for a person when the formal rules and regulations they are expected to work to are totally at variance with the informal rules and regulations of an organization. That leaves the employee, like James, totally exposed when there is an accident because they have not complied with the formal rules but the informal rules. CASA and ATSB have dutifully ignored the informal culture of Pel Air and instead hung the pilot out to dry. As has been stated elsewhere I believe, strict application of relevant fuel planning principles by a competent chief pilot would have meant that it was impossible to use the Westwind for this mission. But the Westwind was used, so we have to ask the question that the ATSB and CASA studiously ignored: are the operations manuals for Pel Air adequate? Apparently not according to the secret CASA audit. So now we get to the question, assuming James followed Pel Airs manuals to the letter, would he have been safe? apparently not. That begs the question: what would have happened to James had he got up on his hind legs and told the CP that he was in error as evidenced by the less than stellar Pel Air documentation? whAt would have happened if James had then lectured the cp on the correct fuel planning technique and announced that he would ignore the manual and employ a better and correct procedure instead? What would have happened to James if he had decided to bring the manuals shortcomings to the attention of CaSA? What would have happened to James if he told the CP that this flight was just too dangerous in the aircraft concerned? That's right Gaunty, every single one of those courses of action finishes with D. James out

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on the street and another dumb schmuck at the controls of the Westwind. Pilots are just like everyone else, if they aren't supported in the pursuit of safety, let alone undermined, they can and do make mistakes. #784 The CVR would provide very strong evidence of what sounds were actually in the intercom system, with a corresponding strong inference that those sounds were actually heard by the crew. But only the human listening can give first hand evidence of what s/he heard and what s/he interpreted what s/he heard to mean. True story from someone close to me (I spell the words phonetically to make the point): Heard in the cockpit: ABC tern rite too wun zero. ABC: ABC tern right too wun zero. [ABC’s pilot ‘heard’ an instruction to “turn right, two one zero”. ABC takes up a heading of 210 degrees magnetic. In fact, a second zero was clipped from the instruction to ABC. The words out of ATC’s mouth were: Turn right to one zero zero.] Heard in cockpit: ABC is your heading wun zero zero? ABC: Negative, heading too wun zero. Is that outcome really just the fault of the pilot of ABC? Rugby League fans may be aware of an hilariously funny song, by Denis Carnahan, about the selection process for the Queensland State of Origin team. The song’s called “That’s in Queensland”, and the first verse goes like this (copyright Denis Carnahan):

Quote:

Could somebody please help me? I’m a little bit confused. When selectors choose for Queensland Could you tell what map they use? Where you’re born and where you come from, surely that’s your origin So could somebody please tell me, what States these towns are in … Where is Sydney? That’s in Queensland! Suva Fiji? That’s in Queensland! Where is Nowraville? That’s in Queensland! Queensland’s everywhere!

And so it goes. It’s worth a view on youtube. It struck me that a similar concept applies to the Pel Air ditching matter. I call this song: “Symptomatic Of Other Ills In Society”. It’s in ‘C minor’. Could somebody please help me?

15

I’m a little bit surprised When I’m in a commercial aircraft

Who’s keeping me alive? The system’s there to protect me: surely that’s my safety net

So could somebody please tell me, who’s helping my Pie-let … Phone unanswered? Blame the pilot!

Mistake in METAR? Blame the pilot! Outsourced to NZ? Blame the pilot!

Ops manual deficient? Blame the pilot!

That it’s aerial work? Blame the pilot! Not RSVM certified? Blame the pilot!

Rules unclear? Blame the pilot! Hopeless lifevests? Blame the pilot!

Liferaft lost? Blame the pilot! Audit outcomes? Blame the pilot!

Pel-Air breaches? Blame the pilot! Lessons learned? Blame the pilot!

Systemic problems? No way! The pilot’s everything!

#788 Given Creamy's perfect summary in 'C minor' or "K's" 'D major' makes you wonder how the bureau continues to stand by the report, see here page 6 of yesterday's Hansard:

Quote:

MD said:We undertook the investigation of the Norfolk Island accident and published an investigation report under those functions and conditions. A number of claims have been made about the inaccuracy of the investigation report or about omissions in the report. As I indicated, we have provided a range of submissions to the committee addressing the points raised. The latest was yesterday, addressing some assertions that had been made about the fuel planning and management of the accident flight. The ATSB remains satisfied that there is no material error of fact in the report. We have also satisfied ourselves that, at this stage, no significant new information has been brought to light that requires a formal reopening of the investigation.

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I would like to make it clear that the ATSB stands by its report.

Almost totally farcical except in this case it is 'obscene' because this is coming from the 'Australian Transport Safety Bureau'! Or as Senator X mentions on page 4..." A number of pilots have approached me and said that concerns them, because if it goes off to the regulator, to CASA, that may inhibit their willingness to report issues of safety to the

ATSB, as the primary safety body for aviation in this country." Professor McMillan although an obvious expert in the law could best be described as a layman in regards to aviation highlighted perfectly these issues on reviewing the October 22 Hansard:

Quote:

Prof. McMillan: I am interested that the secrecy provision does not apply to the information-gathering powers of the parliament. This committee has requested information that would otherwise be protected against release under the FOI Act. Clearly that is one way in which a balance has been struck in the legislation. The other comment that I would make, and this is just an observation from reading

the earlier transcript, is that I note the comment of the Chief Commissioner, Mr

Dolan, that with hindsight the report could have been a more fulsome report that

discussed lines of inquiry that were decided not to be relevant and arguments that

were not accepted. Generally speaking, that is by far the better way of ensuring

that information gets on the public record in a better form. FOI is certainly a valuable legal means but it can operate in a fairly random way because of its interaction with exemption provisions and because of the range of documents that are released. (my bolding)[/

#792 If: - the upshot of all of this is that CASA and the ATSB stick to the line that the only cause of this incident was bad airmanship on the part of the PIC, and - the basis of that conclusion is that the PIC failed properly to assimilate and make the correct decision in the context of information given to the PIC, the right thing to do would be get the CVR (if its duration of recording goes back to point at which ‘CASA’ says the information was given to the PIC) to find out the quality and content of the transmissions received. (I note that even if the proximate cause of the ditching was bad airmanship, it does not excuse the ATSB or CASA from doing nothing about the lifevest and liferaft issue. The silence and inaction on that stuff really makes me sick to the stomach.) But on the question of the information available to the PIC, let’s continue with the assumption that the PIC received and understood, verbatim, what’s in the transcript. My reading is that at 0801:31 Nadi makes a transmission addressed to NGA, in these terms:

Quote:

METAR Norfolk at 0630 Zulu wind 300 09 knots 9999, few 6,000 broken 2400 temperature 21 dewpoint 19 QNH norfolk 1011 remarks closed till 1930 UTC go ahead.

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The transcript says that the response from NGA was:

Quote:

Ahhh ...copy... just say again the issue time for the METAR.

I note that there are no other “Ahhh”s in the transcript quoted above. Now I’m only a wheelchair-bound geek from Hicksville, and this may be pure speculation, but maybe the crew member who was on the radio felt compelled to respond, so that Nadi knew the transmission had been received, but the “Ahhh” was a verbal ‘head-scratch’ about the “few 6,000 broken 2400” bit. I know that if I were in an aircraft in which that transmission were received by the people with whom I’m fortunate enough to fly, the phrase “few 6,000 broken 2400” in a METAR would produce a ‘WTF?’ moment. Irrespective of what caused the “Ahhh” and what was going on in the cockpit, at 0802:32 according to the transcript – that’s just one minute after the METAR quoted above - another transmission was sent to and acknowledged by NGA:

Quote:

Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at 0800 Zulu... auto I say again auto, alpha uniform tango oscar, wind 290 08 knots, 999 november delta victor, overcast one thousand one hundred , temperature 21, dew point 19, QNH Norfolk 1012...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.

So – again assuming all of this has been received word-for-word – on what basis does the pilot get crucified for deciding to continue? Let’s assume the crew aren’t idiots, and their mutual head scratching resulted in them concluding that the “few 6,000 broken 2400” information may be erroneous, and perhaps instead should be “few 600 broken 2,400”. However, before they ask the question, the SPECI comes through. The SPECI says “overcast one thousand one hundred”. Is that really the basis on which this entire mess gets pinned on the PIC? Has ‘CASA’ really decided that that piece of information should have resulted in a diversion?

#793 I see the good Senator X has caught onto the tautological comment from the DAS that gobbles had in his last post on this thread: Senate Inquiry, Hearing Program 4th Nov 2011

Quote:

Senator XENOPHON: Just finally from me—again, possibly on notice—can you advise whether CASA has any right to access an operator's internal investigations? What about internal disciplinary proceedings? If Mr McCormick reads this I hope he does not

consider this a 'tautological rubbish' question.

(my bold)

Onya Nick! Sorry Creamy almost missed your post, which is extremely relevant because for some reason the ATSB initially missed the erroneous 0630 METAR that was relayed at 0801 UTC (giving few at 6,000') and subsequently due to the 4C program had to correct their report. Something that is equally troubling is that in the CASA Accident Investigation Report 09/3 on page 7 there is this statement for the 0801 UTC NADI communication:

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Quote:

0801 UTC NADI ATC provides the aircraft with the METAR for YSNF issued at 0630 ZULU. This was then updated with an Auto SPECI for Norfolk issued at 0800 ZULU. Wind 290 at 08 Knots cloud (OVC) at one thousand one hundred ft AGL, 21°C and the dew point was 19°C and QNH Norfolk 1012.

Which besides leaving out several parts of the true transcript also totally leaves out the

details for the 0630 UTC METAR and the pilot asking for the issue time to be repeated. So my question would be was the CASA truncated version the one that was originally given to the ATSB and hence the reason why they missed the erroneous "few at 6,000 ft"

message??

#797 Why the book is better than the movie

Hansard Page 7.

Quote:

Senator NASH: You were just saying then that you had no need to make any recommendations because CASA and Pel-Air had told you what they had done to address the issues. When was that? Mr Dolan: It was in the course of finalising the reports. Part of the directly involved parties' process, sending a draft report out with identified safety issues in it is to seek information from those parties as to what action they have taken, or propose to take, in response. Our aim is that by the time the report is complete we have good information about action that is taken or proposed and can satisfy ourselves as to whether further action needs to be recommended. So it is an integral part of the way we run our process. Senator NASH: It is almost as if you have said, 'Here are the issues,' and CASA and Pel-Air have come back and told you what they have done and then you do not make a decision about whether you need to make any recommendations until that point in time—is that correct? Mr Dolan: That is correct. Senator NASH: Has it always been the case? Mr Dolan: I would have to check with colleagues. It certainly has not always been the case; it has been the case for my entire tenure of 3½ years in the organisation and its predated my arrival by a year or two—Mr Walsh? Mr Walsh: Yes, I think for that specific approachit has been about four years.

Or, to put it the tautological way – our reports started to become risible about four years ago. Should I just wonder why?

#798

Some critically important aspects of the transcript show why relying on hearsay like transcripts is fraught with risk. Understand what the transcript process is. Someone is listening to a recording and typing out what they hear. Have a close look at these extracts, and note some odd things:

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Quote:

… few 6,000 broken 2400 …

Quote:

…overcast one thousand one hundred…

Note that in the second extract the altitude transmission is typed out in words, but in the first extract the altitude transmissions are typed out in numbers. Note also that in the first extract there is a comma in “6,000” but no comma in “2400”. Do people make mistakes when typing? You bet. How do we know there are no errors in the transcript? We don’t. Do we know that “2400” means “two thousand four hundred” was transmitted? We don’t. Do we know that the person transcribing didn’t make a mistake and type “2400” instead of “240”. We don’t. What we do know, for sure, is that: 1. if “few six thousand” was transmitted, that was a mistake by someone – either by the person making the transmission or in the material the person was reading; and 2. we don’t know, for sure, and neither CASA nor ATSB knows for sure, what was heard and understood in the cockpit. For all we know the “aaaah” moment resulted from the Nadi transmitting and the crew hearing “few six thousand broken two hundred and forty”. A double ‘WTF?’, resolved 30 seconds later by the SPECI. And note that a SPECI can be issued for improvements in the weather. Someone should fit voice recorders to these aircraft, so that there would be less doubt about what was received in the cockpit…

#803

'failing to get the extant weather in a timely manner'

But ‘failing to get the extant weather in a timely manner’ is not what ‘CASA’ says is the problem. ‘CASA’ says – that is the whole of CASA apparently – the PIC failed to properly assimilate the information the PIC had, and had the PIC properly assimilated that information, good airmanship would have resulted in a diversion. The trouble is that CASA’s opinion is based on hearsay and an assumption that may be invalid. The hearsay is the transcript of radio communications, and the assumption is that the PIC heard, verbatim, what’s in the transcript. Even if CASA’s opinion is based on listening to the ground recording of the actual radio communications, its opinion is still based on the assumption that the PIC heard, verbatim, what’s in the ground recording. From the ATSB report:

Quote:

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The flight crew reported that, at the time, they were either not aware of or did not

recognise the significance of the changed weather that was reported in this SPECI. They advised that if either had realised that significance, they would have initiated planning in case of the need for an en route diversion.

[my bolding] There’s a profound difference between “not being aware of” something and “not recognising” something. CASA has decided that: 1. the crew heard all of the SPECI transmission as stated in the transcript, and 2. the crew either: a. did not understand what the SPECI meant; or b. understood what the SPECI meant, and therefore the decision not to divert was the result of bad airmanship. Very big call to make on the basis of hearsay and an assumption that may be invalid. Does anyone know if the duration of the CVR recording would be sufficient to cover the 0801:31 transmission and after? It seems to me to be critically important to find out not only whether all of the SPECI transmitted at 0802:32 was received by NGA, and in precisely what terms and at what signal quality, but also what precisely was received by NGA a minute earlier. It seems to me that any reasonable assessment of what the crew should have assimilated and decided can only be conducted on the basis of what the crew actually heard during the SPECI transmission, in the context of what the crew actually heard a mere minute or so earlier.

#804 Courtesy Ampclamp - a gentleman

Following up this lead, but there seems little interest in doing the right thing and retrieving the boxes. The CVR holds the last 120 minutes and would/should be very useful, for many reasons. But I have bleated long and loud about this issue as have many others. Nuff said - beer o'clock.

Quote:

Kharon, I have been following the thread at Dunnunda for some time. I wish you and the other guys there the very best in your efforts to uncover the truth and to expose any alleged cover up or negligence. Considering the Air France prang location this should be a doddle with any concerted effort . 45 metres is deep and Norfolk is some distance away but far from insurmountable. 4 years is long time to survive in salt water though. Not sure how well those things are sealed. It is about 5.5 atmospheres at that depth. Have you them directly asked about survivability?

Aviation Recorders 100 Cattlemen Road Sarasota, Florida 34232 U.S.A. Tel: 941-371-0811 Fax: 941-377-5591

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Website: L-3 Communications Aviation Recorders Documents: L-3 Aviation Recorders Publications Home Page

#810 Catch 22?

Operationally, the whole thing of 'that' METAR from Nadi is not too critical; most crew would have a "6000'? WTF" moment. If it were not for the almost immediate follow up report from Nadi, (the carefully spelled out SPECI), then no doubt questions would be asked and clarification requested. But the next report, hard on it's heels would nullify (or make nugatory as we must now say) the previous, probably erroneous report. Some crews may have privately questioned the previous 6000' call, but most would just join the dots and discard it as 'an error', the 'latest' revised SPECI makes much more sense. I could be tempted to bet a bag of sweeties the TAF for Nadi had a similar cloud base and visibility. Face was saved, and perhaps as a courtesy to Fiji, that tiny bit was left out of Mr. Dolan's available evidence. Thing puzzles me is why it came be omitted from the CASA and ATSB report. It is easily explained; e.g. "our investigation revealed that the ATC in Nadi had inadvertently read 6000 not 600 due to a typographical error, we have addressed this with the Fijian authority"; and endit, off the hook, no foul, no penalty. It is the omissions which now raise the awkward questions.

Quote:

Mr Dolan: I will try and add some information to that. As we tried to make clear, there was an initial assessment of the evidence we had available to us, which was essentially about decision-making en route and what informed us and everything else—whether the guidance that was available was reliable. – Hansard.

The 6000' cloud base element was not 'initially' provided; nor was it provided during the two year head scratching period and was only 'discovered' during the 4Corners report. Why did the ATSB not 'discover' and address the 6000' report error during their research? Was the omission by CASA of the reported cloud @ 0801 the reason the ATSB failed to mention the erroneous details of 'that' METAR? FACT : the first version of the Final Report, after the 4Corners revelation, was corrected by the ATSB. FACT : CASA Accident Investigation Report 09/3 page 7 fails to mention the 6000' CB version @ 0801. Was the information initially provided to the ATSB deliberately misleading or, is the report a joint effort cobbled together by the ‘parallel’ investigation team under the MOU? If you put the two reports alongside they almost exactly mirror each other with the exception of 'that' METAR, lately included and not addressed. The CASA report, concluded two years prior included a summary and basic conclusion of the CASA Special Audit Report, which directly conflicts the final audit conclusions/findings, not sighted until 'earlier' this year. Could this all indicate that during the compilation of the report there was an edict issued

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prescribing how the conclusions/findings should be written? Was this the work of one pair of hands operating under instructions or a joint effort attempting to brush the incident off as a once in a lifetime non safety related event? Was the TSI act 'breached' by the CASA manager 'producing' the ATSB briefing? Page 33 of the Transport Safety Investigation Act 2003, part 24 makes the results of nobbling an investigation pretty clear. Then the MOU 4.1 also spells out why this is naughty. This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof. Taxi Minister?

#813

Kharon, if it’s a choice between conspiracy and something else, go for the something else every time. It seems pretty clear to me that the transcription of the transcript and the references and material dealing with the content of the transcript were changed. But that will be because someone honestly believed that the only material relevant to the foregone conclusion is the SPECI, and therefore the content and implications of the SPECI were the only matters that needed to be dealt with in accurate detail. The error in the METAR, if there was an error, would have unnecessarily confused people, and might have cast unnecessary doubt on the accuracy of the SPECI transcript and other hearsay on which the foregone conclusion depends.

#819

Having now gone through the transcript of the 21/11 hearing what I find most troubling is this accepted shift in the ATSB methodology of their core role as the independent transport accident/incident investigator. This is perhaps best demonstrated in the following quote from the transcript:

Quote:

Mr Dolan: We see a broader issue, which is: what is the support that is provided to flight crews en route in terms of assessing their situation, getting access to weather and other related information, applying that to the management of their fuel and so on? This is in a context where we saw in the AIP something that very clearly said that it is the responsibility of pilots to obtain information necessary to make operational decisions and that pilots will not automatically receive routine TAF information showing deteriorating weather conditions if they are en route to a location. That was the status quo with Airservices, with New Zealand and, as we understand, with Fiji.

This quote is significant as it could be almost perfectly type scripted for CASA. However in terms of the ATSB remit it is totally inappropriate, their scope of inquiry should also be questioning the appropriateness of the applicable legislation and whether ASA, CASA, AMSA etc has procedures and oversight that covers off on the associated risks of this particular operation. In other words the operation category shouldn’t be a factor when it comes to the ATSB scope of investigation in any accidents/incidents as serious as this one. The narrowing of the scope of investigation and the non-issuance of relevant safety recommendations would also appear to be in direct conflict with the ATSB ‘Statement of Intent’ which is written with Ministerial oversight, see here: Statement of intent Therefore this apparent change in policy by the ATSB must have been ultimately signed off and accepted by the Minister. The following quote from the transcript is significant in regards to this:

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Senator NASH: It is almost as if you have said, 'Here are the issues,' and CASA and Pel-Air have come back and told you what they have done and then you do not make a decision about whether you need to make any recommendations until that point in time—is that correct? Mr Dolan: That is correct. Senator NASH: Has it always been the case? Mr Dolan: I would have to check with colleagues. It certainly has not always been the case; it has been the case for my entire tenure of 3½ years in the organisation and its predated my arrival by a year or two—Mr Walsh? Mr Walsh: Yes, I think for that specific approach it has been about four years.

Which is coincidental with the change of government and a change of Minister.

Kharon said: This is all very unfortunate and untidy. Perhaps the Senate FOI request will 'discover' the paper trail. They seem to be a bit keen on that of late and they have asked for it, nicely and politely. They even checked with the IC Prof.

That said I would suggest that the Senators be aware that CASA legal has a history, over a number of years, of blatant manipulation and obfuscation of the FOI Act it might be better if the committee request that ‘paper trail’ under the Parliamentary Inquiry disclosure laws. Because even this case appears to have an example of obfuscation under the FOI by CASA legal, see here: http://www.casa.gov.au/wcmswr/_asset...-ef12-5471.pdf This version of the SAR was in response to flight nurse Karen Casey’s FOI request. However apparently, from people that know, this is still not the full, unadulterated, original version of the SAR. Which is reported to have had an additional 30 odd pages. It is also interesting to take a look at the regulator’s disclosure log page: Civil Aviation Safety Authority - Disclosure log

Down the page you will see this PDF file: 30 April 2012 EF12/1779 http://www.casa.gov.au/wcmswr/_asset.../ef-121779.pdf If you can bear to take the time to download you will see that this file contains scanned documents of all AOC renewals/additions and associated FOI/AWI supporting documents (AOC Checklist Form 069) dating back to 1998 for Transair Pty Ltd.

I’m not sure who made the original FOI request but besides being very revealing of the inner workings of the flight ops and airworthiness inspectorate there is one very notable omission (that I could see) guess what AOC approval/addition is missing? Sorry time’s up…if you go to page 175 (Schedule 1 Part 3) you will see where Lockhart River was first added as an approved route/port. However when you scroll down to the AWI/FOI 069 form that supports the LHR route/port addition you will find there is nothing, zero, zilch for the flight ops section of the 069 AOC checklist! Now we could say that these two apparent omissions are just an aberration, an anomaly, as documents do get lost. However I have been made aware that this, call it the CASA omission factor, COF..COF..err COF is a very common complaint (yeah Creamy I know ‘hearsay evidence’) by people in the industry who have made similar FOI requests. Having submitted several FOI requests with various other federal agencies. I have noted that if an agency agrees to release the requested documents (i.e. not in dispute) those released documents are either pristine full and complete or if there is a ‘lost’ or ‘exempt’ part

24

to the document that will be annotated by a series of blank pages with the FOI reference displayed somewhere. So perhaps, Creamy can probably help me out here, an additional QON could be asked of the Professor: Is this COF acceptable under the provisions of the FOI Act or is it possibly a

breach of the Act?

#821

Just spent a quiet hour reading the Prof. McMillan – Sen Xenophon passage of play on the 21st. I was just going to 'cherry pick' the questions on notice for future reference and let it sit. But, does anyone else get the feeling that Sen X probably knows the answers to the QON and just wants them on record, from the horses mouth, 'official like'? It makes some sense; he was quite specific and no one from the panel seemed inclined to chime in until he was finished. The whole exercise seemed to be 'clinically' and carefully executed to get at the IC' s answers 'on record'. You could assume this was for future reference, rather than to scratch Sen X's curiosity bump. The passage seemed gentile and civilised but did I get a whiff of gunpowder on the breeze? This whiff also creeps into the Dolan later effort once the almost verbatim McCormick style speech had cut no mustard. He seemed to realise that the blustering, 'muscular' stance adopted on entry was not going to work and the rhetoric degenerated almost into gibberish later in the piece. Notably after the FOI and 'paper trail' requests were eased into play, the language descends into an ungrammatical, almost confused state when put on the spot to "read into the Hansard record" (Nash - again). Sen Nash seemed quite determined a couple of times to drive a point home but then ease off after the statement she was seemingly looking for was made. Intriguing stuff, but there was no doubt that the committee wanted the middle level 'paper trail', in camera would do, but they do want it. Perhaps this was not the tame, easyology session we imagined it to be. In combination the two sessions provide much food for thought, even some robust tautological speculation. Have the Senate team got onto the fast and loose methodology CASA legal have developed and perfected for extreme, tailor made uses of the provisions within the FOI Act? There certainly appears to be enough complaints and examples available for serious consideration. Aye well; I'll save it for the Bar Room Barristers, should be a lively debate if nothing else. PS - Creampuff – Agreed: sorry, did not intend to get into 'conspiracy', just joining up some dots, thinking aloud, if you like. So many small unnecessary omissions which, if they had been addressed would not be creating doubt but 'attaboys' for correcting safety issues in a

timely open manner. #828 Jinglie perhaps BH was a secret co-author of that infamous hidden report (CASA Accident Investigation Report 09/3) that PAIN found at the tail end of attachment 4 of the FF

submission?? Pg 28 of the transcript:

Quote:

Mr Dolan: We see our job as a different job from CASA's. The special audit was in relation to CASA's views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired. Senator XENOPHON: Given what you have conceded—that the special audit report

25

contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB's final report? Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason's model, would be viewed as violation; and that is principally the responsibility of the regulator.

If the ATSB remit is.."focus of our investigations is on error and understanding error" it is beyond belief that the ATSB "scope" of the investigation shouldn't include the following areas

(borrowed from Jinglie's post on Norfolk thread ):

Simply put, in an accident like this, how can: ATC/Weather forecasting/Comms/Crash Survivability/ORG issues/Regulatory issues/CRM/Fatigue Risk Management/Aircraft performance not be adequately covered in the ATSB analysis?

Very good question Jinglie but there is also another factor in all this. If we accept Beaker's simplified philosophy (i.e. ATSB deals with error and CASA deals with 'violation'). And we also accept that the bureau's 'standards of investigation' must meet the requirements of both the TSI Act and ICAO Annex 13. What standard does the regulator's (slightly skewed) parallel investigation have to meet in order to possibly be presented as part of a brief to the CDPP, or AAT, or other enforcement action? The bigger question is does it meet that

standard?

#830 AOC THE ultimate SAFETY device!

Quote:

Nature has left this tincture in the blood That all men would be tyrants if they could Daniel Defoe

One point apparently overlooked by most is the requirement for an AOC to conduct such medivac flights. What is this AOC? Is it an attempt by CASA at Commercial regulation or purely a Safety device. As CASA is precluded from the former, it must have to do with safety. In fact it implies the pilot's license is inadequate to conduct such flights without the benefit of an AOC! So what is it about this certification which empowers a pilot to conduct such risky flights? When his license won't allow it. In Dominic James's case, he lost his license. He was found to be inadequately trained, but his authority to conduct the flight was never questioned because he was guided by an AOC. The AOC was not cancelled as was his license yet it alone made the flight legal. The now proven shortcomings in the AOC documentation had the CASA imprimatur, obtained at great expense after having been exposed to expert scrutiny prior to issue and again at renewal.

26

After the event these same experts have been able to identify numerous (safety) deficiencies yet the AOC is still in place. Surely CASA are selling a defective product! And this for a monopoly. What makes Pelair so different to receive such lenient treatment. There were numerous AOC holders out there who lost their livelihood for far less, my own included. Could this perhaps explain the delay in the ATSB report, the several versions and exclusions.

#831 What makes Pel-Air so different?

Quote:

What makes Pelair so different to receive such lenient treatment. There were numerous AOC holders out there who lost their livelihood for far less, my own included. Could this perhaps explain the delay in the ATSB report, the several versions and exclusions.

Perhaps it may have something to do with the Chairman of the Board, the Honourable John Sharp. After all, he rode to fame on the back of Monarch and Seaview and now makes millions as an aviation consultant. I imagine he was able to provide excellent advice to both

CASA and the ATSB on how things were within Pel-Air. Why hasn't Pel-Air as the

AOC holder appeared before the Senate Committee?

#834

All of the submissions are well worth a read. The ATSB’s flawed approach to investigations is demonstrated by the selective quoting of the transcript of the HF communications. Note the ‘partial transcript’ in Appendix A of the ATSB report finishes at 0803:24, just after the 0800 SPECI was (according to the transcript) transmitted to NGA (at 0802:32). The Pel-Air submission is very interesting on this point. It says, under the report finding “The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination:

Quote:

The crew did request actual weather reports (either METARs or SPECIs). WEATHER PROVIDED BY NADI: The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. [CP Note: this is the SPECI quoted in the ATSB report’s ‘partial transcript’.] This was the first indication to the crew that the weather at Norfolk Island was becoming marginal. WEATHER PROVIDED BY AUCKLAND: [CP Note: According to the Pel-Air submission, this all happened after the end of the ‘partial transcript.] The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with

Auckland would have alerted the crew to the true situation with time enough to

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divert. At 0839 the aircraft was still around 32 min away from the last diversion

point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew. While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.

The bolded text is in red in the Pel-Air submission. So let’s assume the ‘partial transcript’ is accurate and the Pel-Air submission is also accurate in relation to what was transmitted after the period covered by the ‘partial transcript’ ended. Let’s also assume the crew heard and understood everything transmitted. Based on those assumptions, here’s what was actually transmitted and received, and when, starting from the 0630 METAR:

0801:31 – Nadi: METAR Norfolk at 0630 Zulu wind 300 09 knots 9999, few 6,000 broken 2400 temperature 21 dewpoint 19 QNH norfolk 1011 remarks closed till 1930 UTC go ahead. [Let’s not worry about what was really transmitted, other than to assume the ‘few 6,000’ was transmitted verbatim/] 0802:08 – NGA: Ahhh …copy… just say again the issue time for the METAR. 0802:14 – Nadi: Issue time for the METAR this is the latest 0630 Zulu. 0802:22 – NGA: Victor golf alpha thank you. 0802:26 – Nadi: Victor November golf alpha nadi 0802:29 – NGA: Go ahead nadi victor golf alpha 0802:32 – Nadi: Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at 0800 Zulu... auto I say again auto, alpha uniform tango oscar, wind 290 08 knots, 999 november delta victor, overcast one thousand one hundred , temperature 21, dew point 19, QNH Norfolk 1012...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead. 0803:21 – NGA: Thank you nadi… much appreciated november golf alpha. So over the period of less than one and half minutes, the METAR with the mistake, then the 0800 SPECI, is transmitted and received. Nadi then passes NGA to Auckland and the ‘partial transcript’ runs out at 0803:24. According to the Pel-Air submission: 0839 - NGA transferred to Auckland. [CP question: Who said what, to whom, between

0803:24 and 0839??]

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0904 - NGA requested the latest weather Norfolk at and were given a ‘0902’ SPECI that said, in part, “broken at one thousand one hundred and overcast one thousand five hundred”. So here is what the 2 SPECIs said, and NGA received and understood, about cloud (assuming my assumptions about the transcript and Pel-Air’s submission and reception by the crew are correct):

0800 SPECI: Overcast one thousand one hundred. Note also that this SPECI said nil

rainfall recorded in the ten minutes prior to the SPECI time and nil rainfall

recorded since 0900 local time.

0902 SPECI: broken at one thousand one hundred and overcast one thousand five hundred

On what basis should the PIC have asked for anything more? Should the pilot have said to Auckland: “Thanks for that, is there anything thing else that we should know about the weather at the destination to which you are aware we are proceeding?” Would Auckland have said: “As a matter of fact, there was a 0830 SPECI that said cloud broken at three hundred and overcast at nine hundred. Lucky you asked!”

#837\ Why why why?

The question that needs to be asked of Beaker again for clarity and to be put on record is simply "why weren't the boxes retrieved"? Any investigator or investigation bureau knows that the evidence from the boxes is more than likely to be the 'smoking gun'. There can only be two logical, non-tautological explanations here: (a) Beaker was totally focused on cents and dollars over safety, or (b) Beaker is completely and utterly out of his league and does not have the capability or understanding to run the ATSB. Either way, the answer to either of these propositions would indicate he is certainly not the right person to remain in his position. As for learning from history and mistakes, the example of the AF47 crash and the tenacious efforts by the Bureau d'enquête sur les accidents d'aviation is something the nimrods in Canberra could learn from. In the case of the Pelair crash the location of the boxes are pretty much known, sitting on the ocean floor like a pearl waiting to be eagerly snatched up by a Diver. It is a crime that these boxes have not been recovered. Why hasn't the Minister delved into his trough and pulled out a handful of extra coin to be thrown at a Blackbox search and retrieve mission before now? And the actions of the heirachy in CASA, the Regulator, not understanding the basic concepts of safety and vehemently standing by their statement of only looking at the pilots actions and ignoring all other factors almost leaves me speechless! Perhaps the Senators, if they haven't already, could review Annex 13 and compare ATSB and CASA actions in relation to this accident? Then they could pose additional questions, if need be, to the upper echelon of these organsiations in the Senate under oath? A further review of 3.2 State Safety Program is also enlightening. CASA and ATSB = Fail. http://www.cad.gov.rs/docs/udesi/an13_cons.pdf #838 So in summary, here’s some of what we know for sure:

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1. Neither CASA nor ATSB knows the precise terms of the transmissions actually made by Nadi and Auckland, unless someone from CASA and ATSB listened to the recordings of those transmissions. 2. There are errors in the ‘partial transcript’, or there were errors in the transmissions recorded in the ‘partial transcript’, or both. 3. Neither CASA nor ATSB knows the precise terms of the transmissions actually heard by the crew of NGA, or what the crew interpreted what they heard to mean. Irrespective of what the precise terms of the transmissions and received interpretations were, it appears (but it is not certain) that: At around 0757, NGA requested a METAR for Norfolk. At around 0801, Nadi transmitted a METAR for Norfolk. At around 0802, NGA requested and Nadi provided the issue time for the METAR. At around 0802, Nadi transmitted and NGA acknowledge receipt of a report identified as the 0800 SPECI for Norfolk. At around 0803, Nadi transmitted and NGA acknowledged receipt of an instruction to contact Auckland at DOLSI. At around 0839, NGA contacted Auckland. At around 0904, NGA requested the latest weather Norfolk, and were given a report identified as the 0902 SPECI for Norfolk. NGA was not given the report identified as the 0830 SPECI for Norfolk. At around 0911, NGA flew beyond the last diversion point to Tontouta (according to the Pel-Air submission). One of the ATSB’s finding is:

Quote:

The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.

Let’s assume that these words were all received and fully understood by NGA, verbatim, at the noted times (I’m sure they weren’t, but let’s assume for the time being): 0801 Transmitted by Nadi after a request from NGA – “METAR Norfolk at zero six three zero Zulu wind three zero zero, zero niner knots, niner niner niner niner, few six thousand, broken two thousand four hundred, temperature two one dewpoint one niner QNH norfolk one zero one one remarks closed till one niner three zero UTC go ahead.” 0801 Transmitted by Nadi, on initiative from Nadi – “Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at zero eight zero zero Zulu... auto I say again auto, alpha uniform tango oscar, wind two niner zero, zero eight knots, niner niner niner niner, november delta victor, overcast one thousand one hundred, temperature two one, dew point one niner, QNH Norfolk one zero one two, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.”

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0904 Transmitted by Auckland after a request from NGA – “SPECI Norfolk at zero niner zero two zulu, alpha uniform tango oscar, wind two zero zero, zero seven knots, seven zero zero zero, scattered five hundred, broken one thousand one hundred, overcast one thousand five hundred, temperature two zero, dew point one niner, QNH one zero one three, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero.” What more should the crew have done, and when, to “source the most recent

Norfolk Island Airport forecast”, or to “seek and apply other relevant weather and

other information”? We know that CASA’s “opinion” is that “good airmanship should have resulted in a diversion”. For those who agree with CASA’s opinion, at what point, precisely,

should the decision to divert have been made by the crew of NGA, on the basis of what information, precisely?

#839 Idle speculation.

Quote:

Norfolk Island suffers from notorious fog. Being a small island the fog often rolls in at short notice closing the airport while aircraft are mid flight from Australia or New Zealand. The disappointed passengers are often told they need to turn back and try tomorrow.

Quote:

However Norfolk Island’s airport is very primitive and only suited to clear weather flying. Nervous flyers should drink their duty free before boarding. Some pilots will not fly to Norfolk Island due to its lack of emergency services and inadequate night time lighting. Norfolk Island's limited airline traffic means it can not justify sophisticated facilities.

Quote:

"It's a piece of rock that sits in the middle of the Pacific Ocean subject to sea fog, and if a plane cannot land it's in deep trouble. Ely said that Flight West, the main Australian carrier serving Norfolk Island racked up $40,000 in costs a month due to flights that could not land and had to return to Australia or New Zealand.

The spin variables between ATSB and CASA reports are mind blowing, that's to be expected; but not really expected from the BoM. The temperature and dew point are very close, the wind is easing and there are clear indications of a bad patch approaching; with NLK being as fog prone as it is makes me wonder why there was no 'FG Prob' on the TAF, or a TEMPO or even an INTER for the later period of the 0700 TAF. The cloud base and visibility are fluctuating, the cloud is being called deteriorating between 1300' and 500' throughout the period. Was this simply the BoM not forecasting, but relaying the automatic information to allow the pilot to do the forecast? It is also intriguing that no one has made a fuel study using SGR and the grid winds, effective TAS at LRC on a Northerly heading to NWWW seems to have been neglected. 0545 TAF OK. - NO PROB FOG ?? 0700 METAR - Not received (9999 FEW 008). 0730 METAR - Not received (9999 FEW 006). 0739 SPECI - Not received (9999 OVC 013). 0800 TAFOR - Not received AMEND (7000 SCT 005). 0801 received the 0630 METAR (9999 FEW 006). *Reported as 6000'.

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* Issue time questioned, expected 0800 METAR?? 0802 received 0800 SPECI (9999 OVC 011). 0803 – NADI HAND OFF. 0830 SPECI – Not received (9999 SCT 005). with NADI. 0841 – ∆ DOLSI – and Auckland contact. BINGO 1. No Met requested or offered?? 0856 SPECI - Not received (9999 SCT 005). BINGO 2. with AUK. Ditto Met. 0900 METAR - Not received (8000 SCT 005). 0902 SPECI - (7000 SCT 005). 0925 SPECI - Not received (6000 SCT 005). 0928 – Contact NLK. 0940 TOD. Climate statistics for Australian locations Norfolk Is to beat fog with $15 billion GPS - Computerworld Recommendation R20000040

#840

Reference page 56 Appendix B of the ATSB report:

Quote:

Flight plan submitted at Apia - METAR YSNF 180430Z 29014KT 9999 FEW008 22/18 Q1010 RMK RF00.0/000.0 HZ METAR YSNF 180500Z 29014KT 9999 FEW015 22/18 Q1010 RMK RF00.0/000.0 HZ Takeoff from Apia, Samoa at 0545 UTC - METAR YSNF 180530Z 29013KT 9999 FEW010 22/18 Q1011 RMK RF00.0/000.0 HZ METAR YSNF 180600Z 31011KT 9999 FEW008 BKN025 21/19 Q1011 RMK RF00.0/000.0 HZ First reported weather observation at 0800 UTC- METAR YSNF 180630Z 30009KT 9999 FEW006 BKN024 21/19 Q1011 RMK RF00.0/000.0 CLOSE TILL 1930UTC (Note: Reported as 6000ft) METAR YSNF 180700Z AUTO 29011KT 9999 BKN017 BKN024 21/19 Q1011 RMK RF00.0/000.0 METAR YSNF 180730Z AUTO 29010KT 9999 OVC013 21/19 Q1012 RMK RF00.0/000.0 SPECI YSNF 180739Z AUTO 29010KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0 Second reported weather observation at 0800 UTC and Norfolk Island TAF

amended at 1803 - SPECI YSNF 180800Z AUTO 29008KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0 SPECI YSNF 180830Z AUTO 22007KT 9999 BKN003 OVC009 20/19 Q1013 RMK RF00.0/000.0 SPECI YSNF 180856Z AUTO 21007KT 9999 SCT005 SCT012 OVC015 20/19 Q1013 RMK

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RF00.0/000.0 METAR YSNF 180900Z AUTO 20007KT 8000 SCT005 OVC015 20/19 Q1013 RMK RF00.0/000.0 SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0 SPECI YSNF 180925Z AUTO 20008KT 6000 BKN003 BKN008 OVC011 20/19 Q1013 RMK RF00.0/000.0 SPECI YSNF 180930Z AUTO 20007KT 4500 BKN002 BKN006 OVC011 20/19 Q1013 RMK RF00.2/000.2 Arrival at Norfolk Island at 1005 - TAF amended at 0958 - SPECI YSNF 181000Z AUTO 18009KT 4500 OVC002 19/19 Q1013 RMK RF00.2/001.0 Ditching at Norfolk Island at 1026 - SPECI YSNF 181030Z AUTO 16009KT 3000 OVC002 19/18 Q1013 RMK RF00.4/002.4

There was METAR/SPECI reports issued for 0700 METAR, 0730 METAR and an 0739 SPECI and yet the METAR that was passed at 0801 UTC was the 0630 UTC METAR. It is interesting to note that had either the 0730 METAR or 0730 SPECI or (preferably both) had been relayed by Nadi then maybe the Captain and FO would have picked up on the trending weather and then possibly made more inquiries which would have triggered Nadi to relay the 0803 Amended TAF and especially the 0830 SPECI which put the conditions below the

landing minima. Kharon I take your points with the dew point split and the INTER/TEMPO. It would appear that BOM have withdrawn a proper forecasting service for Norfolk Island simply relying on

the auto station (for METAR/SPECI). And what is the BOM rule for forecasting PROB FOG? It is interesting when you look at the TAF issued over the period of the flight out and back to Norfolk on page 58-59 of the ATSB report you will see the only time a INTER/TEMPO or PROB was forecast was at 0958 UTC, see here:

Quote:

TAF AMD YSNF 180958Z 1810/1824 26008KT 9999 -SHRA BKN010 FM181500 16012KT 9999 -SHRA BKN010 TEMPO 1810/1824 4000 SHRA BKN005 RMK T 19 18 17 18 Q 1013 1013 1012 1014

Maybe the lax forecasting has something to do with the fact that most aircraft are required to carry an alternate for Norfolk, either way it would appear that there was some critical wx info that was issued but not relayed that could very definitely have helped make an early

decision to divert, especially that 0830 SPECI! The most disturbing thing is that the ATSB missed or chose to ignore these factors in the compiling of their final report, oh that’s right it was outside the ‘scope’ of their

investigation…bah humbug!

#843

Creampuff:

What more should the crew have done, and when, to “source the most recent Norfolk Island

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Airport forecast”, or to “seek and apply other relevant weather and other information”?

Assuming that Airservices still retained the FIS delivery responsibility for NFI at the time of the accident, as per my other posts and reference to the Airservices Act and the Airspace Act, your question could realistically be rephrased to ask what more could Airservices have done? Under the provisions of the Australian AIP Gen 3.3-3 para 2.1, pilots are ultimately responsible for obtaining information necessary to make in-flight operational decisions, however Australian ATC also have an obligation under AIP Gen 3.3-4 para 2.5 to assist pilots in the information sourcing process by broadcasting at regular intervals on appropriate ATS frequencies the availability of "pertinent operational information such as: a.

meteorological conditions and the existence of non-routine MET products etc" . A SPECI and AMD TAF qualify as non-routine MET products. If indeed Australia retains FIS delivery responsibility for NFI, then Airservices should have broadcasted on the appropriate HF frequencies, the availability of the 0739, and subsequent, SPECIs as well as the 0800 AMD TAF. Did Airservices fufil its obligations in this regard and, if not, why not? If Airservices had made the appropriate broadcasts on the appropriate SP6 HF frequencies, then the possibility exists that the flight crew of NGA may have been alerted a lot earlier to the changed and fluctuating weather conditions at NFI and taken appropriate diversion action earlier. Kharon:

The temperature and dew point are very close, the wind is easing and there are clear indications of a bad patch approaching; with NLK being as fog prone as it is makes me wonder why there was no 'FG Prob' on the TAF, or a TEMPO or even an INTER for the later period of the 0700 TAF. The cloud base and visibility are fluctuating, the cloud is being called deteriorating between 1300' and 500' throughout the period.

Good point and another issue that needed to be investigated and commented on by the ATSB, particularly considering that CASA and the BoM worked on a project sometime around 2000, I think, to look at ways of improving met forecasting at NFI.

#845

Creamy in answer to your first question here is a segment from the transcript:

Quote:

Senator XENOPHON: So, regarding the bureau's staffing at Norfolk and Christmas Islands, what is the current position in those two places? Mr Hanstrum: At Norfolk Island there are three observing staff rostered on duty from around seven o'clock in the morning through until— Senator XENOPHON: It is four o'clock sometimes? It could be as early as 4 am? Mr Hanstrum: Normally it is 6 am to 7 am.

Which would appear to gel with the remark on the end of the 0630 METAR; "CLOSE TILL 1930UTC". So from around that time of the day BoM forecasters are totally reliant on the auto wx station, sat pics and synoptics plus the NFI wx radar to produce a forecast (TAF). In terms of the forecasts for Norfolk that were put out, I find the TAF AMD put out 0803 the most disconcerting given the METAR/SPECI info prior to 0803, see here:

Quote:

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TAF issued at 0803 UTC on 18 November 2009 TAF AMD YSNF 180803Z 1808/1824 26008KT 9999 BKN010 FM181500 16012KT 9999 -SHRA BKN010 RMK T 21 18 18 17 Q 1012 1013 1013 1013

Just doesn't seem to fit the pattern of trending weather and when you read the 0958 UTC TAF:

Quote:

TAF issued at 0958 UTC on 18 November 2009 TAF AMD YSNF 180958Z 1810/1824 26008KT 9999 -SHRA BKN010 FM181500 16012KT 9999 -SHRA BKN010 TEMPO 1810/1824 4000 SHRA BKN005 RMK T 19 18 17 18 Q 1013 1013 1012 1014

Kind of like the forecasters in charge of that region have gone to sleep for 2-3hrs to then

wake up and have a "oh fcuk" moment...

By the way the BoM submission has been posted on the Senate submissions page Senate Committees – Parliament of Australia

#851

L6 as UITA says the reporting date has been extended:

Quote:

Aviation Accident Investigations Information about the Inquiry On 13 September 2012 the Senate referred the following matter to the Senate Standing Committees on Rural and Regional Affairs and Transport for inquiry and report. Submissions should be received by 12 October 2012. The reporting date is 29 November 2012. On 20 November 2012,the Senate granted an extension of time for reporting until 27 February 2013. The Committee is seeking written submissions from interested individuals and organisations preferably in electronic form submitted online or sent by email to rrat.sen@aph.gov.au as an attached Adobe PDF or MS Word format document. The email must include full postal address and contact details.

Senate Committees – Parliament of Australia Also worth a download is the supp submission from Mr Richard Davies which more than adequately refutes the ATSB supp submission and evidence given on the 21/11 by the Beaker in an attempt to discredit the Davies original submission: Senate Committees – Parliament of Australia

Good stuff RD you are making the ATSB and CASA look very amateur!

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#852

For those considering making a submission the email from CASA to staff may well prove the prod needed. Section of the CASA email extracted from Ben Sandilands article on the 21st November.

However, do not be dismayed by our vocal but largely uninformed minority of critics; they

are symptomatic of other ills in society. I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material.

Comment. The McCormick email, like the ATSB final report, and its failure to deal openly and in detail with the systemic failings of CASA and Pel-Air, brings the administration of air safety in Australia into disrepute.

Ben's comment is so true. Pel-Air inquiry to get critical CASA-ATSB crash documents | Plane Talking

#860 A three pipe problem.

Quote:

Back at Baker Street, he needs time to think hard about the mystery and says to Watson, "It is quite a three pipe problem, and I beg that you won't speak to me for fifty minutes." Holmes – The Red Headed League.

Indeed the "doc" has a three pipe problem, and probably not enough thumbs to plug all the holes in the dyke. What began as a just routine game of 'bluffing the Senators' is slowly turning into a nightmare. There is simply too much evidence available within the industry which, compiled presents an ugly story that will not just go away, ever. Pipe 1 – By agreeing to be the cats paw the "Doc" is now firmly tied to the sinking ship. Attempting to threaten and denigrate honest critics, while grovelling and slobbering before the Senate, previously treated with open, hostile contempt; is quite a party trick. One of our learned colleagues here recently asserted the Senate can't touch them. Wrong. "He who cannot be shamed" must learn to write his own letters of apology and explanation, not hide behind the "Doc's" skirts. The 'Mc email' was bully's low shot followed by a cowards response, now recanted by the ever faithful if misguided willing accomplice. Hong Kong: anyone? Pipe 2 – Preventing the truth from leaking out. Mission impossible. Certainly not simply because the morale of some of the more sensitive souls at CASA may be damaged. Those sensitive souls should have considered the results of their actions before merrily denigrating and destroying the morale and lives of those affected by their actions. Pipe 3 – The Credibility gap is a yawning chasm which cannot be repaired: no court, tribunal or inquiry can ever safely again rely on the "CASA" version of "facts and circumstances". PA has, for many, proven the lies, deceit, manipulation, arrogance and corruption pudding beyond all reasonable doubt.

For they have sown the wind, and they shall reap the whirlwind: Hosea 8.7.

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#861

It is interesting to take a look at the reference to which the Acting DAS refers i.e. pg 201-202 Hansard Supp Est 20/10/2009. This was the DAS second appearance and second major speech before the Senate Estimates and was given after some deckchair shuffling and much bloodletting. Nowhere is this more apparent than in the name changes, deletions and job titles of those sitting at the FF table:

1st appearance: Thursday, 28 May 2009 Senate Estimates Senate Committees – Parliament of Australia Civil Aviation Safety Authority Mr Peter Cromarty, General Manager Airspace and Aerodrome Regulation Group, CASA Mr John McCormick, Chief Executive Officer Mr Shane Carmody, Deputy Chief Executive Officer, Strategy and Support Mr Mick Quinn, Deputy Chief Executive Officer, Operations Dr Jonathan Aleck, Chief Legal Officer Ms Betty Edwards, Chief Financial Officer Mr Simon Denby, Group General Manager, Aviation Licensing Group

There's a couple of names in that lot which have a couple of bit parts in the PA debacle!

2nd appearance: Tuesday 20 October 2009 Supplementary Estimates Senate Committees – Parliament of Australia Civil Aviation Safety Authority Mr John McCormick, Director of Aviation Safety Mr Greg Hood, Executive Manager, CASA Operations Division Dr Jonathan Aleck, Chief Legal Officer Mr Peter Cromarty, Executive Manager, Airspace and Aerodrome Regulation Division Dr Pooshan Navathe, Principal Medical Officer Mr Terry Farquharson, Executive Manager, Office of the Director of Aviation Safety

Now to the part that the good Doc refers... "Mr McCormick— Before concluding, I would like to make an important point, one that should probably have been made long before now. CASA is certainly no stranger to criticism, complaints and variably informed expressions of dissatisfaction with the things we do and the way we do

them from the diverse industry we regulate, amongst others. I welcome this, as a responsible director of any regulatory authority should welcome balanced, reasonable and constructive advice about where we may have gone wrong, or where we may at least be seen by some to have gone wrong, or where we might do better. Well-meaning criticism can

be helpful, even if it is wide of the mark, and it gives us a better understanding of the way our actions are perceived and experienced. So let me be clear: I have absolutely no interest in discouraging or dissuading our critics

from drawing CASA’s actual or assumed shortcomings to my attention, to the government’s attention, or to the attention of the Australian public. As I said, I welcome and embrace this. At the same time, however, let me be equally clear in highlighting the very significant

difference between candid, robust criticism of CASA’s actions as an organisation and what cannot fairly be characterised as other than mean-spirited, tendentiously self-serving and frequently false accusations about, and the vindictive public disparagement of, individual CASA officers by name and by station.

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This is wrong and unfair and, in some cases, I think it is downright cowardly. It does nothing to advance the interests of air safety or organisational improvement, and it almost certainly is not intended to do either. If left unaddressed, it impugns the reputations and integrity of

committed, capable and professional individuals who are dedicated to the critical, and sometimes thankless, regulatory and other safety related tasks, and it takes a serious toll on the morale of the entire staff in ways that, I dare say, some of those who try to conceal

what is often nothing more than demagogic vitriol behind the facade of a pointed evaluatory critique could not begin to understand. CASA is and I, as the Director of Aviation Safety, am, and all our employees are fully

accountable for our words and actions, including our regular appearances before this committee, Chair. Clearly, these critics have no intention of exposing themselves to anything like the kind of scrutiny to which we are, and should be, subject. Frankly, I seriously doubt whether many of them could withstand it if they were. To those who constantly challenge

CASA to lift its game I say, ‘Thank you and keep it coming.’ To those whose intent is merely to insult, denigrate, vilify and, in some instances I suspect, to defame individual CASA officers, unless and until they might be held accountable for their words and actions, I can

only say, ‘Shame’. Thank you, Chair."

Kharon said: Pipe 1 – By agreeing to be the cats paw the "Doc" is now firmly tied to the sinking ship. Attempting to threaten and denigrate honest critics, while grovelling and slobbering before the Senate, previously treated with open, hostile contempt; is quite a party trick.

I'm not so sure "K"? Given that the Acting DAS (ADAS) could go straight to that reference (2nd DAS speech) and given that the Doc's letter is almost verbatim from that speech, I'd be more inclined to believe that the Doc was the original speech writer and the script for this

play is his script! Certainly food for thought hey?? Doc

#862 CASA executives are feeling gaunt!

Kharon, Well worded my friend with robust factual commentary direct from the River Styx. Good work! Make sure the boat is in working order, the oars in good shape, crew and Captain have their log books in order and the safety briefing cards comply ICAO Annex 6, as more passengers are coming shortly! (Also refer to S.O.P - Rev 20:1,2) Chief Screaming Skull's outburst is part and parcel of his attitude towards others whom he holds in contempt (pretty much anybody who disagrees with him). Fort Fumble have done a good job in decades gone past, dazzling Senators and impressing them with spreadsheets, fluffy mission statements, and so called commitments to all things safe. This round is different. Different Senators, in fact clever ones, ones not prone to being fooled by party tricks and silly pantomimes. This will be third poo poo sandwich he has ingested in recent weeks. The Senators are no mugs and they can see the attitude of this bloke. The 'CAA' have for decades treated industry, Senators and aviation like fools. The game is up. The smoke has disappeared and the mirrors are all broken and the tricks are exposed. And it is funny how they are crying poor over 'attacks' on senior management? As Kharon points out, it is ok for them to bully industry individuals (and staff), bankrupt businesses, gang up and annihilate individual reputations, yet if there is even a resemblance of finger wagging pointed at them it is time to grab the Kleenex? Somebody ought to remind them that they are public servants providing a public service (supposedly) so on that basis they are and will remain in the public eye somewhat. they have a charter to uphold, and they are not doing it. If they don't like the negativity then the answer is simple - Retire and go play lawn bowls or knit cardigans. Otherwise toughen up, lead by example and maybe you will earn a measure of respect.

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#863 Kessel pauken.

Senate Estimates.

Quote:

28 May 2009 : Consultation does not equate to agreement and, while all views will be seriously considered and taken into account, at the end of the day CASA, as the regulator, is responsible for making, and will make, the final decisions. Oct 20.2009: We are committed to full and frank consultation and discussion with all and every comer, but in the end the regulator must make a decision. That decision must be legal, in the interests of the Australian public, and must be a decision made with the thought in mind that CASA and the associated processes decide, not the industry. 28 May 2009 : So let me be clear: I have absolutely no interest in discouraging or dissuading our critics from drawing CASA’s actual or assumed shortcomings to my attention, to the government’s attention, or to the attention of the Australian public. As I said, I welcome and embrace this. At the same time, however, let me be equally clear in highlighting the very significant difference between candid, robust criticism of CASA’s actions as an organisation and what cannot fairly be characterised as other than mean-spirited, tendentiously self-serving and frequently false accusations about, and the vindictive public disparagement of, individual CASA officers by name and by station. Oct 20.2009: I have delivered the message to our staff that CASA is a regulator, that ‘regulator’ starts with the letter R and that, in my opinion, it is a capital R. That means neither that we bully all until they submit, nor that we abandon consultation with the industry. Indeed, consultation is specifically required by the act. But it does mean consultation, and not endless attempts to reach consensus. 28 May 2009: CASA is and I, as the Director of Aviation Safety, am, and all our employees are fully accountable for our words and actions, including our regular appearances before this committee, Chair. Clearly, these critics have no intention of exposing themselves to anything like the kind of scrutiny to which we are, and should be, subject. Frankly, I seriously doubt whether many of them could withstand it if they were. To those who constantly challenge CASA to lift its game I say, ‘Thank you and keep it coming.’ To those whose intent is merely to insult, denigrate, vilify and, in some instances I suspect, to defame individual CASA officers, unless and until they might be held accountable for their words and actions, I can only say, ‘Shame’. Thank you, Chair. Oct 20.2009: I will stress: this is no criticism of anyone past or present. To further these aims, we are in the process of writing a governance manual for all parts of CASA. Beneath this manual will live all our policy and procedure manuals, going a long way to ensuring consistency. To facilitate this, some rearranging of our structure will be necessary. Oct 20.2009: As a regulator, we should be able to be approached and all our activities should stand the test of scrupulous probity. Oct 20.2009: It will allow the industry to receive more consistent interpretation of legislation and directives. Oct 20.2009: These changes, such as the increased emphasis on governance, will directly address some concerns raised by the Senate inquiry in the aviation green paper. Oct 20.2009: CASA is required to carry out surveillance which, on one level—that is the level that is best generally understood—involves physical presence on an aerodrome and the actual inspection of aviation activities that are being undertaken. Given this fact, and

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viewing all information at arm’s length, I am unable to reconcile a decision to close Townsville with the superior desire to increase surveillance. Oct 20.2009: The future of aviation in Australia relies on the success of general aviation. To be blunt, if we kill GA, we kill aviation and many other activities that rely on it. In summary, I look forward to contributing to the ongoing success of aviation in Australia. I cannot do anything about the past, but I can do a lot about the future, and that is what I intend to do. Thank you for your polite indulgence.

No bolding, no highlighting, just a comparison between Senate speak and the stark realities of life. Like six people dog paddling for their lives in a dark dangerous ocean after surviving a ditching impact; an industry living in fear, the Regulator living off the fat of the land and GA on it's knees. Perhaps we should all just shut up now, lest we delusional, dysfunctional, bullying hypocrites be accused of upsetting the rosy garden. Can't have morale affected, can we now; perhaps, a consultation with the truth then? - No. Then what about with Quadrio and others?– Nah - why am I not surprised?

#864

The concern I have is that there does not appear any mention of proportionality, procedural fairness and natural justice when it comes to perceived offenders - the excuse given for the lack of these general administrative requirements is "safety".as a very minor public servant, I lived in perpetual fear of the auditor general, as did the rest of us. Our protection was rigid and careful compliance with written policy and procedures such that a complete audit trail of every decision was available to the AG or anyone else. What mystifies me is the apparent total lack of standardization and written policy and procedure in CASA. For example, I fail to understand why a standard template for the entire suite of documents to gain an AOC for typical operating organizations, for example a small flying school, a small sight seeing operation, SE piston charter, etc. is not available to the public on the CASA website, and that adoption and compliance with such a template automatically ensures CASA approval. Same goes for typical add ons - the system should be modular and cross referenced with the regs. But most importantly standardized right across the country, as should be all inspection and operating criteria. For example, how the f@/-( in 2012 can there be ANY shadow of doubt about the conduct of simulated engine failures? To put that another way, it is not the technical detail that actually matters, it is what practice a CASA FOI is required to adopt that is important and it should be the same right across Australia and from top to bottom. To put that yet another way, CASA itself stated that it's FOIs were evenly divided on the question of alternates in the Norfolk Island ditching. This state of affairs is bureaucratically INTOLERABLE and must be immediately addressed. Better still if the FOI community is divided on any other issues this should be rapidly discovered and immediately fixed. Bureaucrats are required to be consistent in all their decision making.

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#870 The problem is that the sum of the individual parts in the system does not produce a whole that is competent to deal expeditiously and appropriately with everything with which the system is expected to deal. In that kind of system, the expedience of the ‘blame the pilot’ line in the Pel-Air ditching is, understandably, irresistible, but undesirable. Each of the individuals in the system disclaims responsibility for the system’s failure to deal competently with, for example, completion of the regulatory reform program, following up recommendations arising out of investigations and coronials, and ensuring there’s clarity of AIS information responsibilities for aircraft inbound to Norfolk. Bob was overseas at the time, George was in a different job at the time, Fred only joined a year ago. From the Hansard of the 22 October 2012 hearing:

Quote:

Senator FAWCETT: There is actually a broader issue, though, Mr McCormick. There is no closed-loop system so that recommendations that are made by ATSB, that CASA agrees—particularly we have seen a number where, in a coroner's court, the coroner has said, 'We'll close out this issue, because ATSB made a recommendation and CASA said they will do it,' and then a decade later there is has been no action. Is that an issue for the travelling public? I hear you that you were not there for that whole 10 years, but we are talking about a system now, not personalities. Is the system not working as it should? Mr McCormick: I cannot speak for what happened in 2000. I only got here in 2009. … Senator FAWCETT: Mr Boyd, were you around? Mr Boyd: Yes, but not in that position. Senator NASH: Anybody else? Mr Farquharson? Dr Aleck? Dr Aleck: I was in Montreal. [CP note: Apart from the stint in Montreal, Dr Aleck has occupied various senior management positions within CASA for an accumulated period of about 10 years to the present.] [CP Note: Messrs Farquharson and Anastasi, both of whom have been in CASA for all or most of the period 1999 to the present, were also at the table but, according to Hansard, remained silent.]

So there we have a sizeable chunk of the senior management of CASA, including the person who’s in effect CASA’s PIC, and each of them considers himself to have no responsibility for a commitment made by CASA, on the public record, which remains unfulfilled 10 years later. There are numerous other examples. By implication, each of those persons, including the CEO, is saying it’s not his responsibility to inform himself of, or to progress the resolution of, any issue, except for the ones that land in his own ‘in’ tray after arrival in his current position. The Committee got effectively the same line from Airservices. That commitment was made before I took over as CEO. Why would it be my problem? It was my job to deliver on that commitment, but I moved to a different job in the organisation before it was delivered. Why would it be my problem? I was aware the commitment was made, but I didn’t move across to the job of delivering on those kinds of commitments until later. Why would it be my problem?

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We’re all aware that the commitment was made. Someone (else) will (hopefully) get on with doing something about, soon. Airservices witness one day: We’re waiting for a safety recommendation. ATSB witness a different day: We don’t issue safety recommendations, because proactive action to address safety issues is more effective. No one’s lying. Everyone’s doing their blinkered bit to the best of his her abilities. But that’s not good enough, because no one’s responsible for patently obvious systemic problems (unless you're the PIC of NGA...) That is why the Committee – the whole Committee – is so frustrated and astonished by what it’s hearing. #871

Mr McCormick: I cannot speak for what happened in 2000. I only got here in 2009. … Senator FAWCETT: Mr Boyd, were you around? Mr Boyd: Yes, but not in that position. Senator NASH: Anybody else? Mr Farquharson? Dr Aleck? Dr Aleck: I was in Montreal. [CP note: Apart from the stint in Montreal, Dr Aleck has occupied various senior management positions within CASA for an accumulated period of about 10 years to the present.]

The technical name I was taught in organizational behaviour at business school is "diffusion of responsibility". The best historical example I know was the debacle of the treatment of the British sick and wounded in the Crimean war - over which Florence Nightingale made such a fuss. The eventual royal commission found that the entire mess was caused by the non arrival of a shipment of hay, due to stress of weather. So no one was to blame, it was an act of God. But lets cut to the chase. Is it not "troubling", perhaps even hypocritical, that an organisation like CASA, which preaches and administers criminal sanctions for aviation offences of strict liability, and which sheeted home the entire blame for the Norfolk Island crash on the pilot while allegedly deflecting and concealing any criticism of its own role, should opine that "no one is to blame" for its own administrative shortcomings????? Are not its own administrative mistakes, when they occasionally happen, offences of strict liability? Does it apply the same standards to itself as it demands we apply to our own operations? To put that another way: Perhaps if CASA could issue itself with a "request for corrective action" (RCA) as it does to any participant in the rest of the industry whose performance it judges as less than stellar, its own alleged problems would be speedily fixed. Physician heal thyself.

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#872

perhaps even hypocritical

From my perspective, there’s more than a whiff of hypocrisy in Mr McCormick disclaiming responsibility for the outcome of pre-existing systemic issues in the organisation of which he has been CEO for over 3 years, on the one hand, and on the other hand insisting that the PIC of NGA must bear sole responsibility for the ditching despite the patently obvious pre-existing systemic issues that contributed to that outcome. The average lifespan of the CASA CEO/DASR is 4 to 5 years. Mr McCormick is therefore likely to be gone, soon. (Sooner, if he continues to lead with his chin.) And that’s one cause of the systemic problems. #873 Interesting Observation

Throughout this whole sorry tale it is interesting that the one document that demonstrates the inadequacies of both the ATSB "investigation" and the regulator's past and present deficiencies was the special audit of Pelair that ran concurrently with the investigation. Of course blind Freddy could assess the ATSB output and call it the crock that it is but it is another thing in an organisation (I'm using the word loosely) like CASA to draw attention to obvious flaws in previous oversight of that and other operators. Not the best career move. From what I heard one of the audit team got a "well done" and is now being shafted for some mysterious reason.

#874

Throughout this whole sorry tale it is interesting that the one document that demonstrates the inadequacies of both the ATSB "investigation" and the regulator's past and present deficiencies was the special audit of Pelair that ran concurrently with the investigation

FS what is more interesting is that although, as you say, the audit and investigation ran concurrently there was no swapping of information between the two teams. The fact that the ATSB have only been given a copy of the SAR in July this year over 2.5yrs after the report was first produced stinks of a major cover up. However it can be explained because the ATSB and CASA were running a parallel investigation (as per the MOU) and therefore the ATSB relied on the CASA investigative team (ALIU) to give a summary of the findings of the Special Audit. The bigger question that needs to be asked is if the Special Audit Team had the bases covered for any possible enforcement action to do with the company management, pilots etc..etc why then deploy an investigative team at all? Although the accident had the potential to be very serious with possibly up to six fatalities the potential violations would seem to be encompassed by the remit of the special audit team. Supposedly the investigative team carry out accident investigations when there may potentially be signs of breaches of the Act that could lead to criminal or administrative charges. So the investigators are essentially compiling a report that could end up being the basis of a brief of evidence. However if you read the CAIR 09/3 it doesn't draw on any evidence chain, document exhibits, use any forensic analysis (especially as they refused to recover the CVR/FDR), basically that report reads like a 'bare bones' version of the ATSB Final report except it was

produced over two years before!

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#875 It's a puzzle.

Quote:

FS # 990 –"From what I heard one of the audit team got a "well done" and is now being shafted for some mysterious reason".

The questions posed by the inestimable Sarcs very subtly give you all the clues and points out various rocks which need to be turned over. Examine them further against the known 'modus operandi' of the infamous Sydney regional office and the management situation within that office. To do so 'publicly' would require the Senate to widen the scope of the current enquiry and provide protection to those who know the 'facts'. The answers are there, it's a question of getting the RRAT to the point where they can understand the need to expose the underlying reasons for the current mess. There is only a tissue thin layer between the Senate and an accurate appraisal of exactly what happened, and why. Consider a hypothetical scenario:- after the event, the standard make CASA shine response from Sydney was to 'develop' a 'hand crafted' brief, designed to destroy the operator and the pilot. This is done by the amplification of various breaches to ensure they become "Breaches" (SOP). The Breaches are then 'fitted' into various parts of multiple, assorted laws and – hey presto, you have your neatly packaged 67 serious 'safety' items available for use in the AAT. Crucifixion details complete. Then comes the curve ball, for some reason the crucifixion is cancelled and a tea party is ordered instead. But what to do with all this lovely paperwork and the honest men who compiled it? The rest you know; Sarcs is on to it. But will the truth ever surface from under the paper mountain?; that friend Spike is a bloody good question.

Quote:

"You will not apply my precept," he said, shaking his head. "How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth? - Holmes – The Copper Beeches.

#

876

one of the audit team got a "well done" and is now being shafted for some mysterious reason

. Which audit team Mr Spike? The special audit team or the less competent audit team? If you refer to the special audit team then that may be the very problem Mr Spike. If one does their role correctly and professionaly it could make the more senior yet incompetent folk there look even more stupid? It could also be frowned upon that a robust in-depth audit took place because that can result in a lot of deficiencies being aired, which in turn could lead to more work for the regulator to undertake, and they wouln't enjoy that would they? It may also make the regulator appear to be incompetent of not doing it's job correctly if an Operator has excessive findings. So it is probably no surprise that the special audit has actually backfired on CASA from that perspective. Hence the alleged shafting of one of the auditors. Is that CASA's version of 'just culture 101'? It looks as if the real issues, the bigger problems in the place stem from the top tier rather than the frontliners. Cut away the chaff at the top and some robust wheat may shine from underneath?

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On a final note, my guess is that at the end of the day as long as the executives receive their bonuses and huge salaries they won't care what happens to the audit team anyway. And can anybody out there explain what CASA managements bonuses are based upon? Even better, can anybody explain why they receive bonuses in the first place? On some of the data posted on prune I have worked out that almost 800k was paid out in bonuses last financial year? It certainly can't be based on performance that is for certain? How is it quantified? What are each persons KPI's and/or measurables? The DAS earns roughly the same as the Prime Minister (who by the way is also overpaid). His minions are not far behind. That these guys get paid so high and get bonuses is beyond belief and beyond reasonable. Time for the Senate to recommend an overhaul of that lucrative set-up don't you think? Might be time for the business class travel perk for the executives to be removed as well, and make them travel on the cheapest economy fare of the day, like all the other plebs have to. It might help Swanny in his quest for the almighty surplus. #886 # SMS - ATSB report.

Quote:

An ATSB review of the effectiveness of safety management systems in Australia completely contradicts the position in took its much criticised final report into the crash of a Pel-Air medical flight near Norfolk Island in 2009.Ben Sandilands – Plane Talking.

#887 Answers to Questions on Notice for the RRAT Senate Pel-Air Inquiry hearing (21/11/12) have been posted:

Quote:

2 Answers to questions taken on notice on 21 November 2012, in Canberra;(PDF 4052KB)

Link: Senate Committees – Parliament of Australia There are some very interesting revelations and discrepancies in the answers/documentation

provided, hopefully the good Senators and their staff are all over this?? One of the most outstanding pieces of spin and attempted obfuscation is contained within the answer to ATSB QON 8:

Quote:

8. HANSARD, PG 21 CHAIR: Mr Dolan, could you assist the committee by giving us the date on which the decision was taken in the ATSB to downgrade the report from intolerable to broadly acceptable? You can take that on notice if you like. Mr Dolan: I will take that on notice. Mr Dolan: I will take that on notice. ATSB response: Early in the investigation, initial information indicated that there was a safety issue and the ATSB wrote to CASA about that issue. Subsequently, CASA brought additional information to the attention of the ATSB that they believed mitigated the level of risk associated with the safety issue. Additionally, during the interim period, the ATSB was gaining a better understanding of the interaction of the individuals/organizations involved. As the investigation and report underwent reviews within the ATSB the safety issue remained open.

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The day the Commission approved s25 release of the final report, on 16 August 2012, was

when the safety issue was formally re-classified as a minor safety issue.

The last documented correspondence between the ATSB and the CASA ALIU Manager is dated 26/03/2010 on the ‘critical safety issue’. What that effectively means is that, despite the spin in the answer to QON 8, this ‘critical safety issue’ wasn’t acquitted or downgraded for nearly 29 months. I don’t know about anyone else but that ‘fact’ alone should require

several heads on sticks…sheesh! Another disturbing fact is that the extremely well researched and factual report compiled by the ATSB Pel-Air investigative team into the ‘critical safety issue’ was completely omitted from the ‘Safety Action’ section of the ‘Final Report’, where all it reads is this:

Quote:

Fuel planning and en route decision-making Minor safety issue The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

So in effect all the good instructive safety information contained within “Attachment One to ATSB letter AO-2009-072 of 26 February 2010” would have been lost forever had it not been

for this inquiry. It is also interesting to note that had the ATSB issued a safety recommendation, like they did in the good old days (pre-Beaker), for this ‘critical safety issue’ that it would have been totally transparent and placed on the ATSB database for the rest of the world to peruse and learn from. It would also have meant that CASA would have been forced to respond/acquit

the ‘CSI’ (do you like that?) in a timelier manner!

# #894

I'm afraid I know where all this ends: The ATSB slides into complete irrelevancy and operators take their cues from overseas regulators. If you keep producing garbage, no one will take any notice of it because they can't learn anything of value from it. When, not if, there is a major accident with great loss of life, there are Five certainties: (1) The ATSB will conceal evidence and cover its backside. (2) CASA will cover its backside, most probably by blaming the pilot. (3) Air Services will cover its backside, (4) Any airport and airline involved will cover their backside. (5) Everything possible will be done by the Minister and his Department to suppress honest reporting and conceal the truth from the Australian Public.

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#898 OBR, CVR and FDR.

Suitably fortified with a large slice of Christmas pudding and a bottle of Ireland's finest I had another look at the fuel issues which have caused much throwing of toys and squabbles within the rank and file. First thought was of the Caribbean incident and the NTSB approach – the aircraft had a 4.5 hour supply of fuel on board, which was exhausted after 4.6 hours – "furry muff" sayest the guru's of NTSB; "now lets find out why". Not so with the Norfolk night swimming championships. I must say the Davies fuel burn effort was at least logical, believable and nicely done; but as for the rest, well. But, that said I wondered why the fuel squabble generated so many pages of assumptions and rhetoric. All the questions and guess work could have been avoided had the actual OBR data from the flight and previous flights been examined to accurately determine the fuel status of the aircraft. There are now three "expert" fuel burn analysis (by assumption) on record and not a shred of hard data for any, not even an analysis of the grid winds and temperature for the day offered in support. This of course lead to other questions like: why is there no company or pilot supplied version in defence?; and why was the On Board Recording device (OBR) not recovered? So, to a reading session; the TSI Act 2003 (Part 6 :48-58) and the Civil Aviation Act 1988 (section 32 AO-AU). Note that CASA "intended" (bluffing) a prosecution and from the 1988 Act you can see that only the Cockpit Voice Recorder (CVR) is of interest, strictly in a prosecution only sense, not the rest of the On Board Recording devices (OBR). The TSI includes the lot. I still wonder why the "Black box" was not recovered, the combined unit would have provided an independent eye witness to the events. We are obliged by law to install and keep serviceable the "boxes": not recovering the thing makes it pointless to do so. The report is happy with 'edited' transcript and 'expert' opinion. I guess expecting the facts and evidence to support assumption are not required in the modern era of investigations. CASA and the ATSB have dreamed up some bull about there being 'enough' evidence without the CVR/FDR; and yet questions are stll being asked against spin, speculation and assumption. We have three independent witnesses to the event ignored, unheard and buried under a mountain of paperwork; the CVR, the FDR and the co pilot. It would be a brave judge who made a ruling without hearing all the witnesses. #899

Interesting post “K” and highlights yet another unexplained and unresolved, tainted area within the remit of the Pel-Air enquiry that hopefully hasn’t got past the attention of the good Senators. A quick Sunday afternoon google search for unrecovered blackboxes turns up a list total of twelve (I guess soon to be 13) from 1965. Some of those cases it wasn’t from a lack of trying to retrieve them. And sometimes they were totally or partially destroyed or lost. The irony of the Pel-Air Norfolk ditching is that if the crew and pax had of perished then the bureau and FF would have been obligated to recover the blackbox! Besides being a rather embarrassing retraction by the DAS and points to the question whether the DAS is indeed the puppetmaster or the puppet, the following is interesting in the context of the unrecovered blackbox:

Quote:

At page 41 of the Hansard from Monday 22 October it was stated:

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CHAIR: So your department had no part, no conversations, in the recovery of the black box? Mr McCormick: No, Senator, we did not. CHAIR: No input at all? Mr McCormick: No, Senator. I have since been advised that this statement is not correct. On 8 December 2009 the ATSB raised with CASA by email the possibility of contributing to a joint fund sharing arrangement to recover the black box and was advised that CASA did not have the funds to contribute to that exercise. I was not aware of this email at the time of my advice to the Committee. I apologise if my comments have been in any way misleading.

Besides the fact that the Hansard reference to which he refers is actually located on page 53 this revelation may call into question some of the issues that Kharon raises in post #961. § How can it be that FF doesn’t have the necessary funds and where’s the cost/benefit/analysis? § As “K” infers could it be that FF legal considered the CVR information could be detrimental to their case of trying (initially) to prosecute the pilot under S20A of the Act and given the protections section 32 AO-AU afford the flight crew? § Could it also be that FF were aware that had the blackbox been retrieved then the bureau would have full and privileged control over the CVR/FDR information as per the TSI Act? The DAS revelation would have been a contributing factor to bean-counter Beaker’s ultimate decision not to recover the black box, which he explained to the committee on page 67 of the Hansard:

Quote:

Mr Dolan: At the initial stages, we understood the aircraft was in comparatively shallow water and that access to the recorders would be reasonably achievable by a diver or other mechanisms without too much difficulty. That brief was to convince me to make the necessary allocation of resources to retrieve the flight data recorder and the cockpit voice recorder. Upon investigation, it became clear that the depth at which the aircraft was in the water, its location at a remote island, Norfolk Island, and the work health and safety standards applying to diving to those depths meant that there would have been a substantial cost of recovery. The requirement was effectively that there be a decompression chamber, none of which was available on Norfolk Island, for the full time of the retrieval because of the depth at which the divers would be operating. When we got a reasonable and first approximation assessment of that, in the knowledge that, from our point of view, the key information we had about flight decision making would not have been recorded on the cockpit voice recorder which only had a two-hour time on it—

You got to say what a load of bollocks! And what about the FDR, surely the invaluable information that it holds over a 100hrs of ‘power on’ was worth the cost of retrieval

alone?? Not sure about the FA2100 combined CVR/FDR but a lot of FDR’s these days have so many more flight system parameters measured/recorded. Whose to say if fuel flows, fuel burn etc wasn’t recorded not to mention (as “K” said) actual winds aloft, ground speed etc..etc. Even PTT actuations, which could have possibly shown transmissions that weren’t received or recorded by ATC. The list isn’t endless but there is a

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100hrs of possibly relevant information that is still sitting on the ocean floor. Hopefully the good Senators are all over this because it certainly is an area that raises the

stench of this whole Pel-Air debacle to an extreme level!

#

900 Gotta love Google.

Sarcs #954 –"A quick Sunday afternoon Google search for unrecovered black-boxes turns up a list total of twelve (I guess soon to be 13) from 1965. Some of those cases it wasn’t from a lack of trying to retrieve them. And sometimes they were totally or partially destroyed or lost".

Good catch Sarcs, the rest of the world seems to be able to make an effort, mostly successful it seems to recover "hard" evidence. I couldn't find a copy of the ATSB policy or investigators manual, but the Canadians and the NTSB seem to have no problem making public theirs :- NTSB Investigators Manual. From page 156 (PDF) – there are guidelines for OBR which make no bones about how important the recovery of the CVR etc. is to their investigations, most refreshing attitude. Now I know the manual is 'dry' reading, but there is some really good stuff tucked away in the 'procedural' parts worth cherry picking, just for reference. I also found this from an interview with NTSB 's James Cash:-

Would the thing even spit out anything useful after four months in salt water? While we can’t answer the first question, we talked to James Cash, chief of the vehicle recorders division at the National Transportation Safety Board, to get some answers to the latter two. Cash also says it is absolutely possible that a plane’s black box would still be in working condition after four months on the ocean floor. The current record goes to a recorder that, after nine years at the bottom of the Mediterranean, was perfectly fine. “The water, in general, doesn’t hurt them at all,” Cash says. “It’s the air that hurts them once they’ve been wet. It starts the corrosion and rust process.” Once the black box is found at a wreckage site, it’s transferred to the lab in a water-filled cooler so the data can be retrieved and copied right away. So although we know Widmore has the black box, we’re still not entirely sure he has a copy of the data that it recorded. According to Cash, it only takes a few days before the leads on the SSD start to corrode. The exact time that needs to pass before the data’s not retrievable is unknown. “I would say a couple of days,” Cash says, agreeing that a month out of water is probably sufficient time to render the black box useless. “We try not to experiment with that so I don’t know if I have a good answer. But if you let it dry out for quite a period of time, it’s going to make [data] much more difficult to recover.”

Cash interview.

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#906

Kharon good catch on the NTSB investigator’s manual, although very dry reading it is worth the time to read and there are some extremely relevant sections when comparing to the

ATSB investigation process. Trying to find the ATSB equivalent is a totally different matter, although it is listed here: Operational information But it appears to be spread across multiple volumes and you also have to pay for the privilege to access, still the FF equivalent referred to several times in their Enforcement Manual as the ‘Investigators Manual’ is either a work of fiction or buried somewhere in Flying Fiend’s basement?? Anyway back to NTSB CVR/FDR and wreckage recovery priorities reference (‘Wreckage Recovery’ pg 57 and CVR/FDR pg 79, pg 155 onwards)…. As the NTSB investigator’s manual displays the retrieval, protection and analysis of the CVR/FDR is given maximum priority in the conduct of their investigation. I have no doubt the NTSB would have moved heaven and earth to retrieve the blackbox from VH-NGA and probably any other parts of the aircraft that they thought would be relevant to their

investigation i.e. ‘no stone unturned’. This extract from the NTSB manual is also of particular interest in regards to information that the FAA (not including the ATC section) are required to provide to the NTSB:

Quote:

Federal Aviation Administration Information (1) "Blue Ribbon" medical and pilot certificate records. (2) Violation and other certificate actions on flightcrew and airline. Obtain certified copies. (3) Inspections performed on the airline during the previous 12 month period including base, ramp, en route, ground and flight training program, crew member; dispatcher records (including flight and rest), trip records, dispatch center/flight following/flight/locating facility. Obtain certified copies. (4) Latest regional inspection performed. Obtain a certified copy. (5) Latest national inspection performed. Obtain a certified copy. (6) Frequency of surveillance. Compare the number and types of inspections performed with regional and national inspections guidelines. (7) Workload of POI. (8) Background and qualifications of POI. (9) Authorized and current staffing level of district office. (10) Most recent pre-accident/incident flight inspection and post flight inspection results of pertinent en route and approach facilities/aids. Obtain certified copies. (11) Most recent pre-accident/incident airways facility inspection and post inspection or pertinent en route and approach facilities/aids. Obtain certified copies

Talk about transparency and independent authority …begs the questions; Q1/ If Fort Fumble were required to provide all of the above would we even be having this

enquiry?? Q2/ If the ATSB had the same head of power as the NTSB and were operating to a similar investigator’s manual would the ATSB have produced such a flawed, defective ‘Final Report’

in the first place??

Certainly food for thought!

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#917

HMHB in reference to your mentioning the Hempel inquest perhaps the ATSB could of

utilised the RAN to raise the Yak?? Also relevant to the Hempel accident and from the NTSB investigator’s manual is a memo put out by the NTSB Director of the Office of Aviation Safety back in 1991, the subject being the “Implementation of Selective Criteria Policy”, here’s an extract from that memo:

Quote:

A review of our investigative activity has revealed that although the overall number of accidents are down, our number of field investigations remains relatively constant. Of more significance is the finding that many of these field investigations involve types of accidents that historically and predictably have no safety impact. They very seldom result in anything other than the determination of probable cause. Accidents that involve experimental, amateur built and aerial application aircraft fall in this category. Because the FAA is required to investigate these accidents to satisfy their obligations, we developed an agreement with them to delegate the investigations when their workload permits. This delegation process has not always been consistent in the number and types of accidents delegated nor in the quality and timeliness of the completed reports and a more uniform application of delegations is needed. Therefore, in the future, no experimental, amateur built, or aerial application accident will be done as an NTSB field investigation unless there are unusual circumstances that the regional director feels justify the field investigation, and that action has been coordinated with either AS-1 or AS-2.

Although that sounds similar to the way the ATSB prioritise their investigations there is some very notable differences in their actual selective criteria list:

Quote:

2. Selected emphasis areas: a. Part 91 accidents with elements common to Part 121/135 operations (e.g., aircraft typically used in Part 121/135 operations; Part 121/135 training flights, etc.). b. All fatal general aviation accidents.* c. Commercial passenger flight incidents with safety improvement potential. d. Air traffic control incidents with safety improvement potential. e. Aging aircraft. *The Safety Board, through a letter of agreement with the FAA, delegates the investigation of all agricultural, home-built, and experimental category aircraft accidents to the FAA. However, for those cases in which the FAA does not accept a delegated accident, the Safety Board must perform the investigation.

Although I can’t imagine the ATSB ever delegating an investigation to CAsA it is apparent from the above that had the NTSB been notified of the Hempel accident and the FAA (FF) refused the delegation, then the NTSB would still be obliged to carry out the field investigation. And even if the FAA (FF) accepted the investigation delegation the NTSB still keeps an element of control or supervision over the investigation:

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Quote:

When an accident is delegated to the FAA, it will be the regional director's responsibility to make sure the delegated accidents meet minimum quality control and timeliness standards.

Which is very different to the Hempel investigation where the ATSB and CAsA totally wiped

their hands of the matter. Just like the CVR/FDR issue with Pel-Air the ATSB should have been obliged to salvage the wreckage. With the relevant history of prangs in the Yak (FOD jammed controls etc), I have no doubt that the NTSB would have recovered the wreck regardless of whether the investigation had been delegated to the FAA (or in the Hempel case the QPS Forensic Crash

Unit)!

No as HMHB says it is going to be an interesting month and a half!

#918 VH-NGA OBR 49er’d ?

Further to the non-recovery of the blackbox, section 49 of the TSI Act reads:

Quote:

49 OBR ceasing to be an OBR under declaration of ATSB (1) The ATSB may, by published notice, declare that a recording, or a part of a recording, identified in the notice is not to be treated as an OBR on and after a date specified in the notice. (2) If the ATSB decides not to investigate the transport safety matter to which an OBR relates, the ATSB must, by published notice, declare that the OBR is not to be treated as an OBR on and after a date specified in the notice. (3) If: (a) the ATSB decides to investigate the transport safety matter to which an OBR relates; and (b) the ATSB is satisfied that any part of the OBR is not relevant to the investigation; the ATSB must, by published notice, identify that part and declare that part is not to be treated as an OBR on and after a date specified in the notice. (4) The ATSB cannot revoke or vary a notice published under this section. (5) When an OBR, or part of an OBR, ceases to be an OBR because of a notice published under this section, then any related OBR information also ceases to be OBR information.

Q1/ Given Beaker’s decision to not recover the blackbox and that the Final Report has been published, have the ATSB effectively 49er’d any useful evidence contained on the OBR? It would appear from the TSI that if the OBR has been 49er’d then even if the Pel-Air investigation was miraculously re-opened then two eyewitness statements would be regarded as inadmissible evidence. Which probably suits the likes of Fort Fumble and the

operator but may not please the victims and the interested insurance companies.

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Q2/ However could this also mean that any interested party can now recover the OBR devices or is the wreckage still effectively quarantined by the ATSB? Q3/ What would be the legal implications if the wreck and OBRs have been written off by the ATSB and someone, say an insurance company or two, salvaged the wreck/OBR devices i.e. could the OBR evidence then be used in any legal action? The more that is revealed, or rather not revealed, of this sordid tale the more the pile of pony pooh grows, as flight nurse Karen Casey said: “CASA & ATSB have a lot to answer for, dragging this on for selfish intent is criminal & at the least cruel to all on board. The coverup

is surfacing and all will be revealed about the incompetency's of all parties involved.” One can only hope she is right and to quote her again they… “Just stop the B.S & tell the

truth.”

#919

Here here.

Sometimes I sits and thinks – sometimes I just sit. ATSB - Ben Sandilands – Plane Talking.

#920

So Beaker’s mob prattles out this: Under reporting of occurrences But in the enquiry environment Beaker wants us to believe his justification for decimating the once obligatory ‘Safety Recommendation’ is as stated in the following Beakerised policy:

Quote:

From ATSB supplementary submission 2[1]: Managing safety issues and actions Traditionally, accident investigation agencies produce final reports and issue safety recommendations to other organisations or individuals, to encourage change in order to prevent a recurrence of an accident. Further, performance targets are often associated with the number of recommendations issued by investigation authorities. The focus of an ATSB investigation is on achieving safety outcomes; that is through the identification of the factors that increased risk, particularly those associated with ongoing/future risk (safety issues), such that action can be taken by relevant organisations to address the identified 'safety issue'. This does not in itself require the issuing of safety recommendations, although that is an option. Noting that safety recommendations are not enforceable, the issuing of a safety recommendation in itself may not achieve any tangible safety benefit, if the target organisation elects not to accept and react to the recommendation. In this regard, the ATSB prefers to encourage proactive safety actions that address the 'safety issues' identified in its reports. Other benefits of this approach are that the stakeholders are generally best placed to determine the most effective way to address any 'safety issues' and the publication of the safety actions that address an issue proactively should be viewed as a positive step that provides for timely safety action prior to the release of the report and a level of completeness when the final report is published. This approach is reflected in the difference that Australia has filed with respect to Annex 13 para 6.8. The response to a safety recommendation is most often unlikely to be any different to the safety action reported by an organisation in response to an identified safety issue, but the latter is likely to be more proactive and timely. That is specifically the case with respect to the Norfolk Island investigation, where the responses to any formal safety recommendations

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to CASA and Pel-Air related to the two identified safety issues, are likely to be as per the safety action detailed in the report. The ATSB is in the process of redeveloping its website to be 'safety issue' focused rather than 'recommendation' focussed. The point of importance is that the safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required. The ATSB's Safety Investigation Information Management System (SliMS) provides tools for investigators to record and track safety issues and actions, including through the setting up of alerts to prompt periodic follow-up of progress with safety action where a safety issue is open and the safety actions are being monitored (the same process applies if a recommendation were issued). In addition, a standing agenda item is included in the quarterly Commission meetings to review safety issues and actions during the previous quarter, with particular focus on those that remain open. The ATSB's Annual Plan and part of the ATSB's Key Performance Indicators specifically relate to a measurement of safety action taken in response to safety issues; in the case of 'critical' safety issues, the target is for safety action to be taken by stakeholders 1 00% of the time, while for 'significant' safety issues, the target is 70%. For the FY11 /12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.

(NB Carefully read this passage a couple of times and try to understand the Beaker logic,

stuffed if I can!)

Hmm…clear as mud yet??? WTF? Beaker’s left hand appears not to know what his right hand is up to, although after

reading this crap I think I’ve got a pretty good idea! The “Managing safety issues and actions” extract also seems to conflict the importance the TSI Act places on the ‘Safety Recommendation’: "25A Responses to reports of, or containing, safety recommendations (1) This section applies if: (a) the ATSB publishes a report under section 25 in relation to an investigation; and (b) the report is, or contains, a recommendation that a person, unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action. (2) The person, association or agency to whom the recommendation is made must give a written response to the ATSB, within 90 days of the report being published, that sets out: (a) whether the person, association or agency accepts the recommendation (in whole or in

part); and (b) if the person, association or agency accepts the recommendation (in whole or in part)—details of any action that the person, association or agency proposes to take to give effect to the recommendation; and (c) if the person, association or agency does not accept the recommendation (in whole or in part)—the reasons why the

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person, association or agency does not accept the recommendation (in whole or in part)."

Maybe the Beaker regime is breaching the TSI Act….what a joke!

#921 A Fifth column – perhaps.

A coffee and 5 minutes to mull over Ben's latest provokes some interesting thoughts; like I wonder if there is still a "real", old ATSB struggling to get out from under the pile of dross CASA have left them saddled with. The ATSB were always a well respected, world class operation and very few of the main players have changed in the engine room. Some of the 'old school' must be tearing their hair out, but I expect protecting the family rice bowl must come above professional pride and integrity. Whilst it's an understandable position, the aftertaste must be grim. Perhaps the Senate could dig some of them out and find out exactly what happened with not only the Pel Air investigation but with a few of the other stinkers laying about, Hempel, Canley Vale etc. etc. etc. I believe permanent protection would be available under privilege; any future threats could be passed off as revenge for spilling the beans. QED. A worrying thing is the time and money required to get 'proper' legal opinion on the 'legality' of the CASA operations with PA. Someone has shot from the hip again only this time, shot their foot off. The question as to whether due process under the Investigation manual and the TSI act was followed is worthy of some serious consideration. Clearly the outcome was pre defined, pre ordained by the gods and executed by the willing accomplice – no question there. Then the deeply hidden first agenda is revealed then the 'amazing' back flip, then the ATSB joining in. Who was the masked man with a smoking gun and only one foot? Bet a dollar he was not wearing a hood or a mask at the time. Lots of lovely big fat legal issues right there, the legal fandango on the extremes of the law begs so many questions I doubt that simply grilling a few of the top dogs will divine the truth. We need to see managers, auditors, FOI and IIIA investigators, under oath giving their version of events. That would clear some of the deckchairs which cannot any longer support the arses, large and small stuck there. Did I mention managers ?– I believe I did. #

922 Mr Kharon, I believe you to be correct. The ATSB does have an inner core that are bursting to be break free of the Beakerology that has been inflected upon them in recent years. Those people can only do what they are permitted to do, even if it includes sitting by as the upper echelon put a red pen through their investigation reports and insist that they are diluted to worthless pieces of paper. And I must agree that a higher level of inquiry that goes beyond the Senate is desperately needed. The answers are out there, but who wants to sacrifice their careers and the livelihood of their families in the pursuit of truth? Not many bold souls, and that is fair enough. A royal commission would see all stones overturned and an assortment of evidence providers brought to the fore, some willing and some by chain and hook. I know that out there in aviation land will be an ATSB investigator who has kept his original notes, concerns, drafts and final report, before it was 'modified' by the upper echelon. I know that out there somewhere are the auditors from the 'CASA Special Audit' of Pelair. They too would have transcript, evidence, and the draft version of their initial report. I know that out there are the audit team who undertook the general audit of Pelair, they too would have copies of what was handed to their seniors and what actually made it into the mainstream. These people are the keys to unlocking the 'mystique' of CASA and ATSBeakers actions in all of this. But they too would be held at the mercy of senior management, hence the need for a robust inquiry.

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So again dear Senators, it's over to you. You hold the keys to the chest full of treasures, will you unlock it? #923 Top posts Oleo and "K"!

Oleo said:

Quote:

I know that out there somewhere are the auditors from the 'CASA Special Audit' of Pelair. They too would have transcript, evidence, and the draft version of their initial report.

Oleo don't forget that a couple of those very same auditors were also tasked to help at least one designated CAA Part IIIA investigator conduct and contribute to the infamous, hidden investigation report titled CAIR 09/3. A report that appeared to initially support the findings of the ‘Special Audit Team’ but then

did an almost complete 180 by the time they got to their own findings and conclusions. NB It would also appear; much like the ATSB A320 report, that the ATSB ‘Final Report’

pretty much mirrored the CAIR 09/3. As FF is a recognised federal government investigation/enforcement agency they are obliged to conform to the ‘Australian Government Investigation Standard’. Therefore it should follow that the Pel-Air investigation team should have documented, managed, compiled evidence (chain of evidence etc) as per the AGIS 2011, see here: http://www.ag.gov.au/RightsAndProtec...GIS%202011.pdf Which I suggest Oleo could/should be made readily available for the good Senators to review?? It would be interesting to see if the FF IIIA investigator(s) have followed ‘due process’ in the conduct of the Pel-Air investigation…perhaps a few more required witnesses

to give evidence, the list is growing!

As Mr. Buzzy would say…Bbzz..bbzzz..bbzz…or the Kelpie: “More to follow”!

#924

Sarcs, agreed. The Pelair special audit report, along with the relevant documented observations, NCN's, obtained evidence, written notes and list of persons spoken with, along with the names list of the Inspectors who undertook the audit will be on file. The audit report will also contain references to which part of the regulations they were non compliant with. If the audit report can't be produced then CASA has breached it's own procedures and due governance. Then again it's executives are promulgators of the 'do as I say not as I do' philosophy. I see no reason why the Senators cannot be given this full audit documentation at a moments notice, it is as simple as pressing the print or send button. Any delay or stalling tactics should be viewed as suspicious to say the least. That is my concern, the stalling game. A royal commission would remove that little ace in CASA's deck of cards. The commissioner could simply call up all who he/she wishes to the witness stand your honour! The other option is obtaining material under FOI however that is a wasted drawn out exercise as government departments have that issue nutted out perfectly, and getting anything tangible takes years, blacked out page at a time. So yes, lot rests on the shoulders of the good Senators.

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#926 Totally agree Oleo that all the information collated in the SAR and previous Pel-Air audits should be made available to the Senators and the FF auditors be made available to give

evidence. However in all due repect you kind of missed my point about the FF investigative team that was apparently headed up by the Manager of the then newly formed 'Accident Liaison and Investigation Unit', which was tasked to conduct a parallel investigation with the ATSB. Whereas the ATSB's investigation team is governed by the the TSI Act 2003 and their own investigation procedures manual, as a Government Enforcement agency FF is totally different and are beholden to adhere to the "Australian Government Investigative Standard (2011)". This is even quoted on page 11-4 of the CAsA enforcement manual, which reads: "The tasked investigator will conduct an investigation to provide the Manager EPP with a report and recommendations in accordance with the procedures set out in the Investigators Manual which incorporates the Australian Government Investigations Standards." One of the team (at least) has to be a Part IIIA investigator and must manage the investigation as per the AGIS 2011 (previous version was AGIS 2003):http://www.ag.gov.au/RightsAndProtec...GIS%202011.pdf What this means is that all the required documentation, evidence, case notes, meeting minutes etc..etc has to be filed and correctly collated as per the AGIS. So therefore these required files should be made available for the Senators to review, or on the other hand if it hasn't been done properly (i.e. due process hasn't been followed) then the obligatory Friday afternoon pineapple insertions and beheadings will soon be a regular

feature! #927 Boxes that need to be ticked.

Perhaps the Senators could make sure, to be sure that all the boxes which needed to be ticked, were indeed ticked. It should not be too difficult to produce a man with one foot shot off and all of his paperwork. If not the TRIM system works just fine.

Quote:

Investigation, evidence and investigators manual references: If the relevant manager considers that there may be evidence of a breach then the first action to be taken is initiation of the CEP (see Chapters 2 and 3). It is only after

discussion in this forum that a request for investigation should be made using form

333. The tasked investigator will conduct an investigation to provide the Manager EPP with a report and recommendations in accordance with the procedures set out in the Investigators Manual which incorporates the Australian Government Investigations

Standards. (Reference 11-4 enforcement manual.) If a prima facie case exists and prosecution is considered, a Brief of Evidence will be compiled and submitted in accordance with the procedures set down in the Investigators Manual. Alternatively, on consideration of the investigator’s report, the Manager EPP may decide that the issue of an AIN is a more appropriate penalty. This will also be discussed as part of the CEP. (Reference 11-4 enforcement manual.)

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11.5.2 Reporting The Investigators/Coordinator Investigations make entries on AIRS, on the ASIS database and on the Enforcement Action Register on the Enforcement Action Rooms. (Note: This would be as per the AGIS 2003.) 13.6.2 Staff Responsible Inspectors. At any time, where inspectors may be unsure of exhibit-handling procedures,

advice should be sought from EPP. Note: Investigators are also responsible for evidence/exhibits and should refer to the Investigators’ Manual. (reference 13-7 enforcement manual). Note: For procedures for evidence and evidence handling (for Inspectors) refer to section 13 of enforcement manual. Investigators procedures are contained within the Investigators Manual.

#931 Oleo said:

Quote:

However the accident investigations liaison manager put a team together and told them to 'go forth and audit'. That is the most of what he did, then in the wash up he toyed with the reports wording, and a robust here and a robust there. If the holistic task was left up to him you would be left with blank pieces of paper and the odd doodling.

Oleo what you say maybe entirely the way it happened and old mate the ALIU manager is just manipulating the situation to gain a carte blanche invitation to the esteemed trough but

I believe that could be where he ultimately trips himself up. As you seem to be in the know was said manager a Part IIIA designated investigator? If not who was? Because it would appear that one was required. On pg 6 of CAIR 09/3 it reads; “Synopsis The Accident was notified to the Australian Transport Safety Bureau (ATSB) who in turn notified the Civil Aviation Safety Authority (CASA) on Wednesday 18 November. The ATSB decided to conduct an investigation. The CASA Manager Accident Liaison and Investigation

Unit (ALIU) was tasked with conducting a parallel investigation for CASA purposes. An investigation into the circumstances of the accident was commenced the next day. CASA informed the ATSB of the investigation in accordance with sub section 4.1.2 of the joint

MOU.” So this was definitely a parallel investigation and I don’t believe FF were doing it… “to help those poor under funded ATSB boys’n’gals out”. It was most likely that they were exploring the possibility of cuffing some poor bastard under section 20A; or if that didn’t work “we’ll get him administratively under CAR 265”; or “whatever works as long as the mud doesn’t

stick to our new, best pals from Singapore”!

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“4.1 Parallel investigations: 4.1.1 The ATSB may undertake ‘no--blame’ safety investigations in accordance with the TSI Act and CASA may separately undertake investigations with a view to possible safety—

related action pursuant to its functions under Section 9 and/or Part IIIA of the Civil Aviation Act.” Oh in case your wondering 4.1.2 of the MOU reads: “4.1.2 As soon as reasonably practicable after either the ATSB decides to conduct an investigation, or CASA decides to conduct an investigation in relation to a matter that would

be a reportable matter to the ATSB, each organisation will notify the other organisation.” So Oleo regardless if old mate Aliu is on the take, rogering the DAS’s missus or he is just a lazy bugger, the half assed investigation that he was tasked to do still had to comply with an “Australian Government Investigative Standard” and if for some inexplicable reason it doesn’t then his ass is definitely ripe for a pineapple rheeming courtesy of the Senators

canteen.

#932 Double, double toil and trouble;

Quote:

"If the relevant manager considers that there maybe evidence of a breach then the first action to be taken is initiation of the CEP (see Chapters 2 and 3)".

Think about that for a second. What we do need to know is the basis of an unqualified "office" manager's (admin, load control etc.) decision that part 20 A (for anything) of the Act has been breached. It's a hell of a call: From this 'informed' decision being made, all hell is let loose, on one mans say so. It's a stock standard, catchall bluff from Sleepy Hollow; they know the impact but they also know just how hard it is to prove at law. But, none of that matters; they have a "suspected" breach, which lets the dogs out. Now, you may suspect chemtrails, alien life forces, or the way your Grannies tea leaves fall dictate the fate of the universe. You are quite entitled to believe in Santa, the Easter bunny or even that all politicians are honest; but, you cannot prove it too easily. So why, on the whim of one man, is such a mighty pony pooh storm able to be called down? Who is this masked man? The brakes need to applied before any such "decision" is made; that suspicion needs to be better than a whim or a 'standard departure' point for the AAT. Before a 'manager' is allowed this much horsepower a case should be presented; the cops can't get a search warrant without reasonable grounds, so how come some office wallah can decide that a serious criminal investigation can be initiated. I refer you to Macbeth Act 4 scene 1 to discover the way in which these matters are arranged, I reckon the three witches were closer to being legally concise than the 'masked manager' and his crew. Talk about foxes in chook houses. Selah.

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#933

Sandilands - "In an election year it’s quite clear no-one in government or opposition really gives a damn about questionable standards in air safety investigations in this country.

Plane Talking – Ben Sandilands. This short piece by Sandilands highlights, once again the lack of service to industry from the ATSB new system of recording and reporting and the evils of the MOU. It is not the tail strike per se causing the problem, but that industry must now rely on the Aviation Herald to report the incident and make it's own decisions based against the report there. Aviation Herald. How are developing trends to be isolated and rectified if there is no "authoritative" voice; tail strike 1 = something nothing. Tail strike 15 from one company = a different animal; 15 tail strikes across a fleet different again. Different responses required. No matter where the funding for service is drawn from, in the end the travelling public pay – one way or the other. They pay for a first class analysis and reporting system, which oversights accidents, in the hope of preventing a recurrence. Even the humble tail strike. ATSB is not there to cover the CASA arse, to save a few dollars by not examining accidents, or sign off on reports which are not only sub standard, useless and flawed but could allow a repeat incident to occur. It's hard to believe that in Australia we have a size 10, million dollar bun fight in the Senate just to get these people to do the job they are asked to do.

#934 The perils of a warts and all investigation

Oleo is correct, the names of the CASA members on the investigation and special audit team are freely available. A look at the list of inspectors shows that as well as the usual flying ops and airworthiness inspectors there was one of the relatively new breed of Safety Systems Inspectors. Their task is not only to look at the effectiveness of the systems that should have plugged the holes in the cheese and not only the systems of the operator but also the regulatory systems that should have plugged the holes. Rumour has it that the latter were raised particularly in relation to the fatigue risk management system that CASA had previously approved. Being the devil's advocate and highlighting deficiencies in your employer is fraught with danger but that is the lot of a proper investigation and apparently the inspector concerned was given a pineapple previously for, when asked to examine CASA's responses to ATSB safety recommendations from the Lockhart River accident, he did not hold back on criticising those responses ( or lack of them). Admittedly the pineapple was purported to have been launched not from the person that requested the report but from the person who attracted the criticism. Or so I hear. #936 Mr Spike, interesting sir, very interesting. If your sources are also correct then it certainly appears that FF are harvesting a frickin pineapple plantation? Industry complaint to the ICC? Score a pineapple? Industry prove that CASA are incorrect over their interpretation of an issue? Score a pineapple. Industry disagree on an audit finding or an NCN stemming from op surveilance? Score a pineapple? Work for CASA and do the right thing, act with fairness and integrity toward industry? Score a pineapple.

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Highlight a CASA deficiency or incorrect action in regards to an internal matter? Score a pineapple? CASA - Write some silly comments making the Senators out to be buffoons, then apologise, brown nose and eat a poo poo sandwich? Dodge a pineapple. CASA - Trick ICAO and FAA with circus acts and amazing tricks against a darkened background? Dodge a pineapple. Continually lie and deceive by promising completed regulations for decades then simply stall and play magic tricks until a new government is elected and then start playing the same game over again? Dodge a pineapple. Respond to Senators questions with imbecile comments, 'take it on notice' (and never come back with an answer), and treat Senators with contempt? DESERVED PINEAPPLE. I think Mr Spike also made an interesting but brief reference to Lockhart River? Although a different topic I interested in hearing more about this? I have always said that FF dodged a bullet on Lockhart, and the Norfolk mess as well as Canley Vale seems to be rapidly building a profile of Regulatory ignorance, arrogance, incompetence and bot bot covering. Again I believe that decades of individuals avoiding accountability has created a horrid culture of 'we shall do as we f&king please and you can all get stuffed'. A royal commission needs to be granted, there no longer is any other option. #938 Depth perception.

FS #991 – and Oleo # 993. Two clear posts which bring us to a fork in the road. Both pathways forward are murky, muddy and guarded by ferocious beasts. One path takes us down into the operational levels and to the resignations of two very well qualified safety inspectors; where to say the least, the timing is interesting. Where the Lockhart farce raises it's ugly head in the mix and there still remain questions of the RCA not signed by the well qualified individual who raised them, but signed by a person considerably less professionally qualified and regarded. It would be interesting indeed to have the two highly qualified persons in question provide their 'expert' version of the "facts and circumstances", i.e. who rogered who and who paid. The other path takes us upwards toward departmental governance, to the ever ready legal crew who seem to manage the most extraordinary twisting, bending and shaping of the rules to suit a pre determined outcome, with an ease that beggars the imagination. This leads to the high altitude plateau of oversight and thus to management, the board and minister. I feel a Royal Commission is a heavy, expensive blunt instrument to crack the Pel Air nut. A Judicial no holds barred enquiry into this one event will tear the lid off a can of worms. I believe the Senate is almost there; they cannot, for the sake of public credibility be fobbed off with another soft white paper. In an election year it will be interesting to see which path they take – in any event both pathways meet at the well of truth and the public safety. It has been suggested that the Senate is, at the end of the day, powerless. It's time to take the kid gloves off and demonstrate where true power lays; and NO, it is not within the halls of Fort Fumbles. #943 Post Valentine's Massacre??

Stan also heard from a reliable source that the next public hearing is the 15th, pity it wasn’t

the 14th we could have dubbed it the ‘Valentine’s Massacre Mark II’! Anyway should be confirmed tomorrow when the Senate sits. Going off the PAIN reference and spike’s post…. “Rumour has it that the latter were raised particularly in relation to the fatigue risk management system that CASA had previously approved. Being the devil's advocate and highlighting deficiencies in your employer is fraught with danger but that is the lot of a

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proper investigation and apparently the inspector concerned was given a pineapple previously for, when asked to examine CASA's responses to ATSB safety recommendations from the Lockhart River accident, he did not hold back on criticising those responses ( or lack of them). Admittedly the pineapple was purported to have been launched not from the

person that requested the report but from the person who attracted the criticism. Or so I hear.” ….my money is that spike would be referring to BC rather than MC, although both gentleman have CVs that would put them in the top 2% of experts in Human Factors in aviation for

Australia, if not the world! Going off Oleo’s post maybe compiling a list of questions might help to clear some of the bullshit and corruption we’re beginning to get flooded with here! Q1/ So why did they both jump ship(BC&MC)? And the timing is very suss, especially BC (August 2010)?? Q2/ And those countersigned RCAs WTF is that all about? Q3/ And in a normal world should some of those RCAs have required a ‘Safety Alert’?

Following assessment of the response and on the Recipient Response portion of the RCA carry out the following actions: ccComplete the Verification and Action section; this section must record objective evidence to support the decision for acquittal. ccComplete the name and file reference sections. ccAcquit the audit response by signing the document. ccNotify the Auditee of the acceptance of the response in accordance with the local field office procedures. ccForward the acquitted RCA and supporting documentation on the file to the data entry operator for entry into the support systems (see data entry Guidelines for ASSP and Pentana). ccEnter the RCA information into the relevant support systems. ccEnsure all RCA acquittal and closure documentation is filed on the appropriate audit file.

Q4/ So where is the acquittal documentation for the RCAs, hmm maybe they’ve got a stuck

TRIM or no one could manage to hit the Pentana?

There’s a possible RRAT committee document request in there me thinks??

The more that is revealed the more the reeking pooh piles up!

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#944

Sarcs, BC may have signed off on the RCA's but my source tells me that the 'author of the RCA's' has more qualifications than BC! There are more twists to this than in Michael Jacksons colon. It would also be rumoured that there has been quite a number of audits in which others sign off on RCA's they have not written themselves. I am lead to believe that BC left not because he was pushed but rather because he had a gutful of the FF shenanigans, silliness and also because his salary was a lamentable joke. Indeed there was not room for him to dine at the trough with those more royal than he. He was 'hand picked' by a former colleague and went back to the RAAF to apply his HF trade, along with a more robust remuneration package and a uniform that makes the Skulls Friday outfits look like rejected St Vinnies clothes! I am still curious about one thing. The Special Auditor of Pelair after the Norfolk accident was, according to Spike, also involved in a special review of Transairs handy work at Lockhart. Why? Lockhart occurred several years before Norfolk, and Lockhart was all done and dusted, closed off, finished , finalised, finito. So why review the whole accident again? For the majority of us it would be a natural part of any investigation once all the dust settles and the clock had ticked forward, review, improve, change and learn. But we are talking about FF here, anything and every they do has an alterior motive, and dicing with Lockhart several year later is very suspicious indeed. Is there a 'Lockhart special review' document out there awaiting the Senators perusal? Is there something out there that our friends at Stalag CASA are a little nervous about?

#945 Lockhart - Norfolk - ALIU

Spurred by Oleo's comment I contacted the inspector involved and he does have a Masters in HF etc. although CASA had him remove the appropriate post nominal from his business card as it embarrasses those "superiors" who only qualified in preschool finger painting and pooh flinging. As for the Lockhart paper he said it was a test to see if he was appropriate material for the ALIU manager's position prior to Norfolk and when he bagged CASA's responses in the paper he wasn't surprised to learn that he was judged to not fit the position even though he was an accident investigator with a previous employer. Still, he finds it all an amusing memory now that he has had to retire. #946 Spike, interesting insight. It would seem CASA have really been concentrating on all those important things in life - business cards, fancy letters after ones name, not promoting any underling who is more qualified than the nimwits farther up the ladder. As for prioritising safety matters?? Hmmmm. You are correct about the finger painting aspect. But that stopped a year or two ago after the old geriatrics hands cramped up with arthritis. Now they place a brush in their mouths and paint the canvass that way. It's quite effective and they are good at it because they are use to bobbing for apples . As a side point, EASA have released their 2013 - 2016 European Aviation Safety Plan, with SMS on its way. It certainly beats any folly that CASA has in play within its own structure (oh sorry, did I forget the SPM which is around 13 years in production) and it pi#ses over Albo's silly White Paper and any glossy spin documents the CASA Board has ever churned out. I simply can't imagine CASA with its own SMS, after all a SMS does incorporate accountability, which not surprisingly is not a CASA strong point. Perhaps CASA execs should

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shun Montreal as their choice of taxpayer funded holiday destination and head to Europe instead? It is time for 'out with the old geezers, in with the new'. #947 Oleo you said:

Quote:

Sarcs, BC may have signed off on the RCA's but my source tells me that the 'author of the RCA's' has more qualifications than BC! There are more twists to this than in Michael Jacksons colon. It would also be rumoured that there has been quite a number of audits in which others sign off on RCA's they have not written themselves.

If you take a close look at the SAR (version II so far??) that Flight Nurse Karen Casey was able to get under FOI and then look at the list of RCAs: http://www.casa.gov.au/wcmswr/_asset...-ef12-5471.pdf You'll see that other than the first 13 RCAs that were signed by the FOI assigned to Pel-Air the rest, although appearing to be written by various Special Audit Team members

(including BC), are countersigned and filled out by the Audit Skulldinator....

Quote:

FS said: As for the Lockhart paper he said it was a test to see if he was appropriate material for the ALIU manager's position prior to Norfolk and when he bagged CASA's responses in the paper he wasn't surprised to learn that he was judged to not fit the position even though he was an accident investigator with a previous employer. Still, he finds it all an amusing memory now that he has had to retire.

So Spike it was more a test of whether he would tow the party line? And the dude failed miserably...so Messr RW gets the gig because he is itching to feed at the trough and has previously been a reasonable master of spin and obfuscation and considered more than a

match for the numpties at the bureau...hmm makes sense I guess??? For those interested I also found this interesting released FOI documentation, which is a

copy of an audit on Pel-Air in March 2008 : http://www.casa.gov.au/wcmswr/_asset...ef12-10004.pdf

#948

Sarcs, it's interesting reviewing these 2 audits independently. Some highlights (or should I say highshites) are: - In 2008 80% of the 20 FLT crew reviewed had no evidence of life jacket/raft training. Then after the ditching in 2009 the special audit found inadequate life raft refresher training. Not much changed in 12 months. - In 2008 that audit uncovered basically nil FRMS training. Then again in 2009 after the ditching the special audit found inadequate FRMS policy/procedures. - And the RCA's. Mr RC signed the RCA's that were written by Mr MH, Mr BC and Mrs KS. WTF? Although questions about Pelair are obvious and inevitable, my interest is in the Regulators oversight, ability and activities during this time period. What were they doing? The similarities to Lockhart are more than concerning. CASA is meant to be oversighting safety yet here are 2 accidents that occurred not long after CASA had been 'hanging around'? Is the role of the CASA pretty much redundant? They certainly don't appear to add any value to safety? They certainly don't seem capable of identifying risk prior to accidents? Proactive

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vs reactive I hear you say? The CASA are reactive! And as far as I am concerned when it comes to organisational culture CASA are pathological. If they were an airline I would rather take my chances and cross the pacific ocean on a Segway than fly with them. The holes in the cheese are big enough to fly a Starlifter through. How much longer? Over to you Senators. #949 As the stomach churns.

It's a fair question – just how much individual, unchecked power does a manager have? When you get down and dirty on the Special Procedures Manual (SPM) and Safety Trend Index (STI) system you find that Transair, of Lockhart River fame had an audited STI score of 15, the normal red flag is raised at seven. Safety alert, No, Show cause, No? kick in the pants, No?; but shortly afterward they are granted significant changes in the AOC despite clear evidence that under the 'robust' CASA system this was the last thing that should happen. There is no empirical evidence that the Operations Manual was significantly amended to rectify any of the items reflected in their STI score. There is no data to support the idea that the audit was 'audited' and that changes, if any, were ticked off. The failings in the oversight system were huge and 15 people died. Pel Air - same - same. Only in this case we have the auditors investigating their audit: now how in all the hells does that happen? Even more intriguing are the resignations shortly afterward by people who were eminently qualified to assess the operation, the audit and the proposed corrections. In part, the 'investigation' process, was supposedly to determine if previous RCA and audited deficiencies had been corrected; and that both the CASA and P-A systems were functioning correctly. So we task the auditors to examine their own work – sorry, but why am I not surprised that despite a fairly hefty STI count and no positive proof of improvement a Safety Alert was waived and evidence deeply buried. P-A was back in business within a Christmas week of the "changes" being initiated. It would take a week of hard work just make to amendments let alone have them tested, accepted, executed and ticked off. The required training programs alone would have taken a week full to complete. Seems there exists either a massive systematic failure; or a truck load of discretionary power at work. Compared to Hardy, Barrier, Airtex and a couple of others where the 'managers' discretion is used to produce the desired outcome you just have to ask questions of the system, the integrity of the audit and the investigation process. Is the system there to ensure a safety outcome, or to produce a safe outcome under discretionary privilege? Quick twirl of the red pen – problems all go away; shut up or resign. Men of integrity did. I find it intriguing that Airtex had independent, senior, experienced ICAO 'qualified' auditors determine a clean bill of health for the operation and were shot down in flames by, shall we say, slightly less qualified people; and had a safety alert issued on the flimsiest grounds; yet P-A in seven days, over Christmas manage to convince almost the same audit/ investigating team that all was well. Here Johnny, mark your own exam paper. What a system. Unbelievable? check it out your self, all there on the public record.

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#951 Shooting the messenger

Unfortunately for those who consider CASA to be a dysfunctional organisation, Paul Phelan's article "shooting the messenger" proves the opposite. https://senate.aph.gov.au/submission...7-e114756fe994 If only it had some connection with flight SAFETY!!! 47 years, 24,000 incident free hours don't count for much ? Thanks again Paul. #957 VH-NGA serial offender!

It would appear from yesterday's release of AQONs for 21/11/2012, that the accident

aircraft had a some what chequered history :

Quote:

8. HANSARD, PG 9 Senator FAWCETT: Could you take on notice whether you passed on to Pel-Air the concerns about their Westwind aircraft. Mr Harfield: Yes. Answer: In the period five years before the Norfolk Island accident (2004 to 2009) Airservices reported to both CASA and the ATSB, 19 safety incidents that were known to Airservices involving VH-NGA. In July 2005, VH-NGA was involved in a safety incident during a flight from Nowra to Darwin whereby the aircraft was unable to maintain it’s assigned level in RVSM airspace and another aircraft was therefore required to change its altitude in order to maintain the separation standard. Pel-Air was informed about this incident under a standing Letter of Agreement. Also in the period, VH-NGA was involved in 18 other safety incidents – 16 were pilot or aircraft attributable (2 engine failure, 2 fuel dumps, 1 Loss of Separation, 3 incorrect time and position reporting, 8 pilot errors) and two were air traffic control attributable information display errors. Pel-Air was also informed about the details of these incidents under the Letter of Agreement.

Err what was FF doing while the magical adventures and exploits of NGA and it's illustrious

crew were being documented and tracked by their ATC cousins?

#960 Chair extends report date!

Extension date to enquiry. From Senate 'Dynamic Red'

*1106 Chair of the Rural and Regional Affairs and Transport References Committee (Senator Heffernan): To move—That the time for the presentation of reports of the Rural and Regional Affairs and Transport References Committee be extended as follows: (a) an aviation accident investigation—to 27 March 2013; and (b) Foreign Investment Review Board national interest test—to 19 June 2013.

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Commenced 12:08 PM (today) Agreed to as amended

Also notice the AQONs for RRAT Committee Sup Estimates (Oct 2012) are finally in....so

there will be more to follow (Kelpie classic).

Sarcs, perhaps you could collate your data monthly on operator incidents, accidents and occurrences and provide the info to FF directly for their monthly RRG meetings? They don't seem capable to do it themselves.

Oleo you say it all yourself...all that kind of info would be possibly likely to get is a fart from

the trough, or maybe a series of farts!

#961 3 little pigs

How's that old story about a big bad wolf and three little pigs go? Sarcs #1014 – little pig 1 - ASA response, nice catch. Little pig 2 - ATSB response:-

Quote:

Sen X. - 16. Did the ATSB form a view about the adequacy of CASA’s oversight of Pel-Air in general and the aeromedical flights in particular? ATSB response: A review of CASA’s audit documentation found that regular, scheduled audits of Pel-Air’s documented processes were carried out by CASA in the years preceding the accident. No safety issue was identified in respect of CASA’s oversight. No contributing or other safety factors were identified in respect of CASA’s oversight of Pel-Air.

Now we have the ASA and ATSB opinion, it will be interesting to see what little pig 3 spits out. Can't wait. The Written QON are a gold mine, starts at about Q20 – 30 have a read. They surely built a big haystack to hide under.

963 ATSB mythology!

Massive amounts of spin and obfuscation in the latest ATSB answers to written QONs

21/11/2012. Here’s just one example…

To follow on from Kharon’s post here is QON No 25:

Senator X: 25. Documentation indicates a s32 request was made on 4 July 2012 for the CASA Special Audit. When was the audit sent by CASA? When did it arrive? The committee is aware of the fact that the ATSB knew about the CASA Special Audit when the audit was announced. That being the case, why did the ATSB wait for over two years to request it? Your supplementary submission (annex), which covers where the special audit was included in the ATSB report, appears to come from the March version of the report. Is that the case? How can the ATSB

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report refer to the Special Audit in the March 2012 draft when it appears the ATSB were not yet in possession of it?

Ok clear as mud? Now here is part of the spin answer (my bold):

ATSB response: As advised in its 14 December 2012 response to the Committee’s questions on notice of 21 November 2012, the ATSB requested a copy of the CASA Special Audit Report under a S32 notice on 4 July 2012. A copy of the special audit was received by the ATSB on 9 July 2012. As part of its investigations, the ATSB has not routinely obtained CASA Special Audits. As an independent investigation agency, the ATSB focuses on obtaining its own evidence in consideration of its evolving investigation hypotheses, and in support of its analysis and findings. This need not include the results of investigations or other activities that

may be undertaken by other agencies for their own purposes. The decision of whether to obtain such outputs by other agencies would generally be informed by the evidence already gained by the ATSB’s investigation, and the perceived benefits of obtaining them.

So the ATSB do not routinely request FF special audits or for that matter any audits of the

operator involved in an investigation , although they can (under the provisions of the TSI

Act) if they want?? Yet they espouse to adhere to world’s best practice accident investigation methodology (reference Q/ 32 pg 23) and use the example of the NTSB as a

fellow ‘world leader’ in the field. However if you refer to the NTSB Investigator’s manual pg 137 you will see what the NTSB require the FAA to produce in an operator’s overview context and regardless of whether the

investigator(s) believe it will be relevant or not :

Quote:

Federal Aviation Administration Information (1) "Blue Ribbon" medical and pilot certificate records. (2) Violation and other certificate actions on flightcrew and airline. Obtain certified copies. (3) Inspections performed on the airline during the previous 12 month period including base, ramp, en route, ground and flight training program, crew member; dispatcher records (including flight and rest), trip records, dispatch center/flight following/flight/locating facility. Obtain certified copies. (4) Latest regional inspection performed. Obtain a certified copy. (5) Latest national inspection performed. Obtain a certified copy. (6) Frequency of surveillance. Compare the number and types of inspections performed with regional and national inspections guidelines. (7) Workload of POI. (8) Background and qualifications of POI. (9) Authorized and current staffing level of district office. (10) Most recent pre-accident/incident flight inspection and post flight inspection results of pertinent en route and approach facilities/aids. Obtain certified copies. (11) Most recent pre-accident/incident airways facility inspection and post inspection or pertinent en route and approach facilities/aids. Obtain certified copies.

There are also plenty of examples in the past, Seaview comes to mind, where the BASI/ATSB investigators relentlessly turned over all the FF previous audits/surveillance

activities and records in the search for the truth . Nah this is just another Beakerised adopted methodology that another world’s best practice agency the NTSB appears to be in

no hurry to adopt! Definitely more to uncover in this haystack….hmm next this

SR/Safety issue myth me thinks.... doin a Kelpie..or an Arnie.."I'll be back"!

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#964

Sarcs, unfortunately all that you post is true. The ATSB 's 'quality non political work' came to an abrupt end the day Beaker took command. Once he 'CASArised' the ATSB it was all over red rover. They are in meltdown, Team Beakers responses are illogical, contradictory and down right ridiculous. He has shot both feet off, and the more they try to spin their way out of this mess the more deeper they dig their hole. At least with FF they deliver exactly what they have done for decades - crap. But the ATSB was indeed a stellar outfit, well respected and highly regarded internationally, they really were second to the NTSB, and that is something to be proud of. But now? Just another bunch of executive wankers who have ego's the size of the Hindenberg. And we know what happened to it don't we? These geniuses sadly, and in a disillusioned fashion, actually think they are more intelligent and intellectual than the rest of mankind. This is nothing new, there have been idiots throughout history who have also thought this highly of themselves only to have things end in tears. These clowns are just like Doctors who for some reason think they are god. Message to them - you're not!! You are nothing short of the shite beneath our shoes. Even if the CASA, ATSB, ASA end up using their political might, free immunity and indemnity clauses and millions more in taxpayer money stretching, stalling, deflecting, spinning and crushing the Senators crusade, make no bones about this - your number is up, you have been outed. Industry know what you are, the Senators know what you are, the FAA know what you are and so do ICAO. And eventually, after we lose a 200+ seater into a smoking hole the Australian public will know what you are. As Stan would say, ironically under the present oversighting bodies 'safe skies are indeed empty skies'.

#965 Foresight Zero - 20/20 Hindsight.

COMPARISON OF DRAFT AND FINAL REPORTS AO-2009-072 WITH THE CASA

SPECIAL AUDIT REPORT. Audit finding Final and Draft investigation report references in ‘pXX’ and ‘[pXX]’

format respectively. Inadequate fuel policy for Westwind operations. P25 [p33] of the report refers to CAR 220, highlighting that an operator also shares the responsibility for ensuring that sufficient fuel and oil is carried, and was required to include specific guidance for the computation of the fuel carried on each route in their operations manuals. Discussion of the operator’s fuel policy that appeared somewhat less than ideal included at: • P29 [p37] of the report, which highlighted a disparity between Parts A (9.11.2) and B (6.1.2) in respect of the calculation of critical points for use depending on the availability of critical or intermediate aerodromes. • Also in respect of abnormal operations, p29 [p37] of the report also highlights that aerodrome ‘criticality’ and ‘adequacy’ were not defined. • In addition, p30 [p37] of the report relates that whereas the operator’s planning methodology for determining the point of no return (PNR) was satisfactory for determining a return in the same configuration as the outbound leg but was not appropriate for a return leg where that leg had a higher fuel burn than that outbound

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It is quite acceptable that the ATSB can with hindsight, determine that there were issues with the operators fuel planning policy. But where's the foresight??, where's the robust, steely eyed oversight? drinking latte and eating chocolate Monte's in the kitchen, that's where. Where is last years memo to the CP from CASA saying - "I note a lack of guidance in the Operations manual for pilots operating between remote islands; as the company appears to be regularly staging aircraft through NLK in the middle of the night; perhaps the section could be expanded to provide improved guidance to the 'junior' flight crew currently on roster". "Perhaps you would consider providing a route guide and port advice notes, CFIT and ALAR risk analysis and some (CP/PNR) release points for operational control". This is Not rocket science - Then, where is the ATSB recommendation to CASA suggesting that perhaps, as a result of a near fatal, attention to company fuel policies could be increased; just to ensure this cannot happen again. They could even produce a joint report suggesting that company fuel policy should reflect the operational realities of life, rather than the minimum legal requirements with dire threat of goal. Hell, they could even lose their heads completely and revisit 'bad law 101', i.e. Reg 206 and CAO 82 and cover the bets properly. Sheeit, CAAP, instruments, [AIP], legal head of power; so much wriggle room, so much power, so very little common sense. So simple, and yet so far, far away. "Lay on, Macduff, And damn'd be him that first cries, 'Hold, enough!'

#968 Coroner, questions of.

Oh G' day Blackie, glad to see your posting again, early release?? Now you're out, perhaps you could give us the benefit of your opinion on a question from Sen. Fawcett to DoiT about closing the loop on Coroner recommendations. The question was prompted by the fact that there is no open system in place to ensure that if a Coroner makes a recommendation, it is addressed, where appropriate actioned and closed off. The side bars to question bring into play issues like a public Coronial data base tied to the ATSB data and a record of CASA response and actions. Now, there is system of sorts in play, but a little research soon reveals that (a) A WA Coroner looking at an accident may make a couple of recommendations; (b) a Qld Coroner may look at a similar accident and make recommendations; but, there is no correlation of information, no way to ensure that all recommendations have been examined or to see what has been done to prevent a reoccurrence. 1) Unless you personally get a transcript there is no way to see the Coroners recommendations. 2) Unless you personally monitor CASA actions on those recommendations, there is no way to determine exactly what has been done, why, by whom or the method used. 3) Unless you are a mind reader there is no information available from the ATSB on any of it. So, to explain fully; Coroners recommendations can and do disappear (like bubbles in the bath), promised changes to legislation accommodating Coronial recommendations does not appear, safety actions don't occur and, no one knows. Then there is the notion that a Coroner may have based some part of a decision against the "promise" of changes; once again who would know.

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There is some bloody good research (Thanks PAIN_Net) on this out there now and the results are grim. Clearly the Senator would love some answers. So Blackie, how about it; perhaps you could once again enlighten us mere mortals here on PPRuNe with your usual

insight, wit and eloquence.

#969

Perhaps Blackie this will help gel an answer for you! Start of the story...Scene 1: Act I Once upon a time in a land called Crat city a certain new Lib bright star Senator asked a particularly poignant question of a certain head sherangacrat in a committee hearing

room…but first the lead up because it is important. "Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow

those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years

after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again? Mr Dolan: We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond

our brief. Senator FAWCETT: Who should have that role then? Mr Dolan: I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when

there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations. Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must

implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred? Mr Dolan: I think I will limit myself to comment that that is the way we try to do it. We

have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken. Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer? Mr Mrdak: I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and

security regulators, as necessary, with the coroners. It is probably one I would take on

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notice and give a bit of thought to, if you do not mind. Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually

complement their activities for the outcome that benefits the aviation community? Mr Mrdak: We certainly do ensure that agencies are working together. That is certainly

occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay. Senator FAWCETT: Thank you." This was followed by a non-answer to what the Lib rising star Senator thought was a QON (must forgive him as he is still learning the game) at the Sup Estimates hearing in October. However no harm done as it was eventually formally listed as a QON that was addressed to DOit head-crat Mrdakari. However it would appear that Mrdakari has deferred to his most submissive minion to put forward, yet again, the safety investigation methodology and supreme spin according to

Beaker. So headcrat Mrdakari has again played the Senator back into the court of spinners and crats, the question is will the Senator accept this play? When you read SU’s submission, especially the following from Samantha Hare, I think the Senator is well justified pursuing his original line of inquiry (i.e. FF ignoring Coroner

recommendations/findings and 'closing the loop')!

“My partner died in a yak-52 joy flight on 31 August, 2008. His name was Ian Lovell. I along with many others continue to feel shock that such an accident has happened. I think this is because people do not expect such an accident to happen in Australia. Nearly five years later and I now know that the lack of regulation in the Australian aviation industry

makes flying a very dangerous venture but my experiences are that the general public continue to be unaware. They do not know that Ian died in an accident waiting to happen, that it could have happened to any member of the public and unless there are changes it is likely to happen again. The flight was sold to me as a gift certificate for Ian’s 35th birthday. Hempel’s Aviation was recommended to me by Archerfield Airport, the company was

advertised on the internet, Hempel’s Aviation employees recommended Barry Hempel as the pilot, I bought the gift certificate directly off Barry Hempel at Hempel’s Aviation located at Archerfield Airport; I paid Barry Hempel of Hempel’s Aviation $495 for what in the past has been referred to by the media as the ‘death’ ticket. At no time would I have bought this ticket if I had known that the pilot, Barry Hempel did not have a commercial license. At no time was this flight referred to as an adventure flight.

At no time were the risks of flying in a warbird discussed and at no time was a waiver signed. I shared in Ian’s elation at the best present that had ever been bought for him; I drove Ian

to Archerfield airport; I dismissed a dream that he had about the plane crashing into water; I had a laugh with him when he told me he was listening to the soundtrack of top-gun whilst waiting to take the flight; I took him out to the tarmac and took photos of him as he was strapped in for his first flight in a warbird, his first experience of aerobatics and first real

taste of g-force and we both expected that he would return safely. Ian’s flight was the third joy flight of the day that Barry Hempel had piloted and all

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customers were under the impression that the flight was commercial. I waited on the tarmac to take photos of his arrival. Ian didn’t arrive. Soon after there was a phone call to say a plane had crashed into the water just off South Stradbroke Island. I

knew that Ian was gone. Devastated, traumatised, shock. There aren’t any words that can describe losing a partner in

such a way. A motorbike accident is comprehensible and something tangible that I had worried about, but a plane crash seemed as likely as being taken by a shark whilst dangling your feet in the Brisbane River. Since I have lost Ian I have noticed that planes fall out of the sky regularly. As do most people who lose a significant person in their lives, I think about Ian every day.

We had planned our future together, a home, children, travel, he was the only person I had ever looked to the future with. But now I don’t only grieve the loss of Ian but I also grieve what has been taken away from me by a system that has failed Ian and I for the last four

and half years. Put simply, the ATSB did not investigate; the QPS never recovered the plane; the police report took 3 years to complete; CASA will not admit any fault to prevent any further

accidents happening; the Inquest took approximately four years to begin; CASA stalled the Inquest recommendations for another hearing date and now I have been told to wait again with the additional hearing date being postponed. When I found this out on the 15

November 2012, not even two working days before the hearing date was set to begin, I cried. The tears started at work and basically did not stop for the rest of the day. I feel sheer disappointment that I continue to be put through this, so many years after Ian’s death. Four and half years and ongoing, is a long time in a person’s life. I was 30 years of age when Ian died and am now nearly 35. The grief and shock of losing Ian has at times consumed me but I have been able to work through it so it is now something that I can control. What I can’t control four and half years on is the legal/regulatory system. I cannot

control when I’m going to get that next phone call. When I will be re-traumatised again? It feels like the system is trying to break me, hoping that I can’t handle it anymore and I’ll walk away. What will break me is if I do walk away after all this time. I’ve lost too much.

Ian’s death was preventable and four and half years later we are still waiting on recommendations from a Coroner on what needs to happen to try and prevent another accident of its kind. In the last four and half years my friends have either become engaged, got married, had children, advanced in their career, travelled. It feels like the legal system/CASA has pressed pause on these aspects of my life. I can’t work in social work because the ongoing and

unpredictable nature of the legal process impacts on my emotions and my capacity to work in a crisis setting, I have mounting legal fees, the emotional toll impacts on my relationships with other significant people in my life and I can’t travel freely because my life is dictated by the systems schedule. I wonder when the victims are considered in the process. I wonder what new information is going to come from yet another hearing day called by CASA. I wonder whose interests this serves. I wonder how much more obvious it needs to be that CASA and the medical

practitioners involved breached their duty of care. I wonder how many more planes will fall out of the sky. I wonder why my life continues to be put on hold by the system, when I lost my partner due to other people’s/CASA’s negligence. I wonder how those in the aviation industry who turned a blind eye have been impacted. I wonder whether 2013 will be the year that there is legal resolution for Ian. I wonder whether there ever would have been an Inquest if Ian’s loved ones did not demand it year

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after year. I wonder whether changes will occur in a flawed Civil Aviation Safety Authority and I wonder whether I will then be able to sit with my grief for Ian peacefully and remember the beauty that he bought to my life without it being tarnished by an incompetent and unjust legal/regulatory system. Samantha Hare (fiancé of Ian Lovell) Hempel’s Yak 52 South Stradbroke Is 31 August 2008. 2 fatalities.”

There's the background Blackie, hope it helps?

#970

And don’t forget this:

Quote:

Senator FAWCETT: There is actually a broader issue, though, Mr McCormick. There is no closed-loop system so that recommendations that are made by ATSB, that CASA agrees—particularly we have seen a number where, in a coroner's court, the coroner has said, 'We'll close out this issue, because ATSB made a recommendation and CASA said they will do it,' and then a decade later there is has been no action. Is that an issue for the travelling public? I hear you that you were not there for that whole 10 years, but we are talking about a system now, not personalities. Is the system not working as it should? Mr McCormick: I cannot speak for what happened in 2000. I only got here in 2009. … Senator FAWCETT: Mr Boyd, were you around? Mr Boyd: Yes, but not in that position. Senator NASH: Anybody else? Mr Farquharson? Dr Aleck? Dr Aleck: I was in Montreal. [CP note: Apart from the stint in Montreal, Dr Aleck has occupied various senior management positions within CASA for an accumulated period of about 10 years to the present.] [CP Note: Messrs Farquharson and Anastasi, both of whom have been in CASA for all or most of the period 1999 to the present, were also at the table but, according to Hansard, remained silent.]

You see: no one's responsible.

975

Isn't it strange that Ana stasi managed to misplace this mater#

Unbridled power

Sunfish, Oleo, No need to quote third party threats. Refer to Paul Phelan's Shooting the Messenger page 11

Quote:

OLC believes that this is a borderline case and were it to appear before the AAT, that the results of a review could not be guaranteed. However, both OLC and the Area Office argue that it is an important policy position to take action against Schutt, in order to dissuade other companies from attempting to circumvent legislation in this way.

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These bastards haven't the intelligence to have "policy" translated into legislation, assuming there is even a "safety" case. But with a monopoly there is usually "reprisal" and unlimited legal $$$s. So no worries. She'll be right,mate! Based on policy there should be an immediate halt to "charter flights" as they could not meet the absolute safety requirements demanded for "paying passenger" ultimately "empty skies are safe skies"

Euthanasia of the G.A. Industry appears legal, evidently supported by the highest echelons of Government. Australia once again leading the world!

Quote:

the DPP's view is that a prosecution could not be implemented or proceeded with by them because it was not in the public interest and it was highly unlikely that it would succeed. I herewith request approval to cease the investigation of this matter forthwith and approval not to submit a brief of evidence to the DPP.”

https://senate.aph.gov.au/submission...7-e114756fe994ial for the AAT hearing, yet McC was aware of it, not considering this as New, must be a special power of insight? Might it also explain why Adam was elevated to the top position in the now renamed LSD. Shows there is reward for excellence. There are several more examples of similar misplaced communications, but McC is on top of them all. Always good to light the open fire! "empty skies are safe skies"

#977

Having dutifully ploughed through the 228 page response, AQON 211112 and identified several howlers, contradictions and plain, old fashioned 'porkpies'; I can report that as a definitive study of corporate spin, it is a masterpiece. The tabled data is the work of master craftsman. Clearly history is repetitive:-

AQON 211112_PDF page # 48. ATSB response to the question ‘Is this new methodology internationally recognised?’: The first significant investigation undertaken using the new analysis methodology was the ATSB’s investigation of the fatal Metro 23 accident near Lockhart River, Queensland on 7 May 2005 (ATSB investigation 200501977). Following the completion of this investigation, there was some criticism of aspects of the ATSB’s methodology by the Civil Aviation Safety Authority regarding the ATSB’s use of a Reason-type model and the ATSB’s definition of ‘contributing safety factor’, and the Queensland State Coroner had concerns regarding the description of the standard of proof associated with the ATSB’s definition of ‘contributing safety factor’.

Quote:

Norfolk - Sub03_Currall. 14. As pointed out on the 4 Corners program the ATSB’s final report was flawed, causing it to be quietly withdrawn some 24 hours after publication. The report was then reissued with no form of version control. I now have two versions of the final report and do not know which to believe. 15. The report omitted crucial information on the issue of Reduced Vertical Separation Minima (RVSM). This issue, together with apparent deficiencies of the Operations Manual severely limited the pilot’s ability to plan the flight effectively. This apparently deliberate omission ensured that the blame for poor flight and fuel planning was pinned on the pilot

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despite the constraints that each of the above placed upon him. 16. There is no attempt by the ATSB to undertake root cause analysis of the issues raised in their final report. This was exemplified by the issue of Threat and Error Management (TEM), a procedure to improve flight safety by identifying potential threats and errors. According to the report ICAO regulations require training in TEM, though not for this category of flight. CASA regulations however do not require training in TEM. The logical outcome of these points would be to analyse the reasons why there is no such training requirement in Australia and why this flight was in this particular category. If such training is required, or does help prevent accidents and the flight was found to be in an inappropriate category for this type of operation then CASA could be held accountable for this. Instead, the report simply omitted analysis of these issues. 17. Despite the requirement in the Operations Manual neither of the crew had undertaken training in Crew Resource Management (or in TEM). The ATSB’s investigation went further; in a survey of both trainee and experienced pilots the report found inconsistencies in their approach to the legal requirement to divert to an alternate because this is not part of the syllabus for a trainee pilot. Despite these findings the ATSB declined to offer any recommendations that may improve this clearly unsatisfactory situation.

Quote:

Lockhart River - Urquhart – Coroner Barnes. 20 Aug, 2007. " Evidence clearly provided to the inquest both by CASA witnesses and others, showed how CASA has not really changed anything in the way it operates and its serious disregard for promoting safety within the Regional Airline Industry. This is supported by reams of information and statements I have read over a long period of time. Does CASA not have some duty of care in an industry where safety is paramount and should there not be serious consequences imposed on individuals and the organisation for breaches of this? " etc.

#978 Tomorrow's schedule!

Looking at the proposed timetable for RRAT committee additional estimates it looks like it'll

be beer'n'nuts arvo viewing of the fun and frivolities : http://www.aph.gov.au/Parliamentary_...1213/rrat.ashx Broadcast Link: Watch Parliament – Parliament of Australia #980

Senator FAWCETT: There is actually a broader issue, though, Mr McCormick. There is no closed-loop system so that recommendations that are made by ATSB, that CASA agrees—particularly we have seen a number where, in a coroner's court, the coroner has said, 'We'll close out this issue, because ATSB made a recommendation and CASA said they will do it,' and then a decade later there is has been no action. Is that an issue for the travelling public? I hear you that you were not there for that whole 10 years, but we are talking about a system now, not personalities. Is the system not working as it should? Mr McCormick: I cannot speak for what happened in 2000. I only got here in 2009. … Senator FAWCETT: Mr Boyd, were you around? Mr Boyd: Yes, but not in that position.

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Senator NASH: Anybody else? Mr Farquharson? Dr Aleck? Dr Aleck: I was in Montreal. Creampuff: Apart from the stint in Montreal, Dr Aleck has occupied various senior management positions within CASA for an accumulated period of about 10 years to the present. Messrs Farquharson and Anastasi, both of whom have been in CASA for all or most of the period 1999 to the present, were also at the table but, according to Hansard, remained silent.

So although The Skull has been around 5 years, he takes no responsibility? As for the others who have been at CASA ranging from 12 - 20 years and who conveniently deflected Senator Nash's probing, they don't get off so easy I am afraid. Anybody in those positions and who has been in CASA for that length of time would have had a say and had influence in decision making. No high level decisions are made without consulting with others, so the 'hand washing' by these guys is laughable. And I reiterate that most of FF's issues lay within its structure of 'long termers' who have spent decades playing the system, and playing it well. But the piece of string has been pulled by the Senators and the whole lot is unravelling. The stench of incompetence flows all the way to the Minister, and people like Mrdak, the Boards, the whole lot of them need to be held to account.

It is a real shame that Samantha Hare and Shayne Urquhart couldn't take all these executive individuals to the morgue with them to identify their loved ones. Or have those executives with them at Xmas or birthdays, to show them that we are dealing with lives, not executive salaries and bonuses. None of these executive clowns has earned a clean conscience nor do they deserve a peaceful nights sleep while people continue to die and accountability is mocked. On a final note, in regards to the CASA's inability to 'close the loop' this too is a farcical outrage. They preach from the book of James Reason yet don't practise what they preach in reality. If an operator didn't 'close the loop' on an investigation, incident, occurrence or non-compliance' then a NCN would be issued by CASA quicker than a CASA executive boarding a plane for Montreal! Hypocrites. To be con't............

#981

Senator FAWCETT: There is actually a broader issue, though, Mr McCormick. There is no closed-loop system so that recommendations that are made by ATSB, that CASA agrees—particularly we have seen a number where, in a coroner's court, the coroner has said, 'We'll close out this issue, because ATSB made a recommendation and CASA said they will do it,' and then a decade later there is has been no action. Is that an issue for the travelling public? I hear you that you were not there for that whole 10 years, but we are talking about a system now, not personalities. Is the system not working as it should? Mr McCormick: I cannot speak for what happened in 2000. I only got here in 2009. … Senator FAWCETT: Mr Boyd, were you around?

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Mr Boyd: Yes, but not in that position. Senator NASH: Anybody else? Mr Farquharson? Dr Aleck? Dr Aleck: I was in Montreal. Creampuff: Apart from the stint in Montreal, Dr Aleck has occupied various senior management positions within CASA for an accumulated period of about 10 years to the present. Messrs Farquharson and Anastasi, both of whom have been in CASA for all or most of the period 1999 to the present, were also at the table but, according to Hansard, remained silent.

Quote:

Messrs Farquharson and Anastasi, both of whom have been in CASA for all or most of the period 1999 to the present, were also at the table but, according to Hansard, remained silent

Folks, The comment by Creampuff is significant, perhaps the good Senators should ask about who was involved in the drafting of a CAO that completely changed the meaning of "Island Reserve", and placed specific fuel requirements on Norfolk, Lord Howe, Cocos etc. --- in 2000, or thereabouts, as a reaction to the Seaview Royal Commission. Tootle pip!!

#985

MOIE # 1040 –"So although The Skull has been around 5 years, he takes no responsibility? As for the others who have been at CASA ranging from 12 - 20 years and who conveniently deflected Senator Nash's probing, they don't get off so easy I am afraid. Anybody in those positions and who has been in CASA for that length of time would have had a say and had influence in decision making. No high level decisions are made without consulting with others, so the 'hand washing' by these guys is laughable.

The sad part is the 'willing accomplice', those who sit back counting the days, even "tut tut" in your kitchen, then sneak back to the office to pen the 1700 special. The CASA fifth column should be given the opportunity to speak up, without fear or favour. The 'good uns" seem to toddle off into obscurity, quietly shaking their heads over a beer, rightly scared of speaking out. The "ring of iron" is supported by those who know better, that are too scared, apathetic or even happy to go along with a blatant, overtly corrupt culture need to be dragged out, named and shamed. We pay for a service to the public – not to service some bloody Minister. I don't how some of these people can shave every day, take wages and have the brass neck to appear in public, pontificating on safety. Bollocks – they know it, I know it.

#988 Tea and biccys Friday??

Senator Nash: Joke.. "Did you hear the one about the $150,000 dollar taxpayer funded pot

plant?"...gold Fiona pure gold!!

Now tea, biccys and maybe a snort of chardy over lunch??

Schedule for Friday's hearing has been posted : Senate Committees – Parliament of Australia

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#989 "Ave, Imperator, morituri te salutant"

Comedy hour or two. Dutifully convened at a salubrious watering hole this afternoon were

the Bar Room Barristers; all awaiting the Senate Estimates. STAR of the show, Fiona Nash and the "pot plant" saga, hereafter to be known as the best laugh, stuff of legend and plain old ordinary "we gotcha" ever. The crew is still rolling about the floor. Brava, Lady –

Bravo!! If you missed it – I can't help that. What she said of course is, we know, down to cost of maintaining your plants, exactly what you are about. The confusion was priceless, the response – hilarious. Nearly as funny as Beaker asking "what?, what's a mid air? - followed by two minutes of "fluff" until a paper was provided for him to read. Priceless, PLEASE if any one recorded the estimates session this pm, with the parts involving "He who will not be shamed" and "Beaker", put it up for the boys and girls who were working; I still can't even construct a cohesive sentence without laughing. No horse power in the Senate eh?.... Dream on. Friday, bloody Friday. "I am thy father's spirit; Doomed for a certain term to walk the night, And for the day confined to fast in fires, Till the foul crimes done in my days of nature Are burnt and purged away. But that I am forbid To tell the secrets of my prison-house, I could a tale unfold, whose lightest word Would harrow up thy soul, freeze thy young blood, Make thy two eyes, like stars, start from their spheres, Thy knotted and combined locks to part And each particular hair to stand an end, Like quills upon the fretful porpentine: But this eternal blazon must not be To ears of flesh and blood. - List, list, O, list!" - William Shakespeare, Hamlet, 1.5 #995 Poor Beaker. He certainly looked confused about the phrase 'mid air'! He is only the head of the ATSB I guess, why would he need to know about 'mid air's'?? He would be more understanding of the words 'bonus, Montreal, tautology, Minister, spin' etc etc. It was a good thing that Darth Beaker had Sith Mrdak there to show him on paper what the Senators query was. As for 'he who shall now be called Devo', the pot plant question was incredibly hilarious! I thought 'Devo' aka Mr Skull the pot plant man, was going to choke on his Bex!! Perhaps they are some kind of special gift pot plants that ICAO or the FAA gave Fort Fumble? Or some kind of mystical hocus pocus PNG plants that contain healing powers and soul soothing ability? Maybe they are an aphrodisiac or hold some kind or medicinal ability to heal a badly pineappled bot bot? I can picture it now, Terry, Devo, The Doc, Adam, Herr Boyd, Sith Mrdak, Beaker all wearing pot plants on their head singing 'Working In A Coal Mine' while Big Chief Albanese plays the guitar! #998 One bite from the gritty sandwich

Trawled through some of the documents this morning, still anticipating the Hansard release of the 'pot plant shenanigans', however Mr Urquharts submission when read in deatail is not only touching but he clearly outlines the failing of government, CASA and the ATSBeaker.

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Also of interest is John F Devo's letter to Senator Heff, dated Feb 13, in which the pot plant puppeteer digests a small poo sandwich by retracting his use of the term 'audit'. Devo and Richard Dreyfuss are becoming accustomed to writing such letters over recent months. Are they exhibiting a side of their moral compass never before seen?? Nah, I didn't think so either, just more CYA activities me thinks. 'safe skies are clarified and transparent skies' #999

Halfmanhalftimtam, A directions hearing is scheduled in SYD this Friday. No doubt FF will try to stretch the matter further, Barrier is currently bleeding around 30k per day. But i wonder if CASA legal will be available for the SYD hearing as most are at the Senate, or perhaps in Montreal?

For those interested here is the listing for Barrier tomorrow...err watch AA monitoring his phone!!

Quote:

Justice RaresCourt Room 19E 9:30 AMFirst Directions 1(P)NSD2242/2012LEE-ANNE FOLKERS v WESTPAC BANKING CORPORATION ACN 007 457 141 2(P)NSD1918/2012LINFOX AUSTRALIA PTY LTD v TRANSPORT WORKERS' UNION OF AUSTRALIA & ANOR 3(P)NSD2240/2012CIVIL AVIATION SAFETY AUTHORITY v BARRIER AVIATION

PTY LTD ACN 056 643 531 4(P)NSD2170/2012PATRICK BYRNE v MLC LIMITED ABN 90 000 000 402 5(P)NSD2011/2012SYKES GROUP PTY LTD ACN 004 093 752 v POWERHOUSE LOGISTICS PTY LTD ACN 050 065 631 & ORS

Notice the Ginger Ninja's favourite Justice is overseeing this one...hate to say it but the

signs aren't good!

#1000 Potted version.

The vision is not great – but you get the message. In the middle of a meltdown, pot plants. The body and facial language cracked me up. Courtesy of the Good Senator Fiona Nash – The great pot plant saga. #1001 Is the hearing being broadcast via webcast on the senate site? If anyone knows and has the link please post! Was in the right place now live - time for some fun. Watch Parliament – Parliament of Australia 30 minutes to first question on notice to JM. think there was some betting on that. If not watching you should. Senators giving them a very difficult time. #1002 I hope like hell that these people appearing this morning NEVER, NEVER operate machinery

where they have to make an on the spot decision.