A Sunday ramble – Part 1, (the long version).

28 Feb

It was my intention to draft a pleasant Sunday ramble through the dark woods which surround Sleepy Hollow.  But the Canley Vale matter has been so very poorly dealt with; and IMO, needs either a Royal, Judicial or Senate inquiry leading to a royal commission.  It is a disgraceful affair, by any measure and following so closely on the heels of the Pel-Air debacle/report, which shamed us all, it sets precedents which cannot continue, unchecked.  Anyway, FWIW read the P2 data above and then come for a walk on the dark side.  Ready?– right then, “Steam On GD”.

The ‘Ollow as it’s known is a dark, dangerous place, not really suitable for picnics with the little uns.  Things happen; but, if you can avoid the deep dark dells, then a stroll through the surrounding woods are; or can be enjoyable, provided the Purdy ‘over and under’ is handy and your dogs know their business.  Today’s ramble, sans canine support, takes us deep into the dark, dank, sinister woods surrounding the ‘Ollow itself.

We shall take the time honoured pathway and start at the beginning.  First there is the incredibly steep up hill slope to get to the canyons rim; once there, AOC nirvana seems secure, the tough part is over.  Then there comes the gently sloping plateau, things look good and we bowl along merrily, ignorant of what awaits us.  The descent into the actual ‘Ollow.

Now then children, you all know my job and where I work; and, if you think that’s tough wait until I tell thee what occurs on that treacherous descent.   First lesson; you must not presume that ‘you’, personally, are a target of choice for the denizens of this deep dark place.  You are not.  You are just another tasty morsel delivered ready for the feast.  Those who have come in peace and abject compliance are tolerated.  But those with delusions of rights, those who actually dare think they have a right to exist, will be picked off long before they reach the tower of Babble, where the big beasts live in obscene luxury and decadence.

There are a vast array of ‘treatments’ available.  If, for example, you have carved up an innocent cake with a Minister; you will be given the de-luxe service, where nothing is too much trouble and annoying details are made to vanish (by the palace vizier) at no great monetary cost. There is always a cost though, ain’t there?  And so, for those on ‘soft ride’ packages, small annoyances, like ATSB reports can be arranged so that there is the minimum of fall out.  Take the latest Pel-Air go around; the audit was neatly and swiftly laid to rest, the report massaged to suit and there was even a handy scapegoat.  The management of this wonderful atrocity was entrusted to a non qualified (aeronautically) manager with top cover from the home office.  It was one of Sleepy Hollows finest moments; aircraft lost, passengers recovered, no big deal, even the CVR unit was left to disintegrate in the still, warm, not too deep waters off Norfolk Island.  No point to recovering them; the die was cast  (Alea iacta est) – pilot error.  The safety report was doctored to suit and the cake was cut, shared amongst the mates.  It was, as I say, a fine effort by all concerned, there was even scope and time to plagiarise ‘write’ a powerful, although private report on the matter.  That report of it ‘self, was a master stoke.  It achieved (in some circles) fortune and glory for the author; it neatly skewered the qualified ‘drones’ while appearing to be the answer to a pagans prayer. A definitive discourse of all that the CASA fellahin had got wrong; drafted by the saviour of ‘aviation safety’.  Top secret of course, alas, despite strenuous redaction, the author could not prevent his name appearing on the top of the first page.

Even so; let us forgive this atrocity for the nonce.  Let us focus on the benefits this audit and report provided for aviation safety.  Well of course, the pilot ‘dunnit’; gross negligence verdict assured and embuggerance to follow for the rest of his days.  It shows just how effective a safety guru the manager in charge was; a Senate inquiry, independent report and a peer review all nugatory, thanks to the work of one man.  The company got off Scot free, not a blot on a very messy copy-book.  CASA even hired the incumbent chief pilot, so ‘delighted’ were they with him.   Bravo..

Conversely, this treatment is not available to the general hoi-polloi, the riff-raff, who don’t have connections to seats of power beneath the grand viziers of Sleepy Hollow.  No Sir.  Under the same safe hand as managed Pel-Air we find the airtex case file: and a complete reversal of form.  NCN by the ream, fact, circumstances and ‘evidence’ provided, as and when required.  Made by the mile, cut off as needed.  It matters not that fact had little to do with that which has been preordained.  In fact; ‘facts’ can be distorted, manipulated and bent to suit.  Airtex was; as a case in point, worthy of mention, for many reasons.  One being the incumbent head pooh-bah needed a juxta position from the soft, fluffy, friendly treatment Pel-Air received; a balance if you like; a Ying and Yang if it pleases.  From between way too soft through to way too harsh, balances the scales.

For those not familiar, here’s the background.  Airtex lost a Metro and pilot one night.  There was much speculation about the cause, although little was provided by way of support for any one particular theory.  ATSB finally decided, despite expert advice and demonstration that their theory was the right one.  For example:-

Quote:The practical demonstration also included other failure scenarios, and the various warning lights that could not have gone unnoticed.

As far as I am concerned, this demonstration conclusively proves that one ATSB scenario, that the Right Essential DC bus was not powered, and the static inverter selector switch was selected to this unpowered bus.

In none of the scenarios could the warnings have gone unnoticed. The notion that enough double bulb indicators all had blown bulbs, such that all visual warnings were absent is not credible, the statistical probability (even without an engineering reliability analysis) is too unlikely.

The ATSB dustcart followed along behind the Lord mayors parade.  The manager of ‘Bankstown’ at the time (Botany Bay) was a reasonable fellah.  There had been some questionable reports and there was some evidence of things not being done according to Hoyle. So, rather than shut down the operation some fairly hefty ‘directives’ were attached as conditions to the Airtex AOC (see P2 above), tough but not onerous, if Airtex played the game. One of the top weight conditions was a complete rewrite of the check and training system (which was bloody awful) and a conversion to multi crew operations, which for Metro aircraft is, IMO a first class idea.  So, they set to work and by the September 09, a new chief pilot and support crew were in place; big tick and Airtex staggered into the real world.  Compliments were offered, independent audits were passed, even a couple of CASA audits were passed without too many problems.  The future looked reasonable.

Here we must pause and examine time lines : Pel-Air happened in November 2009 and by Christmas 2010 the audit and reports were pretty much done and dusted, there was some pushing and shoving but, to all intents and purposes; the dissenters had been ousted and Wodger was pinching penning his secret report for either McConvict or fat Terry.  There had to be a balance struck and a show to convince the world that CASA had acted in good faith with Pel Air; one soft audit deserves a tough one to follow up with; just to maintain the legend of the big R.

The Airtex boss about the new year decided that despite the conditions being gradually removed from the AOC, he wanted the last four gone; now – now.  Against advice, he wrote a letter demanding the immediate withdrawal of the remaining conditions.  That poked a wet noodle up the tiger’s arse and an audit was declared.  Due to past bad blood, remnants of a couple of shouting matches, the edict “shut ‘em down” was issued.

What happened next is truly mind bending.  Many senior, qualified aeronautical and legal experts have been asked to make comment (or even sense) of the ‘bizarre’ audit conducted in Feb. 2010; all have failed to produce a rational explanation.  Whichever way you cut it up, always the same result and verdict.  Bastardry on a grand scale.

For those still with us at the end of this introduction, there is more to follow, next we shall take a look at a potted version of some very strange happenings and the lead up to the Canley Vale tragedy.   I’m not deliberately stretching the story out; but it’s complex and to do it any sort of rough justice; it needs some explanation and background.

Here endeth the Sunday ramble – Part 1.

Second and final verse.
All sitting comfortably?  Good, then I’ll begin.   Before we get too deeply embroiled in the Airtex saga a little more background is required.  One common misconception a lot of folk have is that Skymaster and Airtex were one and the same; they were not.  They were both owned and directed by Avtex as were a couple of other associated ‘sister’ companies, such as maintenance, travel agent, flight nurses system were yet another separate ‘sister’ entity, independently managed. One good result of the Botany Bay fatal and the operational conditions imposed was that the two AOC’s became clearly delineated; each company had an independent chief pilot, different SOP’s, philosophy and system management.  In truth there was only ever one ‘joint’ operational meeting scheduled, which the CP of Skymaster refused to attend – but I digress.  Suffice to say that the two AOC management ‘teams’ were very different animals, not given to spending time together.

Where there was a clear connection, the only one, was through the flight crews.  Both companies employed ‘permanent’ contract crew; no fly, no pay.  Skymaster operated single pilot, piston engine <5700 Kg; Airtex operated Metro II and III, multi crew.  But it made good sense to take Metro First Officers (FO) from the piston fleet and train them up.  This kept the troops busy enough and provided valuable experience for career future, so that was win-win.  It was through this in house cross pollination that some of the less than ideal practices of Skymaster were revealed.  It often happened that two or perhaps three aircraft would meet at a common destination for an over night stay; naturally enough whenever possible, the crews would get together for a couple of beers before dinner, even more natural that tall tales were swapped.  Now pilots bitch and moan; they do and an experienced man learns to take another’s tales with a pinch of salt in the spirit of the evening.  But once the same tales start to be repeated by others, in this case the Skymaster pilots, it’s prudent to pay a little more attention.  After series of ‘man to man’ confidential chats and some hair raising reports made to the Airtex senior pilots (N.B. not Skymaster), it was decided that something must be done before there was a serious accident.  So a report was drafted and sent to the company director, management, CASA, the independent auditors and the safety committee; and yes, it was that serious.  The report was distributed almost a 12 month to day ahead of  Canley Vale.   In less than 48 hours, two CASA FOI turned up.  Now a logical person would assume the Big R heavies had arrived panting to add their weight and considered opinion to the discussion.  Not so, in essence, the Airtex senior pilots were informed, in no uncertain terms, to forget about it and to remove the report from the SMS.  As late as last October, CASA still deny receipt of any such missive or taking such action.  Prove it, they snarl.  This from Skidmore mind you; so much for reform progress, right there.  But again, I digress, although it is germane to the Canley Vale crash.

So audit day arrived; now Airtex had, as part of the AOC conditions, employed a very professional, internationally respected, highly qualified and skilled team of independent auditors who turned up on a regular basis to monitor the Airtex growing up process and report back to CASA.  Their reports were all positive and often complimentary.  There had also been two CASA audits of the Airtex training and checking system and an initial series of CASA check flights to examine both system and the CT pilots involved, there had also been a couple of approvals made by CASA, all positive.  With this backing up a well run operation which had for 18 (or so) months being steadily improving there was every reason to expect Airtex to withstand a CASA audit; one supposedly designed to decide whether the remaining conditions, those not already removed through AOC re-issue, could be removed.  Bog standard stuff right?  Wrong, wrong, wrong.

The story goes that the full Airtex front line were there to meet and greet the CASA FOI team; all seven of them.  Engineering was represented, flight operations and a special crew to discuss with IOSA auditors the proposed SMS which, if approved would become the ‘group’ standard.  Except for Skymaster who refused to be party to any of it, preferring to write their own.  Enough said.

So the two FOI armed with coffee and biscuits took over the chief pilots office, the two senior guys sat in visitors chairs waiting requests for the usual paperwork to be provided.  I would love to have seen their faces when the ‘senior’ FOI opened the bidding with the following statement; “there’s a load of shit coming down the pipe line and it’s all headed in your direction”.  It must have set the tone, it certainly rang the bells. Before lunch there was a small gathering in the directors office, the independent expert auditors and senior pilots.  No one is sure who actually said it first, for they almost in unison said “not audit -witch –hunt, get some legal weight in here now, before this gets out of control”.  It was a mistake to ignore that advice.  IMO the audit should have been stopped right there and then and a conference with CASA management arranged before it was allowed to continue; alas. So, it went on for Airtex, every full stop, comma and uncrossed ‘t’ was analysed and neither logic, reason or even sanity was allowed to gain a foot hold.  CASA was on a mission.

Did lunacy or pure evil prevail is a question still asked to this day.  One example of passing strange, to some observers clearly defines the malice aforethought.  This part has puzzled much cleverer folk than I, so rather than comment, I’ll just tell the tale and let you decide (if you can) – deep breath:-

You see some 24 months previous to ‘the audit’ it was officially decreed that the only way Airtex could continue to operate was with an entirely new suite of manuals and an upgraded check and training system to support multi crew operations, among other things.  It was quicker and easier to redraft the entire thing, soup to nuts, rather than attempt a repair of the ‘old’ manual which had not received the TLC it needed to keep it up to date and a good ‘fit’ for the proposed operations.  So, out with the old and in with the new.  Remember this takes time and note that although Airtex was not generating income, the CEO never, ever pressured those involved, never showed impatience and paid the freight on the spot, without quibble.  To my mind that spells responsible, executive management.  Anyway -A complete renovation was directed, roof top to cellar floor.  This was done, CASA received the manuals and after a series of CASA tests the AOC and Check Training was approved; it must have been.  Operations started, AOC re-issued, pilots checked and the doors opened for business.  Job well done some would say, the independent auditors certainly did.

“Not so” declares the new CASA manager, this statement made after some 18 months of operations under the ‘new’ manual suite.  A particularly useless, bumptious new start FOI declared that all previous check flights were illegal, because the head of CT proficiency check was ‘time’ expired; all operations to cease immediately.  WTF? It is fact that the CT pilot had been involved in no less than six ‘checks’ of his proficiency with independent ATO and CASA within the previous 12 month; it is fact that less than 48 hours previous to this remarkable edict, the CT pilot had passed a base check, MECIR with an independent ATO.  “Not valid” declares this worthy; the proficiency check conducted by Airtex to validate the independent ATO approval previously was deemed invalid, therefore last check was invalid also.  As was the previously CASA conducted check, all invalid.  Why?   All tests were conducted under the company operations manual, the immediate response; look here, here and here; all Kosher, by the book, done and dusted according to Hoyle.

“Only under the ‘new’ manuals and they are not approved” says the manger with a smirk.  “The only approved manuals you have are these” and he fondly pats the redundant, long forgotten, single pilot manuals.  So it came to pass that a full blown safety alert was issued because CASA no longer accepted or approved the ‘new’, CASA demanded operational suite.  Go figure.  This notion was ruthlessly and relentlessly pursued.  How in the seven hells CASA ever got that crock to stick beats me hollow, it really does.  From there it was a classic CASA panzer attack.  I got to look over some of the RCA/NCN, some were risible, others plain bollocks, some lethal had they been allowed.

One outstanding RCA (as was) springs to mind every time I revisit this shocking tale.  Under the old CAO 40.1, for a co pilot rating Metro, there was no requirement for ‘stalls’; even so approach to and recovery from was introduced into the training program, for sake of completeness.  It was asserted, that this was incorrect and that a co pilot endorsement required not only the full stall lexicon, but this must be conducted with the stall avoidance system (SAS) disabled.  You know, it took a very strongly worded letter from the certificate holder to convince the CASA FOI that this was not good thing to do, even for test pilots.  The RCA became woven into the fabric of the faery tale that Airtex training was deficient.  It’s also worth mentioning that the grossly deficient training given at Skymaster was carefully never mentioned.  Aye, it’s good to know that the robust, much touted safety watch dog knows it’s business.  Enough, there’s more, but the boiler is struggling to keep up.

But mostly the RCA were straws gathered to make a haystack in which to hide the needle of truth; never the less even the acquitted ones were trotted out in the AAT, bent, twisted and untested, sworn into ‘evidence’  It is noteworthy that the ‘evidence’ (for wont of better) supposed to be presented by the bumptious new start was abandoned late in the piece and he ‘returned to industry’, in some haste, very shortly thereafter.  Even the ‘manager’ knew that ‘evidence’ could not withstand casual scrutiny, let alone a test under oath.  Aye well, more than one career went to the crapper as a result and Airtex was forced into closing, a million dollars and change worse off thereafter.  That’s history.

Two further elements require your careful consideration; one is Canley Vale; the other is the stark contrast in treatment between Airtex, who got hammered and Pel-Air, who danced off into the moonlight with barely a scratch, even after the Senate did it’s job.

Consider and compare the Airtex case to the remarkable eight day turn around for Pel Air and the picture emerges; eight days to a fresh, no penalty start for Pel-Air.  Doom and the destruction for Airtex, $100,000,000, a business, 40 jobs and a couple of careers ended with many others suffering through no fault of their own; all due to the difference of treatment.

Hitch wants FOI stories; well that has been one of them.  Not all of it; but the backdrop to some of the most venal, vicious embuggerance ever inflicted, by FOI on flight crew.  If you think Dom James got the rough end of a pineapple; think again.  Honestly, IMO  he escaped lightly penalised in comparison, as did Pel Air.

There are other tales surrounding this matter, which, for the sake of prudence I will not tell, they are the stuff of nightmare, likely to scare the horses and frighten the little ‘uns.  The Canley Vale whitewash needs to be scrutinised as does the marked difference in treatment of audit by the same individual.

Industry gossip is a hard beast to manage once it’s got a juicy story, no doubt truth plays little part in the great gabfests and tea room character assassination.  Too late to change any of it now, and anyway, why spoil a good yarn?  There is a sound case to reopen the whole sorry affair.  Should the Senate committee investigate?  I believe so, it may put an end to the current pantomime.

But, FWIW that’s my two bobs worth.

Selah.

Now, “GD, saddle those elephants mate, lets go outdoors and play in the free wind.  I’m in great need of some fresh, clear air, a wide horizon and the silent companionship of something I can respect”.

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