[Peetwo]

A hat trick. - Part II

The ABC seems to be trying to whip up ‘drone’ accident in Wyndham WA into something – honestly. You can bet on two things, the solid wall of silence that comes with any ‘experimental’ military project and that whatever went sideways will get sorted. End of.

Instead of providing a vicarious ‘conspiracy’ fillip for breakfast consumption, perhaps the media could get down and dirty by getting some ‘real’ investigation done; the recent two fatal aviation accidents in Qld ain’t a headline grabber; but we do have a steady stream of fatal crashes. Almost a pattern; now, if the ‘rules’ are not preventing the accidents and the investigators take so long to come up with a report into the accident; there is genuine scope for real inquiry.

When a report into an accident eventually gets published – and we are talking in years here; any useful information which may assist in stopping a developing ‘trend’ is rendered useless; and, worse - accepted as 'normal'. Provided the flight ticked all the legal boxes, it’s fine. You can die whenever and wherever you please – you’re legal – no wukkers – case closed. You become part of a data base and forgotten – RIP.

Our much vaunted ‘safety system’ is becoming a very expensive operation which has not in the last decade provided any substantive decrease in the accident rate. Yet the media seem to quite happy to accept this, publish trite little stories which attract little interest, without getting into the underpinning foundations of this now ‘normalized deviance’. Ayup, we loose a few every year, so what…………Pathetic.

What say you P2 – VFR into IMC and NVMC accidents – facts and figures? Worth doing?

Toot – FDS – toot.

 - Wilco "K" - 

How about we kick it off with this? ref: https://www.atsb.gov.au/media/4462266/ao..._final.pdf

&..from here: Joining the dots on Fort Fumble's 18 year obfuscation of ATSB identified Night VFR safety issue

Although it needs an update Appendix A is particularly relevant:

Appendix A

Accidents involving night VFR operations The ATSB reviewed its occurrence database for accidents in Australia from 1993 to 2012 that met the following criteria:
• occurred at night
• conducted under the visual flight rules (VFR)
• occurred in visual meteorological conditions (VMC) or probable VMC
• involved a pilot that had either a night VFR rating or a command instrument rating (CIR)
• involved an aircraft equipped for night VFR flight or instrument flight rules (IFR) flight
• involved either controlled flight into terrain (CFIT) or a loss of aircraft control in flight, and the loss of control did not appear to be related to any technical problem with engines, flight controls or primary flight instruments.

Table A1 lists 13 accidents that met these criteria. Another five accidents that occurred during agricultural spraying operations also met the criteria. In addition, there were other accidents that may have met the criteria but there was insufficient information available to determine the nature of the accident or whether the conditions were VMC or IMC. At least six other accidents probably involved VFR flights entering IMC at night during the same period.

Of the 13 accidents in Table A1, the following was noted:
• 11 occurred in dark night conditions
• none occurred immediately after take-off, one occurred on final approach, three occurred during flight at low level, and the remainder occurred during climb or en route
• in only one case did the pilot in command have a current CIR
• in four cases there were passengers on board but the pilot had probably not met the relevant recency requirements for carrying passengers at night
• five accidents involved helicopters, three of which were CFITs and two involved loss of control.
• 10 accidents resulted in fatalities, with the only non-fatal accidents being three helicopter accidents involving CFIT at low speed from low level or during climb. During 1993 to 2012 there were also eight accidents involving IFR flights at night that otherwise met the same criteria.

Three occurred very soon after take-off and four were CFITs during approach. All occurred in dark night conditions. The rate of IFR versus night VFR accidents could not be determined due to very limited information available on the amount of night flying under the two types of rules. However, it would be expected that significantly more flying at night is conducted under the IFR than the VFR.

Senator FAWCETT: When there is an aircraft accident and there is a fatality and the coroner becomes involved, can you describe the relationship between ATSB and the coroner?

Mr Dolan : The legislation, the Transport Safety Investigation Act, requires us to cooperate with coronial processes. Therefore, coroners have, if you like, a special relationship with us. There is a range of information and support that we are required to give to coroners that we do not give to other legal processes. We try, as far as possible, to ensure that our reports are reliable and comprehensive and therefore can be used by coroners to form their views, which are largely no blame and in parallel with what we are trying to establish.

We recognise that there are areas where coroners will investigate and we do not. We are trying to deal with that carefully. We do that mostly by making sure we are in close contact with the police who are working with the coroner so that there is clarity from the beginning as to whether we are going to be playing to any significant extent. We are always happy to explain our reports to coronial processes. In addition, we have been offering accident fundamentals training, the basics of how we approach our job, to a range of police officers across the jurisdictions who are likely to be assisting coroners in carrying out their duties.

Senator FAWCETT: Do coroners ever face the situation where they have to choose between your advice and that of another aviation expert?

Mr Dolan : Quite often. It used to be more common than I think I have noticed in the last year or two that alternative views were put to coroners—

Senator FAWCETT: Who would those other stakeholders be?

Mr Dolan : Our experience has been that counsel assisting, in trying to do a comprehensive job in support of a coroner, sought other lines of information and brought it to bear in the process. Other parties, all of whom have their own interests in a coronial process, often find it necessary to test a range of alternative hypotheses. Sometimes the weight comes down to a different place than we placed it. That is just part of the relationship. If there is a coronial finding that is inconsistent with what we found or more information comes to light in the course of an inquest that is relevant to our investigation, we will reopen the investigation and make sure that is properly weighed up in our processes.

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 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.

And the follow up by Senator Fawcett in the October 2012 Supp Budget Estimates:

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.

Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.

Mr Mrdak : Yes.

Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.

Mr Mrdak : We will come back to you on that.

This time there was a listed QON to which M&M conveniently sidestepped by hand balling it back to Beaker and the ATSB:

Mr Mrdak: It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.

Answer:

One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed,
not addressed, no longer relevant or withdrawn.

A 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 policies and procedures for identifying and promoting safety issues, including
through the issuance of a formal recommendation, is outlined in its submission to the Senate
References Committee Inquiry into Aviation Accident Investigations.

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 100% of the
time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, 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.

As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for
following up on recommendations and safety issues identified by the ATSB, as provided for
in the Memorandum of Understanding between the agencies. Aviation safety agency heads
will continue to monitor the present arrangements to provide an adequate system for
addressing issues identified through ATSB investigations.

This was the answer to Q59 from the May 2012 Budget Estimates: 

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.

Answer:

In terms of coordination between agencies there are in place a number of mechanisms that
ensure effective cross agency handling of issues in relation to safety matters having regard to
the specific legislative roles of each agency. These include the establishment of formal
Memorandum of Understanding between the Australian Transport Safety Bureau (ATSB) and
the Civil Aviation Safety Authority (CASA) and between the ATSB and Airservices Australia
(Airservices).

In relation to interaction with coroners this takes place in a number of ways. The ATSB
supports the coronial process by explaining the findings from its own investigation through the
provision of briefings to the coroner and giving evidence at inquests.

The ATSB also brings any aviation safety related issues identified in the ATSB investigation or
from the coroner’s findings to the attention of the Civil Aviation Safety Authority (CASA),
Airservices Australia and industry by publicising them on the ATSB’s website. Where
appropriate, comments are specifically sought from both CASA and Airservices, and that
information is also included on the ATSB’s website.

In relation to CASA, Airservices or the Department, all organisations participate in the coronial
process when requested. Where coroner’s findings are directed at any of these organisations,
the coroners’ recommendations are fully considered and where agreed, actions are
implemented to enhance aviation safety.

ref - pg 2 here: https://www.aph.gov.au/~/media/Estimates...ports.ashx

All that weasel worded rhetoric and supposed proactive actions, by M&M and the three Aviation Safety Stooges back then, some seven years later - amounted to what exactly, in addressing or closing the loop on significant identified safety issues (like the Night VFR accident issue)...  



MTF...P2