[Peetwo]

BRB brain teaser: The Iron Ring mole within?

Damn that Blind Freddy is good -  

Still haven't worked out all the dots and complimentary dashes myself and yet BF is already second guessing the brain teaser plot...  

As many will be aware I have been otherwise engaged in hoovering up the ATSB ADREP/ECCAIRS aberration crumb trail and what I have discovered so far poses more troubling questions than answers. However I will try to step the BRB through the mess of scattered and fragmented crumbs in order to provide background to this year's AGM brain teaser...  

 Quote from previous post: "..From that PDF it would appear that the original report was modified on 10/11/2015 at 8:13:02 am (click 'file' then click 'properties') by 'author' E.Hargreaves (ATSB REPCON Manager & ICAO co-ordinator)..." 

The date is interesting as it was 8 days out from the anniversary of the VH-NGA ditching. In the context of the re-opened investigation this should mean that a public interim statement was about to be released with details of the progress of the ongoing investigation.

Although not obliged to under Annex 13, most States tend to keep ICAO in the loop and forward the interim statement (e.g. MH370).

Given the nature of the VH-NGA re-investigation (findings from the Senate AAI inquiry & TSBC peer review) I believe EH has felt obliged; or was instructed to file a ADREP/ECCAIRS notification/progress report.

In that process it would appear that EH has discovered that the VH-NGA ditching had no prelim or original final report on file...  

In an attempt to track any other similar aberrations/duck-ups I began to work my way through all Australian serious incidents and accidents notified to ICAO from 2008 till today.

That was when I noticed that a large volume of ATSB AAI prelim/final PDF reports were created and forwarded to ICAO ADREP/ECCAIRS in the same week the ATSB REPCON manager/ICAO co-ordinator modified the PDF copy of VH-NGA prelim report.

Most of the reports submitted to ICAO in that week and a bit were investigations from 2008 to 2010 and had final reports made public before 2012. This just so happens to correspond to when EH was appointed in the role as REPCON Manager.

For obvious reasons, this got me thinking to who it was that EH had replaced in the role...  

Here is an extract from the previous manager's LinkedIn webpage:

former Manager, Notifications & Confidential Reporting

Company Name: Australian Transport Safety Bureau
Dates Employed: Nov 2001 – Apr 2014
Employment Duration: 12 yrs 6 mos
Location: Canberra

Oversight of the assessment and categorisation and data entry of all mandatory aviation safety incident reports and the ATSB's confidential reporting system (REPCON). Other responsibilities include:

Safety education coordinator and presenter
Database management including data extraction (non technical)
Change management board member
TSI Regulation reporting oversight and development
International Confidential Aviation Safety Systems (ICASS) member

 
Still many fascinating connections and parallels to explore with this individual but for the benefit of the BRB, I refer to the before (ATSB) & after (ATSB) vocation entries for SY:

Before:

Flight Data Officer/Research Officer/Administration
Company Name: Airservices Australia
Dates Employed: Jan 1990 – Nov 2001
Employment Duration: 11 yrs 11 mos
Location: Adelaide & Canberra

Joined as FDO in Adelaide and transferred to Canberra as an admin officer. Held positions in Regulation (pre CASA), AIS, Flow Management (database admin), HR and Environment (ESIR data management). Seconded to the ATSB for 3 months before ultimately transferring there 12 months later on promotion as the Database Administrator.

---

[/url]
Loadmaster

Company Name: Royal Australian Air Force
Dates Employed: Jul 1975 – Nov 1987
Employment Duration: 12 yrs 4 mos
Location: Canberra, Pearce, Sinai (Egypt)

[url=https://www.linkedin.com/company-beta/946571/]Operations and instructor on Iroquois (UH-1B/H) And Squirrel (AS350B). Total flying time 2,750 hours. Search & Rescue duties 2FTS at RAAF Pearce, WA. Peace keeping duties in the Sinai Peninsula between Aug 83 to Feb 84

---

After:


Data Analyst
Company Name: Airservices Australia
Dates Employed: Jul 2015 – Present
Employment Duration: 2 yrs
Location: Canberra, Australia

   
Which finally brings me to the BRB (pop quiz) brain teaser : Q/ Why would such an experienced, long serving and faithful public servant, leave a secure middle management job with the ATSB, for an unexplained 15 month leave of absence, only to return to a lesser position with AirServices Australia?    


MTF...P2  

[P7_TOM]

Ahem; (cough): if I may, I’d like to interrupt P2’s fun and games for a just moment, to mention the small revolution building within the BRB and IOS. For those who don’t play – it’s a simple enough explanation; once a year, there is a ‘puzzle’ set, usually to do with ‘matters aeronautical’, the prize of Choc Frogs and bragging rights, is contested, robustly. Apart from one or two lone wolfs, many form ‘teams’ – bit like a pub quiz sort of thing. The bait is tossed out and they set to work. Provided the ‘clues’ are ‘plentiful’ they usually manage to arrive close, if not spot on to the solution.

Now this ICAO puzzle P2 is ‘researching’ and the paltry information provided so far is creating rumbling noises – not only with the BRB, but within ICAO itself. Seems they are as puzzled as we are. That aside; it would be politic to throw out a few more breadcrumbs, before the rumbles become howls of protest. Now I know that the final ‘question’ will be fully researched and the solution unimpeachable; however….

That’s it P2; they have smelled the stew and are milling about the back door; throw ‘em a bone or two, just to keep ‘em happy until supper is served up. Go on, you know you want to.

“Two more here please barkeep” – (aside) perhaps another ale or two will loosen “K’s” tongue – unlikely; but you never know - any excuse eh?

[Kharon]

The adventure of the veiled question.

Watson – “The source of these out-rages is known, and if they are repeated I have Mr. Holmes’s authority for saying that the whole story concerning the politician, the lighthouse, and the trained cormorant will be given to the public. There is at least one reader who will understand.”

Much like Watson; I find myself in a similar, tantalising position. I know, that within the confidential archives, there is a story begging to be told. The BRB can smell the whiff of outrageous scandal and speculation is rife. P7 did indeed try to ply me with ale; and, much as I dislike disappointing him; and the crew, fact is they have about as much information as I have. Breadcrumbs and signposts are about the limit of my knowledge; well, that and the digging I have done, but P2 holds the strings on this one, albeit a tenuous hold. This is the problem when ‘digging’: layers of disconnection, miles of ‘legal’ wriggle room, carefully concealed bolt holes and more smoke than is healthy.

Clues? Well, without the faintest notion of the final research result, anything I may tip is likely to be misleading; but, I may without leading anyone astray say that it all has to do with the reporting of accident and incident to ICAO. I can also state that at present we seem to have more idea of what is going on than ICAO’s Australian ‘Excellency’; but I doubt that will last for long. The chap in Montreal is deemed ‘proper’, righteous and upright; I expect P2 is awaiting that response before getting ‘fair-dinkum’ about his brain twister.



So patience and forbearance is required; speculate away, no harm there: but, be advised, the ‘tote’ is firmly closed. I cannot even frame a field of runners yet, let alone lay odds. No doubt when P2 finishes on the 18th green and marked his card, we shall hear more.

Meanwhile, I am always happy to have an ale or two with a mate – I can set several rabbits running, enjoy my ale and watch the fun; fair warning.

Toot – toot.

[Peetwo]

BRB BT: The IR mole & the ADREP cock-up(rort)?   
Sorry guys got tied up checking with some sources at the 19th -

Anyway still waiting on some feedback from his 'Excellency' but in the meantime I have some more dots & dashes on the Iron Ring 'mole' that should help "K" firm up the field for the 'ICAO Obfuscation Cup' -

Reference: 2004 ICAO ATSB - Audit Report [ Download PDF: 2.86MB]

At page 5 to 6 and para 4.6:

4.6 Safety recommendations are issued by the ATSB in conformity with Annex 13 requirements. ADREP Preliminary Reports and Data Reports sent by the ATSB to ICAO were incomplete, partly due to the differences in the taxonomy format. Since the ATSB is in the process of acquiring a new accident and incident data reporting system, it is recommended that the new database system be ADREP-ECCAIRS compatible in order to facilitate reporting and international exchange of data. Between 1988 and February 2004, the ATSB managed a voluntary incident reporting system named Confidential Aviation Incident Reporting (CAIR). A new voluntary non-punitive incident reporting scheme, entitled Aviation Self-Reporting Scheme (ASRS), replaced the CAIR on 21 February 2004 but has not yet been broadened to receive CAIR reports, pending further legislative measures. In addition to accident and incident investigation, the ATSB undertakes safety data analysis and research. All the ATSB reports, safety recommendations and key safety information are available on the ATSB website.

---

& from Appendix 5-1:

FINDING:

The ATSB has been reporting accidents and investigated incidents to the ICAO ADREP data system (Preliminary Reports and Data Reports), however, they are incomplete partly due to the differences in the taxonomy format.

---

RECOMMENDATION:

Since the ATSB is in the process of acquiring a new accident and incident data reporting system, it is recommended that this new database system be ADREP-ECCAIRS compatible. It is also recommended that further discussions take place between the ATSB database system personnel and the ICAO ADREP system administrator in order to facilitate the reporting to the ADREP using the ATSB existing system before the new ATSB system becomes operational.

---

CORRECTIVE ACTION PROPOSED BY THE ATSB:

There was some confusion prior to the audit between the ATSB and the ICAO secretariat which meant that the ATSB was not aware of the ADREP reporting problems. The ATSB is currently investigating the feasibility of incorporating an ECCAIRS compatible ADREP into the new accident/incident database. However, a determination is still several months away. As a result of the audit, the ATSB has obtained a copy of the latest ADREP (Form D) and is seeking to create a template that will capture the necessary data applicable. The ATSB is committed to fully meet the ICAO obligation in both the short and longer terms.

---

ACTION TAKEN BY THE ATSB:

The use of ECCAIRS was considered as an option for the occurrence database module of the ATSB's newly developed Safety Investigation Information Management System. Given that most of the aviation data collected by the ATSB is high-volume, low-detail data, the complexity of the ECCAIRS taxonomy was not considered appropriate. A bespoke taxonomy for safety events and safety factors was developed by the ATSB which better suits its needs, particularly for the purposes of safety research and for the application of its investigation safety analysis methodology. However, a mapping exercise was carried out to ensure that there was comparability between the ATSB and ECCAIRS taxonomies. For the purposes of notification, preliminary and final ADREP data reports, the ATSB continues to provide this information in the ECCAIRS format, including the use of the ECCAIRS taxonomies.

P2 comment - In other words the ATSB will continue to forward only those (PDF copied) reports it deems not politically and (big end of town) industry sensitive for the ICAO ADREP Secretariat to input via the ECCAIRS IT application - and it remains so to this day. 

And for the benefit of the BRB here is the list of the ATSB officials contacted for the 2004 audit:

Mr. Kym Bills Executive Director

Mr. Rob Graham Director Safety Investigations Branch

Mr. Alan Stray Deputy Director Aviation Safety Investigation

Mr. Patrick Hornby Legal Advisor

Mr. Lawrie Brown Team Leader, Quality and Audit

Mr. Christopher Filor Deputy Director Surface Safety Investigation

Mr. Ian Sangston Senior Transport Safety Investigator

Mr. Phil Robertson Senior Transport Safety Investigator

Mr. Julian Walsh Acting Team Leader, Technical Analysis and

Notification

Mr. Joe Hattley Team Leader, Aviation Investigations

Mr. Greg Walsh Notifications Officer

Mr. Steve Young OASIS Data Administrator

Mr. Andrew Roberton Senior Transport Safety Investigator


 
MTF...P2

[Kharon]

Entry form now available.

P2 – “I have some more dots & dashes on the Iron Ring 'mole' that should help "K" firm up the field for the 'ICAO Obfuscation Cup'”.

The imp in P2 emerges from behind the mountains of research, with a cheeky challenge. Very well – I accept.

Any sponsored event in the Race to the Bottom series requires a rule set, to make the rules we need to know ‘how is the winner to be decided’, this is based on information available. It appears, from data on hand, that someone, for some reason has been playing fast and loose with the ICAO statistics; which may have had the effect of making the nations great safety record a little better than it actually is, in reality. Not proven yet, but, there is enough data available to ‘frame’ a race, make some rules and begin accepting entries. The ‘tote’ will remain closed and no ante post bets will be accepted as this may change when ‘his Excellency’ finishes his research.

[Aside]: There has been some gentle probing done, just to establish basic facts – such as why Canley Vale, Mildura, the Coal loader and other events were not on the ICAO data base. There has been a ‘reaction’ from the more sensitive parts of the bureaucratic anatomy; which means they are aware of the probes. So, to factor odds at this early stage is almost impossible – we need to see and hear the ‘official’ spin machine cover story first; which will provide a final field and allow the setting of realistic odds.

There are two elements which require consideration – if we are to accept the premise that someone, for some reason, has been at silly buggers with ‘statistics. This naturally begs the questions – who and why?. Then we must ask is it the one agency or a joint effort by the big three stables to ‘fix’ the odds? Given that all three have some serious skin in the game – funding, credibility, kudos and power; it is hard to deny the possibility of collusion – we have, after all, seen it done before. This Muddy’s the waters and makes setting both field and odds difficult.

However; P2 has provided a list of potential, entrants from the ATSB, although this is considered incomplete as the ALIU (bridge between ATSB and CASA) has been omitted on a technicality. We shall, at a later date, define which stable this amorphous entity is racing for.

So, the napsters cryptic picks for the ATSB potentials:-

Singalong Lad – ran a close second in the Pel-Air cup narrowly avoiding disqualification from racing.

Walshing Mitdolan – also implicated in the scandal following the Pel-Air cup; the connections were offered an option of a long suspension or being warned off.

Walky-Tawky – another serious contender, veteran of the Pel-Air cup and winner of last years ‘Bully boy stakes’ made infamous by his persistent attacks on mares and filly’s which challenge his running. The sponsors will definitely accept that entry.

Oasis Dreamer – never raced publicly in the major events; however, rumours of a murky history in interference and cooperative running in minor events, away from the main game are persistent.

Uriah Heep – veteran of the Obfuscation cup may yet emerge from retirement; the connections unable to resist the prize offered. If they decide to run UH in this championship race, it will be tough to get sensible odds.

That, boys and girls is as far as the organisers are prepared to take the field. Much depends on the sponsorship to hold event being forthcoming; we shall wait and we shall see. Not too many sleeps now, then I’ll get it sorted. BRB and IOS protests will be ignored.

Toot – toot.

[Kharon]

More crumbs from P2 -

Aussie O&O of the ICAO ADREP system: cont/-

To perhaps help provide a running form guide for the potential entrants to the BRB sponsored ICAO Obfuscation Cup, I will continue to publicly reveal my discoveries as I troll through the records of Australian (non-)conformity with occurrence reporting to the ICAO ADREP system.

Reference: BRB BT: The IR mole & the ADREP cock-up(rort)?

   Quote:
   ACTION TAKEN BY THE ATSB:


   The use of ECCAIRS was considered as an option for the occurrence database module of the ATSB's newly developed Safety Investigation Information Management System. Given that most of the aviation data collected by the ATSB is high-volume, low-detail data, the complexity of the ECCAIRS taxonomy was not considered appropriate. A bespoke taxonomy for safety events and safety factors was developed by the ATSB which better suits its needs, particularly for the purposes of safety research and for the application of its investigation safety analysis methodology. However, a mapping exercise was carried out to ensure that there was comparability between the ATSB and ECCAIRS taxonomies. For the purposes of notification, preliminary and final ADREP data reports, the ATSB continues to provide this information in the ECCAIRS format, including the use of the ECCAIRS taxonomies.

   Reference: 2004 ICAO ATSB - Audit Report [ Download PDF: 2.86MB]

Okay so from the above it can be seen, that even as far back as 2004, the ATSB had some serious deficiencies in forwarding safety issue information, occurrence notifications and preliminary/final reports to be inputted into the ICAO ADREP (iSTAR and ECCAIRS databases). So for other than the original occurrence notification, the ATSB solution (ref: Appendix 5-1) was not to try and match the ECCAIRS taxonomy but for everything (data/prelim/final reports) to be forwarded to the ICAO ADREP Secretariat in a copied PDF format.

On a read of the minutes of the 2008 ICAO IAG divisional meeting it was discovered that the taxonomy issue with the ECCAIRS IT application, was a common problem with some individual States. The IAG recommended a proactive action plan to tackle this.

Based on the 2008 ICAO audit report on Australia (the audit occurred before the IAG meeting), it would appear that the issue had been effectively addressed by Australia.

The problem was also lessened for Australia by the introduction of notified differences to ICAO Annex 13. In particular the ATSB exempted itself from forwarding all preliminary reports for discontinued/not to be investigated occurrences.

There was also a ND for the requirement to investigate the accidents/serious incidents that would normally be required under Annex 13.

This was discovered in the course of the 2008 ICAO audit, with the finding leading to the issuing of an audit recommendation:

   Quote:
   [Image: App-3_6_1.jpg]
   [Image: App-3_6_1_1.jpg]

 
Remembering that the IR data input mole was in charge of the forwarding of data to ADREP from 2001 until sometime in 2012. This was when EH became the REPCON manager and presumably the ATSB ICAO coordinator.

I then fast forward to November 2015 with the discovery that EH had modified a PDF copy of the VH-NGA prelim report (created 15/01/2010). However tracking the changes to this document finds no changes. I could be wrong but IMO signifies that this document was on file at the ATSB and was simply forwarded by EH to ADREP on the 10/11/2015.

This then got me thinking that maybe there were other similar aberrations...
This led me to reviewing all PDF copied prelim/final reports from 2009 till 2015. What I discovered was that nearly every report from occurrences between 2009 till 2011 was inputted by an ATSB Officer in the course of a week before and after EH modified the VH-NGA PDF copied prelim report.

I also discovered that there are still a significant number of serious incident/accident reports that have to this day not been submitted to ICAO and are not listed on either the ECCAIRS or ICAO iSTAR databases. One of these occurrences just so happens to be an occurrence that had the real potential to be Australia's worst aviation accident disaster - i.e. the Mildura Fog landing...

TICK..TOCK 6D, Malcolm in the middle & Barmybaby, TICK..TOCK indeed!

MTF? Definitely...P2

[Peetwo]

Pel-Air re-investigation rumour mill -  

Word is that there is going to be an extension to the DIP review of the 500+ page VH-NGA re-investigation 'DRAFT' final report...

As a consequence there is also a rumour that the IIC, Dr 'Ghost who walks', is none too impressed with this delay...

While we wait for the rumours to be confirmed, here is a rehash of why it was that PAIN always had issues with the ATSB guru of Human Factors being appointed in the position of IIC of the PelAir re-investigation...

Ghost who walks & talks beyond Reason-


Off the selfie-King & miniscule Dazzling Dazza's thread, a full boiler post from the Ferryman... :

Full Steam GD.  Pour it On.

Damn the guns and hammer the engines – we have an urgent pick up and delivery mission.

Made a routine ‘how gozit’ call Karen Casey, see what was new and how things were progressing. On the positive side Sen. Cameron has taken an interest in the matter and there are positive signs from that. Here endeth the good news.

To business: stunned is the only way I can describe my reaction to the following; incredulous followed, then fury. Plain old fashioned outrage, in spades, redoubled.  It goes like this, paraphrased for brevity.

KC rings ATSB – Walker, to see when the second ATSB report may emerge from deep sleep chamber.

Walkers response was unbelievable; but notes and a statutory declaration take the matter to truth. In short, he was rude and aggressive. Statements like “Karen, just what do hope to gain from this report” “What do you want to get out of it”.  “It is your fault there is a delay”.  The whole debacle seems to be Karen’s fault all of a sudden and the ATSB is offended; etc. grossly miffed.

It was not Karen’s fault the aircraft ditched; it was not Karen’s fault she got badly hurt and it most certainly was not Karen’s fault that the ATSB and CASA got caught sweeping the whole thing under the table; nor was it Karen’s fault that Albo dived out of the back door as soon as the smoke alarum went off.  Karen had little to do with the Senate findings and the pasting dished out to both ATSB and CASA was well deserved. They got away very lightly, considering.

None of this is any excuse for being rude to anyone. Who the duck does Walker think he is? ATSB should be calling for his resignation.  No matter who rings with a genuine concern no one should be treated in the manner Karen was.

What chance a honest report when the man in charge turns out to be a coward and a bully?  Those types, when under pressure and attempting to justify that which cannot be justified habitually turn out to be not only disingenuous but happy to offset the blame to anyone else they can.

If the Walker attitude reflects the ‘new’ ATSB approach to victims of air accident then it is time for the minister to step in. I know that had I spoken to anyone in the workplace in that manner, my head would be following my arse out of the door before I could say ‘Sorry’.

If Walker won’t resign, then the minister needs to act, swiftly.  Fair warning, this is not going away.

A metaphorical head in basket is demanded: I don’t care how it gets there.

I cannot properly express the full measure of contempt and disgust this story has generated. The Pel-Air charade was a national disgrace; mentally kicking an accident victim when they are down and struggling to get through life with pain and grief is beneath contempt, particularly when the thread which keeps Karen attached to this world is tenuous, even on a good day.

Lets go and pick up this prick GD; seems he is late for his appointment with the Boss.

More to follow - bet your life on it.

Toot – bloody – toot.

As you would expect when someone has just been bumped up to PAIN public enemy No1.; down the pipe came the order for me to cyber-troll and re-visit the PAIN archives for any scurrilous dirt on the infamous black-box whisperer and the man who believes the causal chain for accidents, for example QF1's embarrassing runway overrun at Bangkok in 1999; or the Lockhart River tragedy, can be simply explained through a 'cloud association' diagram.

Here is Walker's cloud diagram for the Lockhart River causal chain:


 

 (Hint: take note of dates) This is where it starts to get interesting because that diagram was extracted from a research paper that was co-authored by Walker and the former ATSB CEO Kym Bills, which was subsequently published in 2008 (P2 - note the research paper title): Reference - AR2007-053 

Analysis, Causality and Proof in Safety Investigations

Summary

The quality of a safety investigation's analysis activities plays a critical role in determining whether the investigation is successful in enhancing safety. However, safety investigations require analysis of complex sets of data and situations where the available data can be vague, incomplete and misleading. Despite its importance, complexity, and reliance on investigators' judgements, analysis has been a neglected area in terms of standards, guidance and training of investigators in most organisations that conduct safety investigations.

To address this situation, the Australian Transport Safety Bureau (ATSB) developed a comprehensive investigation analysis framework. The present report provides an overview of the ATSB investigation analysis framework and concepts such as the determination of contribution and standard of proof. The report concludes by examining the nature of concerns that have been raised regarding the ATSB analysis framework and the ATSB's consideration of these concerns.

The ATSB believes that its investigation analysis framework is well suited to its role as an independent, no-blame safety investigation body. It is hoped and expected that ongoing development and provision of information about the framework can help the safety investigation field as a whole consider some important issues and help develop the best means of conducting safety investigations to enhance future safety.

Type: Research and Analysis Report
Author(s): Michael B. Walker and Kym M. Bills
Series number: 2007053
Publication date: 26 June 2008
Publication number: 08196
Related: Human factors
 



Last update 07 April 2014

In the lead up to that research paper Walker also made a presentation to an ISASI seminar in Mexico 2006 - see page 10 HERE:

...In recent years, the ATSB and other safety investigation agencies
successfully used the Reason Model of organizational accidents
(Reason 1990, 1997) to guide the analysis phase of some investigations.
Although the Reason Model is widely accepted, some
of its features limit its usefulness. The ATSB has adapted the Model
to better suit the requirements of safety investigation and to make
the Model more applicable to a wider range of investigations.
The primary changes to the Reason Model include broadening
the scope beyond a focus on human factors, and to more functionally
define the components of the model so as to reduce overlaps and
confusions when categorizing a factor. In particular, ATSB’s model
clearly distinguishes between the things an organization puts in place
at the operational level to minimise risk (i.e., “risk controls” such as
training, procedures, warning alarms, shift rosters) and the conditions
that influence the effectiveness of these risk controls (i.e., “organizational
influences” such as risk-management processes, training
needs analysis processes, regulatory surveillance)... (P2 - Hmm...that sounds familiar -  
)

...Therefore I now believe that Dr W is in fact the bureau version of Hoodoo Voodoo (i.e. Dr A) and was the primary motivator for Beaker launching and adopting his 'beyond (all sensible) Reason' methodology. Which ironically IMO means Dr W is part of the 'causal chain' in the diabolical original Norfolk Island VH-NGA ditching accident investigation and the now approaching 2 year re-investigation...

Combined with the discovery that Dr W is also a Sociopath (Ferryman post) and speaks with forked tongue, has to represent the biggest conflict of interest for this parasite to be anywhere near the PelAir re-investigation, let alone the Investigator in Charge...FDS!    

MTF...P2  

[Kharon]

The Bookmakers lament:

P2 – “Word is that there is going to be an extension to the DIP review of the 500+ page VH-NGA re-investigation 'DRAFT' final report...”

I wondered how big a pile of paper 500 pages actually is – the answer was easy – within easy reach, the neat package for the printer. Got me thinking, if one allows lets say that every page in the ‘new’ Pel-Air analysis is printed single side, that reduces the reading to 250 pages; lets say that 70% of each page is actually used, this reduces the volume of reading down to 135 pages; we can safely allow a 20% discount on that for waffle, tables, graphs etc. and possibly a few more off for indexing etc. Let’s say there are approximately 100 pages of pertinent information (just for a number). Then we may ask ‘what’ may we expect within those 100 pages. That, boys and girls is my puzzle for today. As the Pel-Air report release time approaches I must set my tote odds. One of the board lines represents the number of ‘useful and of value’ pages will be found within the information provided. Most of the BRB can do the simple math, but the numbers are now being refined; varying from a light weight 1% to an optimistic 40%.  It’s not really fair play, but, intrigued, I asked some of the BRB how they settled on the % selected.

Those (many) who were opting for the lower >2 - <10 % values – simply stated that the ‘accident’ stand alone was a simple, single issue affair. The holes in Mr Reasons famous cheese lined up, perfectly synchronised, the results inevitable. Nothing new there and a rehash of the same circumstances, no matter how clinical, would provided little in the way of ‘new’ data, let alone point at the under laying causal chain. Perish the thought of departmental or company shortcomings being mentioned.

Those (not many) who selected >20 - <50 % values believed that a ‘factual’ analysis would provide some additional data of value - provided ‘all’ the data was included.

Which left me with a problem – if I am to keep my shirt – how to lay off the bets of those who are solidly backing a < 1% result. There are a lot of ‘em, heaps; and I must accept the wagers and formulate the odds. Don’t believe that the Bookies always win; sometimes the tote gets a flogging and I feel it in my bones; this is going to be one of those times. In a nutshell, the general consensus is that the ‘new’ report will be ‘clinical’, cut and dried but only on the ‘facts presented’ and those are pretty well known anyway. Where the report will stumble is in the ‘language’ used, many believe that will subtly, but inevitably lead back to it all being pilot error. “This is a crock” say my punters; “why”? I ask. So they tell me (paraphrased without the invective).  “The company and every single government agency owns a piece of this accident, James was let down by his own operating culture and lack of training – which CASA happily accepted, failing miserably to ensure that the thin policy and procedure promulgated was ‘alive and valid’”. “Fatigue, training, operational support, lack of proper planning procedure, lack of even RTOW data all sent a flight crew into a high risk situation”, they say, and more.

“Condensed”, they add, “it all comes down to the report ‘justifying’ and excusing everyone ‘official’ from any part in the event; ATC, BoM, CASA, Company”. “These contributing factors will not only be written out of the story, but be exonerated”.

The real story of the Pel-Air at Norfolk saga is not that of the ditching ‘how’; but one of the ‘why’ and the actions taken after the event by ATSB and CASA. My punters all say the same thing; “show us a report on that and we’ll read it – all of it; or, get the Senators to finish what they started: getting the lid off the real tale, the one of appearing to defraud the public and misleading the Senate; now that is a tale of interest”  

That is how the betting stands; there are some other ‘interesting’ lines on my tote odds board related to this; I may get some of my shirt back from them. More on those closer to the release date.

Toot - toot.

[Peetwo]

Willow brings up PelAir ditching at ISASI presentation - WTD?? 

Reference:

Similar occurrences to that at Mildura in June 2013

A further review of the ATSB occurrence database identified five occurrences that had happened since 1999 and were similar to this occurrence. These occurrences were investigated by the ATSB  website and are detailed below.

ATSB investigation 199904029

ATSB investigation 200401270

ATSB investigation 200605473

ATSB investigation AO-2012-073

ATSB investigation AO-2015-067

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..In order to better quantify the residual risk, specifically the likelihood of unforecast weather deterioration, the ATSB is examining the reliability of aerodrome forecasts as part of research investigation AR-2013-200 Reliability of aviation weather forecasts. This research investigation will initially examine the reliability of the aerodrome forecasts for Mildura and Adelaide Airports, before expanding to cover other major Australian airports.

With the release of the ATSB AO-2013-100 (Mildura fog duck-up above) I was critical that in the 'related occurrences' section there was no mention of the VH-NGA ditching; nor was there mention of the previous unforecast weather related incidents that led to the ATSB issuing safety recommendation R20000040 on 22 February 2000...  

(P2 comment: As a 'passing strange' coincidence I have also now discovered that all the listed un-forecast wx related occurrences, including the Norfolk serious incidents/accident, have mysteriously not been listed/recorded on the ICAO (ADREP & ECCAIRS) iSTAR database.)

I was also critical that in the first David Wilson - AR-2013-200 - report that again the Norfolk incidents and ditching had seemingly been glossed over yet again...

However I am pleased to inform people that I can actually retract some of my previous criticisms...

This is because 2 weeks ago Willow made a presentation to the ISASI 2017 annual seminar (see HERE, day 2 between 1:30-2:30pm), which included much data related to unforecast wx at remote islands plus a reference to the VH-NGA ditching: Effect of ICAO Type Aerodrome Weather Forecasts on Aircraft Operations 

Comparison between remote islands and mainland airports

This algorithm was used by the ATSB to support an investigation of a serious weather-related incident at a remote Australian island. Specific hypotheses were put forward regarding the reliability of remote island forecasting, and the analysis conducted allowed definitive conclusions to be drawn regarding the relative reliability of these forecasts from the perspective of the historical likelihood of unforecast weather conditions below the landing minima.

        
This would seem to indicate that Willow's 'algorithm' will be featuring in the upcoming re-investigation final report into the ditching of VH-NGA...

So does this mean the ATSB finally acknowledge the very real parallel causal factors between the Mildura fog duck-up and the PelAir cover-up?

Well apparently not as it is rumoured that in the title of the 500+ page VH-NGA re-investigation final report, 'fuel management' is mentioned but not a serious weather-related incident (ditching).

 However this does not mean that the BRB can't examine in detail the (IMO) striking parallels related to the unforecast wx Swiss cheese hole...

Reference Willow's ISASI presentation:

Methods

The results presented required the development of a computer program (the algorithm). Full details are available on the ATSB’s website (www.atsb.gov.au) under investigation AR-2013-200.

The objective of the algorithm was to help calculate the probability of using the weather forecast system as it affects pilots, and number of expected aircraft arrivals during selected weather conditions. It uses actual historical weather forecasts (TAFs and TTFs) compared to reported observations (METARs and SPECIs) as they would be used by pilots. It also can examine what would have happened if a different type of forecast was used or the forecast was retrieved later in flight.

        
Now a relevant reference from AO-2013-100:

Use of weather observations for decision making

The flight crews of Velocity 1384 and Qantas 735 reported assessing the Mildura weather prior to diverting from Adelaide Airport. Both reported considering the observation reports that were current at the time as a more reliable indicator of the weather at Mildura Airport than the relevant forecast. The captain of Qantas 735 reported feeling that the observation reports were more reliable given the inaccuracy of the forecast at Adelaide.

The crew of Velocity 1384 reported using the observation reports to confirm their understanding of Mildura’s suitability as an alternate destination.

The ATSB asked CASA for a ruling on the use of observations in-flight. CASA responded that a pilot is able to use a valid forecast and observation information. They also cautioned that observations should only be used if the arrival time was proximal to the observation and, if the forecast indicated conditions below minima, the forecast would have precedence over observations. That is, crews must carry sufficient fuel to meet the forecast requirements affecting a destination, even if the observations at that location indicate that the weather is suitable for an arrival.

While the crew of Qantas 735 reported considering the implications of the TEMPO on the 0158 Mildura TAF, and calculated that they had sufficient fuel to meet this requirement, the crew of Velocity 1384 did not complete that consideration. The FO of Velocity 1384 raised the TEMPO as an issue with the captain; however, at that time the captain’s attention was on another matter and the TEMPO was not discussed. As such, when the crew of Velocity 1384 initiated the diversion to Mildura Airport, they had not confirmed sufficient fuel to meet the TEMPO requirement.

Irrespective, the extent and duration of the deterioration meant that even meeting the TEMPO fuel requirement, this would not have provided sufficient fuel to hold until the fog and low cloud at Mildura cleared sufficiently. Unless early consideration was given to a return to Adelaide Airport for an emergency autoland approach, a landing below minima at Mildura Airport was the only option at Mildura Airport.

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Mildura Airport

The 0358 amended TAF for Mildura that morning forecast light winds and scattered cloud at 3,000 ft and broken cloud at 6,000 ft. The TAF also included TEMPO periods between 0500 and 1000 in which the cloud base was forecast to reduce to 600 ft AGL.

A new routine TAF was issued for Mildura at 0902 that was valid from 1000. This TAF forecasted visibility in excess of 10 km and scattered cloud at 3,000 and 5,000 ft. No significant weather was listed on the TAF and no indication of low cloud or fog was given. Neither crew were aware of this TAF nor would they have been able to use this forecast in support of their decision to divert. This was because the Aeronautical Information Publication (AIP) Australia stated that a TAF that is valid for 30 minutes prior to the arrival must be used for flight planning purposes. As such, it could not be used for arrivals at Mildura prior to 1000.

A further amended TAF was issued for Mildura at 0952 and covered the period 1000–2200. This TAF forecasted a visibility of 3,000 m in mist, with scattered cloud at 300 ft AGL and broken at 4,000 ft AGL. In addition there was a 30 per cent probability of 500 m visibility in fog and broken cloud at 200 ft AGL between 1000 and 1200.

Next a reference from the once hidden now infamous CASA parallel investigation report CAIR 09/3:

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Now referencing Fig.2 &  original VH-NGA final report:

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& finally the part that highlights the (apparently) completely glossed over 'fact' and elephant in the room related to the PelAir causal chain, reference page 16 of the original VH-NGA final report:

An amended Norfolk Island TAF that was valid for the aircraft’s ETA was issued by the Australian BoM at 0803. In that TAF, the visibility was forecast to be 10 km or more, with Broken cloud at 1,000 ft above the ARP. Those conditions indicated that the weather would be below the alternate minima for Norfolk Island at the aircraft’s ETA, but above the landing minima. The flight crew were not advised, and were not required by any international agreement to be advised, of the amended forecast and they did not request an updated forecast for Norfolk Island during the flight.

  
So on one hand we had two crew that were (nearly) fully aware that their alternate airport had a TAF operational requirement (60 minutes TEMPO YMIA), but on the other hand we had a crew who had no idea that an amended TAF had been issued which automatically placed a operational (alternate) requirement on the conduct of the rest of the flight...

MTF...P2

Ps It should be remembered that auto wx observations do not place a legal operational requirement on a flight crew...

[thorn bird]

Its not too hard to imagine that the whole ATSB report on the NF event is designed to support the Skulls hypothesis that the "pilot Dunnit" and justify his subsequent embuggerance. I think its curious the way he was treated compared with the RPT guys for essentially the same "Offence?".

[Kharon]

TB – “I think its curious the way he was treated compared with the RPT guys for essentially the same "Offence?".

Just by the numbers alone – at no time did James receive a met report indicating an operational requirement. The RPT took off with full knowledge and full operational support and both flew past viable options and diverted to a field with an operational requirement.

Going to be interesting to see what ‘the report’ contains by way of meteorological updates, advice and warnings – particularly on the ‘time line’ and amended forecasts.

The report should only now contain the CVR data and a couple of twiddles – how it got to be 500 pages is going to make for interesting reading. Will they call a ‘fuel’ related incident or a ‘weather’ related accident ?– the title page will say it all.

Toot toot.

[Peetwo]

TB – “I think its curious the way he was treated compared with the RPT guys for essentially the same "Offence?".

Just by the numbers alone – at no time did James receive a met report indicating an operational requirement. The RPT took off with full knowledge and full operational support and both flew past viable options and diverted to a field with an operational requirement.

Going to be interesting to see what ‘the report’ contains by way of meteorological updates, advice and warnings – particularly on the ‘time line’ and amended forecasts.

The report should only now contain the CVR data and a couple of twiddles – how it got to be 500 pages is going to make for interesting reading. Will they call a ‘fuel’ related incident or a ‘weather’ related accident ?– the title page will say it all.

Toot toot.

"..Going to be interesting to see what ‘the report’ contains by way of meteorological updates, advice and warnings – particularly on the ‘time line’ and amended forecasts..." - Yes indeed "K" it will be very interesting...  

Reference 4 Corners transcript:

GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.

It says there's some cloud over Norfolk island at 6,000 feet.

This is wrong.

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.

That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.

MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...

GEOFF THOMPSON: So it might be a mistake.

MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.

GEOFF THOMSON: And he did.

Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.

DOMINIC JAMES: If I'd been told that there was cloud at 600 feet, even given the fact that I suspected the automatic system was overstating the weather at Norfolk, I would've gone to Fiji.

GEOFF THOMSON: But moments later another weather report comes from Fiji which is acknowledged by the flight crew as the latest weather available.

It contradicts what they've just heard and says weather conditions on Norfolk Island are in fact deteriorating.

DOMINIC JAMES: I maintain that that weather report, exactly as it appears in that transcript, is not what we had on the flight deck. That's not what I copied down, it's not what I comprehended.

GEOFF THOMPSON: And how do you explain that?

DOMINIC JAMES: To be honest with you, I can't.

I am also curious as to whether there will be mention of what I believe led to the ATSB making the above elementary but crucial factual error in the original VH-NGA final report...

My theory is that in the course of the dodgy CASA AAI, that was apparently being conducted under the parallel investigation terms of reference (paragraph 4.1 'parallel Investigations) of the then yet to be released 2010 MoU, it was agreed (as per subpara 4.1.4) that in order to conserve resources that the CASA ALIU would take responsibility for interpreting the ATC transcript and the subsequent dissemination by the flight crew of the ATC relayed wx reports for Norfolk island.

This was ultimately what led (my theory) to the ATSB making the fundamental factual error of 600ft versus 6000 feet as conveyed by Nadi. This error and the CASA biased interpretation of what the Flight crew actually assimilated from the ATC wx report transmissions and which was subsequently reported on in the dodgy CAIR 09/3..

 

From PDF page 45 here - Attachment 5(PDF 6032KB)

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...was what ultimately led to the ATSB completely glossing over the significance that the only wx report that placed a legal operational requirement on the PIC, the 0803 AMD TAF, was never relayed by ATC to the flight crew of VH-NGA -

One would hope that the record of all the interactions between the CASA ALIU and the ATSB, in the course of the conduct of the 2010 MoU defined parallel investigation, will at least be an appendix to the re-investigation final report as IMO it could go a long way to explaining how the first final report was so comprehensively ducked up...


MTF...P2

[P7_TOM]

P2 – “[as] IMO it could go a long way to explaining how the first final report was so comprehensively ducked up...”

Cluster O’ Ducks is more like and that is putting it mildly. This second report should trigger a Judicial inquiry into the entire ‘investigation’. There are some pressing questions of both operational legality and of a legal (as in the Act) nature which the 500 page manhole cover will go nowhere near.

I would be intrigued to understand what prompted he CASA ‘parallel’ investigation and the existing head of power under the MoU which allegedly supported. Then there is the question of how many ALIU ‘parallel ‘ investigations have been triggered since the Norfolk event – did the Mildura fiasco prompt such feverish activity from CASA? Did any of the recent ‘big ticket’ incidents (ATR’s for example) bring a swarm of CASA auditors and managers and FOI’s to the investigation? Bear in mind the latest round of ‘incidents’ have all been RPT; not AWK.

This new report should be used as a tombstone. All this time, trouble, effort and money to regurgitate what is, in essence, a simple accident. The report will not explain why ATSB and CASA did the things they did and went as near as toucher to attempting to deceive a Senate committee and the public. There are harsh words used in the real world to define their combined actions; usually preceded by the time honoured “you have the right to remain silent” etc.

500 pages of soft soap; and, the BoM off the hook just wont do; nowhere near good enough, not by a long shot. We need a report into the actions of the regulator prior and subsequent to the event. This to explain the miraculous speed of the return to normal services, the dreadful operations manuals, fuel policy, training, operational control and stuff like that. Don’t care if the new ATSB report don’t delve too deep – we have: and, not one of the 500 pages will answer our questions, bet the next round on it – and I ain’t even read the bloody thing yet.

Ah, my medication arrives – thank you barkeep – yes: we’ll have two more shortly, before the crew lobs in.

[Peetwo]

Of parallel investigations, MoUs, MALIUs & Directives -

P7 - "...I would be intrigued to understand what prompted the CASA ‘parallel’ investigation and the existing head of power under the MoU which it allegedly supported..."

Still trying to fathom the very strange disconnected timeline with the original VH-NGA ATSB investigation and apparent change in CASA policy for parallel investigations in the lead up to the introduction of the 2010 MoU...

Reference CAIR 09/3 (see PDF link above):  

Note that the MoU reference that the MALIU uses actually predates the introduction of the 2010 MoU (PDF Page 28) and not the 2004 MoU:

 
I have also come across another bizarre connection with the 2010 MoU and the introduction of the CASA ALIU. The following is quoted from this former DAS McComic's Directive - Download das-pn015-2010.pdf (Ps Note the date):

Policy

In addition to meeting any obligations under the Transport Safety Investigation Act 2003 and the Civil Aviation Act (1988), CASA is committed to cooperation with the ATSB in accordance with the Memorandum of Understanding (MoU) established between the two agencies.

CASA has established an Accident Liaison and Investigation Unit (ALIU) to manage the day-to-day interaction and to act as a contact point for the ATSB. The ALIU is headed by the Manager Accident Liaison and Investigation Unit (MALIU) who reports to the Deputy Director of Aviation Safety.

Under the terms of the MoU, all requests from the ATSB for assistance, advice or interviews should be coordinated through the Accident Liaison and Investigation Unit (ALIU).

If CASA personnel are contacted directly by the ATSB in respect to any investigation or requests for information they should refer the request to the ALIU.

The ALIU also acts as the conduit for advice back to the ATSB. Staff should not contact or provide advice to the ATSB without first consulting the ALIU.

CASA officers participating in or supporting ATSB investigations have a responsibility to keep Manager ALIU informed of the progress of an investigation and to advise him immediately of information which indicates a need for CASA to take urgent safety-related action. 

John F. McCormick

Director of Aviation Safety

Date 03 August 2011

    
Hmm..wonder what it was that prompted former DAS McComic to issue that directive 1 year, 5 months and 25 days after the 2010 MoU was officially signed?
The chain of command and the underlying warning to not step outside the official lines of communication with the ATSB is quite specific:

　

Responsibility

The Director of Aviation Safety is responsible for approving all CASA regulatory policy.

The Deputy Director of Aviation Safety is responsible for the development, maintenance and publication of this policy.

All amendments to this policy shall be made in accordance with CASA Document Control policy and procedures.

Purpose of the Policy

The purpose of this policy is to govern the way in which CASA performs its functions under paragraph 9(3)(a) of the Civil Aviation Act (1988) and fulfils its obligations under the Memorandum of Understanding (MoU) established between CASA and the Air Transport Safety Bureau (ATSB).

Application of the Policy

This policy is intended to guide the actions of all CASA staff in their interaction with the ATSB.

 
It is also interesting to note that, much like the current version of the CASA enforcement manual, the DAS Directive was revisited in February 2016 but was not amended in any way that I can detect: https://www.casa.gov.au/files/das-pn015-2010pdf

Download das-pn015-2010.pdf (52.25 KB)

Date modified: 17/02/2016

 
In terms of the 2015 MoU and probably in the interests of embracing the ASRR recommendations in relation to the SSP...

3 STATE SAFETY PROGRAMME

3.1 ATSB and CASA are committed to ensure the effective implementation of the

State Aviation Safety Programme, as published by the Department of

Infrastructure and Regional Development. Cooperative priorities for improving

implementation of the Programme during the period of this MOU include, but

are not limited to:

(a) Improving information collection and sharing processes, having regard to

the standards and recommended practices in Annexes 13 and 19 to the

Convention on International Civil Aviation, done at Chicago 7 December

1944

(b) Cooperative research and analysis to review safety trends and identify

areas for safety improvement

© Public communication and education on aviation safety matters.

...it would appear the concept of parallel investigations as intended in paragraph 4.1 of the 2010 MoU has been abandoned (see paragraphs 6 & 7, plus ATTACHMENT A ­‐ Participation in investigations).

However it would also appear that the position of the MALIU is still the go to person as per the still in force McComic directive:

Participation in investigations will be co-ordinated through the Manager ALIU, CASA and the Director Aviation Safety Investigations, ATSB.

MTF...P2

[ventus45]

Do we yet know, when the new, revamped, rumored 500+ page, PelAir Mk-2(alpha) report is "actually" due out ?

[Peetwo]

"V" the rumour is that there is a couple of minor delays with the DIP review process and due to some DIP feedback the ATSB is now considering some changes to the DRAFT Final Report...

MTF? - 'YAWN!' - yeah eventually...P2

[Peetwo]

Further delay in DIP process -   

Via the ATSB update fairies... :

Updated: 6 October 2017

Following release of the draft report to Directly Involved Parties on 23 June 2017, a number of requests for extensions to the draft comment period were received from several parties. Almost all comments were received by the end of August 2017 and the work associated with assessing those comments as part of the finalisation of the report is complete.

Comments from a further directly involved party were received on 3 October 2017. To allow the necessary time to consider those comments, it is now expected the report should be finalised and released in early-mid November 2017.

"...further directly involved party.." Note singular DIP - Hmm...wonder who that might be?

MTF...P2

[Peetwo]

PelAir MKII: ASA Swiss Cheese slices & bunnies -

References: Willow brings up PelAir ditching at ISASI presentation - WTD?? 

..An amended Norfolk Island TAF that was valid for the aircraft’s ETA was issued by the Australian BoM at 0803. In that TAF, the visibility was forecast to be 10 km or more, with Broken cloud at 1,000 ft above the ARP. Those conditions indicated that the weather would be below the alternate minima for Norfolk Island at the aircraft’s ETA, but above the landing minima. The flight crew were not advised, and were not required by any international agreement to be advised, of the amended forecast and they did not request an updated forecast for Norfolk Island during the flight...

I still have to pinch myself when I re-read the above quote and then remind myself that the identified safety issue of non-provision of critical wx flight information...

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By:

• Nadi in not providing the 0803 amended TAF, which forecast conditions below the alternate minima; plus
  
• Nadi not proactively providing the 0830 SPECI, which included broken cloud below
  the landing minima and finally;
  
• after responsibility for the aircraft was transferred to Auckland FS at 0835, the Auckland ATCO did not confirm that the flight crew had received the 0803 TAF and/or the 0830 SPECI.
  

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...did not even rate a mention in the original 'Findings' and/or 'Safety Actions' sections of the AO-2009-072 Final report:

Contributing safety factors
• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• 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.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Other safety factors
• 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. [Minor safety issue]
• Given the forecast in-flight weather, aircraft performance and regulatory requirements, the flight crew departed Apia with less fuel than required for the flight in case of one engine inoperative or depressurised operations.
• The flight crew’s advice to Norfolk Island Unicom of the intention to ditch did not include the intended location, resulting in the rescue services initially proceeding to an incorrect search datum and potentially delaying the recovery of any survivors.
• The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands. [Minor safety issue]

The irony is that if 'Staibbed in the dark' and Harfwit et.al hadn't of given evidence at the PelAir cover-up inquiry, we may well have remained oblivious to the significance of this identified but yet to be adequately addressed safety issue.

Reference: Rural and Regional Affairs and Transport References Committee
(Senate-Monday, 19 November 2012)

Senator XENOPHON: On page 7 of the ATSB report it states:

Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew

Does that not seem to be an unsafe practice in that it is tantamount to the withholding of critical safety information that might otherwise prevent a flight from continuing into a dangerous situation, which occurred here?

Mr Harfield : Yes. However, they are the rules for Fijian air traffic control as instructed by Fiji and international agreement. Within the Australian airspace that we manage, we are required to pass that information on to the flight. Those are rules of Fiji air traffic control.

Senator XENOPHON: But we are talking about an aircraft heading into Australian territory though, are we not?

Mr Harfield : It was going to Norfolk Island, yes, but Norfolk Island is managed by New Zealand air traffic control.

Senator FAWCETT: So it is not Australian airspace?

Mr Harfield : It is not Australian airspace.

Senator XENOPHON: Are you saying because it is managed by New Zealand, there is nothing you can do about it?

Mr Harfield : I am not saying there is nothing we can do about it. We can talk to our New Zealand colleagues about—

Senator XENOPHON: Have you spoken to your New Zealand colleagues about the Pel-Air ditching?

Mr Harfield : No, we have not.

Senator XENOPHON: It has been three years and one day since the ditching.

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 FAWCETT: A string of those comments point to the fact that if there were a recommendation coming out of an accident report it would be an enhancement to safety for a neighbouring service provider to proactively push an equivalent of a hazard alert. Then you would act on behalf of the government to talk with your peer, but that would need to come from a recommendation that CASA picked up, which was then put as a requirement. Does that all lead to the fact that ATSB reports should, in fact, have recommendations? If there were no recommendation, where would you take your action from?

Mr Harfield : From our perspective, as an air navigation service provider, we do not just rely on an ATSB report. If we see any particular safety issue we have regular meetings and discussions with our neighbouring air navigation service providers, talking about the number of safety issues that come to our attention. It may not necessarily be in an ATSB report. We are constantly having those discussions with them to try to improve the integrity of the system.

Senator FAWCETT: How long has it been since this accident.

Mr Harfield : 2,00—

Senator XENOPHON: 2,097 days.

Senator FAWCETT: How many meetings have you had with your New Zealand counterparts since this accident?

Mr Harfield : We probably would have them twice a year, but this particular issue is something where we did not know the intent of what was being passed to that particular flight—because it is New Zealand air traffic control with the Pel-Air aircraft. It is the same with Fiji air traffic control with the Pel-Air aircraft. Not until the ATSB report was released were we aware that there could have been a deficiency with the passage of weather. It is something that we would normally discuss. New Zealand air traffic control would be doing their own particular review. I want to make sure it is understood where our role is, reference the rules and procedures of a foreign jurisdiction.

Senator FAWCETT: I accept that. The intent of this committee is to make sure that we have the most proactive approach to enhancing air safety. It means that occasionally we expect people to lean across the boundaries of their organisation and say, 'We see something that needs to occur' and if it is not within your current powers or within the rules, the expectation of a reasonable person is that it will be flagged so that this place, which makes rules, can take appropriate action. We would welcome discussion around what proactive steps Airservices has or can take as opposed to saying, 'That is the regulator's problem.' So forgive us if we appear a little tetchy on this, but we are hearing a lot of 'That is someone else's responsibility.'

---

Senator NASH: Okay, so it was not on the agenda before now. If we were not having this particular inquiry, what would have triggered the decision to collectively with your counterparts examine this issue of the fault line and the fact that there is an anomaly? Would it not have happened? What I am trying to get at is this: if we had not asked you these questions this morning—if we had not been discussing it here this morning at this inquiry—would you have raised this at the Pacific forum as an issue.

Ms Staib : My expectation is that that is why we have those sorts of forums: so that we can share lessons learned from incidents that occur.

Senator NASH: Okay. Then why wasn't it already on the agenda?

Ms Staib : I cannot answer that, because I have not seen the agenda.

Senator NASH: What?

Mr Harfield : The fact is that we do not have the agenda in front of us, so we do not know the detail.

Senator NASH: So you get an agenda and then figure out if you are going to add something?

Mr Harfield : No. The agenda is set by—

Senator NASH: No, hang on; Ms Staib just said that she has not seen the agenda.

Mr Harfield : the various coordinators that we have. For example, the manager of upper airspace, who is the manager of the airspace that abuts Fiji and New Zealand, is the representative of Air Services Australia who goes along to the forum. They set the agenda. I do not have the agenda in front of me.

Senator NASH: So do you have any opportunity to have input into the agenda from Airservices?

Mr Harfield : Yes, Airservices has—

Senator NASH: Okay. Airservices does. So who within Airservices would have responsibility for placing this issue on the agenda for the Pacific forum?

Mr Harfield : Our representative at the forum.

Senator NASH: And who is that?

Mr Harfield : It is the manager of upper airspace for Westwind.

Senator NASH: Okay. So why didn't they put this on the agenda before? Why has it taken this committee inquiry to get this on the agenda?

Mr Harfield : We will take that on notice. I am not saying that it was not already on the agenda. We are unaware whether or not it is on the agenda, and we have said that we will ensure that it is. It could already be on the agenda. I am just unaware.

Senator NASH: I find it extraordinary that you do not know whether or not this issue is on the agenda for the Pacific forum. That is extraordinary.
CHAIR: With respect, if your mum or dad or one of your k
ids was in the plane, I bet it would have been. I have one question. How many Pacific forums have we had since the accident?

Mr Harfield : We would have to take that on notice.

CHAIR: You are a perfect bureaucrat. Senator Fawcett.

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Senator NASH: Mr Harfield, further to the answer you gave me before?

Mr Harfield : The question that I was asked before was, 'Who would be responsible if something happened again?' As I was saying, if the ATSB report has been passed to the New Zealand civil aviation authority and they, taking that up, have identified there is an issue then it is their regulation and their change.

Senator NASH: That is my point. There is no issue in their report for them to identify. That is my exact point.

Mr Harfield : Then there is no mechanism for the foreign jurisdiction to be aware there is an—

CHAIR: So you are the bunnies and the ATSB have, 'Do not ask, do not tell.' Senator Fawcett?

Mr Harfield : Say that again, Senator?

CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question. Senator Fawcett?

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.

We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?

Mr Harfield : That is a correct assumption.

Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?

Mr Harfield : That is a fair assumption.

Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?

Mr Harfield : In this case I do not recall and I do not think that they did. However, in other instances where things have occurred they have come to us to ask for assistance—for example, with some incidents that have happened in Indonesia.

CHAIR: But no-one cared about the prang off Norfolk Island?

Mr Harfield : That is not correct, Senator; I just do not recall the ATSB coming to us to ask us for assistance in this particular jurisdiction.

CHAIR: How long have you been at Airservices?

Mr Harfield : Nearly 25 years.

CHAIR: I think you need a change of career.

 
Or in pictures...

The RRAT Committee's findings included the following recommendation in relation to this committee identified significant aviation safety issue:

Recommendation 22

9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

One would hope that in the context of the PelAir MKII 500+ page Final Report there will be an official recognition of this SSI accompanied by an ATSB promulgated safety recommendation issued to all regional FIR States, to proactively risk mitigate this particular mouldy slice of Swiss cheese...



MTF...P2

[P7_TOM]

The 0803 from Nadi.



The 0803 from Nadi: much like Agatha Christie’s yarn – ‘the 4.50 from Paddington’ is a tale of official denial, departmental arrogance and independent investigation to solve the riddle. Silly story of course, but entertaining nonetheless. The ‘real’ investigation into the ditching of a Pel-Air West-wind, off Norfolk Island is, like the Christie novella, slowly, but with certainty, picks up the clues and the villain is, eventually, exposed.  

P2 and the mouldy cheese. – “I still have to pinch myself when I re-read the above quote and then remind myself that the identified safety issue of non-provision of critical wx flight information...”

By:
• Nadi in not providing the 0803 amended TAF, which forecast conditions below the alternate minima; plus:-
• Nadi not proactively providing the 0830 SPECI, which included broken cloud below
the landing minima and finally;-
• after responsibility for the aircraft was transferred to Auckland FS at 0835, the Auckland ATCO did not confirm that the flight crew had received the 0803 TAF and/or the 0830 SPECI.
________________________________________

If you remove (as Holmes would say) “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.”

Had there not been gaping gaps in the ‘systematic’ cheese; the Norfolk accident simply does not happen – End of. James was quiet legal; it has been clearly established that even with full tanks; the accident would have occurred. At no time, until it was far to bloody late, did James even contemplate that a landing at Norfolk would not be a happening thing.

You can’t get a bet on ‘K’s’ tote board for CASA failure, Company failure, ASA failure or BoM failure to perform; the odds against any ‘official’ agency getting a canning are astronomical. Mind you, a bet on the Senators getting involved is equally impossible. There are tales in the wind of CASA running about, desperately trying to avoid any and all ‘political’ involvement; at any cost. I reckon they are pupping blue lights at the thought of any serious, heavy weight Senators asking the awkward questions. ‘News Flash’ too bloody late boys; too late by a country mile. Read the Hansard; or, watch the movies; then ask yourselves – who do you think you have fooled with Motherhood statements, gabfests and no duckling Safety Recommendation. Jesus wept….

There are a couple of groups, probably comprised of the ‘experts’ Carmody so dearly wants charity from who can’t wait for the ‘new’ report to be released. The title of the ‘report’ has seen some fairly heavy betting; for example “Fuel related” is currently at 100 – 1 against 'Weather related', which is still at a comfortable each way 4/1. The chance of Senator non involvement is off the scale and a closed line. ICAO is still running at even money; the odds for went up a while back to some value; but a stony wall of silence has been hanging about just a shade too long. We intend to inquire of ICAO what progress, if any, has been made, but no one is holding their breath.

My old clock says ‘Ale-o;clock’. I could get used to this relaxed life style (zipper advantage); although, you know I still look at the clock, count the hours (and the counting shall be eight) to be sure before heading to the refreshment tent. Not tonight though, the Sand pit crew are scheduled for a grudge match, honour, kudos, bragging rights and ales, all to play for.

Bring it on - Taxi -

[Peetwo]

PelAir reality check - Norfolk Islander style. 

While the Australian Government, the MSM and the average Aussie punter, through ignorance or denial, continue to be totally oblivious to the serious implications of the fast approaching 8 year PelAir (re-cover up) investigation; it is refreshing to see that in a historical Norfolk Island online publication - 'NON DII EN DAA (This and that)' - that there was no pulling any punches when it came to Norfolk Islander condemnation of the ATSB, CASA and the department.

SIX YEARS ON, ATSB ABOUT TO RECOVER PEL-AIR FLIGHT DATA RECORDER

In another triumph of administrative efficiency, diligence and focus the Australian Transport Safety Bureau or ATSB, is poised, after almost six years, to recover the flight recorder from the Pel-Air Westwind corporate jet that was ditched in the sea near Norfolk Island on 18 November 2009.

The small jet had intended to refuel at Norfolk Island on its way from Apia to Melbourne as part of a medical charter flight, but had insufficient fuel on board to divert to an alternative airport when despite four missed approaches it was unable to land because of deteriorated weather conditions.

All six people on board were rescued by an island fishing boat and in the course of its original and since discredited investigation into the accident the ATSB decided not to recover the recording device, which is less sophisticated than those on larger jets, and of a design which in some quarters is said to be prone to medium term salt water corrosion.

The decision of the ATSB to blame everything on the pilot, and not recover the flight recorder led to a prolonged and continuing controversy.  A peer review of the ATSB’s conduct of the first inquiry by the Transportation Safety Board of Canada found (for those who managed to read all of it) that not all of the relevant information available to the ATSB may have been taken into account, and referenced internal frustrations and divisions within the ATSB investigation.

A review of that report can be read here.

The ATSB was subsequently ‘invited’ by the Deputy PM and minister responsible for aviation, Warren Truss, to revisit its report, which the agency after a delay removed from its web site pending its in effect, being redone.

Recovering the flight recorder is part of this process.

The dysfunctional manner in which the prolonged ATSB inquiry was conducted was laid bare in the peer review by the TSBC although this was only apparent on a full reading of that document rather than in relying on the summaries offered by the Department of Infrastructure which is responsible for both the safety investigator and the air safety regulator CASA.

The crux of the Pel-Air controversy is that the pilot was framed by the ATSB and CASA while the safety regulator improperly withheld an internal report which found gross failures on its part to correctly oversight or remedy what was found to have been serious safety deficiencies by the operator.

One of the critical matters raised by the controversy is the integrity of the ATSB in relation to the first Pel-Air accident investigation report, including its disinterest in that suppressed internal CASA review of its own performance.

That internal report, known as the Chambers Review, concluded that had CASA done its job the accident might not have happened.

The ATSB website has been updated on the recovery operation.

The image below from the ATSB shows what the wreckage looked like in March this year.

MTF...P2