[Peetwo]

Update: ATSB PC accident investigation AO-2014-032

Remember when High Viz Hoody was singing like a Canary at the Drone Wars inquiry in regards to the 3.5 year VARA ATR busted tail investigation? Here is a reminder -  

Well there is still no sign of the 3rd interim report - see HERE. However there was some progress recorded on the ATR safety recommendation (AO-2014-032-SI-02) that occurred prior to the singing Canary Hoody's proclamation at the 29 Aug DW1 public hearing..

Recommendation


Action organisation: ATR

Action number: AO-2014-032-SR-014

Date: 05 May 2017

Action status: Released


The ATSB recommends that ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.


Correspondence


Date received: 11 August 2017

Response from: ATR  

Action status: Monitor

Response text:

In an update provided on 11 August 2017, ATR briefed the ATSB on the results of:
•flight testing to determine the pilot input profile following an intentional pitch disconnect
•a comparison of the dynamic model computation against flight test data
•the analysis of the pitch system jamming cases.

The flight testing identified a consistent post-disconnect pilot input profile for use in the dynamic model and indicated that there was no discernible difference in the profile across the tested speed range. Also, the results from the dynamic (engineering) model compared well with the flight test results, indicating that the dynamic model satisfactorily represents the aircraft behaviour during an in-flight pitch disconnect.

ATR applied the dynamic model to assess the effect of an in-flight pitch disconnect at the maximum operating speed (VMO) in two representative pitch system jamming cases. The results indicate that there is a margin between the peak elevator deflection during the pitch disconnect and the deflections required to generate the ultimate loads, at VMO.


ATSB response date: 05 September 2017

ATSB response:

The ATSB accepts that ATR has completed part of the engineering assessment of the transient elevator deflections following an in-flight pitch disconnect.

The ATSB notes that to date, we have only been provided with basic analysis results and that those results have been presented to EASA in a similar timeframe. The ATSB has not yet been provided with documentation showing an independently reviewed engineering assessment, but acknowledges that this would not be practical until the engineering assessment has been completed.

The ATSB also notes that the following engineering analyses will be required to meet the intent of this Safety Recommendation:
•Cases of inadvertent pitch disconnect events from dual control inputs
•Evaluation of the effects of variation of the pitch channel stiffness in the fleet

The ATSB will continue to monitor the work carried out by ATR in response to the identified safety issue.

Then about a week ago the following new investigation was initiated (note new investigation No.) that was bizarrely co-joined to the ongoing ATR broken tail investigation -

Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 

• Tab - Summary
  

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
• reviewing other investigations and references where similar themes have been explored.
  

.
 
General details

Date: 19 October 2017
 
Investigation status: Active
 
Investigation type: Safety Issue Investigation
 
Location   (show map): 47km WSW, Sydney 
 
State: New South Wales
 
Occurrence class: Technical
 
Occurrence category: Other
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: October 2018 
 
 

Last update 19 October 2017

Hmmm....why does the summary and ToR for this case study investigation sound so familiar -


MTF...P2

P2 OBS: This is an investigation within an investigation that has some very real parallels to the PelAir cover-up re-investigation (examining 'organisational influences').  Yet the PelAir ongoing investigation still carries the original investigation No. - Why?

[Kharon]

The ledger – debit and credit.

Book keeping is one of the ‘black arts’; an arcane art and a mystery to the uninitiated. I’ve no idea how the figures on a bank statement are produced – but even I can read ‘em and remember  Mr Micawber's famous, and oft-quoted, recipe for happiness:

"Annual income twenty pounds, annual expenditure nineteen [pounds] nineteen [shillings] and six [pence], result happiness. Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery."

Seems to that the ATSB annual income is less than their outgoings and credit is going to be hard to get. Make no mistake, it is credit they’re asking for. To me they are high risk bet and I’d want lots of security, a high interest rate and my own bookkeeper ‘on the job’. Even the ‘new’ business plan is riddled with holes, makes many promises and yet fails to convince. For example:-

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

One could forgive a new credit manager for believing the above statement; for many would. To the jaundiced, experienced eye of a veteran, the big red flags would be waving and the little bells would be ringing. Why – because it’s Bollocks, that’s why.

With the ATR case we have a very serious event, it could, so very easily, have ended in tragedy. Consider this – all over the world, some in tough conditions the ATR variants deliver passengers to destinations without the elevator channels disconnecting; hour after hour, day in day out, 24/7 rain, hail or shine. The ‘engineering’ aspect which ATSB have been ‘investigating’ for a number of years now, whilst important is not, statistically at least, the main suspect. A thorough inspection of the elevator system for the usual suspects, should have put an end to that element of the investigation; and, if it weren’t broke then another cause must be sought. The investigation into ‘how’ the initial disconnect was a disgrace. But only now, under a new investigation number is ATSB going to have a look behind the scenes.  


Statements like – “[investigation] was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, etc.” are purest pony-pooh. There is no such ducking thing when CASA is involved. When a company elects to use an aircraft, like the ATR, there is a long, complex process to be gone through. Even if the company go with the ‘off-the-shelf’ training and operating procedures it takes time to process. Lots of time and lots of money. Which only leaves the SMS system for ATSB to fool about with. Now what the hell the SMS has to do with two pilots buggering up a descent and disconnecting the elevator channels is beyond my comprehension. Perhaps it’s time to look elsewhere for the answers. Watch closely as ATSB take another three years to exonerate CASA and blame the SMS. CASA approve the training systems, the operating systems and the SMS. However:-

[and] also explored the role of the regulator in oversighting the operator's systems.

Did they now? Sorry ATSB, no credit at this bank. Maybe your Granny can assist….

Toot – toot.

[Peetwo]

High viz Hood and his merry men take over the Comedy Hour -



Today in the Oz Dick and 'that man' yet again 'rock' Hoody's Chookhouse shed...

Why was crash pilot at controls?

12:00amEAN HIGGINS

Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened.

---

Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened with the revelation that it will have been 2½ years ­before the agency reports on a ­potentially catastrophic near-collision of two aircraft at Mount Hotham in Victoria.

The near-miss in September 2015 is particularly significant ­because the pilot allegedly at fault, Max Quartermain, was killed, along with four American passengers, when his plane crashed near Melbourne’s Essendon airport in February this year.

Former Civil Aviation Safety Authority chairman Dick Smith told The Australian that if the ATSB had completed its Mount Hotham investigation within a reasonable timeframe, and concluded that Quartermain had ­engaged in poor airmanship, ­endangering lives, he might have been grounded or given retraining. In that case, Mr Smith said, the second incident, in which Quartermain crashed a Beechcraft King Air into a retail outlet nine seconds after take-off from Essendon, might not have happened.

The ATSB, in its initial determination of the Essendon disaster, could find no evidence of catastrophic engine failure.

Despite publicity about the same pilot being in charge in the Mount Hotham and Essendon incidents, the ATSB has again ­delayed the release of its report into the 2015 near-miss.

In April, with 18 months having passed since the Mount Hotham near-miss, the ATSB said it would make its report public in June.

But an ATSB spokesman has now said the investigation will not be completed until February, and even the draft report was “currently undergoing an internal ­review process prior to approval by the ATSB commission”.

“Once this is complete, the draft report will be forwarded to the relevant directly involved parties for comment prior to the completion and public release of the final report,” the spokesman said. “The involvement of directly ­involved parties is an important measure for the ATSB to ensure factual accuracy, and the validity and transparency of its investigation processes. There have been some delays experienced; most ­recently due to new information becoming available.”

The ATSB launched its Mount Hotham investigation after a pilot claimed Quartermain, flying a King Air from Melbourne, had confused other pilots in his radio communications and nearly crashed into his aircraft, also a King Air, as they both were preparing to land.

Quartermain was flying staff from Audi to an event at the alpine resort when, investigators determined, he came within 1.8km horizontally and 90m vertically of the other aircraft. At one point, it was alleged, Quartermain radioed to say he was 10 nautical miles west of Mount Hotham, before correcting himself to say he was 10 nautical miles east.

Mr Smith said he was suspicious about the delay, and whether it reflected concerns about whether action should have been taken against Quartermain after the Mount Hotham incident.

He said the ATSB’s system of sending draft reports to interested parties gave them the chance to frustrate the process, including requesting that adverse findings or implications be censored.

“It’s sent secretly to those who have a vested interest before the general public see it, and it’s wrong,” Mr Smith said.

The ATSB spokesman said the bureau was “independent of regulators, service providers and policymakers and this is reflected in the integrity of our investigation ­reports”.

Hmm...I can feel another Hoody 'correcting the bollocks' moment coming on -    



...said the bureau was “independent of regulators, service providers and policymakers and this is reflected in the integrity of our investigation ­reports”.

 In the meantime the Carmody hour comes to the HVH (ATSB) studios -

MTF...P2

[Peetwo]

Part II of Comedy HR comes to HVH (ATSB) studios -

High viz Hood and his merry men take over the Comedy Hour -



Today in the Oz Dick and 'that man' yet again 'rock' Hoody's Chookhouse shed...

Why was crash pilot at controls?

12:00amEAN HIGGINS

Doubts about the Australian Transport Safety Bureau’s ability to conduct critical investigations have deepened.

Via the Oz today:
  

ATSB vow to be more selective in investigations


ATSB chief commissioner Greg Hood, right, and Transport Minister Darren Chester.

The Australian
12:00AM November 10, 2017

ANNABEL HEPWORTH

Aviation Editor
Sydney
@HepworthAnnabel

---

The nation’s transport safety ­investigator has vowed to become more selective in the accidents and incidents it investigates as it tries to rein in a backlog of reports.

Australian Transport Safety ­Bureau chief commissioner Greg Hood said the ATSB was trying to “improve its efficiency by becoming more data-driven”.

While the ATSB has a target of publishing 90 per cent of complex investigations within 12 months, in 2016-17 it got just 32 per cent away within that time frame.

“By being more selective with our investigations, and with the introduction of more resources through a recent recruitment drive, we will be in a better position to meet this target over the coming year,” Mr Hood said.

Fresh questions about the ATSB’s ability to conduct air safety investigations in a timely manner were raised this week when it emerged that an investigation into a 2015 Mount Hotham occurrence involving pilot Max Quartermain — the pilot involved in February’s Essendon plane crash — will now not be released until February.

Infrastructure and Transport Minister Darren Chester said he understood the report had been delayed for many reasons, including the need to consider recently-obtained material.

“Timeframes for investigations can vary based on their complexity, available resourcing and a range of other factors,” Mr Chester said.

“I am confident that, should a critical safety issue be identified during the course of an investigation, the ATSB will immediately bring this to the attention of relevant authorities and organisations to be addressed.”

Mr Chester also backed ATSB moves to improve the timeliness of its reports.

The ATSB’s latest annual report shows that for complex aviation investigations, 39 were completed in 2016-17, with 31 per cent done within 12 months, compared to 18 per cent the previous year. At June 30, there were 69 ongoing complex aviation investigations.

Mr Hood said the ATSB aimed to complete most of its complex investigations within 12 months.

As there were 17,000 incidents, serious incidents and accident notifications made to the ATSB last year — an average of 46 per day — “it is not possible for the ATSB to investigate everything”.



He said the ATSB was looking to use its data of safety-related occurrences to bolster its efficiency.

“By actively interrogating this data, we are able to more selectively allocate our resources to investigating those accidents and incidents that have the greatest potential for improving transport safety, with a particular focus on the travelling public,” Mr Hood said.

“If there is no obvious public safety benefit to investigating an accident, the ATSB is less likely to conduct a complex, resource-intensive investigation.”

The 2014 Aviation Safety Regulatory Review report, chaired by industry veteran David Forsyth, compared the time the ATSB had taken to produce reports compared to the US’s National Transportation Safety Board, New Zealand’s Transport Accident Investigation Commission and Britain’s Air ­Accident Investigation.

This followed criticism in submissions over the time the ATSB took to produce safety reports.

“The panel considers that the ATSB’s reporting timelines are longer than desirable and significant delays for some individual reports are a concern,” the report found. “However, the panel notes that the timelines are broadly consistent with international performance.” That analysis looked at 2004 to 2013.

Mr Hood said that daily senior managers and safety data analysts would review notifications they got in the last 24 hours. Decisions would be made on whether to investigate and what type of investigation to do.

“There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather,” Mr Hood said.

“Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity.”

---

Comment from Sandy... :

...I think we get it, ATSB with around 100 staff and the CEO (former Civil Aviation Safety Authority Manager) in his hi vis jacket can take as much time as they like to finalise reports. Rubbery figures? In this report we have 17,000 incidents to consider, funny, it was a nice round 15,000 a couple of days ago. Then we have to work out what is a ‘complex’ incident, do they mean like the one where they and CASA whacked the pilot who ditched at Norfolk Island? Luckily the Senate took an interest and after nearly nine years it seems that the authorities were at fault, not the unfortunate and officially maligned pilot. The first investigations, with G. Hood working in CASA at the time, were sloppy at best or malicious at worst, take your pick.

Alex in the Rises. 

MTF...P2

[Peetwo]

Aviation safety issues and actions

If you click on the web link above you will see it takes you to the ATSB webpage with links for 849 recorded safety issues and/or recommendations dating back to 1996 when the ICAO Annex 13 State AAI was called the 'Bureau of Air Safety Investigation'.

Example:  

Output No: R19980161

Date issued:18 August 1998

Safety action status:

Background: See report B98/90 -'Systemic investigation into factors underlying air safety occurrences in Sydney Terminal Area airspace'.

Output text

The Bureau of Air Safety Investigation recommends that Airservices Australia review the relationship between the Sydney Safety and Quality Management section and the Sydney Terminal Control Unit with a view to developing procedures to improve the effectiveness of the safety management system, thus contributing to the overall "safety health" of Sydney Terminal Control Unit operations.

Remembering that in 1998 the concept of SMS was still some 14 years away from being enshrined and written into ICAO SARPs in the form of Annex 19.  

Quote from post - Yes: But…. - from the Ferryman gives a bare bones explanation to the average layman on how a properly functioning SMS is supposed to work and how an ATSB identified 'safety issue' leading to a safety recommendation could interact with that company/AOC SMS:

 "..One of the little problems ATSB have is that their ‘recommendations’ have no legal bind on company management. A small shift in ‘thinking’ could remedy that. An ATSB recommendation to the company SMS system would need to be acknowledged and considered through the SMS. Say ATSB recommended that pilots wear Pink socks on Tuesday and Blue on Friday. This is fed into the grass roots level of the SMS; the system is then triggered. This is a legitimate call by the government safety agency and cannot be denied entry. So the ATSB recommendation is duly considered; dealt with and the system decides it’s a crock. This is fine, but should the next incident involve pink socks, not blue, then there is a paper trail leading right to the top mans door. If a middle level decision to deny the recommendation was made it matters not – at the end of the shift the responsibility lays with the top dog. That is how a SMS is structured..."

However the ATSB under Beaker and now Hoody would seem to have lost sight of what the purpose is (other than a CASA auditable tick-a-box routine) for a properly functioning SMS i.e. to identify and risk mitigate 'safety issues' through a company hazard and incident reporting system operating under a 'Just Culture'.

In fact from recent correspondence between DJ and ATSB legal it would appear that the bureau are internally fractured or confused on what exactly their remit is when it comes to proactively addressing identified safety issues.

From the bottom of the ATSB 'Terminology, investigation procedures and deciding whether to investigate' webpage there is a 'safety issue' definition: 

Safety issue: a safety factor that:
a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and

b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

    
However the legal weasel from the ATSB would seem to be arguing the toss on the term and definition of a safety issue within the TSI Act - WTD??

Dear Sirs,

See attached internal CASA email correspondence, which is a clear breach of the TSI Act. I expect there are other similar emails and I will forward them to you as soon as I have them. Further, it would appear that CASA have not controlled the distribution of the draft internally, and that persons not providing or contributing to the CASA’s draft feedback document have copies of the draft report or are privy to the draft report’s contents.

As the ATSB prides itself as a ‘no blame’ organisation, I would hope the ATSB would act on this matter promptly and appropriately.

Regards,

---

Dear DJ

Thank you for your email regarding correspondence within CASA concerning the draft report from the reopened investigation into the ‘Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009’.  The ATSB will confirm with CASA its practices for disclosure of the draft report in this matter in the context of section 26 of the Transport Safety Investigation Act 2003.  Please note that section 26 of the Act does permit disclosure and copying of the draft report necessary for:

                  (a)  preparing submissions on the draft report; or
                  (b)  taking steps to remedy safety issues that are identified in the draft report.

Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.  The email you have provided does not establish, prima facie, a breach of the Act with respect to copying or disclosure of the draft report.  The ATSB will make enquiries with CASA.

I note that you have included the ATSB’s Chief Commissioner, Mr Greg Hood, in the recipients list for your email.  As you may be aware, Mr Hood has recused himself from this investigation acknowledging his employment at CASA at the time of the accident.  Mr Hood is not involved in the ATSB’s decision making with respect to this investigation.  You may send any future correspondence on this particular matter to either myself or Colin McNamara, Chief Operating Officer.  Mr McNamara’s email address is colin.mcnamara@atsb.gov.au.

Regards

---

Hi ATSB Legal Weasel,

Given that this accident occurred 8 years ago and that the information in the draft is not materially new, how can this be viewed as CASA remedying a safety issue? I’m already back flying and this matter deals with an opportunity for me to be promoted to a captain, so what contemporary safety case or pressing hazard needs to be addressed? To me it appears that a CASA officer is using an ATSB draft to inform their administrative processes, so doesn’t TSI Act 12AA (3)(d) refer?

If this is of no interest to the ATSB, then why would anyone participate candidly in an investigation if the ATSB doesn’t protect those involved from CASA inappropriately using draft reports?

Regards,

P.S. the link below to a Youtube clip of the recent CASA Estimates relates, especially at the 4:00 mark.

https://www.youtube.com/watch?v=tt7DDChxI-Y

---

Dear DJ

Thanks you for your follow up email.  I watched CASA's appearance at Senate Estimates on 27 October 2017.  As I advised in my email of 1 November 2017, the ATSB is making enquiries with CASA with respect to this matter

Regards

LW

---

Hi LW,

I'm not trying to labour the point, but I sincerely don't understand how no breach is evident in the CASA email extract; maybe I've referenced the wrong part of the Act.

Does 26(1) limit what a draft report can be used for, and in this case, CASA are acting outside of this?

Regards,

DJ

---

Dear DJ

Section 26 of the Transport Safety Investigation Act 2003 places limits on copying and disclosing the draft report.  However, there are exceptions to the prohibition on copying and disclosure.  As mentioned, it can be copied and disclosed where it is necessary for the purposes of:

(a) preparing submissions on the draft report; or
(b) taking steps to remedy safety issues that are identified in the draft report.

The content of the draft report can be taken into account to remedy safety issues.  This could include CASA performing its safety related functions  The issue is whether or not the report was disclosed for the purpose of remedying safety issues.  I am following up with CASA.

There is a restriction on use in subsection 26(6) which states that a person who receives a draft report is not entitled to take any disciplinary action against an employee of the person on the basis of information in the report  Further, s.27 prevents the draft report (as well as the final report) from being admissible in evidence in civil or criminal proceedings.

I hope this clarifies the operations of section 26.

Regards

LW

---

Hi LW,
 
Thank you - that answers my question.
 
Re CASA’s DIP protocols, I would expect that CASA has:

• carefully identified those persons with history or expertise in this accident whose input is essential to their DIP feedback
  
• formally retained those persons in writing and explained to them how the TSI Act applies to them and the draft’s contents
  
• ensured that those people in the DIP process are aware of who else is a DIP participant and therefore aware of who they cannot discuss the draft report’s contents with  
  

 
Do you know if the above resembles CASA’s present protocol?
 
Regards, DJ

---

Dear Mr James
 
The Transport Safety Investigation Act 2003 details that the report should not be copied or disclosed except as provided for by section 26.  We are checking that they follow that practice.
 
Regards
 
LW

---

Hi LW,
 
Thank you for that - much appreciated.
 
Re an earlier email where you said that CASA were entitled to use the draft report to respond to 'safety issues', can I draw your attention to the following ATSB document and a section from it:
 
ATSB TRANSPORT SAFETY RESEARCH REPORT
Aviation Research and Analysis Report – AR-2007-053 
2.3 Safety issue

1. 2.3.1  ATSB definition
   

A safety issue is a safety factor that:

1. • can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
     
   • is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. 
     

 
Is this definition consistent with the definition used in the TSI Act? If not, could you please direct me to the definition of ‘safety issue’ that is used in the TSI Act?
 
Regards, DJ

P2 comment: Note that the safety issue definition from AR-2007-053 is the same as the current listed (above) definition off the ATSB webpage. Ironically the person who came up with that definition is none other than the PelAir re-investigation IIC Dr I'm a Psychopath-Ghost-who-walks  

---

Dear Mr James

 
The Transport Safety Investigation Act 2003 does not define the term ‘safety issue’.  The Explanatory Memorandum to the Act does not indicate that the term in the Act is limited to identification of organisational safety issues.
 
Regards
 
LW

I can only presume this ATSB legal stance is to support the provision of top-cover for CASA while faciliting the CASA Sydney Regional office continued 8yr embuggerance (anniversary today) of DJ...



MTF?- Definitely...P2

[Peetwo]

ATSB search for IP remains elusive -  

Extract from the ATSB press release yesterday: reference - PelAir coverup MKII - Final report released.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.


The significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

Due to the above statements yesterday from the slightly less 'invisible Manning' it is now obvious that the ridiculous addition of 454 pages to the original Final Report, in what should have been a relatively straightforward systemic investigation and AAI factual report, is a very expensive ($?) attempt to regain credibility in the eyes of industry and the average ATP (Australian Taxpayer) 

Therefore I am proposing to use the search 4 IP thread to systematically analyse the new 531 page incarnation to highlight how this report falls far short of the ATSB achieving any respectable probity and credibility.

To start with here is the 'safety message' summary from the FR:

Safety message

The investigation report contains 36 safety factors that provide lessons to flight crews, operators, regulators and/or other organisations. Overall, the most fundamental lesson for all flight crew, operators and regulators is to recognise that unforecast weather can occur at any aerodrome. Consequently, there is a need for robust and conservative fuel planning and in-flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.

Additional safety messages include:

• Flight crew should discuss and consider options to manage threats when there is time available to do so.
  
• Operators should ensure their flight crew proficiency checks assess the performance of all key tasks required of their flight crew.
  
• Operators should not rely on informal risk controls for managing the performance of safety-critical tasks, particularly when there is significant turnover of pilots in a fleet.
  
• Operators of air ambulance flights should ensure medical personnel have clearly defined procedures and appropriate practical training for using the emergency equipment on board to ensure they can effectively assist a patient in the event of an emergency.
  
• All organisations in safety-critical industries should use proactive and predictive processes to identify hazards in their operations.
  
• Organisations that use a bio-mathematical model of fatigue as part of their fatigue risk management system should ensure they have a detailed understanding of the assumptions and limitations associated with such models.
  
• Regulators should develop effective methods for obtaining, storing and integrating information about operators and the nature of their operations so that they can develop effective surveillance plans.
  

The 'safety issues & actions' starts at page 356 and goes to 387.

To kick it off I will (reference - PelAir coverup MKII - Final report released.) quote what is IMO the major hole in the Swiss Cheese the non-provision by Nadi of both a weather report (SPECI 0739) and an amended weather forecast (the 0803 AMD TAF that contained a operational - Alternate - requirement).  

ATC weather updates?

Given the huge missed opportunity by ATC to inform the co-pilot and myself of the new TAF which changed the fuel requirements for Norfolk, and that exemptions from ICAO policy have been granted in this regard re informing crew in international operations of such changes, why is a lengthy discussion on this topic missing?

ATSB IIC Dr Walker's nasty and arrogant reply to the above Captain DIP comment:
  

No change required

In addition to the content in The occurrence section, the draft report discusses the provision of flight service in the Nadi and Auckland Oceanic FIRs in detail (about 5 pages). The topic is also discussed in the Safety analysis (2 pages), and findings are included in relation to the Nadi IFISO and Auckland air/ground operator’s actions.

It is not clear what ‘exemptions from ICAO policy’ the captain is referring to. In relation to amended TAFs, ICAO guidance (in document 7030 for most regions) stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination. However, this did not apply to the Nadi FIR (although it did apply to the Auckland Oceanic FIR and the Australian FIRs). Overall, the Fijian and New Zealand flight information service providers’ procedures were consistent with ICAO standards and recommended practices.

Limited information about the reasons for the actions of the Nadi IFISO and Auckland air/ground controller regarding VH-NGA on 18 November 2009 were available to the ATSB reopened investigation. The ATSB discussed the topic in as much relevant detail as it could, given the available information. The importance of the meteorological information that was not passed by ATS to the flight crew has also been highlighted in the draft report.

Overall, further discussion of the topic was not considered warranted.

The dismissal by Walker of what essentially is IMO an ATSB identified significant safety issue...

ICAO guidance..(sic)..stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination

...is extremely problematic and disturbing in an international perspective.

How hard would it have been for the ATSB to issue a safety recommendation or notice to ICAO suggesting that maybe the document 7030 guidance should be revisited and possibly amended.  

Now from the MKII report some relevant quotes from the Dr Walker referred pages.

From Pg 97:

CAAF also reported:

- The Nadi Air Traffic Management Centre normally received METARs/SPECIs and TAFs within a few minutes of them being sent by the disseminating station.
 - METARs/SPECIs and TAFs were delivered automatically to two printers, including one at the IFISO’s workstation.
 - The IFISO’s workstation was enclosed in a soundproof booth.
 - When SPECIs were received, they were displayed to both the IFISO and the controller.

On 20 November 2009, the ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI.

P2 - Note the non-inclusion of the 0739 SPECI & 0803 AMD TAF. However this was explained in the next paragraph where the timeline of investigation bizarrely seems to jump from the original investigation back to the present reiteration:

CAAF advised it was not aware of the 0739 SPECI and the 0803 amended TAF until it received the ATSB’s investigation report in 2012. CAAF contacted the ATS provider, who advised it had provided CAAF with all the weather reports it had received at the time (in 2009). The ATS provider advised CAAF it no longer held the hard copy print outs and therefore CAAF could not verify whether the 0739 SPECI or the 0803 amended TAF had been received.

Q/ We now know that the ATSB and CASA in their parallel investigation activities were both aware of the existence of at least the 0803 AMD TAF by 23 November 2009. Therefore why did the ATSB in the course of their investigations - especially after receiving the Auckland & Nadi ATC transcripts -  not query the CAAF on why it was they didn't have copies of the 0739 wx report & the 0803 amended forecast?  

Quote from "K" post above - A thumbnail, dipped in tar. - once again the significance of the non-relayed wx report and AMD TAF in the context of this 531 page re-hashed 'the pilot did it' bollocks report...

...The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

MTF...P2

[Peetwo]

Pirate code: "..more guidelines than actual rules" 

I note that off the UP Lead Balloon (aka Creampuff) gets it but then again from my memory I think he always did...   

I seriously believe someone’s hacked Lookleft’s username. The ‘real’ Lookleft would not have been silly enough to suggest that Table 10 is a ‘transcript’. It’s a paraphrasing and summary by a third party. In any event...


A trap was set for the PIC by the system in which he was variously allowed, encouraged and forced to operate. The ‘tripwire’ on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC.

The PIC’s primary sin was that he did not have ESP.

The controversy around the classification and standards applicable to this kind of operation are merely a manifestation of the broader classification of operation dog’s breakfast that will never be cleaned up by CASA.

While on the typical ill-informed, arrogant and narcissistic Lookleft post, I was intrigued by this almost emotive, strangely biased and complimentary statement in regards to the FO's performance on that fateful night :

..The report finally sheds some light on the F/O's contribution to the event. She was doing a lot of managing upwards. The PIC just seemed to be shutting down to any course of action other than ditching. I'm not sure if the first report stated that she had sustained a serious injury but I am not surprised that she did not want any part of any discussion outside of the ATSB investigation. In my view she did a good job but short of taking over she was restricted by the PIC's performance...

 
P2 comment - Perhaps LL has just given a clue to why he has never been able to holistically look at the PelAir ditching investigation in a systemic top down approach and without what would appear to be a personal grudge against DJ...     

This creates a perfect opportunity to bring up another aspect of the report that IMO seems to have been glossed over through either reckless and arrogant ineptitude by the IIC Dr Walker; or once again through 'malice and aforethought' Walker has attempted to muddy the waters...    

From page 14 of the report (note part in bold):

..The first officer did not recall hearing any weather information provided by the Nadi IFISO. Both of the crew stated that at some stage after reaching FL 390, the first officer had a controlled rest (or ‘cockpit nap’), which was an approved component of the operator’s fatigue risk management system (see Cockpit strategic napping). The first officer believed she had this controlled rest at the time the Nadi IFISO provided the weather reports. The extent to which the first officer was subsequently briefed regarding the 0800 weather report could not be determined...

From the pg 14 part in bold, one gets the impression that the IIC and/or investigators have checked that the FO's 'cockpit nap' was being conducted in accordance with the safety risk mitigation FRMS (i.e. SMS) SOPs - from page 225:

Cockpit strategic napping

The FRMS manual stated that, even though the FRMS was intended to ensure flight crew were well rested:

… the nature of Pel-Air operations can present unique challenges to crew alertness, despite meeting crew rest requirements. Pel-Air scheduled and ad-hoc charter operations tend to involve lengthy sectors at critically fatiguing periods of the night as well as fatiguing tasks in demanding flight scenarios, as such deliberate crew napping is seen as a suitable means of improving crew alertness during more critical portions of the flight.

Accordingly, the manual stated ‘cockpit strategic napping’ was permitted subject to specified conditions. These conditions included:

- only one pilot was able to nap at a time
- napping could only be done during low workload parts of a flight
- naps were limited to 30 minutes maximum (to prevent problems associated with sleep inertia254)
- pilots should be woken 30 minutes before any anticipated high workload event
 the autopilot was engaged
- pilots were not permitted to disconnect their headset or turn down the volume of their radio.

Many Westwind pilots reported cockpit napping was regularly used as a risk mitigator on long flights at night.

---

254 Sleep inertia: a short period of time immediately after awakening associated with poorer task performance and a feeling of mental sluggishness.

   
However after a couple of quick phone calls (ala Barry O) I was able to establish a couple of (unfortunately) hearsay facts:

Q1/ Was the flight crew or medical crew aware of the FRMS conditions for an approved 'cockpit nap'?

A1/ Unfortunately I cannot establish whether the FO or Doctor was aware of these conditions but I can confirm that the Capt & Flight nurse were not aware.

Q2/ Was the FO's approved 'cockpit nap' conducted in compliance with the FRMS (SMS) safety risk mitigation conditions?

A2/ Both replies were no:

1/ The 'nap' went for longer than 30 minutes.

2/ The nap was conducted without headsets on or with volume up and neither was the cockpit speaker selected on and with the volume up.

Note: a) It was also stated to me that this 'normalised deviance' was a regular routine for the FO with other aeromed flights and with different Captains.
b) Surprisingly the EP training for medical crew (although not completed under an approved CAR217 CAO 20.11 course) did not include awareness of the FRMS (SMS) fatigue risk mitigation components - WTD?    
c) Disturbingly the safety risk mitigation conditions as published in the FRMS manual were not published in the FCOM (Flightcrew operating manual) and that would be because apparently PelAir didn't have FCOMs for at least the Westwind operations...  

Quote from page 23:

 ..As the first officer had not flown the leg from Apia to Norfolk Island before, the captain asked her if she would like to be the pilot flying. The first officer agreed...

After contemplating all of the above I have to keep pinching myself that the FO was the PF for this flight. Personally I always saw a FO pilot flying leg as an opportunity to display your aptitude and ability for a future command upgrade. Therefore I find it quite reprehensible that the FO saw fit to make an ICUS decision to take a non-compliant 'cockpit nap'.

The command aptitude aside, just consider that if the FO had of been compliant with the FRMS 'crew nap' conditions that she may just have heard the 0801 exchange and therefore may have questioned and discussed the mixed weather messages received from Nadi. This may have led to Nadi discovering the MIA 0739 SPECI & 0803 AMD TAF and (as they say) all this would be history...

IMO the worst command decision DJ made that fateful day was to allow the FO to be the pilot flying on that leg...



MTF? - Definitely...P2

[Peetwo]

PelAir MKII & the quest for IP: cont/-

Quote from this week's SBG: Quantity v Quality. 

...It is small wonder that the aviation world is looking more and more to the Senate and the Senators to lend a hand and get a rope on the lunatics. The ATSB were emasculated during the Lockhart River affair and CASA dodged a large calibre bullet; many years later we have the Pel-Air and Norfolk Island farrago. The total cost of this debacle is staggering, the quality of the result disgraceful; but by far the worst is total zero improvement in system or safety lesson of value; to anyone. When the dust has settled a long, hard look, in terms of value for investment will be taken of this almost unbelievable saga. Perhaps by then there will be a minister who actually gives a damn and finally matters aeronautical will take a turn for the better. Do not hold your breathe…….

Not sure how accurate the estimates are but there are some older wiser BRB heads who reckon that the total cost (so far) for the PelAir cover-up is North of 50 million Aussie dollars. That equates to a conservative figure of $10 million per 100 pages of the PelAir MKII final report. The question is will this 531 page report prove to be the catalyst for the ATSB getting back to AAI (ICAO Annex 13) ToRs and rediscovering it's investigative probity - so far I think not...

However to give Hoody's posse the benefit of the doubt, let us continue with reviewing the ATSB identified safety issues and the recommendations, suggestions for DIP proactive risk mitigation.

Starting with this from the MH370 forum: MH370, PelAir & the ELT connection

Via RT: Many have speculated that MH 370’s ELT failed to send out a signal when the plane disappeared from radar screens on March 8 last year, somewhere near Indonesia, because it had crashed into water. If the ELT had worked, authorities could have avoided the 18-month search that has cost over $100 million dollars so far, and which may only now be coming to an end.

---

&..

From page 31 of PelAir cover-up MKII final report:
https://www.atsb.gov.au/media/5773678/ao..._final.pdf

..During the ditching impact, the aircraft’s 406-MHz beacon emergency locator transmitter (ELT) transmitted one alert signal. Although the alert was detected by a geostationary satellite, the single alert was insufficient for the search and rescue services to determine the location of the ELT...

  
Okay apparently the boys'n'gals on the coalface did identify this safety issue as being significant. The executive/commissioners agreed and didn't deem the issue one that needed to be PC'd...

Extract from page 386-387:

Additional safety action regarding emergency locator transmitters

Satellite detection of emergency locator transmitters
Although unrelated to the circumstances of this accident, during 2003 the International Cospas-Sarsat Programme had commenced developing the Medium-altitude Earth Orbiting Satellite System for Search and Rescue (MEOSAR). The system consisted of search and rescue signal repeaters installed on the Global Navigation Satellite Systems (GNSS) of Europe, Russia and the USA; complementing the existing Low-altitude Earth Orbit (LEO) and Geostationary Earth Orbit (GEO) satellites from the LEOSAR and GEOSAR systems.

Once fully operational, the MEOSAR system will be capable of near-real-time transmission of distress messages and if the distress beacon is within coverage of three or more GNSS SAR repeater-equipped satellites, an independently calculated position of the distress beacon location.

With a full satellite constellation, it will be possible to calculate the location of the distress beacon within 10 minutes, 95 per cent of the time. The MEOSAR system will facilitate additional enhancements, such as a return-link-service to suitably equipped distress beacons acknowledging receipt of the distress message.

The Cospas-Sarsat MEOSAR system was not operational in 2009. A demonstration and
evaluation phase commenced in 2013 and in late 2016, the system achieved an early operational capability for search and rescue agencies. Full operational capability of the MEOSAR system is anticipated during 2018.

Use of emergency locator transmitters
In May 2013, the ATSB published a research report titled A review of the effectiveness of emergency locator transmitters in aviation accidents (available from www.atsb.gov.au). The research report provided an overview of the use of emergency locator transmitters (ELTs) and provided basic quantitative evidence of their effectiveness. Analysis of ATSB’s aviation occurrence database from 1993 to 2012 indicated ELTs functioned as intended in about 40–60 per cent of accidents in which their activation was expected. In addition, ELT activations accounted for the first notification to the Australian Maritime Safety Authority (AMSA) in about 15 per cent of incidents and ELT activations had been directly responsible for saving an average of four lives per year.

In accidents where ELTs did not work effectively (or not at all), it was found a number of factors could affect their performance. Those factors included incorrect installation, lack of water proofing, lack of fire proofing, disconnection of the co-axial antenna cable during impact, damage and/or removal of the antenna during impact and an aircraft coming to rest inverted following impact.

The safety messages highlighted in the research report included:

- pilots and operators of general aviation and low-capacity aircraft needed to be aware that a fixed fuselage mounted ELT cannot be relied upon to function in the types of accidents in which they were intended to be useful.
- the effectiveness of ELTs in increasing occupant safety and assisting SAR efforts could be enhanced by using a GPS-enabled ELT, using an ELT with a newer 3-axis g-switch, ensuring it was correctly installed, ensuring the beacon was registered with AMSA and activating the beacon pre-emptively if a forced landing or ditching was imminent.
    - carrying a personal locator beacon (PLB) in place of (or as well as) a fixed ELT would most likely only be beneficial to safety if it was carried on the person, rather than being fixed or stowed elsewhere in the aircraft.

Additional information regarding distress beacons
AMSA’s booklet Distress Beacons and MMSI Information contains important information and recommendations about the use of distress beacons and their use by persons in life threatening situations (available from www.amsa.gov.au). It provides information on the types of distress beacon and the advantages of beacons that are GNSS equipped. AMSA recommends the use of GNSS-equipped beacons because they provide the quickest and most accurate alerts.

Advice for using distress beacon includes that when in grave or imminent danger, two-way communication (such as phone or two-way radio) is the most effective means of communicating. If two-way communication is not available, then a distress beacon should be activated.

AMSA also recommended that personal locator beacons are physically carried on the person or within easy reach.

Credit where credit is due, that is a good proactive and monitored response to an identified safety issue.

However this identified safety issue obviously predates the PelAir re-investigation. Since May 2013 we have had several high profile aviation accident investigations, including the ongoing MH370 investigation, where the ELT has either failed or not operated as advertised.

Yet the ATSB PelAir reinvestigation report does not expand to include references to these AAI's; nor does the report recognise ICAO and other signatory States; or aviation stakeholders (like NASA above) on proactively addressing the obvious fallibilities of the current technology ELTs.

Reference PelAir MKII post: The hidden agenda of PelAir MKII IIC Dr Walker 

Whatever the reasons for these ATSB administrative glitches it would also appear that there is some serious issues with the ICAO iSTAR receiving office, remembering that the examples mentioned above were only 3 of many that I was able to identify as not existing/filed on the iSTAR/ECCAIRs databases.

Could it be that there are still 'taxonomy' and/or compatibility issues with the current ATSB SIIMS database and the forwarding of safety and accident reports being sent to the ICAO iSTAR database office? Why wouldn't a State endorsed Annex 13 AAI at least check that there are no issues at the receiving end of some important forwarded Annex 13 compliant reports? After all we are talking about the integrity and security of valuable safety information that deserves to be properly disseminated to the worldwide aviation industry as per the good intent and philosophy of ICAO Annex 19.

From the previous post #209, the above reference post and the closed off ELT issue; we are beginning to see a trend that bizarrely the ATSB was a closed shop that did not encourage any outside input, any new information/evidence; nor did they want to address any additional externally identified safety issues....



TBC...P2

[P7_TOM]

I believe the ‘Walker’  (aka Fig-jam )- attitude, arrogance and plain old fashioned rudeness, combined with any form of empathy has been discussed several occasions; not only here. His attitude toward Karen and Dom has offended many – not that he’d give a fundamental fig for those opinions.

We can let this all pass, for the while, as insignificant in comparison to some of the ‘glossed over’ major items which have been given a PC ‘tick-a-box’ treatment from the invisible Manning. Small items, of a ‘psychological nature’ which have been ignored. Like feeling that the SMS is a lip service exercise; or, fatigue is only a figment of imagination; or, that company culture has no effect on the ‘upright’ pilot. There is more, lots more which, in the BRB opinion, shows clearly the deeply flawed approach ATSB is taking – without going into the Mildura bun fight or even the ATR events (now plural) and, heaven forbid we ever mention Essendon.

Walker has some ‘deep and meaningful’ questions to answer; not just on Pel-Air, considering the attitude, although the stance he has adopted toward just to Karen and Dom alone demands answers. Maybe, when the RRAT committee hauls ATSB back in for a ‘chat’ we can have those questions answered.

Dry argument and nearly my throw – best get one in to keep me focussed on the important things – “Yes please – right here”. Why do they always ask “same again”?

[Peetwo]

PelAir MKII & the quest for IP: SMS a lip service exercise -  

From P7's pointed post...

...We can let this all pass, for the while, as insignificant in comparison to some of the ‘glossed over’ major items which have been given a PC ‘tick-a-box’ treatment from the invisible Manning. Small items, of a ‘psychological nature’ which have been ignored. Like feeling that the SMS is a lip service exercise; or, fatigue is only a figment of imagination; or, that company culture has no effect on the ‘upright’ pilot. There is more, lots more which, in the BRB opinion, shows clearly the deeply flawed approach ATSB is taking – without going into the Mildura bun fight or even the ATR events (now plural) and, heaven forbid we ever mention Essendon...

Now to join the dots - from page 353 under 'Contributing Factors':

Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. [Safety issue]

  
Extracts from under Safety Management and management oversight (page 337-341):

Hazard identification processes

The operator had a safety management system (SMS) in some form for several years prior to it being formally mandated in regulatory requirements for Australian RPT operators in 2009. Although ideally an SMS will allow an operator to identify and address hazards in its operations, the effectiveness of these processes can be affected by many factors.

The operator’s processes to identify hazards in its flight operations relied heavily on flight crew submitting incident, hazard and fatigue occurrence reports. If a report was submitted, it could then be assessed and considered by personnel other than those involved in the relevant fleet’s operations. However, the reporting culture within the operator was such that flight crew were generally only submitting reports when requested or for incidents that external parties had already reported. There were minimal voluntary or discretionary reports submitted. Although the available evidence indicates this situation was improving in the operator’s other fleets during 2009, this did not appear to be the case in the Westwind fleet...


...The primary task of the Westwind fleet was traditionally night freight operations. It commenced air ambulance operations with the air ambulance provider in 2002, and the extent of these operations significantly increased from 2007 to 2009, and by 2009 it was the main activity undertaken by the Westwind fleet. During 2007–2009, the number of bases routinely conducting air ambulance operations increased from one to four, and there was a significant turnover of flight crew, particularly with the captains based in Sydney.

Despite these changes, the operator’s formally-defined risk controls, particularly for training and checking, still appeared to be better suited to routine freight operations. There also appeared to be a significant reliance on the informal transfer of essential knowledge to flight crew regarding international operations and operations to remote islands, and an assumption flight crew would acquire the knowledge and skills appropriate for their tasks.

Given the expansion of the operator’s air ambulance operations, and the inherent nature of international ad hoc air ambulance operations, there was a need for the operator to closely monitor and review the conduct of operations to assure itself they were being conducted to an appropriate standard, and that the implemented risk controls were suited to the nature of the tasks being conducted. As indicated above, the processes used to identify hazards and monitor operations were not adequate to achieve this purpose.

Safety management is an evolving discipline, and it is undoubtedly difficult for a relatively small air transport operator to conduct hazard identification activities to the standard expected of major airline operators. There were indications the operator was taking positive steps to improve its hazard identification processes during 2009. However, these efforts had limited effect on the Westwind fleet’s operations up until the time of the accident.

In summary, the operator’s processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. Overall, had the operator adopted more thorough proactive and predictive hazard identification processes, it is likely at least some of the inadequate risk controls associated with its air ambulance operations would have been identified, particularly in terms of flight/fuel planning and in-flight fuel management.

 
On reviewing the various ATSB identified PelAir SMS preamble and deficiencies (above), it is very hard to go past the very disturbing parallels to the tragic Lockhart River investigation, with familiar issues like lack of proper CRM training and obvious deficiencies in the CAR 217 organisation.

The following is some quoted extracts from an excellent 2008 ASASI presentation by former ATSB Executive Director Kym Bills...

...All these factors strongly indicate to an industry where experience levels are reducing dramatically. Add to this the financial pressures of rising fuel costs and rapid growth, and we are starting to paint a picture of an industry that will need to withstand increasing stress in the future. In Australia in particular, there will be significant challenges for the industry to meet societal and political expectations that rural and regional Australian air services will be maintained to a high standard. We face an environment where resistance to pressures to cut corners in training will be paramount; where real and meaningful safety management systems need to be integral to an organisation’s operation. It would come as no surprise to you I am sure that the ATSB has seen many examples during investigations of safety management systems that are little more than a book on a shelf, or loose words that are readily bandied about. Hand in hand with this is the need for commitment to the establishment of strong safety cultures. Again, while we see excellent examples of such strong cultures, we see many examples where translation of the words into action and reality is far removed, and it is clear that manager lack of awareness of human performance remains an issue in this regard...

It is a matter of some frustration that we continue to see the same types of fatal accidents, particularly controlled flight into terrain, VFR into IFR conditions, fuel exhaustion/starvation, wire strikes and needless and indeed reckless high risk GA behaviour. While, some are what I would describe as the unfortunate result of innocent human fallibility, we continue to see too many of these accidents that are clearly avoidable and the result of poor preparation and decision making, and what it seems can only be described as a disregard for the lessons of the past. Learning from others and mindfulness of past lessons are crucial to curbing the continuing trend of avoidable accidents. Understanding of the limits to human performance and organisational behaviour, risk analysis, and threat & error management will need to feature more so than ever in the future.... 

---

...While the need for timeliness in investigation has always been important (if not always achieved), media, political and societal expectations have certainly changed, and there is a need more than ever to strive for better timeliness. (P2 -How's that working out Kym, Beaker err Hoody - ) Careful consideration is needed as to what trade-offs might be made between investigation timeliness and thoroughness, but the greatest challenge is probably how we achieve both.

A prime example is the ATSB’s Lockhart River investigation report. I believe the quality of this 500-page report into the worst civil aviation accident in Australia since 1968 is first rate, but more problematic was that the final report took almost two years to be released. (P2 - Duck me 2yrs that's good) While there were several interim reports and the investigation was complicated by an inoperative CVR, no witnesses and the extent of destruction of the Metroliner 23, two years is a long time. The ATSB is examining ways that this could be improved, which may require directing fewer resources to other lesser priority investigations.

I suspect that the ATSB is not alone in battling with this problem, and while there will always be exceptions, getting the balance right between professionalism and timeliness and explaining any need to take longer than societal expectations, will be an increasing challenge if safety investigations are to remain relevant.

The other matters that featured strongly in the responses from my colleagues when questioned on challenges for the future, were the need to strike the right balance between no-blame and culpability in a ‘just culture’, and the need to strike the right balance between the need to protect safety data and the demands of legal systems. (P2 - "..let's do the timewarp again.." )  

The confusion or industrial agenda that ‘just culture’ means no blame or liability, even in instances of serious and deliberate wrongdoing by aviation industry practitioners is an issue that needs to be addressed. As James Reason has argued, engineering a ‘just culture’ in which the 10 per cent or so of wilful and culpable actions do not escape sanction, while encouraging reporting and learning from the other 90 per cent of actions that lead to accidents and incidents is ‘the all-important early step’. But there are those who would suggest that a just culture involves only ‘no-blame’ investigation and who seek protection for 100 per cent of behaviours. Meanwhile, we have seen judicial systems imprison crew members who have done little more than be involved in an accident because of actions and omissions that were the types of error expected among all humans. Closer to home we are seeing safety investigations becoming increasingly subject to external scrutiny. On one level, such external scrutiny should be welcome and investigations should withstand reasonable objective scrutiny. Significant scrutiny of ATSB investigation reports is applied through coronial inquests. However, while technically inquisitorial in nature, such forums are in reality often adversarial as our increasingly litigious society has led to parties attempting to divert attention from, and dilute important safety issues in pursuit of their own agendas. This unfortunately often leads to protracted proceedings and results in a significant drain on ATSB investigative resources. 

The desired implementation of the Global Aviation Safety Roadmap in terms of protecting safety data to enable its wider and timelier sharing is predicated on robust legislation in member states. This is a great challenge for many poorer ICAO states, but also for some of the otherwise best practice members. For example, the US NTSB is required to make available much sensitive data it holds, including CVR transcripts, in a public docket even where it is sourced from another state of occurrence, and France’s BEA has similar challenges because of the power of its judicial system. The new Attachment E to Annex 13 seeks to provide guidance with respect to some of these legal difficulties but serious tensions remain in the Annex itself.

In Australia, the ATSB has not been immune from legal and regulatory pressures. The Transport Safety Investigation Act 2003 mentioned earlier, protects safety information obtained and analysed by the ATSB as a ‘no-blame’ safety investigator. As an example, the TSI Act recently stood up to legal challenge, in what became known as the Elbe shipping case, where a party in a civil case relating to the leakage of oil from a ship in Gladstone harbour sought to obtain the ATSB’s investigation evidence. The Executive Director refused to issue a certificate for the release of the evidence and the party challenged the TSI Act as being unconstitutional, as it claimed such decisions should reside with the courts. The Federal Court upheld the legitimacy of the TSI Act and the party was ordered to pay costs.

That is not to suggest that the ATSB doesn’t recognise the need for a just culture. A just culture is preserved through the ATSB taking a cooperative approach to any required parallel investigations by regulators, police or other bodies, which must be entirely separate and gather their own data and evidence. This is particularly important because the ATSB can compel evidence that may otherwise incriminate and ATSB reports are unable to be used in criminal or civil courts. However, as I mentioned earlier, they can be used in a coronial inquest. In addition, Australian legislation provides for a CVR to be used in cases of severe criminality unrelated to normal crew duties, such as in the case of drug running or terrorism.

Accident investigation by safety investigators remains essential, if only to remind us of the continuing need for vigilance to avoid the human and other factors that have led to so many unnecessary accidents and fatalities in the past. In many cases, professional investigations do much more than just remind us of past lessons. There are new and novel twists based on differing organisational cultures and pressures, regulatory environments and human interfaces with other humans and with changing systems and technologies.

In closing, it is clear that using all available means to avoid a major accident is a primary challenge. This includes good safety management systems among all key players, understanding of the limits to human performance and organisational behaviour, risk analysis, data collection and analysis, threat & error management, and excellence in regulation. Human factors will without doubt continue to dominate as a key element of safety investigation. It is crucial that we learn the lessons from the past and the experiences of others. Close cooperation within the aviation community is essential to ensure that those lessons that will benefit safety are shared openly.

Please someone bring back Kym Bills - ASAP
 
Next from another 2008 Kym Bills presentation: https://www.atsb.gov.au/media/24560/sia121108.pdf

Safety Management Systems

• Before looking at methodology and aviation

examples, I want to reinforce that robust

safety management systems (SMS) can

make a major difference to safety

• The ATSB often finds poor SMS and weak

safety culture contributes to accidents

• SMS compulsory among aviation operators

from 2009 (aerodromes already)

• An International Civil Aviation Organization

(ICAO) Manual published in 2006 is a key

document and is to be updated with cases.

---

&..

Lockhart River and SMS

• Among the many contributing safety factors

the ATSB Lockhart River investigation

found Transair’s SMS to be poor

• Poor company organisation structure, weak

Chief Pilot commitment to safety, and

inadequate risk management processes

• Other factors included Ops Manual,

variable training including HF/CRM, poor

supervision of flight ops, TAWS not fitted.

---

Transair’s SMS

• Chief Pilot was also MD & head of Check &

Training and regularly in PNG – overloaded

& poor organisational structure back-ups

• He did not demonstrate a high level of

commitment to safety, eg Cairns base

largely unsupervised and checked itself,

reported pilot hazards not addressed, etc

• SMS largely in manuals not reality - virtual.

---

Transair’s SMS

• Transair did not have a structured process

for proactively managing safety-related

risks associated with its flight operations

• This included the move from charter into

RPT with passengers in QLD, & expansion

of operations in QLD and NSW to 25 pilots

with new ports such as Lockhart River

• Training was variable and sometimes

entailed little more than an open book exam

---

Transair’s SMS

• Transair’s Operations Manual involved a

mass of Word documents slapped onto a

CD with no indexing or version control

• Manual requirements for human factors

training, like crew resource management for

multi-crew operations, did not happen

• Transair appeared to have a SMS and a

commitment to best practice but actual

practice reflected a poor safety culture

driven from the top (cf ICAO 2006 Manual).

 
Hmm...see what I mean?


MTF...P2

[Peetwo]

NTSB v ATCB: A point of comparison.

From Independent Australia & the Oz: ref - PelAir MKII post #99

James said:

"They have lost their nerve — they are not courageous. They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result. If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a Senate Inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

Although not an AAI, the following NTSB news presser (& executive summary) for the release of a high profile marine accident investigation IMO perfectly highlights the difference between a truly independent transport safety investigator, versus our version of a politically and commercially captured imitation of a TSI...

NTSB News Release

National Transportation Safety Board Office of Public Affairs

Captain’s Decisions, Shipping Company’s Poor Safety Oversight Led to Sinking, NTSB Says
12/12/2017

Page Content
WASHINGTON (Dec. 12, 2017) — The deadliest shipping disaster involving a U.S.-flagged vessel in more than 30 years was caused by a captain’s failure to avoid sailing into a hurricane despite numerous opportunities to route a course away from hazardous weather, the National Transportation Safety Board announced during a public meeting Tuesday.

The 790-foot, cargo vessel, S.S. El Faro, en route from Jacksonville, Florida, to San Juan, Puerto Rico, sank Oct. 1, 2015, in the Atlantic Ocean during Hurricane Joaquin, taking the lives of all 33 aboard. 

“We may never understand why the captain failed to heed his crew’s concerns about sailing into the path of a hurricane, or why he refused to chart a safer course away from such dangerous weather,” said NTSB Chairman Robert L. Sumwalt.  “But we know all too well the devastating consequences of those decisions.”

NTSB investigators worked closely with the U.S. military and federal- and private-sector partners to locate the wreckage, photo- and video-document the ship and related debris field, and recover the El Faro’s voyage data recorder from more than 15,000 feet under the surface of the sea. 
 

 

 

El Faro at sea viewed from stern (Photo by William Hoey)

Color-enhanced satellite imagery of Hurricane Joaquin taken close to the accident time.
El Faro’s track is identified by the green line.

 

The ship departed Florida Sept. 29, 2015, and had a range of navigation options that would have allowed it to steer clear of the storm that later became a Category 4 hurricane.  The captain, consulting outdated weather forecasts and ignoring the suggestions of his bridge officers to take the ship farther south and away from the storm, ordered a course that intersected with the path of a hurricane that pounded the ship with 35-foot seas and 100 mph winds.

As the ship sailed into the outer bands of the storm, about five hours prior to the sinking, its speed decreased and it began to list to starboard due to severe wind and seas.  In the last few hours of the voyage, the crew struggled to deal with a cascading series of events, any one of which could have endangered the ship on its own.
 
Seawater entered the ship through cargo loading and other openings on a partially enclosed deck in the ship’s hull, pooled on the starboard side and poured through an open hatch into a cargo hold.  The hold began to fill with seawater, and automobiles in the hold broke free of lashings and likely ruptured a fire main pipe that could have allowed thousands of gallons of seawater per minute into the ship – faster than could be removed by bilge pumps. 

About 90 minutes before the sinking the listing ship lost its propulsion and was unable to maneuver, leaving it at the mercy of the sea.  Although the captain ordered the crew to abandon ship when the sinking was imminent, the crew’s chances of survival were significantly reduced because El Faro was equipped with life rafts and open uncovered lifeboats, which met requirements but were ineffective in hurricane conditions.

The NTSB also said that the poor oversight and inadequate safety management system of the ship’s operator, TOTE, contributed to the sinking. 

“Although El Faro and its crew should never have found themselves in such treacherous weather, that ship was not destined to sink,” said Sumwalt.  “If the crew had more information about the status of the hatches, how to best manage the flooding situation, and the ship’s vulnerabilities when in a sustained list, the accident might have been prevented.”

As a result of the 26-month long investigation, the NTSB made 29 recommendations to the U.S. Coast Guard, two to the Federal Communications Commission, one to the National Ocean and Atmospheric Administration, nine to the International Association of Classification Societies, one to the American Bureau of Shipping, one to Furuno Electric Company and 10 to TOTE Services.

The complete accident report will be available in several weeks.  The executive summary, including the findings, probable cause and safety recommendations is available at https://go.usa.gov/xnRAn.

Additional information related to this investigation, including news releases, photographs, videos, and a link to the accident docket containing more than 30,000 pages of factual material, is available on the El Faro accident investigation page at http://go.usa.gov/xnRTW.

Now although this is an extremely high profile and complex marine accident investigation, it is worth noting that it took 2 years, 2 months to complete. It is also worth comparing the chronologically recorded investigation webpage - see here complete with the preliminary report and regular media updates - then review the latest (& presumably last) ATSB VH-NGA (re-)investigation webpage: https://www.atsb.gov.au/publications/inv...-2009-072/  

Anyone else spot the difference...



MTF...P2

[Peetwo]

PelAir MKII: SMS a lip service exercise - Part II

Extracts from CASA PelAir Special Audit Report March 2008: (Ref - foi-ef12-10004.pdf)

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One of the fundamental elements for an effective CASA approved FRMS, is the commitment by the Operator to embrace the philosophy of a 'just culture' within the context of a (now mandatory) CASA Safety Management System. This includes the ability for operational crew and maintenance personnel to submit hazard alert reports on fatigue related incidents, without fear of internal company retribution/reprisals.

Keeping the above historical (Malcolm Campbell signed) CASA 'safety alert' in mind, can anyone else spot the huge disconnect (in CASA oversight of the PelAir FRMS/SMS), when we revisit the following extracts (from page 266) - under the heading CASA oversight of specific system elements (prior to 18 November 2009) - of the PelAir MKII final report??

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"...There was no evidence these actions were communicated in writing to the operator, and no indication the operator formally responded. As far as could be determined, the nominated safety officer did not undertake FRMS training and no additional information was provided to pilots...

...Yet...


...Following the March 2009 meeting, CASA were satisfied the operator’s FRMS was operating satisfactorily and it reapproved the operator to conduct operations according to its approved FRMS for another 24 months..." - WTD??

Q1/ I wonder if the March 2009 meeting included the input from it's former PelAir overseeing FRMS specialist, and/or the former Human Factors manager Mr Ben Cook?

On reading Ben Cook's finding in his FRMS SAR I would suggest not, reference: CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)  

Then we have further proof that Wodger, and his merry band of Sydney Office psychopaths, further white washed the many documented and specialist identified deficiencies of the PelAir FRMS/SMS...

 Extracts from pages 275-276:

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"...When the Sydney region manager advised CASA senior management of the safety alert, he noted he did not think the matter would escalate to a need to consider a ‘serious and imminent risk’, given that the operator was demonstrating a willingness to address the issue. However, he was considering what further action may be necessary..."  Still waiting?? - Obfuscation 101: "Simply deny there is an issue, worst case if some disgruntled employee kicks up a fuss and attempts to submit a HAZARD report; or leak again to some CASA HF expert; we'll slam the individual with some petty enforcement threat; or if there is an occurrence then we'll just throw the book at the pilot"    

Hmm...what say you "K" how does that stack up against one Airtex or Barrier AOC embuggerance?


MTF...P2

[Kharon]

P2 – “Hmm...what say you "K" how does that stack up against one Airtex or Barrier AOC embuggerance?”

The post above defines the P2 pawky sens’aumour. Shall I take the bait; or like an old Pike lay doggo in the cool, green depths of the swamp. Maybe, just maybe, I’ll swim past his bait, give it a nudge and watch the results.

P2 knows, as well as I do the implications of his research. What the ‘Bankstown crowd have been doing for the last seven years will not withstand any serious investigation. The post above provides the erudite reader with enough clues to fathom the riddle. Fact and evidence gathered and consolidated will weigh heavily against this crew of clowns, halfwits and malcontents. The pure hatred of an industry which rejected them, the venom against those who would not countenance their presence on a ‘professional’ flight line and their pathetic attempts to influence anything remotely resembling their deepest desire – to belong – make them beneath contempt. Soon, gods willing, the disgraceful, deceitful actions of this particularly dysfunctional crew will be revealed – then we shall see. For he laughs last, laughs best.

Quack, quack quack.

[Peetwo]

PelAir MKII: SMS a lip service exercise - Part III

IMO very much related - to the attitude of the psychopath Sydney CASA office (back then & apparently still now) to FRMS/SMS - I cribbed the following links etc. off this UP thread: UNSW Fatigue Report 2017

Haven't gone through the whole report yet but if the 'executive summary' is anything to go by the report is going to make for some disconcerting reading...

Executive Summary

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This report describes the findings of an independent survey of 1,132 Australian commercial pilots on their experiences of fatigue while working under CAO 48.0 and various exemptions currently allowed by CASA. The survey was conducted on-line by Transport and Road Safety (TARS) Research at the University of New South Wales (UNSW Sydney). Invitations to participate were sent by the Australian Federation of Air Pilots (AFAP) to all their members and advertisements inviting all commercial pilots to take part in the survey were placed in the fortnightly Aviation pages of The Australian newspaper over four weeks in June-July 2017.

The findings show that fatigue is a significant problem for Australian commercial pilots. Around half of pilots surveyed (52.4%) reported that fatigue is a substantial or major personal problem in their work. The majority had experienced fatigue both before or during duty at some stage in their flying career. Approaching half (46.1%) had experienced fatigue during half or more of their shifts.

Pilots reported significant consequences of experiencing fatigue. Almost all reported that fatigue had produced negative effects on performance. Over two-thirds had made an error due to fatigue at some stage and nearly half (45%) had experienced a microsleep while on duty and one in five had fallen asleep unplanned while on the flight deck.

Regression modelling of the major contributors to experiencing fatigue as a personal problem highlighted long duty periods including high flying hours, flying three sectors or more, night duties and inconsistent roster patterns as work-related factors and short recovery time and insufficient on-board rest as rest-related factors that significantly increased the odds of experiencing a fatigue problem.

Most pilots managed fatigue through use of caffeine-containing drinks and standing up and moving around, strategies that are easily accessible to all pilots. Controlled rest and napping, strategies that have longer term effectiveness for fatigue management but are more difficult to arrange, were used by a minority of pilots. Nearly 40 percent of pilots reported that they worked under a formal Fatigue Risk Management System (FRMS). Just over half (58%) had ever made a fatigue report but nearly half had reported sick instead of fatigued. Over half of pilots felt that their company always encouraged reporting of fatigue, but the most common reasons for not reporting were that they perceived no benefits in reporting or that there was likely to be an adverse response from the company if they reported. Nearly one-quarter didn’t report as they felt too tired and couldn’t be bothered.

https://www.afap.org.au/LinkClick.aspx?f...portalid=0

      
Now compare that summary to the 'executive summary' from the Ben Cook PelAir FRMS special audit report:

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Then remember how that report was given short shrift by McCormick in CASA's second supplementary submission to the Senate PelAir cover-up Inquiry:

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Reference http://auntypru.com/wp-content/uploads/2...13_WEB.pdf

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Is it any wonder that Ben Cook pulled the pin with CASA and that a large percentage of the pilot fraternity to this day still have no faith in FRMS and/or CAO 48.1...  


MTF...P2  

[Peetwo]

 FRMS/SMS a lip service exercise - Part IV

Before we continue to follow the CASA breadcrumb trail of tick-a-box oversight of FRMS/SMS, the following are quote extracts from the last two entries to the now strangely -  - dormant published ATSB REPCON archive: https://www.atsb.gov.au/repcon_reports/?mode=Aviation

Reporter's concern

The reporter expressed a safety concern related to the lack of organisational accountability shown by [operator] when their crewing department contacts flight crew, on their rostered day off, within three to four hours of sign on, to request that they accept an additional ‘back of clock’ duty.

The reporter advised that on multiple occasions they have been contacted by the crewing department to operate a ‘back of clock’ duty, as the pilot in command of a return flight from Sydney to either [location 1] or [location 2]. This involves a continuous duty of between 10:50 to 11:05, if there are no delays, at a time of low circadian rhythm. To operate these flights, the crewing officer was offering no less than $3,870 plus meal allowances on top of any normal remuneration. No questions were asked by the crewing department related to whether they were fit to accept the duty.

The reporter advised that even though it is a crew member’s responsibility to ensure that they are not fatigued before accepting the flight, [operator] also has a responsibility to ensure that the crew member is not fatigued.

Reporters comment: It appears evident that the crewing officers are making requests on a ‘Don’t ask, don’t tell’ basis as it relates to the rest that has been achieved by the flight crew member in spite of the ‘mutual responsibility’ to fatigue management.

This is concerning when considered in the context of the significant financial incentives, flight crew members have to self-define the meaning of ‘adequate rest’ as it relates to any given duty without any objective guidance provided for comparison.

The nature of fatigue on such a duty poses a significant risk to flight safety and the financial incentives for flight crew to either disregard or inadequately address such safety risks is of a compounding nature.

&..

Reporter's concern

The reporter expressed a general safety concern related to the recent management and oversight of [operator].

The reporter advised that under the previous organisational structures, the safety culture was changing and becoming more mature and safety focused. This seems to be reversing in recent times, with staff noticing a change in the focus of management's attitude, where safety is being prioritised after financial and organisational structural change. This has resulted in employees not having a clear direction when safety concerns are experienced.

The reporter advised that due to this, shortcuts are now being taken, where company and aircraft operating procedures are not being followed. The reporter also advised that the focus has changed to non-aviation matters, to the detriment of safety within the operational area. Staff members are still using the safety reporting system, but limited changes and lengthy review times, with many investigations remaining open is making staff lose faith in the system.

Reporter comment: I feel that a thorough investigation into the operation of the operator and the current management structure adopted is required to assist those people in the organisation who are attempting to adopt the safety culture required for an organisation such as this.

  
Now coming back to the PelAir MKII report the following is an extract from the 'Other factors which increased risk' (pg 354 of the 2nd report):

- Due to limited sleep in the previous 24 hours, the captain was probably experiencing a level of fatigue that has been demonstrated to adversely influence performance.
 - The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby
periods. [Safety issue]
- Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days. [Safety issue]

 
And this was how the (top) 'safety issue' was apparently proactively addressed (since 2014??) by the operator:

Proactive safety action taken by Pel-Air Aviation
Action number: AO-2014-190-NSA-031

After the accident, the operator undertook a series of actions to improve its fatigue management practices. These included:

- revised the callout time for air ambulance tasks from 2 hours to 3 hours
- developed and introduced a face-to-face introductory course on fatigue management and revised the content of the computer-based training course
- developed a fatigue assessment form to be used to assess the likelihood of fatigue prior to the assignment of ad hoc charter flights to flight crew who were on standby (with the form including a small number of questions to obtain basic information about a pilot’s recent sleep and rest)
- introduced a requirement to reduce the maximum period of 24 hour standby to 28 days (after which crew required a minimum of 8 days off duty)
- modified the FRMS to include longer required rest periods following duty periods involving large time-zone changes (more than 3 hours)
- conducted a workshop with a sample of the operator’s managers and flight crew (across all fleets) to identify fatigue hazards and risk controls.

In October 2017, the operator advised the ATSB:

Since the accident, continuous improvement and advancement has been made to the Pel-Air FRMS including the use of and understanding of the BMMF.

The FRMS has also become an integral part of the Pel-Air and Group Safety Management System and is a standing item that is tracked and reviewed by the Safety Management Group (SMG).

In addition to the existing recorded pro-active actions, other examples of development include;
- A formal Risk Assessment completed in relation to duty across different time zones and a set of guide lines were published as a result and the document (Acclimatisation Guidelines for Trans-Meridian Operations) is available to crew via the Flight Crew Notices Webpage.
- All Pel-Air crew, when submitting a report in the Safety Management System online reporting system, must select ‘Yes’ in relation to fatigue report, and submit all the required details, irrespective of whether or not fatigue is considered a contributing factor.
- Further review, research and improvements were made in relation to the Extension of Duty assessment process.
- Completion of an FRMS Crew Survey.
- Pel-Air is also ISO 9001:2015 certified and holds BARS Gold Accreditation both of which are heavily weighted on the Safety Management System which include the FRMS.

Current status of the safety issue

Issue status: Adequately addressed
Justification: The ATSB notes the operator undertook several actions to address its risk
controls regarding fatigue management on its Westwind fleet, and more broadly across its operations. Although not every aspect of the safety issue was specifically addressed, the overall level of action reduced the risk of this safety issue.

If nothing else at least this time round the subject of fatigue and the FRMS was comprehensively reviewed and two 'safety issues' identified but the outstanding questions still remain:

Q/ Why didn't this same level of investigative scrutiny of the operator FRMS/SMS not occur with PelAir MK I?

&.. Reference email Steve W to Karen C in 2015:

Hi Karen


These three files summarise the concerns CASA had about PelAir's fatigue management as far back as 2004. This included an RCA (Request for Corrective Action) issued by CASA in May 2006 (2nd file) So there is long established history of CASA being concerned about fatigue management at PelAir. 


The safety alert (a 2nd RCA) was issued in March 2008 (3rd file). This was quickly rectified, and there was a prompt return to FRMS operations. 


So why did the 2009 audit devote 5 pages to fatigue management. The following quotes come from the 2009 audit. 


•                "Most crew identified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective." Page 22.
•                There was an "FRMS knowledge gap displayed by the pilots." Page 22.
•                "PelAir have not managed fatigue risk to a standard considered appropriate..." Page 23.
•                No evidence was found that supported the claim that Pel-Air FRMS had ever managed fatigue risk to a standard considered appropriate, particularly for an operator conducting adhoc, back of the clock medivac operations.
•                It is evident the fatigue reporting culture within Pel-Air is deficient. This cannot be fixed quickly, and will require a number of months to determine whether this reporting culture has improved. An open and honest reporting culture is critical to the success of any FRMS and there is evidence to suggest one or two key personnel may be the root cause of this cultural problem.


So CASA have concerns back at least as far as 2004. There were two RCA’s - 2006 and 2008. Yet CASA still find a litany of fatigue management problems in the 2009 post crash audit.


Very odd


Steve

Q/ Why did CASA (aided & abetted by the ATSB) go to such extraordinary lengths to cover-up the non-compliances and dysfunction of the PelAir FRMS/SMS dating back to at least 2004?

&..

Q/ Why did the previous CASA identified safety concerns with the PelAir FRMS that led to issue of several RCAs and even a 'safety alert' (Ref - Malcolm Campbell signed letter here: foi-ef12-10004.pdf) seemingly have no effect in addressing the systemic deficiencies identified in the - supposedly 'unauthorised' - Cook PelAir FRMS SAR?

&..finally

Q/ Within the ToR for parallel investigations - of either the 2004 or 2010 MoUs - why didn't CASA share their findings on the PelAir FRMS with the ATSB?

Excerpts from CAIR 09/3

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P2 comment - Note that MALIU White refers to the FRMS 'Cook' report. This would appear to contradict the former DAS McCormick's statement (sup submission) that BC was not authorised to produce the PelAir FRMS SAR?  

Ironically there is not one mention of the deficiency findings of the FRMS in either the 'causal factors' or 'findings' of the CAIR 09/3 report:

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To set the scene for answering my (above) QON, here is some document links for the 9 (anonymously provided) Senate AAI inquiry documents, that were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:    

11
Internal CASA report titled "Oversight Deficiencies- Pel-Air and Beyond" also known as the Chambers report (dated 1 August 2010), received 10 October 2012;(PDF 6210KB) 
12
Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB) 
13
Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report (dated 18 August 2010), received 10 October 2012;(PDF 1193KB) 
14
Internal CASA email (dated 4 February 2010) ATSB identification of a 'critical safety issue' may have ramification for CASA actions in relation to Mr James, received 10 October 2012;(PDF 913KB) 
15
Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (dated 11 December 2009), received 10 October 2012;(PDF 881KB) 
16
Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB) 
17
Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB) 
18
Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB) 
19
CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

Hint: Refer to docs 15 to 19 and see if you can spot the FRMS dots...


Time has beat me, so I'll definitely have MTF...P2

[Kharon]

A curiosity.

P2 – “[that] were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:"

Maybe I’m reading the chronology incorrectly – but it seems to me those ‘anonymous’ documents were in some kind of limbo for about 16 weeks, before being marked ‘received’, which is kind of strange anyway.

Any answers there P2 – did the docs get lost in the post? Or, have I missed a breadcrumb.

Toot toot.

I don’t expect many would ever wonder what our archives look like at the end of a week long research effort. I caught this picture of P2 hard at work Wednesday last, to give you some idea… (Big smile).

[Peetwo]

FRMS/SMS a lip service exercise - Part V

A curiosity.

P2 – “[that] were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:"

Maybe I’m reading the chronology incorrectly – but it seems to me those ‘anonymous’ documents were in some kind of limbo for about 16 weeks, before being marked ‘received’, which is kind of strange anyway.

Any answers there P2 – did the docs get lost in the post? Or, have I missed a breadcrumb.

Toot toot.

I don’t expect many would ever wonder what our archives look like at the end of a week long research effort. I caught this picture of P2 hard at work Wednesday last, to give you some idea… (Big smile).

Ok onwards and downwards apparently...

To begin please refer to either this 'dots & dashes' thread post - All Pel-Air lines of obfuscation lead to? - or this SBG post - The best laid plans of mice and men.

P2 - “From that extraordinary public hearing of revelations, obfuscating admissions, spin, bull-dust and denials, it would now appear that some of those involved individuals must have been telling the committee porky pies. This is because the existence of the Chambers Report was known at least 12 days before the first public hearing and is listed as a tabled document from CASA (i.e. 01 CASA_Doc 3_Web - PDF)”.

Of the nine documents, received by the RRAT Secretariat on 10 October 2012, I would argue that the very damning findings of the 'Cook report' far outweighed in significance and importance of the self-serving, 'cut & paste', spin'n'bulldust contribution of Wodger in the 'Chambers report'. Only now is it possible to reflect on why it was so much time and effort was given to trying to bury both the Cook and CAIR 09/3 reports...

In hindsight and based on some recent revelations/intel our breadcrumb trail is starting to thread it's way through all the deviously contrived lines of bureaucratic obfuscation and lies.
So back to those 9 docs and in particular the so called 'Cook report'.

19 CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

To begin I have made some inquiries with the Senate RRAT committee Secretariat, some of which is pending on key staff return to work from hols. However I was able to establish some facts about the way submissions to inquiries were administered.  

First it is very unusual for documents to be received and to then be stated as being received on the inquiry webpage. Normally documents and submissions to the committee inquiry will be processed (tabled) within days of being received. The only possible exception is when documents contain sensitive and/or private information that needs committee approval to be processed as either in camera, or redacted with the private details blanked out. 

Redactions are usually able to be administered again within days of being received or tabled in public hearings. With in camera submissions a submitters consent also has be obtained and the submission will obviously not be published on the Inquiry webpage.

The advantage of in camera submissions is that the committee are immediately able to review the documents. None of the nine documents were tabled, therefore able to be reviewed by the committee, till either the day before or on the day of the extraordinary 15 February 2013 public hearing. 

However all of the 9 documents, including the 'Cook report' have been redacted to protect the identities and contact details of individual officers. This led me to a question that is still pending an answer from the committee Secretariat: Q/ Are the redactions in the format/ composition that the Secretariat utilises?

Point of comparison.

These queries got me thinking about another 'Cook report' that I remember was tabled by former Senator Xenophon in the context of the 2010-11 Pilot training inquiry.

2 Tabled document received from Senator Xenophon on 18 March 2011 in Canberra. Civil Aviation Safety Authority (CASA) report titled on 'Special Fatigue Audit: Jetstar';(PDF 5210KB)  

 
When you download the PDF you will find a pristine document that appears to have no redactions or alterations and where you 'click' on 'file' and then 'properties, you will see that PDF copy was created the day before it was tabled.

Also of interest with this particular 'Special Fatigue Audit' was that it garnered a similar negative CASA executive response to that of the Cook 'PelAir FRMS SAR'.

Via QON 18/03/2011 (note who the CASA 1 QON was addressed to... ):

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Remember that Cook's Jetstar report was produced some 5 months after he co-authored with Mal Christie the PelAir FRMS Special Audit Report. 

Coincidentally (or not) Mal Christie left CASA and started employment with the ATSB in February 2010 and Ben Cook left CASA in July 2010 for a position back with the ADF as an Air Safety Investigator.


MTF? - Definitely...P2

  
Ps Good catch from KC off that 'opinionated' Cook PelAir report...

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[Peetwo]

FRMS/SMS a lip service exercise - Part VI

Before we unearth a couple more putrid but juicy morsels, the following BC article perfectly highlights the problems with just 'ticking the boxes' on FRMS and SMS in transport industries...  

$1.25 million payout for poor fatigue management - it’s time to get serious

Published on February 20, 2017
 

Ben Cook

Chief Executive Officer at Human and Systems Excellence

If the recent award of $1.25 million to a truck driver who crashed during a 430km drive home doesn’t ring alarm bells for Australian workplace standards, I don’t know what will.

The driver sued his employers based on unsafe work practice arising from forced fatigue, small recompense for a man living with structural brain damage for the rest of his life.

The incident importantly raises, not for the first time, the consistent lack of ownership for fatigue risk management (FRM) strategies across industries. I’m here to tell you we can do better.

Let’s look into the detail of the case. In the Supreme Court in Rockhampton, Justice McMeekin found both the mining company and its employment contractor liable for creating “risk by the insistence on consecutive 12-hour night shifts with…inevitable fatigue."

While the companies each denied this to their peril, Justice McMeekin found they owed a duty of care to the driver, a given under any functioning workplace health and safety law in this country. The sheer weight of mismanagement at both firms led the judge to conclude fatigue was at least a contributing cause in the accident.

So how were these companies allowed to get away with it to the point that a member of their staff has lost his livelihood? Over a number of years, I’ve been astounded by Australian businesses’ lack of proactive fatigue assurance, and their endemic incapacity to adequately monitor the effectiveness of their fatigue policies and risk controls.

While fatigue is just one hazard among a myriad that businesses need to manage, it is cases like this that show just how pivotal it is, and how important proper help can be.

Unfortunately, and compounding the issue, Australia has seen a parade of senior fatigue scientists (local gurus), with links to commercial fatigue management products. I’ve been to their sessions and what I can say is this: they’re very convincing. These so-called specialists use the words you want to hear, but trust me, they regularly deliver a false sense of security regarding your ability to actually enhance FRM.

Having seen these products consistently fail at bringing about safer workplaces, I want Australian businesses to get serious. I want our country to no longer accept the breakdown of trust in our workplaces, the endless policy and fatigue booklets, and the so-called ‘simple tools’ espoused by the safety industry gurus. They are just not good enough.

Instead, I want us to come together to build proper safety cultures into our corporate mechanisms. I want businesses to care about fatigue in their workplaces, not just manage it.

Having worked on fatigue management with elite teams including fighter combat instructors, I know first-hand the pragmatic application of FRM in an operational context, and how it can deliver the goods. From my extensive experience in this field I know that there is no effective quick fix solution to fatigue and if you seek one out you are more than likely to be disappointed in the result. Managing fatigue requires serious work in the short term for longer term success. I have learned that you can do more with less and when fatigue risk is managed well there is a concurrent improvement in the wellbeing of employees, which in turn brings with it increased productivity. This is not a zero-sum game.

My view is that if you truly want to deliver long-term, efficient work practices to combat fatigue, evidence-based FRM and enhanced sleep hygiene must be on the top of your list.

For best practice, I would look no further than real sleep and fatigue scientists like Dr Carmel Harrington, Dr Melissa Mallis, and Dr Malcolm Brenner – qualified and passionate professionals at the cutting edge of their fields. Every day I feel honoured to have them on my team at HSE3.

And to close this out, when I think what those experts could have done to help those companies to minimise the risk of this tragedy, I can’t help but feel enormously pained. With forethought, and a little management ownership, it’s easy to see how all of this could have been avoided. It’s a tragedy on so many levels.

If you are struggling with balancing the fatigue of your colleagues with the performance of your workplace, I want to hear from you sooner rather than later. As always, drop me a line at ben@hse3.com.au or simply message me on LinkedIn to start the conversation about improving your workplace.

Have a safe and happy week.

After that short but informative interlude...err back to digging -




After further digging in the Senate RRAT committee boneyard I have now come close to identifying some more PelAir morsels leftover from the 2012 inquiry...

To begin I am now waiting on confirmation that the 9 docs received on the 10 October 2012 were part of a package that was actually compiled by (what was then) M&M's department (DoIRD), on request from the Senator's - WTD??  

Although slightly miffed by this revelation, as I was hypothesising that they were submitted by a whistleblower, I can now see how this chain of evidence fits with the current disjointed bones on offer... 

P2 - hypotheticals X 2
 
Okay, so unbeknownst to both the ATSB & CASA executive management the DoIRD, at the request of the Senate RRAT committee, searches their databases for any relevant documents associated with the CASA ATSB parallel investigation of the VH-NGA ditching.

H1: Those documents are received by the Secretariat officer in charge of processing submissions. He/she decides that the nine docs contain sensitive information that needs the committee to review before being officially tabled.

On viewing the documents the committee decides that due to possible privacy and/or other sensitivity issues that the documents should be reviewed by the Minister's office and/or department for possible redaction. Although it is an extremely rare decision for a non-partisan committee to forward such documents to a government minister of the crown, this decision may have been made due to the nature of the documents and the many individual agency officers mentioned or able to be identified throughout those documents. 

However normally this vetting of documents by ministerial minions would still only take a couple of days to administer so we are still left with the question of how it was those documents were not officially tabled till 4 months after they were officially recorded as being received?

 H2: Those documents are received by the Secretariat officer in charge of processing submissions. He/she decides that the nine docs contain sensitive information that; a) needs to be bumped up the line for review by a superior officer. The superior officer is a mole that subsequently forwards the documents to the minister's office for further vetting and/or obfuscation for 4 months; b) needs to be forwarded to the minister's office for further vetting and/or obfuscation for 4 months i.e. the receiving officer is the mole.

(P2 comment - It could also be possible that the 9 documents had already been redacted by the DoIRD before being sent to the Senate RRAT committee.) 

Unfortunately we'll have to be patient as the key Secretariat personnel that can provide confirmation of H2 (all such committee actions/decisions are recorded) are still on hols...
  
For the record , in the course of an active Senate Inquiry, the current on duty Secretariat staff could not recall there ever being documents/submissions being mislaid or delayed on administrative grounds, for any longer than a week or two - certainly not for 16 weeks...
 

MTF...P2

Ps A big thank you to the Secretariat staff members Helen & Michael who have been extremely helpful with providing information on committee inquiry processes...

[Peetwo]

FRMS/SMS a lip service exercise - Part VII

While we wait for the answers to my QON to come back from the Senate Secretariat I thought now might be a good time to start joining a few more FRMS dots...

Excerpt from BC & MC LinkedIn profiles:

---

Manager Human Factors
Company Name: Civil Aviation Safety Authority
Dates Employed: Oct 2007 – Jul 2010  Employment Duration: 2 yrs 10 mos
- Led and managed the HF section including development of a HF strategy to provide pragmatic, pro-active systems enhancements.

- Developed and managed an annual work program, including financial management of a $1.0+ million budget.

- Led and managed projects/tasks to provide strategies, tools, and policies to support the practical integration of HF within the Australian aviation industry.

---

Human Performance Specialist
Company Name: Civil Aviation Safety Authority
Dates Employed:2008 – 2010  Employment Duration 2 yrs

Provided advice on human factors and human performance matters in the preparation of aviation regulations.

---

"...Coincidentally (or not) Mal Christie left CASA and started employment with the ATSB in February 2010..."

Other than being part of the PelAir special audit team and coincidentally the co-author of the PelAir FRMS SAR, it would seem that MC was the CASA officer tasked to co-ordinate the original CASA project for implementation of mandatory FRMS for certain airline/operator pax carrying operations. Here is a MC update to the Operational Standards Subcommittee meeting on 24 March 2009 (note the reference to ICAO):

---

 4.17 Fatigue Risk Management Systems (FRMS) Update

4.18 Mal Christie, Human Factors Specialist advised that the FRMS is a two phase
project. He advised that Phase 1 includes amendments to Civil Aviation Order
(CAO) 48 covering flight and duty times and guidance material implementing FRMS
for pilots. Mal advised that Phase 2 is due to commence soon for operational safety
critical personnel, and will include cabin crew, ATC, engineers, ground support and
other safety critical personnel. Mal advised that the working group is scheduled to
meet on 8 April to review the working groups proposed changes to the documents.
Mal advised that he hopes he will be able to release the NPRM in the near future
but did advise that this may not occur until we are across the ICAO FRMS SARP
update. He advised that he will be calling for nominations for Phase 2 shortly. Mal
was asked if the working group would be reviewing the ICAO documentation. Mal
said yes and subsequently advised there would be a lengthy three (3) month
consultation period due to the complex nature of the subject matter. He also
confirmed in response to a question from the SCC chair, that the Operational
Standards Sub-committee is being kept up to date on the progress by regular
briefings at its meeting.

---

As we now know it took a further 4 years before the CAO 48.1 (FRMS) amendment was officially written into law and even then it was subject to an attempted disallowance motion by former Senator X.

Ironically the MC update was included in the minutes of an SCC 2 day meeting that was also utilised as the unofficial welcoming/coming out of the then new CEO/DAS John McCormick.

List of attendees (note the 3rd name ): SCC 32

---

Attendance:

Rob Graham SCC Chairman
John McCormick CASA CEO
Shane Carmody DCEO, Civil Aviation Safety Authority-Strategy & Support
Peter Boyd Civil Aviation Safety Authority
Melinda Evans Airservices Australia
Phil Hurst Aerial Agricultural Association of Australia
Phil Gornall Airborne Law Enforcement Agencies
Tim Blatch Aircraft Owners and Pilots Association
Marjorie Todd Attorney Generals Department
Bill Hamilton Australian Association of Flight Instructors
Torben Petersen Australian Airports Association
David Bell Australian Business Aircraft Association
Brian O’Dea Australian Federation of Air Pilots
John Alldis Australian Licensed Aircraft Engineers Association
Colin Adams Australian and International Pilots Association
Bob Hall Australian Sport Aviation Confederation
John Hodder Australian Defence Force
Ken Cannane Aviation Maintenance Repair and Overhaul Business Association
John Guselli Aviation Safety Foundation Australasia
Ritchie Hollands Department of Infrastructure, Transport, Regional Development & Local
Government.
Leanne Dalton Flight Attendants Association of Australia
Pine Pienaar Flight Training Adelaide
Merv Fowler Guild of Air Pilots and Navigators
Peter Docking National Jet Systems
Mark Wolny Qantas Airways Ltd
Warwick Walesby Qantaslink
Phillip Stacy QBE Aviation
Keith Jobson Raytheon Australia
Lee Ungermann Recreational Aviation Australia
Paul Tyrrell Regional Aviation Association of Australia
Ian McIntyre Royal Aeronautical Society
Allan Bligh Royal Federation of Aero Clubs of Australia
Alan Benn Royal Flying Doctor Service
Peter Jolly Sports Aircraft Association of Australia
Paul Machin-Everill Virgin Blue
Grant Mazowita Civil Aviation Safety Authority
Greg Hood Civil Aviation Safety Authority
Peter Cromarty Civil Aviation Safety Authority
Clive Adams Civil Aviation Safety Authority
Richard Farmer Civil Aviation Safety Authority
Megan Barby Secretariat - Civil Aviation Safety Authority

---

Yes a veritable whose who of aviation safety stakeholders...   

In hindsight I wonder how many of those well known Alphabet identities now cringe or have nightmares when they reflect on the following passages off the McCormick brief... :  

  

---

4.23 CEO Briefing

4.24 John McCormick, CASA’s CEO attended the meeting and introduced himself to
industry members of the SCC. He added that today he had signed off an AOD
exemption (which had been discussed earlier under Brenda Cattle’s Alcohol and
other drugs update). John added that he has recently approved the MOS concept
for the Maintenance suite of regulations, and whilst he is philosophically opposed to
a 3 tier regulatory framework, he does understand that the OLDP drafting of a 2
tier framework would not have matched the industry expectations for the
Maintenance suite. John referred to consultation, including CASA’s requirement to
consult under the Civil Aviation Act, and how CASA will try to take the industry
along with it on its regulatory proposals, but in the end the regulatory decisions are
CASA’s to make. He encouraged industry to let him know of their ideas via the CEO
feedback available on the CASA website.

4.25 John referred to the Aviation Green Paper, which sets the target of 2010 for the
end of regulatory reform. This may be very difficult and he sees regulatory reform
as an ongoing process. In relation to regulatory reform John added that Australia
does control a lot of airspace, has a thriving industry and a strong military. He
added that taking on another countries regulations style can often also mean taking
on that countries social standards, which can present other difficulties in the
Australian context. He advised that at this stage it is ‘business as normal’ and that
CASA will try to move the regulations forward, take input and consult, once again
as required under the Civil Aviation Act. He also advised that he wanted to
encapsulate a review of the enforcement regime, though this may not be a high
priority but does need to be addressed at some stage. John then went onto speak
about the structure of CASA and how with any organisation working through a
reform process there is always some reworking required, particularly in relation to
how CASA works with industry. John was very mindful of having a single point of
contact as he is aware that often industry may liaise with several offices with
possible varying outcomes. John then added that he saw the Australian aviation
industry as robust and expressed support for the GA sector of industry within
Australia, as it is the backbone that must not be left behind. John also mentioned
that he intends reviewing the oversight of different sectors of industry.

---

What I find passing strange is that in the next SCC meeting on July 29 2009 there was no further update on the FRMS project, this was despite the fact ICAO were ramping up their campaign to mitigate fatigue risk in the aviation industry. (This included the establishment of a FRMS taskforce in November 2009)

However I guess we shouldn't be surprised when we saw McCormick's attitude to FRMS and the input to fatigue oversight from certain former CASA HF experts..

One area of interest from the July SCC meeting was this:

---

6.1 ICAO Audit Findings PEL/02 - ALAEA

6.1.1 John Alldis representing ALAEA spoke to this item questioning what action CASA had taken to address the issues raised in the ICAO Audit in relation to CASA surveillance of delegated licensing activities and approved training organisations also taking into account the proposed implementation of competency based training in relation to licensing. John also questioned how CASA’s timetable was progressing on the ICAO findings and the recommended actions. Peter Boyd advised that CASA has already made a move on this issue, given the implementation of the new rules, he advised there are some synergies, but CASA has a comprehensive surveillance plan in place. Peter reassured members that CASA does have adequate resources and the transition will be properly managed, and resources appropriately applied. As part of CASA’s realignment it is also looking at resourcing on these transition type activities. John reiterated ALAEA’s concern given his quoted drop in numbers of Airworthiness
inspectors (AWIs) from 100 to 60. Peter undertook to confirm numbers and come
back to the SCC on this issue. In relation to the ICAO Audit findings Peter confirmed
that CASA has provided its response in relation to the Corrective Action Plan in late
2008, and is currently monitoring the implementation of the corrective actions within
CASA, as part of this plan.

Action Item: July 09-1. CASA to report back on AWI numbers in relation to CASA
being able to effectively implement and oversight delegated licensing activities and
approved training organisations.

---

Fast forward that to 7 December 2009 when this WikiLeaks cable was revealed: https://www.wikileaks.org/plusd/cables/0...081_a.html

Two weeks later Ben Cook and Mal Christie submitted their PelAir FRMS special audit report which I can now confirm they were tasked to complete as part of the PelAir special audit.

However on returning from leave the two CASA HF experts were informed that the report would no longer be included as part of the final audit report...

Fast forwarding again, to 30 June 2013 the following are quotes from a AIPA Parliamentary Brief in support of the NX proposal to disallow CAO 48.1: https://www.aipa.org.au/sites/default/fi...3a_002.pdf

---

From pg 2 of the brief:

In summary, the Instrument is a step in the right direction but is unfinished business. There are serious concerns about the application or otherwise of the body of fatigue science and research and the preservation or extension of existing provisions already challenged by parts of the industry as unsafe.

CASA has an abysmal record of regulatory oversight of fatigue management, even without the pressure of trying to get some serious traction on the Regulatory Reform programs that have diverted them for the last 17 or so years. Parts of the industry believe that CASA has seriously underestimated the resources required to implement these new rules and that there will be an inevitable trade-off in surveillance activities of flight operations.

If not disallowed now, this legislation will continue with no incentive for improvement unless and until the inherent risk crystallises into an undesirable outcome. That is not a possibility that this Parliament should allow to persist.
 

---

From pg 5:

ICAO recognises the importance of “operational experience”, but that is a tainted concept if it merely reflects what operators have been doing or what the regulator thinks they are doing.

In Australia, we have already seen how this concept is tainted - recent Senate inquiries that have touched upon Jetstar, Pel-air and Avtex/Skymaster fatigue management processes and largely exposed the gulf between sound fatigue risk management, what operators have really been doing and what the regulator didn’t really bother to see what they were doing. The CASA Special Audit conducted after the Pel-Air ditching revealed all three of those propositions, while explaining a lack of pilot complaints:

…The short planning period, lack of knowledge of possible destinations and lack of support provided by operations staff once doors closed appears to add to this fatigue. All crew interviewed stated that they felt there would be no issues in stating that they were fatigued and pulling out of duty but also felt that they had limited opportunities to fly and had to take these opportunities when they arose… 8

… Most crew interviewed stated that they had been part of a duty that was greater than 15 hours in length but evidence could not be identified that showed fatigue related extension of duty processes had been followed, safety reports had been written following the duty or that management follow-up was conducted as is required in the company FRMS manual. Several interviewees believed that there is a lack of management adherence to safety management requirements and the fatigue risk mitigation strategies as laid down in the company's FRMS manual…9

When CASA was asked about the significance of Jetstar requiring crews on the Darwin-Singapore-Darwin night flight to extend beyond their normal flight duty period (FDP) limits on 12 of 21 flights in January 2011, they responded:

CASA does not consider that these extensions require continual monitoring.
The duty extensions recorded in January 2011 by Jetstar were a result of flight crew agreeing to operate beyond the standard 12 hour initial limits as provided for within Civil Aviation Order 48 Exemption. No breaches of the 14 hour condition were recorded.10

Undoubtedly that is how CASA will regulate operations under the SIE until they expire in 2016, despite the fact that the same flights could not even be contemplated under The Instrument! Finally, from evidence given to the UK Parliament Transport Committee Inquiry into Flight Time Limitations in February 2012 (which we believe to be replicated in parts of the Australian industry):

7.6. More importantly: fatigue is significantly under-reported by the pilots themselves. This is because pilots do not file reports on an aspect that has become a ‘normal’ part of their daily work. Many are afraid their fatigue reports could have negative consequences for their professional future (i.e. reprisals by management) – a phenomenon that is growing – particularly when pilots refuse to fly because they are too fatigued. Indeed UK polling results show that 33% of pilots would not feel comfortable refusing to fly if fatigued, and of those who would, three quarters would have reservations. Once a pilot has decided they have no option but to fly, a fatigue report would be tantamount to writing the evidence for their own prosecution…11

This under-reporting by pilots is exacerbated by CASA being widely seen by the aviation community as having actively disengaged in any intelligent discussion about fatigue regulation for many years. It is highly unlikely that CASA has any defensible
‘regulatory experience’ other than superficial ‘tick and flick’ audit activities and, as such, cannot and should not rely on its perception of the current state of fatigue management to set aside the science or to replicate current rules.

---

Spot the FRMS dots & dashes? If you have any remote interest in the subject I recommend taking the time to read the AIPA Parliamentary brief in it's entirety...


MTF...P2

Ps Caught this in my recent internet trolling...

Via 7:30 Report 16 December 2009:

https://sleepnosleep.wordpress.com/2009/...o-fatigue/

---

Automatic pilot - series of fatal accidents linked to fatigue[/b]
 
Posted Wed 16 Dec 2009, 8:48pm
Updated Wed 16 Dec 2009, 8:49pm

A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.

Transcript

KERRY O'BRIEN, PRESENTER: The Federal Government has set out its vision for the aviation industry over the next 20 years in a white paper dealing with issues from in-flight security to the seemingly endless quest for a second Sydney airport.

But there's another big issue looming for the aviation industry: pilot fatigue, which has been linked to a series of accidents around the world over the past decade.

The International Council of Aviation will put in place new rules next year to manage pilot fatigue in one of the biggest shake-ups in 50 years of commercial aviation.

In 2001, Australia was ahead of the game, introducing a five-year study into the issue. It recommended a whole new approach to the management of pilot fatigue.

But many of those who took part are now musing as to why Australia is still waiting to see what the rest of the world will do.

Thea Dikeos reports.

RICHARD WOODWARD, AUSTRALIAN & INTERNATIONAL PILOTS ASSN: Someone said to me once, "If you want to think about what we do, sit in front of a fish tank at 4 o'clock in the morning and stare at the fish for two hours and see how you feel."

THEA DIKEOS, REPORTER: It was the close call that shocked the Flying Kangaroo's renowned safety record. In 1999, a Qantas 747 overshot the runway at Bangkok, injuring 38 of the 400 passengers on board.

The Australian Transport Safety Bureau investigated the incident and revealed the pilot had been awake for 21 hours and the first officer 19 hours. But the incident report found there was insufficient evidence to conclude fatigue was the cause.

JOHN GISSING, SAFETY MANAGER, QANTAS: We took action after those findings. Fatigue risk is one of the mentions in that report. In the mix of our safety improvement strategy was clearly something that we were very keen to learn more about.

THEA DIKEOS: 10 years on, pilot fatigue is at the forefront of the international air safety agenda. Next year, the global body responsible for air safety standards, the International Civil Aviation Organisation, will announce one of the most significant shake-ups in 50 years of commercial aviation.
It's expected to issue guidelines requiring member countries to incorporate scientific analysis to assess pilot fatigue. Australian airlines will also need to comply.

RICHARD WOODWARD: They'll be the biggest single change in flight time limitations and the risk management of those since the 1950s.

THEA DIKEOS: Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

JOHN MCCORMICK, CIVIL AVIATION SAFETY AUTHORITY: If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority.

RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

THEA DIKEOS: With more than 20 years military and commercial flying experience, Qantas pilot Richard Woodward is providing input for the proposed new international standards. On the ground, he likes to race vintage Monaros.

RICHARD WOODWARD: I've been flying long haul aeroplanes for 24 years or so and, yes, there's times when you feel terrible when you're sitting in an aeroplane, you're just so tired that you feel physically ill.

THEA DIKEOS: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.

RICHARD WOODWARD: At the time it was world's best practice research.

THEA DIKEOS: More than 260 volunteer pilots took part in the study.

DREW DAWSON, SLEEP RESEARCH, UNI. OF SA: We wanted to know how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance.

MATTHEW THOMAS, SLEEP RESEARCH, UNI. OF SA: I have been have on a flight deck where both pilots have been asleep.

THEA DIKEOS: It was this experience years earlier on another research project which prompted Matt Thomas' interest in pilot fatigue.

Can you understand from a person who flies who's in the passenger seat that that might be a bit alarming?

MATTHEW THOMAS: Absolutely. Fatigue is a very real issue in aviation, without a doubt.

THEA DIKEOS: Over 50 years, a complex formula has been used to determine how long pilots can work and how much rest they should have. The Qantas study found that didn't tell the whole story.

DREW DAWSON: We collected data that said even though pilots are compliant with the rules, there are a small number of occasions when they aren't actually getting sufficient sleep to be safe.

MATTHEW THOMAS: The roster simply does not predict at all well a crew's performance. We saw that in the simulator very clearly.

THEA DIKEOS: Disturbingly, the researchers found pilots who had less than five hours' sleep were twice as likely to make safety errors.

MATTHEW THOMAS: Incorrect calculations is a classic example, well known to cause accidents internationally, errors in decision-making.

THEA DIKEOS: Are there many pilots in Australia flying under those circumstances?

MATTHEW THOMAS: The broader studies which show us that it's a small percentage, but every day there would be some. It's in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots.

THEA DIKEOS: This year, Virgin Blue introduced a new fatigue risk management system. Pilots are now trained to assess their own fatigue.

ANDREW DAVID, VIRGIN BLUE: How many hours have you been awake before you start this tour of duty, verses how many hours you've slept in the last 24 and 48 hours. So a simple report card and a mechanism to be able to report fatigue.

THEA DIKEOS: Richard Woodward and the South Australian researchers say they're disappointed that Qantas and CASA didn't move quickly to address all the recommendations in the South Australian report.

RICHARD WOODWARD: We fully expected the airline to move ahead and implement that. We also expected the regulatory authority to move ahead and change the rule-making process. They did start to do that and I participated in that as well and we drafted a set of rules, but then the program basically ceased until we see what happens at ICAO.

THEA DIKEOS: Qantas rejects the criticism and says it's implemented 15 of the 30 recommendations from the report and says it's well placed when the new regulations come in 2010.

JOHN GISSING: We'll be well ahead in terms of the full implementation of our further improvements that we're planning at the moment.

THEA DIKEOS: CASA says it's already approved 70 fatigue risk management plans for various airlines, but prefers to wait for the global regulator to define the standard.

JOHN MCCORMICK: We don't want to make industry or individuals be placed in a situation where this year, say, we mandate something and then find next year the international standard is something different.

DREW DAWSON: I think we know enough about what's likely to come out of the draft regulations and proposed rule-making initiatives to say we could have a pretty fair guess on how to move forward.

THEA DIKEOS: Professor Drew Dawson says it's time for the aviation industry to act.

DREW DAWSON: I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don't wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way.

KERRY O'BRIEN: That report from Thea Dikeos.

[Kharon]

A most inconvenient ditching.

Motivation; is the reason for peoples actions. Etc..

In all good detective yarns the motivation is treated as a major key to solving ‘the puzzle’. It makes good sense to do so, the reason why and qui bono always make good starting places. The chronology HERE defines ‘the act’; but fails to provide ‘the motivation’. To work that out we must, once again, look to the past.

ICAO had gone ‘big’ on pilot fatigue, identifying it as a major concern; and thanks to the good work of some clever folk, Australia was well positioned to shine. However, the period preceeding the ditching had been ‘difficult’ for the ‘watchdog’. The ICAO audit had kicked seven bells out of CASA – McComic reacted and requested an IASA (FAA) audit – to balance the scales and cover Albo’s sorry arse. FAA was not impressed and McComic’s little scheme backfired. The threat of downgrade was very, very real. Government (taxpayer) money and some hefty diplomacy bought a reprieve. But make no mistake – Australia was up to it’s hocks in alligators.

Then came the ditching off Norfolk Island. Any serious investigation into systematic flaws would reveal and confirm the worst fears of the ICAO and FAA audits. Although the mystery of two resignations and the decision to discard some fairly important reports is yet to be solved, there remains one curiously intriguing element yet to be satisfactorily resolved. I will leave providing the ‘dots’ up to P2 (patience, patience). I will make a dash toward a conclusion, the reader may make of it what they will.

That all survived the ditching was most inconvenient; the event had to become ‘pilot error’. Suddenly to protect the ICAO status, the home grown reports which revealed serious flaws in Australia’s approach to and ignorance of FRMS and SMS were a liability. Further independent analysis of CASA’s sloppy handling of the historical flaws in Pel-Air operational management would have shone a bright light into exactly the wrong corner, at precisely the wrong moment. Even so: had there not been a Senate inquiry, the whole event would have been neatly brushed under the carpet.

There had to be a reason for the bizarre, extraordinary behaviour of CASA following the Norfolk ditching event. The life and career of one small, insignificant human became as nothing when compared to the truly shocking notion that the world may discover how seriously flawed the regulator, the regulation and the management of aviation truly was then. It will come as no surprise that nothing – absolutely nothing has changed since then; unless you count the slow, irresistible slide deeper into the pit. Do I feel sorry for the ‘good eggs’ in the CASA basket? No, I do not. ‘They’ could have spoken out, they have had ample opportunity and much encouragement to do so. Resignation and silence – honourable? Oh, I think not.

“Mine honour is my life; both grow in one.
Take honour from me, and my life is done.”

Toot toot.