[Peetwo]

AIOS reaches epidemic proportions at the ATCB

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

P2 edit in blue -

· When the ATSB VH-NGA DIP Karen Casey identified this omission in February 2015 it contacted ICAO and advised them of the situation and offered to send them the original report. ICAO said they would wait for the report from the reopened investigation.

P2 comment - read previous post. 

· After Karen Casey identifyingied the problem with the sending of the AO-2009-072 final report and the 5 year delay of sending the preliminary report, the ATSB also reviewed the status of other reports and found that some at least 15 other reports, mostly from the years 2010-11, had not been sent to ICAO. These were then sent to ICAO.

· Ms Casey has also stated verbally to the IIC that she believed that two other ATSB reports had not been sent to ICAO: AO-2010-043 (Canley Vale) and AO-2013-100 (Mildura). ATSB records show that AO-2010-043 was sent to ICAO as required, and AO-2013-100 was sent to ICAO in early 2017 (although not within the required 30-day period).

P2 comment: Although Walker maybe correct that the ATSB notified the ICAO ADREP office of these occurrences, however after extensive searching of the ADREP & ECCAIRS databases it would appear that neither a preliminary report or final report has been stored on the applicable ICAO iSTAR/ECCAIRS databases.   

Following on from the above I have now conducted a search for all Final and/or Prelim reports published on the last half a dozen pages on the ATSB AAI webpages - ref: https://www.atsb.gov.au/publications/saf...e=Aviation - and so far without exception I cannot find a final report (PDF copy) filed with ICAO. There are some examples of investigation summaries in the ADREP system but no official FRs. This also seems to include the FR for VH-NGA...

I also note that bizarrely the ATSB when filing/publishing a final report now omit the history and/or other reports (e.g. prelim/interim)/updates from the accident investigation webpage -WTD!

MTF...P2

[Peetwo]

ATSB with an up yours to former DPM/Minister Truss -  

Remember this?

Via Oz Aviation:

---

Truss calls for fresh look at Pel-Air ditching
December 3, 2014 by australianaviation.com.au
Westwind VH-NGA ditched off Norfolk Island in 2009. (ATSB)

Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss wants the Australian Transport Safety Bureau (ATSB) to take another look at the Pel-Air Westwind corporate jet ditching off the coast of Norfolk Island in 2009.

Truss told parliament a review of the ATSB’s investigation of the accident by the Transportation Safety Board of Canada (TSB) found “there were errors made”.

“I am concerned that the TSB report raises some concerns about the application of ATSB methodologies in the investigation into the ditching of a Pel-Air aircraft off Norfolk Island in 2009,” Truss told parliament in a ministerial statement on Wednesday.

“As a consequence, I have asked the ATSB Commission to give serious consideration to reopening the investigation.

“I have asked that the fresh review of the Pel-Air accident should take into account the findings of the TSB’s report.”

The TSB report, released on Tuesday, said the ATSB did not follow proper process and had poor oversight during an investigation into the ditching.

---

Couple that with the commitment by the ATSB to give due regard to not only the findings of the TSBC but also the Forsyth (ASRR) review and the Senate AAI inquiry:

 ...On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation... - From the MKII final report.

Therefore it should be natural to assume that the new ATSB investigation should have had at their disposal all the documents that under the spirit and intent of the 2010 MOU, under para 4.1 (Parallel Investigations) and sub-paragraph 4.4.6 of the 2010 MOU,... 

---

..CASA agrees that if a CASA Officer is known to have information that could assist the ATSB in the performance of its investigative functions, CASA will undertake to advise the ATSB of the existence of the information...

---

...CASA should have released but never did in the original parallel investigation. The classic examples were both the Chambers Report and what would soon be referred to as the 'Cook Report' (PelAir FRMS Special Audit Report).

Of course the former DAS McCormick and his executive minions contentiously argued over and over again that CASA had not breached the spirit and intent of the 2010 MOU by withholding the Cook and Chambers reports.

Extracts from 15 February 2013 AAI Inquiry Hansard:

Senator XENOPHON:  On its plain language, you have breached the MOU.

Mr McCormick : No, I do not think we have.

Senator XENOPHON:  But, for whatever reason, you withheld the Chambers report from the ATSB.

Mr McCormick : The Chambers report is an internal CASA document.

Senator XENOPHON:  I am sorry; the memorandum of understanding states:

CASA agrees that if a CASA Officer is known to have information that could assist the ATSB in the performance of its investigative functions, CASA will undertake to advise the ATSB of the existence of the information.

Are you saying this report would not have assisted the ATSB?

Mr McCormick : What I would say is that the Chambers report was not done until we had completed our investigations. In our interactions with the ATSB, we did not give the ATSB any information, on the deliberate point, as I think is under 4.1 of the MOU, that we do not influence their investigation. We completed ours in 2010; it took until 2012 for the ATSB to—

Senator XENOPHON:  That is a curious and bizarre interpretation of 4.4.6 of the MOU, but I will hand back to Senator Fawcett and ask you more questions about that later.

Senator FAWCETT:  Going to that exact point, if you go to 4.1 of the Chambers report, it states that it is likely that many of the deficiencies identified after the accident would have been detectable through interviews with line pilots and through the conduct of operational surveillance of line crews in addition to the surveillance, the management checks.

It strikes me that the Chambers report is quite specific, and that is only one example. There are a number of other areas where it is fairly clear that there were deficiencies in the oversight that had they been addressed through effective audit the accident may well have been prevented. The point though, Mr McCormick, is not so much to say that the surveillance was deficient therefore the world is about to end. Commissioning the Chambers report was commendable upon your taking control of the organisation. The point is, for the public to have confidence that there is transparency and due process, where there is a report in existence, a formal report conducted by a senior manager, it would be the expectation of the public—and indeed, as Senator Xenophon has pointed out, it is clearly highlighted in the MOU—that the information pertinent to an investigation by ATSB would be made available.

With the concept of a systems approach, whereby not only the operator and the piloting command but also the regulator are key parts of the safety system, where there is written evidence in the possession of one department prior to the publication—in fact, prior to even the review of the draft report coming out—it seems inappropriate to the committee that the spirit and letter of the MOU was not implemented to make that information available.

Mr McCormick : As I said, the CASA Chambers report was a report that I started. It did not even require to be done. It was not something that was in our normal procedures. Following the MOU—

Senator FAWCETT:  We appreciate the fact that you started it. Our concern is the fact that, having initiated the report and having it in your possession, the report was not then made available—as required by the MOU, in writing let alone in spirit—to assist the ATSB with their subsequent investigation.

Senator FAWCETT:  We will come later to the issues of collaboration—I will use that word as opposed to 'cooperation'—between the ATSB and CASA.

But there is evidence and there are documents, which we will discuss, that indicate there was relatively frequent and open discussion about the content of reports and alignment between the two organisations, and yet a report that (a) would obviously embarrass CASA was not made available, despite other interactions that go contrary to what you have just stated; and (b) the ATSB report, for example on the issue of fatigue, almost discounts fatigue because they say 'there is a lack of evidence that this is a serious safety concern'—and they take the fact that there have been audits done of the FRMS system used by the company. In the audit that CASA put together, it said:

… it is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during the surveillance audit of March 08 were never appropriately actioned.  

There is a lack of any clear evidence to support corrective actions have been implemented, confirmed by CASA or that there were effective. If this process is indicative of broader practices of CASA, it is considered that CASA is exposed to unnecessary risk, particularly if required to provide evidence to support how it approved and operated a system, in this case their FRMS …

Given that the ATSB chose to ignore the whole issue of fatigue and how that might have affected the errors that were made by the pilot, because of a lack of evidence, and CASA had a formal report within their system dealing with the issue of fatigue and chose not to disclose that to the ATSB as required by the MOU, I think you would have to agree Mr McCormick that that would seem a little unusual to the reasonable man on the street.

Mr McCormick : The issue of FRMS, or the issue of fatigue, at the time was in its infancy, shall we say—even today, the FRMS rules, where they lie and how we are going forward is a matter we can discuss at some length; we are in a regulatory development process at the moment for fatigue risk management. Put in one score forward from a FAID system, which I believe Pel-Air were using, and which is used by many others around the world, gives an answer. Using some other esoteric system, or some other mathematically based system, may give you another answer. Mathematically based systems have not been proven to be accurate in any way, shape or form. I think the important thing is, on page 21 of the Pel-Air Aviation Safety Audit Report from CASA, where we interviewed Pel-Air pilots, under the 'Policy and application of fatigue practices', it says:

All crew interviewed stated that they felt that 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.

I fully agree that Pel-Air could have done more to assist in this flight. We said that from the start. The issue is that, in the end, fatigue—and I think this is in our supplementary submission as well—comes down to two parts: the operator rostering people appropriately so they are not unnecessarily fatigued, to the best of their knowledge; and the last line of defence of the crew not operating. Pel-Air crew have indicated to us that they felt no restrictions about operating. In this particular case of Mr James and the amount of rest he achieved, I think there were three different answers—four hours, eight hours and a couple of hours—to the Four Corners interview. I do not know to this day how much fatigue was induced in Mr James by that operation; only he will know. And so far, with three different answers, the only question we have to ask is which one is correct and which two are the lies.

Senator FAWCETT: With all due respect, Mr McCormick, that complete answer had no relevance to the point that I raised. Everything you have said is quite possibly correct, but it has no relevance to the point that your own internal investigation indicated that CASA's oversight of the Fatigue Risk Management System at Pel-Air was inadequate. And other parts of the document go to their training and implementation and the lack of effectiveness. That is surely a crucial part of the safety information that the ATSB should have considered in its inquiry as to why the error was made. That information was held by CASA—in fact, withheld by CASA, despite the requirement of the MOU to release any relevant parallel investigation that went to a matter that was been investigated by ATSB.

---

&..

Senator FAWCETT:  Mr McCormick, two points: (1) the report I was just talking about was in fact the Special Audit of Pel-Air Fatigue Risk Management System of December 2009, a separate CASA report almost a year ahead of the Chambers report that you are referring to; and (2) this report, and Chambers, that are different to other internal CASA reports—which I accept any good learning organisation will do; some of them will be embarrassing, and there is no requirement, in the normal course of events, for CASA to release internal reports. But, where they are directly relevant to the causation of an accident that is being investigated by the ATSB, there is clearly an expectation of disclosure by the public, and indeed by your own organisation and the government, because it is articulated in the MOU that 'wherever CASA conducts a parallel investigation into a transport safety matter the ATSB is also investigating, CASA will provide the ATSB with a copy of the CASA investigation as soon as it is practicable to do so.' Given that this was tabled in December 2009, is there any reason why this was not provided to the ATSB in accordance with the MOU?

Mr McCormick : If I could make two points on that. If you look at the Chambers report—and I will go away and confirm this—to my knowledge the points raised in there are points that are also covered in our special audit report and our accident report. In other words, they are not raising new information; they are raising information about how internal processes in CASA were carried out. As I said, I will check that on notice, if I can; but I think you will find that there is nothing raised in the Chambers report that is not reflected in our accident report. So if you ask have we given the information, as I said: we gave the information that we were required to give, that the ATSB asked for, we assisted where we could within the confines of the MOU and confidentiality and our differing aims and opinions—and, when it comes to the Chambers report, to me it shows what is behind those points. But I think you will find all those points are raised.

To turn to that report you have in your hand, Senator: in actual fact the major elements in it are, to my knowledge, are incorporated in the accident report as well. I had not seen that report before today, I might add; and you will notice from the front cover that I am not actually an addressee. That is not me trying to sidestep it, but you will find it has not actually been signed by anybody. There were two human-factor specialists involved in that investigation, and to my knowledge their comments were incorporated in the report. I might ask Mr Hood if he can expand a bit of the background of that.

Mr Hood : The findings in relation to Pel-Air in the special audit report of fatigue were lifted and directly placed into the special audit report that was made available to the operator.  - PING! That's a Canary dot...

Senator FAWCETT:  I accept the fact that the detail, if you like, of some of the issues that were found with the operator ended up in the reports.

The issue here, as you correctly point out in most of your written and oral evidence, is that the pilot is the last line of defence and is a key part. The operator is another one. As you correctly point out, many of those things made their way into the report. But the oversight by the regulator is a third tier and that is what is missing from the ATSB report.

It is clear that CASA had in its possession, through these reports—and this is where the Chambers report differs from the special audit. The Chambers report is CASA's own assessment of how it performed its oversight role, which is why, to use your term, it appears 'passing strange' to the committee that there should be such strong rebuttal against witnesses who say we do not think the surveillance was adequate. There was very strong rebuttal, in a public space, saying 'CASA rejects that', when you know your own internal investigations by senior managers are saying that your oversight was inadequate.

We are happy that you are taking steps to correct it. Surely it is in the public interest, rather than us having to drag it out through a committee process like this. There were inadequate processes. The ATSB should be provided with that information so the public have confidence that you recognise there are problems internal that contributed to our culture, environment and practices by pilots that led to an error and an accident. The public should have confidence that, regarding the organisational characteristics and culture as such, (a) you are learning—and yes, that is good and (b) that you are also transparent and will say 'ATSB: yes, we were making mistakes in the past and we are addressing it, but here is a report of our own assessment.' For you to say in things like this rebuttal, in quite strong language and with absolutely no hint of compromise, that you reject any assertion that your oversight may have been inadequate when your own internal reports are damning in that area, is surely not in the public interest, nor does it inspire public confidence.

---

Or in pictures...

Keeping a focus on what IMO was the more important CASA withheld document, i.e. the Cook report, let's fast forward to the Beaker section of the Hansard...

Senator FAWCETT:  Mr Dolan, can I go to the issue of the scope and content of the report. I have just been flicking through—I have not actually counted the pages, but there is clearly a bulk of the report that examines in quite some detail the sequence of the pilot's fuel planning, obtaining the weather, decisions he makes et cetera, and it leads through to the fact that he ended up having to ditch the aircraft. You go to a number of issues about that decision and why or why not some of those consequences occurred. There appears to be very little inquiry in the report about why was the pilot in a position where he felt his decisions were reasonable. There are two issues that come out of that: one is the issue of the culture and the practice of the operator and the oversight of CASA—we will come back to that in a minute—and the other one is fatigue. Did any of your own staff, or any of the directly interested parties, raise the issue of fatigue during the drafting of the report?

Mr Dolan : Yes.

Senator FAWCETT:  There are two very short paragraphs that touch on the hours with respect to fatigue, but that is about it. Can you explain why the issue of fatigue was not pursued in any more detail by the ATSB?

Mr Dolan : This goes to discussions I have had with the committee earlier, which are that there is a lot more work behind this investigation than is necessarily reflected in this report. So we did a quite reasonable amount of work on assessing the relevance of fatigue issues to this accident. Where we came out, as a result of that assessment and reassessment, was a position where it was not possible on the basis of what was available to us to form the view that fatigue was a significant issue in the formation of this accident. That is what were reflected in the report.

There are two possible assessments, which we also reflect in shorthand in the report, one of which relies on the initial report to us of the amount of rest that was available to the pilot, and the second is an alternative report of the amount of rest available that he made to CASA. The reconsideration we did in the process was to try and assess the second of those, less sleep of the order of four hours, rather than making use of most of the available eight hours of rest time. What difference would this have made at the key points? We satisfied ourselves that it was unlikely but always possible that fatigue was contributing, but we did not see it as a major contributing factor.

Senator FAWCETT:  To the point where in one of the emails you provide to us, one of your officers indicates that, 'We will put a comment about fatigue in just to deter or deflect any criticism about the report.' I am happy for you, in any subsequent submission, to give this some background on that.

Mr Dolan : If I could, Senator, I would not want there to be a misunderstanding of the intent of that comment. The concern that has been reflected there is the concern that others would form the assessment that we had not seriously considered fatigue issues in the context of the information available to us. We did. So we are including in the report those references, best assessments, as to the fact that fatigue did not seem to be a significant issue in play in the formation of this accident. Organisationally we were not seeing any basis for having a long discussion in the report of how we arrived at the conclusion.

Senator FAWCETT:  If you had—in your initial evidence base that you keep coming back to about the facts—in that factual base, information that a peer regulator—in this case the UK—had looked at the patterns of sleep and cycle and said that under their system it would not have been acceptable, if you had in your facts base that CASA had done an audit of the operator and CASA's own oversight of the management system. I will quote from the report: 'It is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during the surveillance were never appropriately actioned. There is a lack of any clear evidence to support corrective action had been implemented and confirmed by CASA that they were effective. If the process is indicative of broader practices by CASA it is considered that CASA is exposed to unnecessary risk particularly if the requirement to provide evidence to support how it approves an operator system, in this case the FRMS.' If you had that in your evidence base, the fact that a competent body said. 'We think the fatigue would have been beyond us letting the person fly,' and the fact that the operator clearly had some problems and the fact that the regulator had recognised themselves that the oversight was not adequate of that, do you think you would have gone a little bit further in your report than just saying, 'Perhaps fatigue was a factor but we cannot actually assess it, so we will discarded it'?

Mr Dolan : The principal purpose of our investigation into an accident is to understand those factors that contributed to the accident and particularly those contributing factors that indicate a level of increased risk in the system of safety. On that basis, having carefully looked at contribution in relation to fatigue, we did not form the view that it was something we needed to highlight as a contributing factor that illustrated a heightened level of risk in the system.

Senator FAWCETT:  Mr Dolan, sorry to cut you off. I hear what you did to. My question is: if you had had this additional information would it most likely have made a difference?

Mr Dolan : I was going on to answer the second part of that, Senator.

Senator FAWCETT:  My apologies.

Mr Dolan : I understand you wish to cut through. The other opportunity available to us in the course of investigation is to highlight what we call 'other safety factors'. The focus is on what contributes, understand that and see whether something needs to be done to prevent a recurrence. In the course of investigation sometimes we will identify other factors that are of interest and that may represent an increased level of risk or an inappropriate level of risk in the system.

It is possible—we are dealing to some extent with hypothesis here—that, had a range of other information been available to us that had been acquired in the course of our investigation, we would have formed a view about another safety issue in this case. But it was not the primary focus of our investigation.

UDB! - To this day that response and load of BASR bollocks by Beaker, still leaves me gobsmacked...

However I have diverged enough so to the question - Q/ Did the ATSB stick to the Truss ToR and/or their own commitment to review and/or utilise the findings of the TSBC, the ASRR and the Senate AAI inquiry in the re-investigation of the VH-NGA ditching?

Answer: Using the examples of the comprehensive, scientifically based Cook - Special Audit of Pel-Air Fatigue Risk Management System - Report and the Chambers Report it should be a simple matter of referencing the 'Sources and submissions' section under 'references' of the MKII report (refer pages 389 - 391) - however there is no reference to either report. Nor is there any reference to the TSBC peer review report, the ASRR or Senate AAI Inquiry reports. Nor is there any attributable references to any of the abovementioned reports in the large Appendices, or in the contextual sections of the body of the report. Therefore the answer is NO! 

Hmm...wonder how much ATP (Australian Taxpayer) money has now been spent simply for the aviation safety bureaucracy to once again thumb their noses at the former minister, the current minister, the Australian Senate, the TSBC, the Reverend Forsyth panel members, the industry stakeholders and indeed the travelling public - UDB!


MTF...P2

Ps Another Canary PING! moment from that infamous 15 February AAI inquiry Hansard:

Mr McCormick : This unfortunate accident occurred in 2009. I commenced here in March 2009. In 2009, we introduced a new board, in July, and we were in the middle of a restructure in reporting lines and around our policies, processes and procedures. At the time of this incident, November 2009, we were very much still in the mode we had been in for the previous four or five years. On the Chambers report, I directed operations—


Senator XENOPHON: You say were in the same mode as you had been for four or five years—what mode was that?

Mr McCormick : I mean that the way we were conducting surveillance, the way we were organised and the way our offices were put in place—our policies, processes and procedures—was very much the legacy of our previous years. We did not have much fundamental change in the seven months after I arrived, before this accident had occurred.

CHAIR: Does that imply that they were faulty?

Mr McCormick : No, I do not think they were. As I said at estimates in, from memory, May 2009, in the previous years I think there had been a bit of neglect in the way we went about our business, in that we were not necessarily organised in the best way to go forward and we relied very much on subject matter experts. That is not to say that was wrong; in that respect, we were very much like other NAAs around the world, all of which undergo continual renewal. CASA is an organisation that we had to put onto the correct footing. We had to move forward, build on the things that were right and correct the things that we did not think were working particularly well. At the same time, there were numerous other issues which we were dealing with.

To get back to the Chambers report, I directed Mr Hood, who was then the executive manager of operations, to get an independent internal view of CASA, for my information—a view of how the organisation worked, the efficiency of our procedures and how we were undertaking them. The Chambers report dates from August 2010. We had to wait for the entire investigation to be finished before we did the Chambers report. That report was actually intended for me, and I did say at the time that I wanted warts and all. I certainly did not want any holding back in finding out where we were going and how we were going forward. Many of the issues that were raised in the Chambers report we can discuss individually, if you wish, but, if we go back to the accident—and I am cognisant, Senator Fawcett, that the committee has reached a position in regard to the pilot of the aircraft—the report still does not indicate anything that would have affected the outcome of the accident. What it indicates is that our procedures and way we went about doing some things needed revision, and we were in the process of doing that. We are a different organisation from what we were in those days.

 

[Kharon]

Focal length it really matters.

P2 – “Keeping a focus on what IMO was the more important CASA withheld document, i.e. the Cook report, let's fast forward to the Beaker section of the Hansard”...

P2 –Q/ Did the ATSB stick to the Truss ToR and/or their own commitment to review and/or utilise the findings of the TSBC, the ASRR and the Senate AAI inquiry in the re-investigation of the VH-NGA ditching?”

P2 Answer: Using the examples of the comprehensive, scientifically based Cook - Special Audit of Pel-Air Fatigue Risk Management System - Report and the Chambers Report it should be a simple matter of referencing the 'Sources and submissions' section under 'references' of the MKII report (refer pages 389 - 391) - however there is no reference to either report. Nor is there any reference to the TSBC peer review report, the ASRR or Senate AAI Inquiry reports. Nor is there any attributable references to any of the aforementioned reports in the large Appendices, or in the contextual sections of the body of the report. Therefore, the answer is NO!

The ‘Chambers Report’ served only as a red herring – sure, it created a distraction and gave the Senators a lever to pull on, raised the level of suspicion and, IMO almost defined the cynical nature of the CASA intransigence. The ‘mystery’ surrounding the 16 week delay of nine critical documents being available; and, the missing 20 odd pages from the CARE 09 report and; the dismissed ‘Cook Report’ all make for interesting questions to be asked. If those questions are ever asked, that is.

But, under what terms of reference may the RRAT committee ask those questions? The ATSB was charged with conducting a second investigation ‘only of the accident’ – standing alone. There was no mention made of investigating the process and particulars of the official actions subsequent to the accident which produced the original perverted report. Nor was investigation of the ATSB/CASA ‘behaviour’ (for want of better) during the Senate inquiry included in the ToR for the second report.

Detailed examination of the second report shows that it tip-toes, just as carefully, around the major issues as the original did. For example the ‘Fatigue’ element. I won’t belabour point here – but there are deeper issues than simple flight crew fatigue; the fatigue level of the medical crew from example. It is clear; that both doctor and nurse were ‘out on their feet’ – serious insurance implications had the medical crew missed a vital sign and lost their patient. Even more serious for the contracting company who knowingly allowed a fatigued flight and medical crew to operate. Miles of wriggle room and endless court battles; nothing to do with CASA or ATSB, nothing to do with the contracting company who, in good faith entered the transport agreement; nothing to do with anyone really. Ain’t that grand….

So, here we sit, staring at a 500 page, multi million dollar re-investigation of ‘the incident’. I grant you, it makes a great door-stop, but does it get any nearer to the radical causes of the incident.

Does it explain the CASA acceptance and approval of severely flawed operating practice?

Does it explain the reasons for the ATSB/CASA bizarre behaviour and highly suspect actions subsequent to the incident?

Does it explain the almost indecent haste with which Pel-Air returned to operational status?.

NO, it does not. Ask a silly question; you may well expect a silly answer. The ‘Manning’ second report is useless in terms of defining ‘Why’ this event occurred and ‘Why’ such extraordinary risks were taken by ATSB and CASA during the Senate inquiry.

Aye well, no doubt we shall soon have a measure of the latest ‘minister’ for transport. The ministerial response to this smooth, top cover job will provide a perfect yardstick.

What say you minister? Will ye piss or get of the pot? I hear the Armadale council needs a new dog catcher, so there is hope for employment after the transport portfolio.

Toot-toot.

[Peetwo]

Six year itch finally gets a scratch -

Quote from SBG - Lost – perhaps in translation.

Rather than ramble on, for the serious student I shall provide just one, solitary link. Fair warning, there are some 37 pages to digest – however; the first dozen or so may be skipped past as they are the written Questions on Notice (QoN) and are repeated as part of the intriguing answers. The questions, standing alone, are incisive; IMO the answers are incredibly revealing.

Referring to the same intriguing QIW and answers, that were written in context to the extraordinary 15 February 2013 AAI Senate inquiry public hearing, I believe I may have unravelled the case of the nine (10 October received) documents that were apparently 'lost in translation' for 4 months.

Please note that at CASA Q&As 26-27 and ATSB Q&As 1-4 there was a sub-heading, example (in bold):

Questions in relation to previously in-camera documents

1. An email on 9 Feb 2010 appears to show that you were looking for a way to assist CASA with their early intervention with Mr James. Can you explain that please?

ATSB response: The email exchange was in the context of a discussion about the
complementary but distinct roles of CASA and the ATSB in maintaining aviation safety.

The interest of the ATSB officer involved was in CASA’s concentrating on improvements to the regulatory and other guidance for the future safety of such flights as the Norfolk Island one.

He was of the view that this would be the most effective way for CASA to address the issues arising from the investigation. My response was to advise him that CASA’s assessment of what was required was now focussing on compliance-related interventions, rather than changes to the regulatory framework.

The referred to document in that QIW was one of the nine documents, therefore it should be safe to assume (maybe??) that the other eight documents (which included the Chambers & Cook reports) were all previously held 'in camera'.

This premise is also supported by the recall (of certain involved parties in those documents) that those reports and email exchanges were compiled by the department at the request of the Senate Committee.

I also have it on good authority that the committee makes such decisions on the accepting or filing of potentially sensitive documents and submissions as 'in camera' totally autonomously from the Secretariat.

Why the committee decided to accept the 9 docs on an 'in camera' basis will therefore remain a mystery but given that the documents were redacted prior to their formal tabling on the 14th & 15th of February 2013, is evidence that the committee had concerns for protecting both the identities and roles of some the agency officers.

Examination and comparison of the redactions would seem to fit the methodology normally used by either the department or the minister's office. It does not fit the methodology normally used by the Senate or the committee Secretariats.

So it could be that the documents were lost in limbo because they were conveniently sitting on the bottom of either Albo's or M&M's intray...

What I think then happened was that when Senator Nash gave up her membership to the AAI inquiry to Senator Fawcett, the committee recalled all outstanding documents  for Fawcett to review.

This ultimately led to Fawcett understanding the significance and importance of these nine documents and as they say 'the rest was history'...

Not an excuse I know but if my dot joining is reasonably accurate and this was possibly a procedural committee blunder (or even some kind of political obfuscation campaign on behalf of Albo and even the Nationals  ) that delayed the 'discovery' and serious implications of these docs; I wonder if that is why one of the original committee members Senator Sterle was so subdued at the extraordinary 15 February 2013 public hearing...

Here is one comment from a handful that Sterle made at that hearing that was seemingly out of context with the committee line of questioning at the time:

---

CHAIR: I just want to seek some clarification, with your indulgence, Senator Xenophon. My difficulty with fatigue, and I clearly remember that trip to Perth where both pilots nodded off to sleep. Do you recall that one?

Mr Dolan : It was before my time, but I am aware of it.

CHAIR: It is pretty interesting. My difficulty with having a model for fatigue would be: would the model show whether the pilot was pole dancing or marathon running et cetera in his time off? A lot depends on what the pilot does in his time off.

Mr Dolan : I am probably less colourful than you, Senator. The question relates both to the opportunity for rest and the quality of rest and the extent to which that opportunity is appropriately availed of.

CHAIR: So in this case, you are not to know that it was not pole dancing but just a noisy motel room. How do you overcome that factor?

Senator STERLE: As we have heard, there were three different stories from the pilot as to how much rest he got. With the greatest respect, I think it deflects from the work of the committee, because if you have one man saying three different things—and no one knows about fatigue management more than me, because I do not do it too well. Coming from my ex-industry, that is all I was doing for four years—arguing the toss about fitness for duty.

Hansard link: http://parlinfo.aph.gov.au/parlInfo/sear...%2F0000%22

---

Hmm...just saying -


MTF...P2

[Peetwo]

TICK TOCK - Five years & counting?

Extract from the Senate (PelAir) AAI Inquiry report 23 May 2013:

Executive Summary

On the night of 18 November 2009, Pel-Air VH-NGA ditched into the ocean in bad
weather off Norfolk Island following several aborted landing attempts. The
aeromedical retrieval flight was en route to the Australian mainland from Apia,
Samoa, and planned to refuel on Norfolk Island as it had done on the first leg of its
journey, from Sydney to Samoa. Six people were on board: the patient, her husband, a
doctor, a nurse, the pilot in command and his co-pilot. All six survived.

Their survival is testament to skill and luck. The committee appreciates that the
accident has affected their lives in ways that are impossible to fully understand. What
allowed the accident to happen, however, should not be.

Although this inquiry had at its heart an Australian Transport Safety Bureau (ATSB)
report into a single aviation accident, the committee's primary focus throughout was
the adequacy of the ATSB's investigation and reporting process, rather than the
particulars of the accident itself. The committee is not comprised of aviation experts,
and although it is fortunate to have the benefit of several members who have extensive
flying experience, it did not set out to conduct another investigation of the accident.

The committee accepts that the pilot in command made errors on the night, and this
inquiry was not an attempt to vindicate him. Instead, the committee's overriding
objective from the outset was to find out why the pilot became the last line of defence
on the night and to maximise the safety outcomes of future ATSB and Civil Aviation
Safety Authority (CASA) investigations in the interests of the travelling public. This
report does so by asking:

• why errors were made;
• why, given that a pilot works within a system, the flight crew became the last
line of defence;
• what deficiencies existed in the system, with regard to the operator (Pel-Air)
and the regulator (CASA), which were not explored as fully as they could have
been by the ATSB; and
• whether the travelling public can have confidence in ATSB processes, the
agency's interaction with CASA and the systems in place to ensure safety.

The findings of the ATSB's investigation report are the starting point in untangling
and addressing these questions. The ATSB's firm position is that the ditching was a
one-off event due predominantly to the actions of the pilot, and the agency has
defended this stance without, in the committee's view, a solid evidentiary base. Over
the course of this inquiry the ATSB repeatedly deflected suggestions that significant
deficiencies with both the operator, (identified in the CASA Special Audit of Pel-Air),
and CASA's oversight of Pel-Air, (identified in the Chambers Report), contributed to
the accident. The committee takes a different view and believes that ATSB processes
have become deficient for reasons to be detailed in the following chapters, allowing
this narrow interpretation of events to occur.

---

The committee also focuses on the appropriateness and effectiveness of the interaction between the ATSB and CASA. The committee notes that a systemic approach to the investigation was initially pursued, but that systemic issues were scoped out of the investigation early in the process. This led the committee to ask whether CASA exerted undue influence on the ATSB process. What is clear is that CASA's failure to provide the ATSB with critical documents, including the Chambers Report and CASA’s Special Audit of Pel-Air, which both demonstrated CASA’s failure to properly oversee the Pel-Air operations, contravened the Memorandum of Understanding (MoU) in place between the two agencies and may have breached the terms of the Transport Safety Investigations Act 2003 (Chapter 7). The committee takes a dim view of CASA's actions in this regard.

The survival of all six people on board VH-NGA means that a lot went right—this
should result in lessons for the wider industry, particularly operators flying to remote
locations. At the same time, many things could have worked better, and industry
should also learn from these. Many submitters and witnesses asserted that the ATSB's
report is not balanced and includes scant coverage of contributing systemic factors
such as organisational and regulatory issues, human factors and survivability aspects.

Given the ATSB's central role in improving aviation safety by communicating lessons
learned from aviation accidents, the committee is surprised by the agency's near
exclusive focus on the actions of the pilot and lack of analysis or detail of factors that
would assist the wider aviation industry. The committee notes warnings that the
omission or downgrading of important safety information has the potential to
adversely affect aviation safety.

The committee was understandably troubled by allegations that agencies whose role it
is to protect and enhance aviation safety were acting in ways which could compromise
that safety. It therefore resolved to take all appropriate action to investigate these
allegations in order to assure itself, the industry and the travelling public that
processes currently in place in CASA and the ATSB are working effectively.

The committee recognises that Australia has been a leader in aviation safety for a
number of years through its robust adoption of the accident causation model
developed by Professor James Reason (Chapter 3).1 This approach recognises that
people work within systems – the individual actions of the pilot in command have a
role to play, as do the actions of the operator and the regulatory environment they
work within. Each layer provides a barrier to prevent an accident and each must be
examined for deficiencies when incidents occur.

Furthermore, the committee has strong concerns about the methodology the ATSB
uses to attribute risk (Chapter 4). The methodology appears to defy common sense by
not asking whether the many issues that were presented to the committee in evidence,
but not included in the report, or not included in any detail, could:

• help prevent such an incident in the future;

---

1 This strong reputation was earned by the ATSB's predecessor, the Bureau of Air Safety Investigation (BASI), in particular in terms of accident reporting and its 'no-blame' approach.

---

• offer lessons for the wider aviation industry; or
• enable a better understanding of actions taken by the crew.

The committee examines how this methodology contributed to the downgrading of an
identified safety issue from 'critical' to 'minor', and finds that the process lacked
transparency, objectivity and due process (Chapter 4). The committee finds that the
ATSB's subjective investigative processes are driven in part by ministerial guidance
prioritising high capacity public transport operations over other types of aviation
transport.

The committee considers (Chapter 8) whether the lack of formal recommendations in
the ATSB report led to a lack of action on important safety issues. This absence of
recommendations stems back to the Memorandum of Understanding (MoU) between
the ATSB and CASA, which encourages concurrent safety action rather than action in
response to recommendations. The committee believes both are necessary. It is
regrettable that a Senate inquiry has had to make recommendations which should have
been made by the ATSB.

A number of changes have been made by the operator (Chapter 5) and the regulator
(Chapter 6) since the ditching. The committee is convinced that having these measures
in place before the ditching would have significantly reduced the risk of the accident
occurring. To simply focus on the actions of the pilot and not discuss the deficiencies
of the system as a whole is unhelpful. It is disappointing that CASA and the ATSB
continue to assert, in the face of evidence to the contrary, that the only part of the
system with any effect on the accident sequence was the pilot.

It also emerged in the course of the inquiry that the previous system of mandatory and
confidential incident reporting to the ATSB has been altered. Pilots have expressed
concern that CASA now appears to have access to identifying information, which may
inhibit pilots reporting incidents and will therefore undermine the important principle
of just culture within the aviation industry (Chapter 10).

Finally, the committee notes that many submitters and witnesses provided evidence in
camera due to fear of retribution, particularly from CASA, were they to go public
with their concerns. Many who chose to give in camera evidence did so in the
knowledge of protections provided by parliamentary privilege. The committee also
notes that this reticence to speak in public has been apparent for each inquiry this
committee has conducted in this area over several years, and finds this deeply
worrying. Given the positive statements made about the inquiry by CASA Director of
Aviation Safety, Mr John McCormick, the committee trusts that concerns about
retribution are unwarranted. There is an obligation on CASA to allay these concerns
that retribution could follow speaking out, which appear to be widespread within the
aviation industry. The committee stresses that it takes the protection of witnesses
under parliamentary privilege very seriously. Witnesses—whether public or in
camera—should suffer no adverse consequences from providing evidence to the
committee. Given the numerous concerns expressed, the committee will be monitoring
this situation carefully.

---

If Australia is to remain at the forefront of open, transparent and effective aviation safety systems, then the goal of this committee is to help our organisations to work transparently, effectively and cooperatively. Ensuring that a systemic approach to aviation safety is in place is the best way to maximise outcomes.

Although there is no doubting the incisive dedication and passion of that particular constituted standing Senate RRAT References Committee in their attempts to rectify the many identified wrongs, inconsistencies and duplicities within the aviation safety bureaucracy; one is left asking five years later WTD has changed or been satisfactorily reformed within those self-serving, statutorily independent Government agencies??

However to be fair to the committee the following quoted extract from the report more than highlights what they were up against:

---

 
Order for the production of documents

1.6 The committee decided that there was a need to access relevant information
from the ATSB and CASA to be able to judge for itself the internal processes
undertaken by each agency and the inter-agency dealings. Many thousands of internal
ATSB and CASA documents were received through an order for the production of
documents.1 This material was received confidentially and the committee takes the
protection of such material very seriously.

1.7 Before deciding whether to publish any of the documentation, the committee
discussed the ramifications at length. In doing so it weighed up the request for
confidentiality against the public interest of the aviation industry and the travelling
public having confidence in the key agencies responsible for civil aviation safety in
Australia. Wherever possible, the committee sought the views of the ATSB or CASA
prior to publication. The committee also considered that it needed to be able to
support its analysis and conclusions as the internal documents appeared at odds with
the evidence given publicly. The committee also wanted to provide the agencies with
the opportunity to explain key documents in public. For these reasons the committee
took the decision in the public interest to publish a small number of documents but did
so with care, selecting only those documents needed to support its conclusions.

1.8 Of the thousands of documents received from the ATSB and CASA, the
committee published 12. At the conclusion of this inquiry, the committee decided to
return all unpublished documents to their respective agencies.

---

Yep..the classic bureaucratic hay stacking of evidence -    

The following FOI released email correspondence, from the former ATSB Chief Commissioner Beaker to the former Miniscule Albo, IMO truly highlights the deeply entrenched rot and corruption that the Senate committee naively believed they could reform merely by handing down their findings and 26 recommendations of the PelAir report:

---

From: Dolan Martin [mailto:Martin.Dolan@atsb.gov.au]
Sent: Friday, 31 August 2012 13:28
To: Minister's Office
Subject: Four Corners and Norfolk Island [SEC=UNCLASSIFIED]

As foreshadowed, I was interviewed this morning by Four Corners in relation to the story they will be putting to air on Monday night. It is clear that their main focus will be on trying to show that the pilot was hard done by and that PelAir as operator has been let off too lightly.

The main issue for us was their view that we should have included the details of an unfavourable CASA regulatory audit of PelAir in our investigation report. Predictably, there were at least ten variations on the same basic question: doesn’t the public have a right to know from our report that PelAir had an unfavourable audit report from CASA.

I indicated as clearly – and repeatedly – as I could that we had considered CASA’s report carefully and had regard to those elements of it that related to the safety issues about fuel management that were the principal focus of our investigation. Equally, our job was primarily to focus on lessons to be learned that might improve future safety, in a framework where we are not permitted by law to apportion blame. It is likely that our report will be presented as being too soft on (if not covering up the problems with) PelAir and too hard on the flight crew.

There were other issues raised, including the delays in finalising the report (I agreed that three years was far too long, but put it in the context of all our other investigation activities) and some early correspondence we had with CASA about a potentially significant safety issue about the regulatory standards for fuel management that we had downgraded to a minor issue in our final report (I explained how we reviewed our assessment of issues over time as more information came to hand).

In essence, the ATSB part of the story will be that we unfairly blamed the pilot and let PelAir off the hook. It’s unlikely that our clear messages about ‘no blame’ and a focus on improving future safety and preventing a recurrence will get much of a run.

Martin Dolan

Chief Commissioner
Australian Transport Safety Bureau 

---

As this week's SBG highlights we are on a theme of PelAir disconnections. Therefore, in light of the Beaker bollocks above, for the sake of BRB debate I thought it worth drawing attention to one more document of interest from the Senate PelAir inquiry webpages:

8 Answers to written questions taken on notice on 28 February 2013, in Canberra;(PDF 189KB)

---

2. Since the Lockhart River inquest in 2007, how has the ATSB’s relationship with CASA changed? o Does the ATSB still acknowledge oversight of CASA’s role as regulator?

ATSB response: The ATSB has never had oversight of CASA’s role as a regulator. Its role is independently to investigate transport safety matters.

This was confirmed by Parliament in the passage of the Transport Safety Investigation Act 2003 and in the establishment of the Australian Transport Safety Bureau as an independent commission in 2009.

In the second reading speeches for both of these changes, it was highlighted that the ATSB must be independent from parties or actions that may have been directly involved in the safety occurrence or that had some influence on the circumstances or consequences of that occurrence. For example, the ATSB must be free to investigate and comment on any significant role of the regulator in a particular occurrence and as such must not itself play a regulatory role in the industry. Investigations that are independent of transport regulators, government policymakers, and the parties involved in an accident, are better positioned to avoid conflicts of interest and external interference.

o If so, in what practical sense does the ATSB carry out its duties in this regard?

ATSB response: The ATSB does not have oversight responsibilities for CASA.

o If not, who now has oversight of CASA?

ATSB response: The Civil Aviation Act 1988 clearly sets out accountability arrangements for CASA including reporting to Parliament and the Minister. It also sets out the role of the CASA Board which includes deciding on the objectives, strategies and policies to be followed by CASA; ensuring CASA performs its functions in a proper, efficient and effective manner; and ensuring that CASA complies with certain directions given by the Minister.

o As an oversight body, should the ATSB be aware, as a matter of principle, about internal audits of CASA and what these audits contain?

ATSB response: The ATSB is not an oversight body.

The ATSB by definition may not be an oversight body but it is worth reflecting that since the promulgation of the TSI Act 2003 and the establishment of the ATSB as an independent statutory authority in 2009, that the questions of the ATSB appearing to be captured by the regulator CASA are more, not less, prevalent and the standards of effective AAI would appear to be more politically influenced than at any other time in the history of the ATSB/BASI/DCA??

Finally it is worth reflecting on this passage of Hansard from the 22 October public hearing with Mick Quinn under questioning:

---

Mr Quinn : Captain James in hindsight openly admits to aspects of the flight where his performance and the performance of his first officer could have been better. The point of the investigation is to reveal why this happened not what happened. This report really only represents the latter as a flawed narrative of the events.

I would like to point out—and I can table this government public document, if you like—this accident report from 1993 by the Bureau of Air Safety Investigation which was a groundbreaking investigation using organisational aspects. It appears that in 2012 we have got to a new low where the Norfolk report basically omits organisational aspects of this flight.

It seemed to me that in 1993 we got it right, but I am not sure where we are in 2012. This is no longer about Captain James, Zoe Cupit, David Helm, Karen Casey or the Currolls. They have physical and psychological issues to deal with for the rest of their lives as a result of the accident—that is fact. We need to ensure that this cannot happen again. My submission and that of Mr Aherne addresses these critical issues. I thank the committee for accepting my submission and, following questioning, I would like to have a brief session in camera if possible.

CHAIR: Thank you. Please clarify the document that you would like to table.

Mr Quinn : It is a Monarch Airlines accident in Young in 1993.

CHAIR: I remember it well.

Mr Quinn : I should point out that in that accident report there are nine recommendations regarding all aspects of the organisation, the regulatory side of things.

Senator STERLE: And none in this one?

Mr Quinn : In this report, ditto—no.

CHAIR: By way of history, the president of the Shires Association was killed on that plane and 10 days before he was killed he had said he was getting out of the presidency of the Shires Association and he would be pleased to get out. I asked why and he said, 'Because I won't have to travel on light planes in the way that I do.' He didn't make it.

---

No comment required me thinks -


MTF...P2

[Peetwo]

Courtesy Ben Cook, via Oz Aviation...

---

Pel-Air revisited – The ditching of Australian aviation governance Part 1
April 14, 2018 by Ben Cook 1 Comment



Think about the reason you’re reading this article. I suspect, like myself, your passion for all things aviation began at a young age. Perhaps it was influenced by a family member already working in the industry, or it seemed part of your genetic makeup – something flowing in your veins.

For me it began when I was very young. I spent hours daydreaming, staring into the sky to watch aircraft fly past. I watched endless movies about aviation, space and action heroes, especially Superman, and ran around the backyard with my arms out pretending I could fly.

My first opportunity to experience the true thrill and exhilaration of flying began in a glider in my early teens. My sense of comfort in the sky became immediately apparent. It became difficult to explain to others why having the horizon appear at unusual angles felt so good!

The key players in this article, Dom and Karen, also followed their dreams to live a life where they could describe their careers as a passion. What’s better than waking up and thinking, “I get paid to do this”? It’s the ultimate motivation when work and life blend into a passion, leading to positive releases of the brain’s feel-good chemicals.

In Dom’s case, a flight in a Tiger Moth at 13 was life-changing – a defining moment where he knew aviation was his chosen career path and not just a hobby. He put in the hard yards, saving money for flying lessons and taking jobs that many would reject; all for the love of building hours to eventually become the captain of a small business jet.

For Karen, her journey started a little later. At the age of 27, already married and with three children, she decided to become a registered nurse. Full-time study for three years took passion and perseverance, but Karen was driven by her years of watching other family members experience congenital heart conditions. Her specialisation in cardio-thoracic, intensive care and pre-hospital trauma nursing led her to an aviation workplace, where she cared for critically ill patients.

Both Dom and Karen were fortunate to have good health, great family and friends, and a passion flowing through their veins – for which they were also getting paid.

For many, aviation can be all-consuming, making you feel complete, satisfied, energised and alive. Yet the joys of aviation can turn to nightmares as the skies around you can change so quickly. For Dom and Karen, this began on the night of November 17 2009 – all-consuming stress, physical and emotional pain, and sleepless nights have been part of their lives for almost a decade since their Pel-Air Westwind II ditched into the ocean off Norfolk Island.
Sadly, the two organisations whose core role is to ensure the Australian aviation industry upholds adequate professional standards and gains positive lessons from these types of accidents, are also at the heart of their nightmare.

It is important to note that this article is by no means a reflection of the present organisations or their senior leaders, but I believe both the Civil Aviation Safety Authority (CASA) and the Australian Transport Safety Bureau (ATSB) still have a hard road ahead to rebuild trust within the aviation industry.

Short notice aeromedical evacuation – is this flying at its best?

It’s Tuesday morning and another beautiful late spring day in Sydney. Dom is up a little earlier than normal at 5.30am. Later in the morning he receives a call from his company regarding a possible patient medical evacuation that will require a long night flight to Apia, the capital and largest city of Samoa, a small island about 4,300km north-east of Sydney. Later, Karen and the other crew members (a flight doctor and first officer) are also notified of the planned flight.

For Karen, having been awake since 6.30am, it was a short notice request to cover for another nurse who was unable to make the flight. Given the lack of formal regulations and applied fatigue management practices for the flight doctors and nurses employed within the air ambulance sector, it was not uncommon to work extended periods with limited sleep.
These types of aviation operations are on the top of the list of challenging and exciting roles. Highly-motivated crews are saving lives and flying demanding missions all over the world. The work can be tough for sometimes modest pay, but it meets an intrinsic need to make a difference for the benefit of the community.

Typically, these operations contain all the human factors elements that can degrade normal performance: stress and time pressure (short-notice planning, sick patients needing help quickly); fatigue (lots of late nights and early mornings); distractions (dealing with multiple stakeholders); egos; a reliance on accurate and timely communication; complacency; and most importantly, a high trust relationship and reliance on a broad collective team (the crew, operations support, refuellers, air traffic controllers, meteorological forecasters, the aviation regulator and so on).

The crew spend most of the day waiting for confirmation the flight is happening, including planning to ensure they deliver the necessary response and critical care to protect the life of the patient. At the aircraft that night, the team looks forward to another flight – they’ve done this many times before. While the long night flights and disrupted sleep are a down side, they know when it gets busy their adrenaline will mask their tiredness (and sometimes boredom) and help them deliver the performance required to get the job done.

A Pel-Air Westwind II at Sydney Airport. (Grahame Hutchison)

They like the jet, a Westwind, registration VH-NGA, which performs well at high altitude and gets them where they need to be nearly as quickly as the larger jets used by the airlines. What the crew is less aware of is the impact of inadequate company training, standards and regulatory oversight regarding crew resource and fatigue risk management. These are the processes for teaching teams how to better support each other’s roles, to monitor for errors, to cross-check each other, to manage fatigue and have a genuine understanding of the impact of lack of sleep on decision-making. They are also unaware of what will be some lapses in the standards for fuel management and broken communication, including critical weather updates.

Just like the air crash investigation television shows, there are many systemic (organisational) and regulatory deficiencies that are all about to line up – sometimes referred to as the Swiss cheese model – and set this crew up for failure. It’s also going to test their ability to perform under extreme pressure, particularly at the critical moment between life and death.

The Swiss cheese moments

The flight departs Sydney late that night and it’s a long flight requiring a refuel at Norfolk Island. Just like a few times before, the weather forecast for Norfolk Island is far worse than the actual weather they experience on arrival. On the ground you could see the stars, the night looked quite clear, yet the automatic weather reporting system was suggesting the weather should have been much worse.

When asked about this the local aerodrome support person at Norfolk Island mentioned the automatic system often overstates how bad the weather is. Little do they know this has the potential to set up expectation bias: a false sense of security based on past experiences or norms.

Once refuelled the crew departs Norfolk Island around 2.45am (local time) for Apia. All aboard are looking forward to a bed in a hotel room before the return flight the next night.
The captain, like many of the company pilots, has a history of making conservative decisions, including carrying extra fuel, as flights to remote islands such as these leave little margin for error should there be a need to find another airport to land.

While this approach to carrying extra fuel is appropriate, the company policy refers to other, more complicated, fuel calculations for helping to determine when to divert to other airfields.
For many pilots, these calculations are not a normal part of what they’ve been shown to do – an example where policy exists for the sake of policy. Ever wonder about the possible adverse influence of other more senior pilots in shaping the workplace culture and norms?
Is what you actually do, even when you know it’s different to what is stated in the company policy, what everyone does?

It’s likely you too have experienced this; an initial feeling of discomfort with not wanting to be a lone voice that asks a difficult question. Instead, you accept the workplace practice to fit in with the group.

Although the weather forecast doesn’t require it, on this evening Dom has planned an alternate aerodrome in addition to Apia as part of the flightplan – again another conservative decision. They’ve now flown all night and land around 7am local time. It doesn’t take long to put the aircraft to bed and head to the hotel for some well-earned sleep.

Yet, as sometimes happens, there is a delay with hotel check-in and the already tired crew have to wait a little longer before they get their room keys. The recovery sleep and down time cannot come quickly enough and the delays at check-in are frustrating. It would be easy for the crew to lose it but understanding that fatigue and long nights are linked to being more irritable helps keep the relationship with the check-in staff professional.

Every minute is a minute of lost recovery time, so critical to manage the performance of medical evacuation flights, with the potential to push the body closer to a danger zone, where decision-making is severely diminished. The ongoing delay is time lost for sleep and every hour is moving the body closer to a circadian cycle that makes it harder to get to sleep.
After finally getting the keys to his room, Dom takes a quick shower to raise his body temperature (for some, the normal sleep cycle is made easier when the body is cooling back down and the shower helps recreate this natural process).

Dom’s room is not ideal. Poor curtains mean a fair amount of daylight is streaming into the room. He’s also fighting his normal body clock, which right now, regardless of the extended hours awake, is working against him when it comes to getting good quality sleep during the day. At best, the sleep at this time of day won’t be great.

Now Dom’s mind is working a bit too hard and thinking too much about the real need for sleep and this anxiety is making it even harder to get to sleep. Trying to relax the mind, counting slowly, slowing down the breathing rate, eventually the eyes slowly close and Dom drifts off to sleep.

But just to make matters worse, once eventually asleep housekeeping enter his room twice, waking him momentarily; yet another unnecessary and avoidable disturbance.

Awake, wide awake, Dom wonders what time it is. It’s only 11am. He knows he needs more sleep. He decides to get up and make a couple of calls to home to try to stay relaxed, sure he can get some more sleep later. He manages a little more sleep before getting up around 2.30pm to start the planning for the return flight (Apia–Norfolk Island–Sydney–Melbourne). He can’t get an internet connection and tries to call operations back home to help with the planning but there is no answer. He eventually does the best he can over the telephone to get some weather and to submit a flightplan. It’s not ideal but he has enough to get started and can get further updates once airborne.

Dom is making a number of these decisions at a critical time: the afternoon window of circadian low (WOCL) – a fancy name for that time later in the afternoon where your body experiences a natural degradation in performance. It’s a typical time when you may struggle to stay awake during an afternoon presentation and it’s also a good time to take a nap. At this time, Dom also makes a decision that is not consistent with his normal thought processes: he only fills up the main fuel tanks but not the tip tanks.

The Westwind’s captain made a decision that was not consistent with his normal thought processes: he only filled up the main fuel tanks but not the tip tanks. (AA archive)

The crew conducts a combined brief, loads the patient and her husband into the aircraft and departs for Norfolk Island. Karen and the flight doctor have not had the luxury of any further sleep (other than the three to four hours they managed to get in the aircraft on the flight over) as they’ve been busy all day getting the patient ready for the medical evacuation.

There remains another layer of Swiss cheese that further exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all.

This, combined with the relaxed and inconsistent company-wide approach to fuel planning, means a number of critical decision gates have been missed, exacerbated by lax regulatory oversight.

Many factors have now combined to set this crew on a doomed path and one that will expose them to outcomes they will carry with them for the rest of their lives.

Ditching a business jet into the ocean

“What’s happening, did the captain just say we’re going to ditch the aircraft?”
“Could this really be happening?”

“Just a few hours ago I remember a blue sky and light breeze standing on the tarmac at Apia, deeply satisfied that we were about to get a sick patient to a medical centre.”

These are the random thoughts facing the crew. Yet right now, the pilots are solely focused on landing a small jet onto the ocean.

Other thoughts will flood later: “Why didn’t I do some further checks of the fuel? Where did this weather come from – the forecast looked good when we left? What did I miss? How could this happen?”

From a human performance perspective, it would be ideal to still be under the influence of the parasympathetic nervous system (PNS), which for most parts of this flight has been responsible for sitting back, comfortable, warm, sometimes bored, but mostly helping keep the body in a relaxed state (storing energy) as the aircraft cruises towards Norfolk Island.
Right now, it’s the sympathetic nervous system (SNS), commonly known as a ‘fight or flight’ response, that is in charge. Luckily at this stage, with little to no conscious knowledge, Dom is largely unaware that his body’s stress drugs (epinephrine and norepinephrine) have been released. They’ve increased his heart rate. His bronchial tubes within his lungs and his heart vessels have dilated, allowing more oxygen to flow around the body and tensing his muscles. He’s having to consciously keep himself relaxed and to not tense up too much to ensure his fine motor skills still allow him to fly the aircraft accurately onto the water.

This is the difference between getting it right and wrong, it’s a life and death scenario. He’s delivering this performance under extreme pressure, and courtesy of all his years of training, he’s able to fly the aircraft rather than freeze up, which could result in an aircraft stall and an uncontrolled crash into the water with almost no chance of survival for those on board.

With about three-and-a-half hours of broken sleep, Dom should be experiencing a response similar to combat veterans, such as stress diarrhoea or loss of fine motor control. Yet he’s doing a remarkable job under very difficult circumstances.

File image of a Westwind night flight. (AA archive)

No time for other random thoughts. It’s dark, it’s cool and Dom has no sense of the temperature – he is only focused on landing a business jet onto the ocean.

Concentrating, time feels like it has slowed down, and Dom can clearly hear the first officer calling the altitude to the water. Dom thinks, “I’ve got to get this right; make power adjustments to keep the airspeed steady; quickly scan between attitude indicator, the airspeed indicator and the vertical speed indicator to fly a controlled approach.”

It’s now 9.25pm. The aircraft is around 440ft above the water and the first officer instructs the passengers to brace. An automated aircraft system continues to announce, “too low terrain”, and this is just another distraction that luckily does not impact the performance of this team.

Below 400ft the aircraft is established in a stable descent and airspeed, a pretty impressive outcome under such trying conditions. The first officer calls out 200ft and the same automated system announces, “terrain ahead, pull up”.

During all of this, the first officer recognises the gear needs to be raised (the aircraft is now about 115ft above the water) and calls for “gear up”, which in addition to ongoing annunciation of “terrain ahead, pull up” also activates a gear warning horn.

Think about it: the constant noise and distractions, a dark night, trying to hold a constant rate of descent and airspeed, flying an approach onto an ocean and keeping it together – at this moment it’s certainly an example of human performance at its finest, not perfect by any means but definitely a good standard of performance when confronted with so many stressors.

Furthermore, Dom is performing a task he’s never practised or been adequately trained for, a novel task under extreme pressure, which with consideration to the aviation environment is about as risky as it gets. For many this stress would cause fixation and loss of fine motor skills. Yet Dom has airspeed almost constant, at a constant rate of descent, 80ft to go (descent stabilised at 360ft per minute, airspeed 108kt); 50ft to go (airspeed 103kt and decreasing); the first officer calling out the final descent heights, 40ft, 30ft, 10ft …
BANG… bang… bang. Three impacts as a business jet skips across the water.

Landing on water at such speeds is like landing on concrete, but somehow the aircraft is still right side up. The fuselage separates into two sections soon after coming to a stop, with the tail section afloat.

Surreally, there is no more engine noise and it’s relatively quiet. The primary sound is water flowing very quickly into the aircraft. Fight and flight drugs are still pumping through the bodies of the crew.

And for the patient – at one stage happily on her way to a medical facility – strapped on a bed, unable to release herself, in an aircraft sitting on the ocean and flooding with water; her stress and panic is likely unbearable.

Right now, in a small aircraft cabin quickly filling with water, with a sick patient strapped to the medical bed, Karen, briefly knocked unconscious, has opened her eyes with water already half way up her shins. She feels no pain (due to her own release of fight and flight chemicals), allowing her to immediately collect her thoughts and respond with the flight doctor to get the patient and her husband out of the aircraft. The severe impact has torn muscles and nerves that will result in lifelong damage and severe pain for Karen.

Dom has already reacted instinctively and exited the rear door, which has been partially damaged by the impact and is also flooding with water. The first officer, initially knocked unconscious, has also quickly recovered and is the last to leave the aircraft.

Six people are now out of the aircraft, all huddled together and a few miles off the coast of Norfolk Island. As time goes on, the fight and flight chemicals will start to wear off, but for now it’s a state of ‘high performance’ and shock, so no one has a real sense of the cold, nor fear. Reality will set in not long after the rescue boat picks them out of the water.

A lucky rescue

Even during the high pressure ditching with less than 600ft above the water, the first officer passed critical information to an aerodrome support person on Norfolk Island stating: “We’re going to proceed with the ditching”.

This aerodrome operator contacted the Norfolk Island emergency services coordinator (ESC) to advise him of the situation, who then called out the other members of the airport rescue and firefighting services, including coordination to contact the owners of two fishing charter vessels that could be used for a search.

One of the firefighters responding to the call-out elected to travel via some cliffs west of the airport. He stopped his vehicle to check the sea to the west of the island, believing that it was possible the aircraft had ditched there. He recalled looking out to sea and seeing what he thought was an occasional and intermittent glow of light (which was from Dom’s torch).

 After looking for a few minutes, he was convinced the light was real and at about 10.20pm he phoned the observation through to the ESC.

This initial information was critical and helped deliver a quick response. At about 10.50pm, after about one hour and 25 minutes in the water, the aircraft’s five evacuees were located and assisted on board the search vessel.

Interestingly, Norfolk Island locals had recently completed emergency response scenario training, further enabling them to respond quickly and efficiently.

The real nightmare begins

File image of VH-NGA taxiing to depart Sydney Airport. (AA archive)

So where were you on Thursday 19 November 2009 when the news broke across the country that an Australian aircraft had ditched into the ocean off Norfolk Island? You may have been very interested in the story, or this article may be the first you’ve heard about this tragic accident.

When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills? In this case, Dom had to make small and fine inputs to aircraft controls (one- or two-degree changes in pitch) and power. He had to almost subconsciously control the fine line between muscle tension that could cause paralysis and a complete loss of control.

Unless you’re a human performance subject matter expert, it’s important to be careful about making too many assumptions. I know personally, having flown aircraft to Norfolk Island many times, that my first thoughts were very critical of the organisation and the pilots.

Luckily, I’ve been well-trained as both an investigator and as a human factors practitioner to recognise these initial thoughts were not helpful.

Like thousands of aviation professionals within corporate culture, Dom was doing the best he could aligned to the normal practices, and positive reinforcement, of more senior pilots around him. Certainly, Dom accepts he could and should have done some things differently.

Unfortunately, CASA and the ATSB pointed the finger too heavily at the aircraft captain. It’s his passion for aviation and strong perseverance that has kept Dom going since the accident.

Through any post-accident process, it’s vital that ATSB investigators and CASA auditors use self-awareness – to seek other evidence to support initial assumptions, be aware of biases, and be cautious about the influence of strong-minded personalities.

The combination of bias and strong egos can adversely influence an aviation accident investigation, ultimately leading to breakdowns in communication, assumptions, inadequate collection of critical investigation evidence and, in the worst case, a re-write of a preliminary investigation to align with possible political agendas (this will never be proven).

This only makes the suffering worse for survivors and destroys the careers of seasoned and competent ATSB investigators.

For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.
Most importantly, getting to the cause of what happened and implementing processes to address these is vital for the crew, the passengers, and their families and friends, to get some closure.

A taste of things to come

No surprises but there is talk of a future movie based on this scenario. If you thought the movie Sully (the story about the ditching on the Hudson River) was interesting, some of that content was not factual but rather Hollywood hype.

Our local version has the trademarks of a great documentary, including extracts such as the following made by the Transport Safety Board of Canada after completing an independent review of the ATSB:

• lapses in the application of the ATSB methodology with respect to the collection of factual information;
  
• errors and flawed analysis stemming from the poor application of existing processes were not mitigated;
  
• an early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved;
  
• this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator.
  

And the list goes on.

So why should you trust my interpretation of the events in a series of upcoming articles?

First and foremost, I have one strong belief: we all need a better balance around organisational issues and pilot culpability to genuinely learn some lessons from this accident. If nothing else, the survivors deserve a more balanced understanding as to what caused this accident.

In the most tragic of circumstances, the patient, suffering heavily from post-traumatic stress disorder and fighting for basic medical compensation, lost her will to fight and lost her life to an overdose in February 2015.

Dom and Karen are continuing to battle with a basic need to feel the system has learnt lessons from the tragedy. Just a glimmer of hope will help them get on with their lives and to feel the real story is known.

The medical retrieval interior of Pel-Air Westwind II VH-NGA. (AA archive)

At the time of the accident I was CASA’s human factors manager and I have a good appreciation of the processes that occurred post-accident. I was actively involved with the CASA special audit of the operator. I’ve read volumes of correspondence – accidents and independent review reports from cover to cover – and where necessary, to help manage my own bias and prejudice from a human factors perspective, I’ve had certain material independently reviewed by a former head of a human performance aviation accident investigation division, recognised as one of the best in the world.

So what’s coming in future articles? I’m going to explore the many human factors involved in this accident. I’ll review elements such as egos, trust, expectation bias, professionalism, fatigue, inconsistencies within the systemic investigation report, culture and its influence on behaviour. These insights from a real scenario provide lessons for each of us, and ways for all of us to better manage human factors.

To reiterate, I’ve worked for both the present CASA Director and the Commissioner of the ATSB and I have the utmost respect and faith in their professional standing to return both CASA and the ATSB back to where they need to be – with the trust and confidence expected by the Australian aviation community and the travelling public. My review in these articles is focused on the culture and processes prior to their appointments.

Until next month, safe flying and enjoy those positive feel-good chemicals you get to release every time you head to the skies.

This feature article first appeared in the April 2018 issue of Australian Aviation.

---

Comment from Capt Mulloy:

William Mulloy says
April 15, 2018 at 1:21 am
Wow ! Gripping article . I am from Canada and am now retired after 40 years of flying . I think back of how lucky I am to have survived through my career . My last 30 years were for the most part influenced by a good safety culture oversite from Transport Canada at the airline I flew for but I can say this ; my first 10 years of bush flying ; charter flights & medevac flights where there was very little oversite from either your management or higher ups & I was virtually on my own and doing everything myself ( most of that time single pilot ) on aircraft like Mitsubishi MU-2 & piper PA-31 it is a wonder I managed to keep an unblemished track record . I know that I was extremely lucky because I can tell you this : I scared the hell out of myself more than once & I put myself there but I sometimes think if ther was a bit more oversite in my small company I wouldn’t have exposed myself to several of the questionable situations that I ended up in . Anyway thank you for reading my letter as I have nothing but compassion for those pilots & pax in your article . I really feel for those pilots because I know they set out with the best of intentions in that westwind & other factors helped put them where they ended up . I hope to see the film if it is ever produced. Thank you from Captain W Mulloy CRJ-900 .

---

Excellent stuff Ben, choccy frog is on it's way and I am definitely looking forward to Part II -  


MTF...P2  

[Sandy Reith]

Ben Cook has written a highly descriptive story with some interesting analysis.
But with respect there might be other judgements that go right to the most critical element of cause. Quote:-

“exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all.”

This surely is the question; and if “not at all” or “incorrectly” is true then surely it is very difficult to see that any appreciable blame should fall on the shoulders of the crew. Reading other analysis by PAIN contributors at the AuntyPru website, with time lines, it seems that if certain weather reports had been passed to the crew then they would have had reason, and sufficient fuel, for a diversion to an alternate airport.
This is the impression that is given, please correct if wrong.
Thus a failure to communicate critical weather information did not “exacerbate the upcoming problems” because to that point there was no problem(s).
In which case it then might also follow to give less weight to sleep deprivation as a factor of cause, though obvious enough that proper procedures seemed to be lacking and corrective action was called for.

The above is a comment submitted to the Australian Flying website but further points, hopefully to be taken as respectful criticism, here in addition.

In common with some other writings about the ditching its notable that the individuals named are not accorded with their full names or formal titles. They should be, along with some discussion regarding the role of the co-pilot.

In regard to Ben Cook’s question: “When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills?

I could say last year putting a C150 with engine trouble after takeoff into a wet paddock. Would that do? Or talking to the local ag pilot with three forced landings to his credit, one with a double mag failure, I expect he would know. Perhaps Ben Cook has a similar experience that he could share with us, nothing like the real thing to add to academic expertise. And for sure there’s plenty of pro pilots to compare notes with, Ben could check with the Mildura “fog landing” pilots.

Lastly I have to take issue with Ben’s statement as follows:-
“Unless you’re a human performance subject matter expert, it’s important to be careful about making too many assumptions.”
Reading this literally one can take it to mean that an expert is entitled to make too many assumptions, presumably with impunity.

The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation. Government Industries, headquartered in Can’tberra.

[Kharon]

Ben Cook and the Choc Frog award.

The Ben Cook article published in the  Australian Aviation magazine is of great value in that it casts a wider net over the inherent contributing factors, the systematic failures and the lack of ‘real’ safety related oversight from the CASA, rather than safe, minimum compliance with ‘the law’.

Ben is a respected, acknowledged expert in his field of endeavour, the article reflects that expertise – from his point of view.

BC – "For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.”

Your opinion depends of course on how ‘thorough’ and meticulous your own analysis of the incident has been and where and when the seeds of this accident were sown. For PAIN those seeds were sown with the Lockhart River tragedy. The abominable behaviour of both CASA and the ATSB before, during, after and since that event leaves much to be desired – from an operational safety point of view. The ATSB fall from excellence began with Lockhart. Many believe their ‘spirit’ was broken from then, routed, repressed and regressing to the pathetic ‘milk and water’ PR guff they provide today. The Pel-Air v1 and Pel-Air v2 reports stand testament to their shameful degeneration. ATSB should have drawn many of the same conclusions as Cook, the reports provided fail, dismally, to do so.

For some as yet unidentified reason, Dolan and McCormick embarked on a very risky journey, never expecting for one moment, that it would blow up to a Senate inquiry; well it did that and more. Had Cook and ‘operational’ expert opinion been sought in the beginning then a report of real safety value could have been produced and the disgrace which followed the Senate Inquiry could have been avoided – alas. But I digress.

Sandy raises some valid questions; the most obvious being why the amended weather forecasts were never received. That, in a nutshell is the final gaping hole in that famous Reason cheese. However, the Cook article tracks the chain of events back to Samoa; which is a reasonable starting place, but is it the right starting place?

I, for one, don’t believe it is. From an operational point of view one must dig a little deeper. For one small example of the many operational malfunctions which the CASA ‘experts’ failed, over a number of years to identify and correct, consider CFIT analysis. CFIT is a globally acknowledged killer; much hard work and expertise has been employed to reduce the risk. The Flight Safety foundation even provided a simple, highly effective tool, which, if used draws an operating crew to realise that their risk is elevated. When you run the analysis for the Norfolk flight, it clearly demonstrates an increased risk level of a CFIT event. Had the company procedures specified a ‘low’ and ‘high’ risk score and made it a requirement that a ‘high’ risk score demanded additional operational support - such as flight following or operational assistance on stand by; then, perhaps James may have been given a heads up on the changing weather conditions. There are many operational risk mitigation tools available to an operating company – beginning with clearly defined SOP which reflect realistic operational safeguards. Simple things like fuel planning requirements – how to; a fuel plan and ‘howgozit’ log, with CP and PNR calculations computed pre departure – amended as an where required to reflect actual operational conditions. Again, I wander.

Ben’s excellent article defines many of the background links in a long chain, very well. Certainly the ultimate ‘gotcha’ was the missing weather forecasts – but this accident began many, many moons ago.

I say the real investigation is yet to be done – ATSB and CASA have may questions to answer, the principal one being ‘what the hell were you playing at; and why? That’s before we take a long hard look at the facts of the Pel-Air audit and the speedy return to ‘normal’ operations. A close look at the ATSB second report is also on the cards; there are some questions there which demand satisfactory answers. Gods alone know how we are to get these questions asked and answered, with O’Sofullame at the helm of the Senate committee. No matter, we shall try.

Sandy – “The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation.” Amen to that.

Nicely done Ben, second the Choc Frog nomination and look forward to the next.

Toot toot.

[Gobbledock]

THE GOBBLEDOCK COMES CLEAN.......

At great risk to myself I’m going to put my arse on the line here. I’m not going to reveal how or why I know this, just that it is fact; for many within the CAsA circus the Pel Air accident did not come as a surprise. By that I mean; ‘a moderate sized aircraft on an Australian AOC running out of fuel in that region’. CAsA knew that there were operators pushing the envelope and flying sectors on the smell of an oily rag. The risk was high and Fort Fumble knew it.

They also knew of similar shenanigans taking place between PNG and Australia. One particular B727 operator comes to mind but I won’t identify them. Running aircraft to Oz with barely fumes in the tanks. And I’m not talking about back in the 1970’s.

Fortunately for CAsA they use (or used to use) a wonderfully fucking useless system called TRIM to bury data, surveillance and inspection and audit reports, risk data and all sorts of information. Once it goes in there it’s never to be seen again. Handy for covering your ass in times of need. CAsA are a disgrace. A bloated bureaucratic juggernaut that has been built around CYA of the employees at the coalface up to the Minister. Just like the ATO and any other Government organisation they have the money, power and protection to do what they want, when they want and as they want. Their absolute power makes the Mafia look like a bunch of Kansas City faggots.....

Tick Tock

[Peetwo]

Ben Cook Part II & III - PelAir revisited.




The ditching of Australian aviation governance - Part 2

..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..



Lessons from the Pel-Air ditching - Part 3

...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

MTF...P2 


Ps Part IV to come in the next edition of AA magazine... 

[Peetwo]

Ben Cook Part II & III - PelAir revisited.




The ditching of Australian aviation governance - Part 2

..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..



Lessons from the Pel-Air ditching - Part 3

...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

Ben Cook & AA magazine initiative on fatigue: 

LEARN MORE ABOUT FATIGUE
written by Australianaviation.Com.Au May 11, 2018

In support of human factors expert Ben Cook’s feature article in the June issue of Australian Aviation, we have made available the following supporting documents:

• Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here
  
• Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here
  
• A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here
  

MTF...P2 

[Peetwo]

Ben Cook Part II & III - PelAir revisited.




The ditching of Australian aviation governance - Part 2

..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..



Lessons from the Pel-Air ditching - Part 3

...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

Ben Cook & AA magazine initiative on fatigue: 

LEARN MORE ABOUT FATIGUE
written by Australianaviation.Com.Au May 11, 2018

In support of human factors expert Ben Cook’s feature article in the June issue of Australian Aviation, we have made available the following supporting documents:

• Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here
  
• Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here
  
• A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here
  

Noted point of interest from this week's SBG: Minister for Reality – Really?

P2 comment - Read the Ben Cook PelAir Part 2 article here: The ditching of Australian aviation governance - Part 2

»» CASA’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
»» Consistent with widely agreed safety science principles, CASA’s approach to conducting surveillance of large charter and air ambulance operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the conduct of line operations (or ‘process in practice’).

Although there are pragmatic difficulties with interviewing line personnel and conducting product surveillance of some types of operations, such methods are necessary to ensure there is a balanced approach to surveillance, particularly until CASA can be confident that operators have mature safety management systems (SMSs) in place. [If CASA surveillance is too shallow how do more senior personnel (chief pilot, standards managers, check and training pilots) know whether their own practices are adequate and
aligned with best practice?]

Ultimately, inadequate regulatory oversight also contributed heavily to a false sense of security within Pel‑Air. How devastating it must have been post accident to have CASA inspectorate staff suddenly find so many systemic issues that had not been picked up during previous CASA surveillance.

Now watch again the '$89 million bucket' video (below). Anyone else get the impression there was no love lost between the former DAS McComic and BC 

 MTF...P2 

[Peetwo]

Dear BO - 'Tell them nothing to see here, move along' - L&Ks DPM McNobody 

I note that today there was tabled in the RRAT Budget Estimates Additional Info section a letter from the invisible miniscule responsible for aviation safety. This letter informed the now neutered Senate RRAT committee, addressed to the Chair Barry (I'm not conflicted) O'Obfuscation, that there was no safety issues surrounding the relay of aviation weather forecasts to operational aircrew in Australia and the surrounding regional FIRs -  : 

The Hon Michael McCormack MP, Minister for Infrastructure and Transport - Correspondence to the committee regarding the provision of weather information to flight crews. - 31 May 2018
PDF 2431KB

---

---

---

Notice the 'ATSB' or 'CASA' advises - in other words the miniscule has absolutely NFI what he is putting his moniker to; but basically there is nothing to be worried about, 'nothing to see' and the political elite can continue to bury their heads in the sand while the Dept, CASA, the ATSB and Airservices Australia continue to maintain the MOAS bollocks over the Aussie travelling public -   



Three strikes.





Irony is wasted on the stupid" | AuntyPru.com : Home of PAIN :
AuntyPru.com
Oscar Wilde once said “Irony is wasted on the stupid”. But the 'irony' of the present situation is too delicious to let it slide away, unnoticed.



MTF...P2 

Bollocks.

[Kharon]

Pass that bucket over P2- Ta!

The Australian Transport Safety Bureau (ATSB), the independent national safety investigator advises that while it has received reports of un forecast weather relating to wind-shear/turbulence, thunderstorms, and fog, there is insufficient data and evidence to support a position that there is currently an emerging safety risk and issue in this regard.

However:-

McNaughtman  “In addition to the range of regulatory requirements outlined above, BoM has also commenced implementation of the recommendations of the Review of Aviation Weather Services, which will establish two major aviation meteorological centres by the end of 2020 to improve national aviation weather services provided to the aviation industry.

McNaughtman – “I note that the research report does not recommend improvements be made to the manner in which Airservices disseminates weather reports to the aviation industry and how these matters are regulated. However, as indicated above, Airservices has advised that it has already taken steps to improve processes, including seeking to reinstate the alerting function of SPECI reports, following the findings of the ATSB in the Mildura Report.”

McNaughtman - Further, Airservices is implementing air traffic management system changes that will reinstate alerts to air traffic controllers where weather is deteriorating below the forecast at locations with automatic weather stations, facilitating the provision of this information to pilots. The changes are scheduled for commissioning in November 2018.

Nah; all’s well – nothing needed – but they’re going to plug the gaps anyway – WTD. Save BO the trouble of removing his fat head from the sand bucket, great stuff – ducking stellar.

Toot - retch – toot.

[Peetwo]

Question for the 'notice paper'? 

Speaker: "Nothing to see here, HOWEVER?? - I think the 'Ayes' have it...(HOWEVER) ring the bells for 4 minutes..." 

Serious QON -   : Is miniscule McNaughtman conflicted on matters of aviation safety?  

DPM McNaughtman: ...The Australian Transport Safety Bureau (ATSB), the independent national safety investigator advises that while it has received reports of un forecast weather relating to wind-shear/turbulence, thunderstorms, and fog, there is insufficient data and evidence to support a position that there is currently an emerging safety risk and issue in this regard...

...I also sought the advice of our aviation safety agencies on other issues raised in your letter...

...the ATSB has advised that following on from its investigation, it provided information to CASA about the apparent lack of knowledge in the pilot community regarding which weather products were provided automatically and what needed to be requested. In response, CASA undertook national pilot seminars in 2017 to raise awareness of the process for requesting weather-related information...

...CASA advises that pilots operating to Lord Howe Island can rely on A WIS information broadcast from the two authorised BoM automatic weather stations (AWS) located near either end of the runway.

These weather services are commonly used throughout Australian airports by pilots for assessing the suitability of weather conditions...

...I am advised however that the ATSB Report extensively documents the weather inf01mation on the day, the reliability of weather forecasts, the information that was actually provided and information that should have been provided to the crew...

...However, as indicated above, Airservices has advised that it has already taken steps to
improve processes, including seeking to reinstate the alerting function of SPECI reports,
following the findings of the ATSB in the Mildura Report...

Reply letter from Sen Fawcett to McNaughtman, who was then Parliamentary Secretary to the Finance Minister "I'll be back" Cormann:  

---

---

However in typical ignorant 'all care and no responsibility' bliss, McNaughtman relied on the advice of the 30+ year Iron Ring spin-meister Dr A - who was acting in an unofficial/official capacity as Acting DAS for the former DAS Skidmark - see HERE or HERE.

Does this not suggest that miniscule McNaughtman would now be best advised not to be associated with any dealings or conflicted advice surrounding any aviation safety issues possibly connected to the PelAir cover-up debacle?

Perhaps in an attempt to get some distance, on this perceived COI, the miniscule would do well to illicit the assistance of the former committee member Sen Fawcett to help provide truly independent advice on the matters contained within the original correspondence from the RRAT committee?  

 Here is Sen Fawcett's original letter to Mathias Cormann:  

---

---

 - Just saying - 


MTF...P2 

Ps For DPM McNaughtman: Here is a reminder of how your loyal minion HVH knew full well that he had a COI with the PelAir MKII reinvestigation:

[Peetwo]

Ben Cook's PelAir Part 2 on AA online: 

FATIGUE AND THE PEL-AIR WESTWIND DITCHING
written by Ben Cook June 24, 2018

The tail of VH-NGA is winched to the surface so its cockpit and flight data recorders could be recovered as part of the ATSB’s reopened investigation into the ditching. (ATSB)

THE DITCHING OF AUSTRALIAN AVIATION GOVERNANCE PART 2

 
MTF...P2 

[Peetwo]

Ben Cook PelAir revisited - Part IV:

IN THE BLINK OF AN EYE LID

Pel-Air revisited Part 4

WRITER: BEN COOK



Continuing our review of the Pel-Air ditching, this issue we look into the complex influence of ego and power in determining the outcomes for those affected by the accident. Karen, the flight nurse on board that fateful night, discovered how various egos associated with the investigation process influenced and clouded proceedings, and made her life a living hell.

First, Karen provides her view of life after the accident, then we offer insights into the roles of governance bodies during the investigation. We also suggest red flags so you can recognise and respond to your own ego-driven decision-making for better performance.

The fragility of life: Karen’s world
There is a light breeze surrounding me as I soar gracefully over beautiful green fields. On my right I can see the coastline and a brilliant blue ocean, the sea looks calm and soft and I can hear the gentle tones of the sea as the waves roll onto the sand.

I’m in complete control. I have a sense of happiness, exhilaration, and calm, and am able to easily manoeuvre myself around the horizon. It’s as if I’m not in an aircraft – I’m flying, soaring like an eagle with a free-spirited energy I’ve not experienced for a long, long time. It’s like returning to a childhood holiday: warm, calm and relaxed. If only I could stay in this happy place, completely at peace, satisfied, carefree…

Now where am I? What is all this pain? I am closing my eyes in a desperate attempt to go back to that happy place. I cannot get back there; the pain is increasing, my body aches, yet I’m slowly regaining conscious thought.

It is dark, I am cold, scared and confused. It was a beautiful dream but now I’m back to reality, the constant pain is still there, it never (expletive) goes away and my life is now consumed by it. The same (expletive) process, fighting the system, constant anger, grief, frustration and yet another sleepless night.

Lying awake, I’m watching the clock count down to take me from now (it is 2am) to daylight, and I’m contemplating whether I can do this anymore. Can I keep up this fight? Is there any way I can go back to my dream and remove the pain? There are options but the consequences for my son and daughters would be lifelong. I have a sense of guilt for even thinking such thoughts. For goodness’ sake, I’ve spent a career caring for people – it is my fundamental purpose and destiny in life.

My name is Karen, and I’m the flight nurse who survived the Pel-Air ditching at Norfolk Island. I will never again be able to experience the joys associated with the freedom of flight.

My life changed in the blink of an eyelid. Literally overnight, almost nine years ago, life as I knew it changed forever. I no longer have the normal sense of purpose that comes with an exciting aviation job: the deep satisfaction of performing meaningful work that you care about, the camaraderie, friendships, the excitement of not knowing what you will be doing day-to-day, or which destination is next for a medical evacuation. I miss the laughter, the sense of purpose, and the workplace banter that is unique to air ambulance and aviation operations. For me, each day is now a struggle, a constant grey landscape where I no longer gain the deep satisfaction that I once had with life.

‘My life changed in the blink of an eyelid.’

As a single mum I worked harder than many, raising my three children while also completing university studies to shape a better life for my kids. Overnight, my income went from just over six figures to $37k. The struggles were huge: financial stress, three kids to take care of, seven operations, battling to make sense of the regulatory process, the accident investigation, and fighting through the courts. And on top of that, having to deal with insurance companies that took every step to make life as difficult as possible for the survivors.

Just like air crash investigators, it is ironic that I now use the words ‘if only I had known in hindsight’! Had I known there were inadequate safety regulations for air ambulance I would not have flown. I had no idea we were not protected by robust legislation, that it was acceptable for smaller operators to venture into complex, back of the clock, short-notice medical retrieval operations with limited oversight and company standards.

Those same companies paid the aircrew small wages in comparison to larger organisations, which inevitably meant the levels of experience were substantially lower and the turnover of crew high, resulting in more challenges when undertaking these more complex tasks.

And after all these years the facts get blurred and I get tired.

My journey has been horrific: trying to penetrate what feel like walls of deceit, erected by several people with very large egos. Again, it is ironic that air crash investigators often mention a need to understand your own bias, or that of a collective team, to make sure the investigation process is not adversely influenced. In my case, I feel egos have heavily influenced many processes to make life difficult; at times, unbearable.

I will never fly again, not because I’m scared of dying in a plane crash but because I’m scared that if I survived I could not bear to live through this hell again. The treatment has been nothing short of cruel and disgraceful, and sometimes I do not know how I have survived for this long.

But one thing I can tell you, I am the epitome of a strong, independent woman. And I will not give up this fight, not until the energy and the exorbitant amount of taxpayer resources (Senate enquiries, independent reviews, a second investigation, court cases, etc.) lead to enhancements to the Australian aviation system to prevent you and your loved ones from ever experiencing the same.



Egos and failed governance
Ego can be described as a person’s sense of self-esteem. Everyone has an ego, it is a natural facet of our humanity. The way we invest our egos has major implications on the way we act, what we believe, and how we respond to adversity such as criticism, insults and failure.

It is also worth noting that the ego largely stems from one’s personal experiences. For many people it is challenging to view issues or results rationally if their beliefs are clouded too deeply in their ego. One must always be open-minded to change and criticism. For some, this proves very difficult.

Looking back on the Pel-Air Norfolk Island ditching as the then human factors manager for the Civil Aviation Safety Authority (CASA), there are many memories that make it feel like it all happened yesterday.

At the time, at the very top of CASA there were very firm and clearly held views on the cause of the accident right from the start, even before the Australian Transport Safety Bureau (ATSB) had commenced its investigation.

One strongly held view was that the investigation process should focus primarily on the pilot, and why would anyone be wasting their time with other systemic findings, as in the end it is only the pilot who can decide whether he or she is fatigued and unable to conduct a flight.

That outlook contradicted the fatigue science and best practice available at the time. Fatigue is insidious, hence the crew themselves can lose the ability to self-assess. This is why it is so critical to have robust organisational and supervisory support mechanisms to further monitor pilot performance, particularly when conducting adhoc, aeromedical evacuation flights. And another view dismissed the importance of software to support crew flight planning.

Both those outlooks came from personal experience rather than an informed basis. They do not demonstrate an open mind seeking to understand how organisational culture effected this serious accident.

Within CASA there was also a culture of fear amongst middle and senior managers. This can have detrimental effects within any organisation, particularly when the communication flow is in one direction (down) and messages are changed when moving back up to ensure they meet the expectations of more senior personnel.

And making matters worse, an audit of CASA’s processes just prior to the accident by the International Civil Aviation Organization (ICAO) and/or the Federal Aviation Authority FAA) was critical of several internal CASA processes, including the quality of training of CASA staff.

In my mind this was potentially feeding the need to deflect any further adverse findings away from CASA back to the operator, and in this case, the aircraft captain. There was enough scrutiny of CASA’s own processes without the addition of an ATSB accident investigation report that had clear evidence within the CASA Pel‑Air Special Audit of systemic failures with CASA oversight. Yet, for the first investigation this information was not included or considered relevant by the then Commissioner of the ATSB.

The investigatory policy was robust, yet senior managers unwittingly contributed to a flawed investigatory process right from the start, and confusion reigned. Egos clearly led to failed governance, ultimately leading to the following findings by the Transport Safety Board of Canada after completing an independent review of the ATSB:

»» An early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved…

»» …this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator…

»» ….errors and flawed analysis stemming from the poor application of existing processes were not mitigated…


Recognising ego and power
For Karen, the outcome of failed Australian aviation governance is a shattered life. Other more recent examples of the impact of ego and power have been seen through the ongoing banking sector royal commission, where the lives of many Australians have also been destroyed.

So, what can you and I do to protect ourselves?

Leveraging from the work of a long-time mentor of mine, Dr Tony Kern, the author of a number of aviation books, including Blue Threat: Why to Err is Inhuman and Going Pro: The Deliberate Practice of Professionalism, ego and power is identified as a known violation producing condition that requires careful consideration and management in the aviation industry.

If allowed to grow, it can become a belief that the violator has the skill and stature to do the job better outside the boundaries. It is particularly dangerous because it lives inside most high achievers.

‘Keep in mind that as individual human beings we are limited.’

Somewhere in our lives, most of us will admit that we have moments where we think we are smarter than the people who wrote the rules. This may or may not be true, but it is a dangerously irrelevant question when it comes to compliance.

Here are a few red flags from Tony’s work to warn us when our egos start to get in the way:

»» You find yourself being defensive about an idea or plan and taking it personally when someone disagrees with your ideas. This often leads to noncompliance to prove yourself and your idea can lead to mission accomplishment.

»» You routinely make a point of showcasing your brilliance, as in ‘those rules don’t apply here because…’

»» You view colleagues as rivals and are willing to bend the rules to ‘one up’ them.

»» You disagree with someone simply because you did not come up withthe idea first.

»» You prematurely criticise policiesor procedures that get in the way of your goals without considering their value.

Keep in mind that as individual human beings we are limited, and when we continually compare ourselves to others in an attempt at ego gratification, we often end up looking foolish and unprofessional by our wilful noncompliance.

And this process can start as you become more confident with experience. As an example, when you first learn about longer radio calls from air traffic control (ATC), hopefully the guidance has been to write the message down on a kneepad before reading the information back. You carefully and neatly write it down, pause to collect your thoughts and then read the information back clearly, but not too quickly, to ensure ATC also have the time to process (check) that you have received the correct information.

But, as you gain more experience and confidence there is the propensity to perform this process from memory with an urge to read the information back quickly, just to let ATC and others know that you are highly proficient. Wow, how did you remember all that information and read it back so quickly? You must be very good at what you do.

If you allow this to become your new habit pattern, then no surprises that somewhere down the track you will make an error. Perhaps you’ll be levelling off after takeoff at 3,000ft when in fact you were meant to level off at 2,000ft.

The most professional aviators instil good habit patterns. I admire the slight pause from operators at airfields in between making their readback to ATC because I know they are taking the time to write down and process the information more accurately than the over-confident quick talker, who is also the type that is known for taxiing the aircraft a little too fast.

Furthermore, keeping your ego calibrated – being able to acknowledge your flaws in both your personal and professional life – also builds trust.

High performance and self-awareness 
For any high performer you should always be open to change and improvement because the world is constantly changing. Investing your ego into beliefs to the point where you cannot change them in the face of evidence is one of the most foolish things you can do. It is critical to always keep yourself open-minded to new information and facts.

Take the time to consider the points above, particularly anytime you show signs of being defensive when receiving feedback from others. Similarly, if you start to blame the system (it was the fault of ATC, you did not brief me properly, it is not my fault) then you are entering a phase in your career that can be difficult to overcome.

High performers remain open to considering better ways of doing business; the process of seeking good habit patterns breeds a higher level of self-awareness. And good self-awareness, from my experience, is the most critical factor in understanding your own limitations and what you are truly capable of. With this you can consistently make better decisions to operate within your own personal boundaries of performance.

Working hard at improving self-awareness, always seeking to improve your personal habits and techniques while accepting feedback openly is positioning you to become a lifelong learner and a great leader, unencumbered by ego.

Next issue in our final article of this series, the focus will be on the importance of trust.

 
MTF with the fifth and final part in August...P2 

[P1_aka_P1]

Ben Cook’s articles and Karen’s words need, must be, sent out as far and as wide as we can reach.

They are important.

[Gobbledock]

You blokes really don’t know anything hey? Bens writings are ok and all, but I prefer to follow Dr Jonathan Aleck. He works for CASA, spent time at ICAO and he has a PHD. He has spent more time travelling business class than any other CASA employee. He knows aviation.

[Peetwo]

Fatigue - in another hemisphere.

While on the subject of fatigue and our still obstinate regulator's reluctance to embrace real science and human factors current day (21st vs 19th century) research/findings and practises on the subject, the following is an excellent BCA article that once again reveals the real insidious nature and safety risk of fatigue -  :

Flying Tired: Recovery From Sleep Loss Is Not So Simple
Jul 20, 2018
Patrick Veillette jumprsaway@aol.com | Business & Commercial Aviation


Many of us as youngsters yearned to become pilots. We envisioned the “glamorous” jet-setting lifestyle with plenty of comely companionship on trips to exotic locations like Rio, Tahiti and Paris, feasting on the local cuisine and strolling along wide beaches and narrow cobblestone streets. Little did we know that the occupation would involve long duty days, early starts, multiple time zone changes, uncomfortable hours confined in a tight cockpit while breathing desert-dry air and forcing ourselves not to nod off.

John A. Caldwell, Ph.D., co-author of Fatigue in Aviation, is an internationally recognized scientist in the area of sleep deprivation and fatigue countermeasures. He asserts that “fatigue-related performance problems in aviation have been consistently underestimated and underappreciated” despite decades of research on pilots showing that insufficient sleep significantly degrades cognition, psychological mood “and fundamental piloting skills.”
[/url]

Image Source: istockphoto


None of us are immune to the problems of fatigue. If you have found yourself or crewmates overlooking or misplacing sequential steps, becoming preoccupied with single tasks, having a greatly reduced audiovisual scan and being less aware of poor performance, then welcome to the brotherhood of the flying weary. Other notable warning signs of fatigue include being less likely to perform low-demand tasks, becoming more distracted and more irritable, and finally succumbing to a “don’t care” attitude.

The only way to recover from fatigue is to get adequate rest. Unfortunately, that’s often not an option. Dr. Curtis Graeber, who served as the human factors specialist for the Presidential Commission on the Space Shuttle Challenger Accident, joined [url=http://awin.aviationweek.com/OrganizationProfiles.aspx?orgId=19991]NASA Ames Research Center in 1981 as the principal investigator for a congressionally mandated study of fatigue and circadian rhythm factors in flight crews. The NASA research team found that the sleep deficit for a tour often begins before showing up for the first trip, especially if the report time involves an early wake-up. Under such frequent circumstances, the average pilot reports for duty on day No. 1 with a sleep deficit. Strike one.

If you feel that your sleep on the road is less restful that your sleep at home, you aren’t alone. NASA studies found that the average pilot sleeps an hour less per night during layovers than at home due to the significant increase in awakenings while in hotel rooms. Such sleep disruption is known to result in daytime sleepiness. That’s strike No. 2.

Let’s say you flew the “back side of the clock” and dragged your weary bones into the hotel room at 5 a.m. How many times has the chambermaid knocked on your door a few hours later loudly proclaiming, “Housekeeping,” despite the “Do Not Disturb” sign you hung on the exterior doorknob? And is it too much to ask hotels to put a “quiet close” device on guest room doors so that guests can’t slam them shut?

The quality of the sleep environment is an important contributor to rest and recovery, yet we pilots have no control over it and simply have to endure less-than-restful nights when on the road. That’s strike No. 3. But wait, there’s more to the fatigue problem.

Have you felt yourself getting even more tired during the progression of a tour? This, too, is commonplace since the lack of adequate rest accumulates. This “sleep debt” or “sleep deficit” is real and a real problem. Consider this: You have the dreaded 5:00 a.m. show on day No. 1 of a trip beginning at your home base at Van Nuys Airport (KVNY) in California for a nonstop to Chicago Midway Airport (KMDW), where you pick up additional passengers and continue to New Jersey’s Teterboro Airport (KTEB). Depending on your driving time to the FBO at Van Nuys, it’s quite possible you had to wake up at 3 or 3:30 a.m. Once at the New Jersey hotel, you might try to sleep around 7 p.m., but there’s the call home, shirt pressing, emails and such, and it’s more likely you’ll be lights out at 11 p.m., your normal sleep time. You’ve made it through the day with, maybe, 4 hr. of sleep. Any normal pilot would have felt groggy all day long.

The next morning, you’re bound for Toronto’s Pearson International Airport (CYYZ) with a departure time of 7 a.m. With the paperwork for the international trip you plan to be at the FBO no later than 5:30 a.m. local, which translates to a 4 a.m. wakeup. Will you drop immediately into deep restful sleep? Not likely.

According to Graeber, when sleep is attempted at a time abnormal to a person’s circadian rhythm, that person will have considerably more difficulty getting to sleep and, once successful, will usually awaken within a relatively short time. This is one of the key underlying problems for pilots that creates what is essentially a career-long battle with fatigue. Simply stated, humans get their normal recuperative rest when they go to sleep at their normal time, and wake up at their normal time. Doing otherwise substantially cuts down on the quality and quantity of sleep. We can’t simply “switch ourselves into deep sleep” just because the crew schedulers tell us this is our 10-hr. rest period. Let’s call this strike No. 4.

Then, when the alarm clock jolts you awake in Teterboro — which, by the way, is 1 a.m. on your California body clock — you can be forgiven for reconsidering your career choice. How much deep recuperative sleep did you manage to get? Clearly not enough. Perhaps it was 4 hr. of deep sleep, thus starting day No. 2 with an accumulated 8 hr. of sleep debt. That’s the equivalent of missing an entire night of sleep. Let’s designate the sleep debt issue as strike No. 5.

Changing time zones or operating on the back side of the clock imposes the additional burden of circadian desynchronization. Graeber’s research found that the circadian rhythm system is unable to adjust rapidly to sudden shifts. In effect, the system resists changes in its timing and stability and complete resynchronization of the body’s biological timing system can take several days.

Additionally, resynchronization occurs at a different rate depending on whether the body must adapt to a westbound or eastbound time zone changes. Medical specialists in the field of sleep medicine have determined that, depending on the number and direction of time zones crossed, it can take days for the circadian system to resynchronize. And recovery from eastbound flights is more difficult. The general rule of thumb is that adjustment to eastbound travel requires 1.5 days per time zone crossed. Yet, as pilots it is entirely possible to be in a different time zone each night of a trip. In short, we don’t get days to resynchronize. Circadian rhythm desynchronization is strike No. 6. Two batters down.

There are substantial differences in various people’s ability to adjust to repeated time-zone shifts. “Morning people,” introverts, the elderly and those with stable rhythms have slower rates of resynchronization than others. Furthermore, studies found that crew members over 45-50 years of age experience less total sleep and poorer quality sleep. If you’re in this age group, that’s strike No. 7.

The combination of poor sleep quality on the road as well as trying to sleep at times outside your body’s normal sleep time will worsen the sleep debt during the trip. It comes with the job. NASA research found that air crews tend to accumulate more sleep debt and thus become more fatigued as they progress through a trip.

Does working a pilot hard contribute to fatigue? Yes, it can, but if the pilot is operating during a normal “day” cycle and then has the opportunity to rest during a normal “night” cycle, the average aviator will be able to show up for flight duties the next day adequately rested.

I have asked pilot groups if they would rather work a hard 12-hr. day that begins at 7:30 a.m. or work an 8-hr. day that begins at 5 a.m., and they almost always choose the former. Why? The sleep loss associated with early morning report times is considerable. NASA research found that the timing of flight activities and not necessarily the length of the duty day or the number of segments flown appears to contribute more to fatigue.

You would not be alone if you dread the fatiguing effect of those early report times. (And admit it, how many of us set at least two alarm clocks for those early morning wake-up’s?) An early report time is strike No. 8.

The British Association of Airline Pilots, together with the University College London Psychobiology Group, carried out a survey of fatigue and well-being among British airline pilots. The study revealed that sleep problems are correlated with fatigue. As a consequence, fatigue can become self-perpetuating. It determined that “Pilots may eventually end up in the vicious circle of being too tired to adequately rest or sleep, which in turn will leave them even more exhausted.” (See the “How Bad Is the Problem?” sidebar.)

Dr. David Gozal, both a professor at the University of Chicago School of Medicine specializing in sleep disorders and a deputy editor of the journal Sleep and Frontiers in Neurology, found that recovery from sleep loss does not immediately restore all of the body’s systems. Neural and metabolic activity take much longer to recover. “Recovery is not so simple,” he found, adding, “If you accumulate debt, there will be compounded interest and an uphill battle to recover.”

Up to this point I have not touched on pilot duties in a typical day, the stresses involved, and the fatigue-inducing conditions under which we work. A 6 a.m. show in January for clients who enjoyed a weekend of skiing at a ski resort means you are likely walking out to an aircraft that has been cold-soaked to -20F on the ramp for maybe the last three days. Preflighting such an aircraft on a still-dark morning in the mountains can be breathtakingly unkind. Conversely, getting an aircraft ready for a post-maintenance inspection flight on an August afternoon with the ramp radiant temperature spiked at 120F will spike crew fatigue levels as well.

Let’s say your departure is from New York’s Westchester County Airport (KHPN) on a Friday afternoon with weather all around when your lead passenger shows up with an additional golf buddy for the trip to Bermuda. Suddenly, you have additional customs paperwork to file as well as new weight and balance to calculate that could cause a cascading set of changes on your loading and fuel. Naturally, the principal expects the engines to start turning as soon as he steps aboard and to be rolling within minutes, oblivious to the considerable stress imposed on the crew.

Entering New York airspace at that time and day along with foul weather guarantees a high workload environment for the departure with controllers issuing nonstop instructions as they try to keep the metal moving. You will not really catch your breath until climbing through FL 300.

The view from the flight deck at FL 410 on a clear day is one we would never trade, but the cockpit itself contributes to fatigue. Sitting confined in small seats for long hours induces lethargy, as well as our chances for developing deep vein thrombosis, or DVT. The dry, pressurized air is wicking away precious volumes of our body’s moisture, thus causing us to be in a chronic state of dehydration for most of our hours airborne. Glare, vibrations and noise all increase fatigue. How much does the combined effect of these add up? The anecdotal evidence suggests it is considerable. (See the “Cockpit Environment and Fatigue” sidebar.)

Despite the forging, most of us are Type A personalities who seek out challenges and enjoy the sense of doing a job well. So, as a group, we are not very good at stepping away from the plate and saying, “Coach, I need to sit this one out.”

In the words of Steven R. Hursh Ph.D., chief scientist of the Institutes for Behavior Resources, “There’s no breathalyzer for tired . . . but there should be.” Absent a practical real-time fatigue detector, he says most people underestimate just how tired they are and how impaired they are by that fatigue. 

Admonishments to “be more professional” or “show attention to detail” ignore the underlying pervasiveness of serious fatigue among line pilots. Professional aviators will continue to be warned to use their rest period productively, even though the scientific evidence is plentiful that the human body simply does not flip a switch at 6, 7 or 9 p.m. to begin deep recuperative sleep in preparation for a 3 a.m. report for duty the next day. It is the timing of sleep, not the amount of time awake or “in rest,” that is the critical factor controlling sleep quality.

The facts about fatigue are clear, and something to sleep on. 

   
Even though I might appear to be 'flogging a dead horse' Downunda; I note that the AA magazine last week refreshed the informative BC June article on 'understanding fatigue':   

THE HUMAN FACTOR: UNDERSTANDING FATIGUE

written by Ben Cook July 21, 2018

THE SIGNIFICANT IMPACT OF FATIGUE

Last issue we highlighted the significant impact fatigue can have on crews. In the case of the Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne. This was well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews.


Pel-Air Westwind VH-NGA at Sydney AirportPel-Air Westwind VH-NGA at Sydney Airport (Tim Bowrey)

THE INSIDIOUS NATURE OF FATIGUE

A clear wake-up call across international civil aviation was the 1993 crash of a DC-8-61 freighter while on approach to land at Guantanamo Bay, Cuba. It was one of the first accidents where fatigue was cited as the primary contributory factor. The US National Transportation Safety Board (NTSB) determined the probable causes of this accident were the impaired judgment, decision-making and flying abilities of the captain and flightcrew due to the effects of fatigue. Acute sleep loss contributed to degraded decision-making, visual and cognitive fixation, poor communication and slowed reaction times.

Leading up to the accident, the three crew members had each been continuously awake for 23½ hours (aircraft captain), 19 hours (first officer), and 21 hours (flight engineer).

The outcome being a loss of stabilised approach criteria and an uncontrolled in-flight collision with terrain. The aircraft captain who, like his copilot and flight engineer managed to survive this accident. They regained consciousness post-accident in “what felt like a crunched-up coke can, with wires and panels hanging all around them”. Luckily during the impact, the front part of the cockpit separated from the main fuselage and kept the crew away from the subsequent fireball that erupted as their four-engined jet transport crashed into the ground.

Earlier that day the crew knew they were going to be exposed to elevated fatigue risks and had planned to make a more conservative approach, rather than an approach that required visual guidance from a ground-based strobe light (that on the day was not working).

However, after receiving a request from air traffic control very late in the flight, when fatigue levels were excessive, they elected to change their original plan to a far more demanding visual approach that required steep manoeuvring to make the landing.This was all at the captain’s suggestion, “Just for the heck of it”. During the final minutes of the flight, the cockpit voice recorder (CVR) clearly highlights the negative effects of fatigue.

These include cognitive fixation (too focused on identifying a strobe light to the detriment of other cues), and pattering checklists by rote but not having the cognitive ability to recognise and act on other critical information such as airspeed control or verbal cues that the aircraft was well outside safe parameters.

COCKPIT VOICE RECORDING:

FE: Slow. Airspeed.

FO: Check the turn.

Capt: Where’s the strobe?

FE: Right over here.

Capt: Where?

FO: Right inside there, right inside there.

FE: You know, we’re not gettin’ our airspeed back there.

Capt: Where’s the strobe?

FO: Right down there.

Capt: I still don’t see it.

FE: [Expletive], we’re never goin’ to make this.

Capt: Where do you see a strobe light?

FO: Right over here.

Capt: Gear, gear down, spoilers armed.

FE: Gear down, three green, spoilers, flaps, checklist.

???: There you go, right there, lookin’ good.

Capt: Where’s the strobe?

FO: Do you think you’re gonna make this?

Capt: Yeah… if I can catch the strobe light.

FO: 500, you’re in good shape.

FE: Watch the, keep your airspeed up.

FO: 140.

 [sound of stall warning]

???: Don’t – stall warning.

Capt: I got it.

FO: Stall warning.

FE: Stall warning.

Capt: I got it, back off.

???: Max power!

???: There it goes, there it goes!

???: Oh no!

 [screams]

EXPERIENCED CREW

This crew were highly experienced (far more experienced than the Pel-Air crew), yet they too lost the ability to recognise what, in hindsight, look like obvious cues to us, that could have broken the error chain. The aircraft captain (Jim Chapo) had more than 20,000 hours flight time. He had served as a check pilot with a major commercial airline prior to commencing night cargo work. But, he received no specific training on the effects of fatigue, even though the night cargo work was quite different to the rosters he had experienced with the airline.

As part of an NTSB fatigue factors training course I attended,  I was fortunate to hear a presentation from Jim. He reported feeling “lethargic and indifferent” during the approach and, when he later reviewed the CVR, was surprised at how unresponsive he was to the concerns of others.  It was an emotionally moving presentation to listen to Jim so openly and honestly recount the horror of surviving an accident and the long-term trauma that followed. At the time, the crew were operating in accordance with the regulations and company procedures. It further highlights the true dangers of elevated levels of fatigue and the severe impairment to decision-making and cognitive processing.

Your challenge, in making sure you utilise human factors for high performance, particularly if you’ve made a transition from one type of operation to another – for example, ab-initio flying training to night freight operations – is to make sure you identify such gaps. True high performers don’t accept the status quo. They know their own limitations and they continue to respectfully seek the training and/or enhanced processes necessary to ensure they can maintain proficiency.



Miraculously the crew of the Guantanamo Bay DC-8 freighter crash survived. (NTSB)

PSYCHOPHYSIOLOGICAL INSOMNIA
One of the biggest challenges of fatigue is that certain conditions experienced by one person may have little to no impact on performance, yet another person under the same conditions can be severely impacted.

I’ve been fortunate over the years to gain some detailed operational experience in managing fatigue, including the use of specialist sleep watches to obtain real sleep data. This has involved the development of fatigue risk profiles, not as an academic research project, but rather for the management of a known hazard (fatigue) with the constraints of a safety management system (SMS).

So, look at the following real patterns of sleep, which are shared with consent. The first data column contains 10 consecutive days of sleep hours and minutes during a time when a student was completing a very demanding aviation training course on a high-performance aircraft. The second column contains 10 days of consecutive sleep data for the same person, though this time the person is performing an instructional role.





FIT FOR DUTY?

What are your thoughts? Is this person fit for duty?

I hope you want to ask some further questions. As background, this person does not have a short sleep gene – they’re not one of the less than three per cent of the population that can perform well with much less sleep than most of us. In fact, when on holidays and relaxing (a good way to identify your normal sleep patterns) this person records seven–eight hours of sleep per night.

What’s your answer? Is this person fit for duty in any workplace, let alone within the cockpit of an aircraft? If you’re like most, including several sleep doctors, the answer is no.

LONG TERM HEALTH IMPACTS

Yet this person performed to a high standard throughout the duration of a particular training course. The bigger challenges were the longer-term impacts to the individual’s health and wellbeing.

I remember asking this person, when they were an instructor, their partner’s views on the impact to their sleep patterns. The response: “They just wanted their old partner back”.

It was at this point they sought specialist help from a sleep clinic to re-correct their sleep patterns, including techniques to manage the anxiety that was leading to poor sleep. While this person might be praised for their ability to perform well under such trying conditions, you need to be careful to not consider this as acceptable. The reality is disrupted sleep patterns like this over the longer-term lead to poor health outcomes. It’s also important to consider others that may not be able to perform like this, particularly if the additional stressors (such as a busy conversion course) are quite high and are actively contributing to additional anxiety and disrupted sleep. If, combined with a late night or very early morning simulator runs, you may be failing more than capable personnel at great cost.

HUMANS ARE COMPLEX YET WE SEEK SIMPLE SOLUTIONS

For most of us within our aviation organisations, life is pretty busy. We often seek simple solutions; it helps us tick off our task list and to move onto the next priority of the day. Only a fool dare tread in this space when dealing with human fatigue. For supervisors, you’re probably after a simple set of rules that not only define a broad limit for scheduling practices and fatigue management, but that can be used to make sure people conform to general work practices.

For example, if most of the team can handle a night shift in accordance with the rules yet one team member (we’ll call him Chris) cannot, what assumptions do you make? Have you ever heard phrases such as, “Chris is lazy”, or “Chris just doesn’t cut it in this workplace”? Chris may be more than competent to perform most tasks required to a high standard, it’s just that Chris’s individual biological differences result in a small part of the workplace routine not meeting his needs.

In mature organisations, these differences are understood and managed to align workplace practices to better support individual needs and to better understand the true complexity of fatigue. Yet so many organisations prefer the overly simplistic approach and along the way they lose good people like Chris, or even worse, they create a ‘them and us’ culture between workers and supervisors/managers.

The outcome is often catastrophic. After an accident, workers may state: “We knew that was going to happen, fatigue has been a problem for some time, why wouldn’t our managers listen to our concerns?”. In turn the managers respond: “We’ve got a fatigue risk management system and there’s nothing in there that suggests we had any problems”.

Simple tools applied to complex problems tend to erode confidence and trust in the fatigue management system and can decrease the open and honest exchange of information regarding the real problems.

SYSTEMATIC FAILINGS

As per the previous Pel-Air article, there were numerous systemic failings, and the following highlight typical findings that contribute to degraded levels of trust, which can ultimately lead to blind compliance of poor practices:

- Westwind pilots reported the rostering of their duty periods appeared to be heavily based on a fatigue score. They were never asked about their level of alertness or recent sleep when tasks were assigned, or during the progress of a trip.

- Some pilots indicated they were provided with insufficient information about the fatigue program and they did not understand how it produced its scores or why its scores seemed to be inconsistent with their perceptions of their own fatigue levels.

FATIGUE MODELLING TOOLS

For anyone experiencing similar outcomes, particularly if your company is over-reliant on a biomathematical model of fatigue (BMMF), then look at the following finding regarding limitations with simple tools and/or not validating such tools in close consultation to ensure the model matches the performance outcomes of the operational workforce:

The US Federal Railroad Administration (FRA 2010) compared a local Australian fatigue modelling tool with another BMMF model, the Fatigue Avoidance Scheduling Tool (FAST), which the FRA had previously validated for use in the rail industry. Based on this comparison, it concluded the local fatigue model scores between 70 and 80 can be associated with ‘extreme fatigue’. If there has been very little duty time in the previous seven days, the local fatigue model will underestimate the potential fatigue level associated with the next duty period, and at times this level of underestimation can be significant.

Yet many local operators continue to utilise scores between 70–80 under the watchful eye of the regulator. If you’re experiencing this type of FRMS then stand up as a human factors practitioner of high performance.  Make sure you utilise any reporting mechanisms available to ensure you don’t experience the same outcomes as the crew of the Pel-Air aircraft.



The primary cause of the DC-8 crash was crew fatigue. (NTSB)The primary cause of the DC-8 crash was crew fatigue. (NTSB)

WRAP UP

As humans we’re complex systems with our own unique biological needs. The combination of disrupted sleep, anxiety and/or fatigue (physiological degradation) remains one of the most significant contributors of degraded performance and increased errors, including eroded decision-making. A good starting point in any workplace is to better understand the multiple factors that can contribute to excessive fatigue. It is also critical in larger organisations to develop a high trust relationship where people are comfortable to report sleep and fatigue issues to ensure policy and process can be enhanced.

If you’re a smaller operator then the best you can do is to educate yourself on relevant fatigue factors and to make changes to your own habit patterns for enhanced outcomes.

FATIGUE CHECKLISTS

Given the importance of sleep and fatigue management, in consultation with a number of local human factors and sleep subject matter experts, Australian Aviation has made available the following support tools on our website:

- Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here

- Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here

- A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here


This article first appeared in the June 2018 edition of Australian Aviation.

MTF...P2