Safety Loop or Hang-mans Noose?

26 Jan

The Aunty Pru thread – Closing-the Safety-Loop – was among the first to be initialised.  Before the matters discussed were brought to pubic attention by Senator David Fawcett (SA) the PAIN associates were researching the official response to recommendations made by the Australian Transport Safety Bureau (ATSB) and coroners related to fatal or serious accidents. –HERE – The construct was and remains to numerically quantify the amount of recommendations which were positively adopted, those which were dismissed and those which were agreed to; acknowledged then ‘shelved’ with little more than cosmetic follow up action .

The statistics are alarming. In many instances, far too many, basic elements or actual causal factors which may be repeated have been treated in a Cavalier manner; mostly by the authority which has the power to effect changes which would, at very least, minimise the risk of a repeat, preventable fatal accident.

One of the repetitive mores comes from the incumbent director of that organisation is, “didn’t happen on my watch” which is a euphemism for if a thing happened before his time, the matter will not be addressed; or, Don’t-Wanna-Know (DWK) in local parlance.  The intriguing thing is this approach has now transmogrified into the standard approach to ‘things’ which do happen, ‘on his watch’.

Recently a DH 82, Tiger Moth and two lives were lost.  I apologise for directing the reader to links, but to post the report and comment would make this into a very long read.  (One) is the ATSB report and Safety recommendation.  (Two) and (Three) are comment posted.

Quote:P9_ “In what we called the ‘maintenance section’ we found a newly dumped Safety Recommendation; from an ATSB report the implications are deep and troubling.  Someone, somewhere should be in trouble.  In short, it’s the old story confirming that by using the Australian system for checking if a part is ‘genuine’ it can be demonstrated that a house brick is a fuel pump; don’t laugh; it’s been done before.  So another failed safety system is exposed and dumped in the basement along with the other ‘stuff’.  The fact that this ‘oversight’ caused a couple of deaths just don’t seem to disturb the paper hangers working on the showy, shiny outside wall.”

The following extract clearly demonstrates why the ‘safety loop’ has not been closed and presents a classic of the standard response to any recommendation and how responsibility for safety is abrogated.   A very similar situation was researched which occurred in WA where suspect parts were involved in a fatal accident investigation.   The loop was as open then as it is today; there are others.  It is of great concern that the potential for preventable accidents to repeat is allowed to continue.  It is of greater concern the CEO of the Civil Aviation Safety Authority allows the practice of diminishing, then dismissing legitimate Safety Recommendations (SR) from the ATSB.

Quote:Date: 21 January 2016  Safety issue description

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life limits, were appropriately considered.

Action organisation:
Civil Aviation Safety Authority
Date:21 January 2016
Action status:

The ATSB provided the Civil Aviation Safety Authority (CASA) with written information about this safety issue and then followed up with a meeting on 11 February 2015 to discuss the issue. In correspondence following that meeting, CASA advised of the following safety action:

CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised personsand concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.

In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated.

Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue.

ATSB response:

The ATSB acknowledges CASA’s initial action to address this safety issue. However, the ATSB is concerned that this action does not specifically examine the over 1,000 Australian Parts Manufacturer Approvals undertaken by the Regulatory Reform Program Implementation (RRPI) team in 2003. The effect of the policy direction given to the RRPI team, and lack of CASA files containing records of CASA’s engineering assessments of those parts, means there is no assurance that the tie rod manufacturer’s other RPPI-approved APMA parts were not similarly affected by the issues identified with the tie rod replacement parts approval.

In support of this, the ATSB has become aware that at least one other part listed on the tie rod manufacturer’s APMA approved by the RRPI, for the DHC-1 Chipmunk aircraft, is the subject of an airworthiness directive that places a life limitation on the part. Like the APMA for the tie rods, there is no mention of the airworthiness directive, or life limitation, on the associated APMA documents.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:
Civil Aviation Safety Authority

Action number   AO-2013-226-SR-044

Date: 21 January 2016.   Action status:  Released

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life limits.

It’s not that this accident of itself presents a great risk to the ‘general’ public.  The attitude toward closing the loop and preventing repeat of accident is.  This dismissive, arrogance toward any recommendation, be it government, peer, the accident investigator or coroner is a chronic, deeply entrenched malady which seems not to concern the current director, no one jot.

Well, he owns this one now, let’s see how he and his incompetents deal with it.  We shall watch and we shall see.

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