[Gobbledock]

Rock a by Skull on the tree top, along comes the clock and it goes tick tick tock....

Well I’m not surprised that the Skull stalled the stick shaker over FRMS. In his Star Chamber world fatigue was a weakness and if you can’t handle it then piss off. Fewer hours flown meant less revenue for his beloved CX. And of course at CAsA, the sheer size of the perceived political fallout from introducing stricter fatigue rules for the poor, worn out and battered pilot fraternity wasn’t palatable to the bonus collectors at the likes of QF, VA and so on. The Screamer did not like the thought of wearing a giant airline CEO sized pineapple up his klacker.

Ironic isn’t it? The Civil Aviation SAFETY Authority, the Regulator who purportedly promulgates, enforces and fosters safety, won’t introduce proper fatigue management rules. These are the same fuckwits that will put you in jail for armour oiling your pilot seat, or patting the engine cowl of your plane as you walk past it, or failing to wear your epaulettes on your pilot shirt as you stroll through a hangar!!!

Unbelievable. And is there any wonder why the industry laughs at CAsA and the political tossers pulling their strings. You would think that the Colgan crash would be the ‘game changer’ in our industry. It was meant to be. After all, it is the accident that forced those other trough swillers at ICAO to start taking a serious look at pilot fatigue matters.

Tick tock ZZZzzzzzz

A younger Skull;

[Peetwo]

Ben Cook PelAir revisited - Part V (PDF)

Via AA magazine:

BRIGH T S P O T S
DELIVERING BETTER OUTCOMES AND OTHER LESSONS OF THE PEL-AIR DITCHING
Pel-Air
revisited
Part 5
WRITER: BEN COOK

This is our final in a series of five articles where human factors expert Ben Cook has revisited the ditching of the Pel-Air aircraft off Norfolk Island on November 18 2009 – looking at the numerous human factors that influenced the tragedy. In this article, Ben explores the failings of key organisations and the importance of them rebuilding trust within the aviation community and the broader flying public.

Where are we now?

As noted in previous articles, the failure of the Civil Aviation Safety Authority (CASA) – including the impact of personal bias and ego – adversely affected the accident investigation process for the Pel-Air ditching. The CASA special audit conducted after the accident also highlighted inadequate regulatory surveillance.

Now add to this the inability of the Australian Transport Safety Bureau (ATSB) to remain independent of the influence of strong personalities within CASA. It was unable to genuinely consider all the facts available, including the findings from the CASA special audit, and it failed to conduct a timely and thorough first investigation.

The result: devastating consequences for the accident survivors.

Moreover, the total cost to the taxpayer, via Senate enquiries, an independent review of the ATSB by the Transportation Safety Board of Canada, a second accident investigation and more, has been exorbitant – and for what gain? Some suggest, including the survivors, that even today there has been little to no safety improvements as a direct outcome of these processes.

And while you’ve gained further insights into the horrific impact for some of the crew members, namely Dom (the aircraft captain) and Karen (the flight nurse), it is important to remember that the passenger requiring medical assistance was confronted with ongoing post-traumatic stress and a fight for basic medical compensation, which she could not cope with and ultimately lost her will to live. A terribly tragic outcome for her family and friends.

Timeliness and surveillance

Timeliness is a critical factor still impacting on investigative processes.

Even today I am personally aware of several families and organisations still experiencing the same slow response from the ATSB. For instance, I attended a major safety forum where an aviation small business owner, post-accident, openly discussed their case with a presenter as part of the forum. The business owner spoke about how they were repeatedly told by members of the ATSB that the final report would be ready in another month.

Unfortunately, this was the same response received every month for many months.
Eventually, they were told the ATSB investigator had taken stress leave. You could hear the trauma in the voice of this person as they articulated their story to the forum; the tremor in their voice and the visible stress on show due to the uncertainty about insurance and the viability of their family business – all dependent on the timely outcomes of the ATSB investigation to assist with resolution.

Then, there is regulatory relevance.

From my personal experience working for CASA, surveillance remains a challenge. Ensuring you have adequate time to find the real systemic factors impacting an organisation takes time.

Many years ago, CASA employed systems safety specialists to gain a better balance around such issues, including access to adequate data (safety intelligence) to enhance the ability to conduct risk-based surveillance.

The aim was to avoid the ‘old school’ tick-and-flick checklists and a generally shallow audit response (covering too much too quickly) to better focus and spend more time on those areas that genuinely impacted individual and organisational behaviour.

Ultimately, good surveillance helps organisations improve their own standards for continued business success.

It was a good attempt to enhance CASA processes and worked well in some offices and less so in others due to a lack of clarity around the new role. The net outcome was enhancements for CASA but this still has further room for improvement.

What’s your experience with regulators? Are they helping you identify important issues that are making a positive difference? For some the answer is yes, and that’s a great outcome.

For others, you may receive corrective action that leaves you wondering why you should invest resources into something that you don’t believe will enhance your operations, where the costs potentially outweigh the benefits gained.

So where does this leave CASA and the ATSB today?

My view is the Pel-Air ditching had a significant impact on the trust relationship between local aircraft operators and members of the Australian public. It also led to significant questions about the professional standing of the ATSB.

And that impact continues today.

Why is that trust so important and what’s required to rebuild it?

Trust – the one thing that changes everything

From the work of Stephen Covey, the author of The Speed of Trust, society is experiencing a crisis of trust that always affects two outcomes: speed and cost. Covey cites numerous examples of changes within society and organisations, with research from many companies and broader society indicating a sharp decline in trust, which continues today.

If you consider relationships with low trust what are the typical behaviours you might see within an organisation? Let’s consider writing an audit report involving a highly competent and experienced inspector that requires review by a team leader and a regional manager where there is a low trust relationship at all levels.

Some outcomes could include unnecessary questioning, seeking further evidence to substantiate findings and asking for sections to be re-written; initially by the team leader and again by the regional manager. For the inspector it feels like micro‑management and leads to frustration.

Low trust slows down the process – unnecessary additional administration for potentially no gain. Speed goes down and the cost to the organisation and industry (lost time) goes up.

If we consider something critical to aviation operations, such as effective communication and linking this back to trust, Covey says:

“In a high-trust relationship, you can say the wrong thing, and people will still get your meaning. In a low trust relationship, you can be very measured, even precise, and they’ll still misinterpret you.”

It’s a good reminder that trust is hard, real, quantifiable, and can provide significant enhancement to efficiency and cost within any system.

Leaders must address trust as part of a strong culture. As Covey says, “Leadership is getting results in a way that inspires trust”. It also means that leaders must provide opportunities for personnel to learn from their mistakes and to provide a culture that makes it safe for that to happen.

A starting point for CASA and the ATSB is to be more transparent when they get things wrong. They must be upfront, accept all organisations make mistakes, and provide clear evidence that they themselves are making improvements from the lessons learnt. It’s role-modelling the culture expected of operators as part of applied safety management systems for continuous improvement.

As part of my work with organisations to review their ability to achieve and sustain operational and business excellence, I spend time investigating trust through the lens of ability, character and truthfulness.

When considering this from a CASA and ATSB perspective:

>> Are CASA and ATSB personnel technically competent and do they deliver outcomes consistent to an agreed standard?

>> Do you get a consistent response from CASA or ATSB personnel from different geographical regions?

>> Is there a strong customer focus or do members hide behind a veil of bureaucracy?

>> Do staff have the interpersonal skills to deal with difficult issues while upholding a professional relationship with industry clients?

>> Do the words of employees and the broader organisation match the realities of what is delivered?

For every government employee that sits in bureaucratic, semiretirement mode, where they’re not held accountable, they’re letting down those hard-working, passionate employees performing a competent, professional role.

For every service response that demonstrates disrespect to industry customers, it tends to negate the 10‑20 professional and positive services delivered by those other personnel who are respected and trusted by industry.

Empowered accountability for any organisation means you weed out underperformers to protect your brand and industry reputation – and enhance trust.


Good surveillance helps

organisations improve their
own standards for continued
business success. casa

Now apply these concepts of ability, character and truthfulness to you.

Are you as technically competent as you could be? Do you actively seek feedback to make sure you’re not getting overconfident or complacent?

Do you understand the pros and cons of your character (the mental and moral qualities distinctive to an individual) and seek to modify your attitudes and behaviour to better manage your own personality traits?

Ask yourself and others whether you’re honest, candid, and frank? If you say you’re going to deliver something by a certain time, do you deliver it?

All these elements help to build and instil ongoing trust.

So how does CASA and the ATSB rebuild trust with the industry?

Rebuilding trust – future solutions

The ATSB and other investigatory bodies have a challenge, which was summarised nicely in a statement made by Deborah Hersman, a former chairman of the National Transportation Safety Board (NTSB):

Looking beyond its core mission to investigate accidents, the National Transportation Safety Board also is seeking a major role identifying aviation hazards before they can cause crashes…a departure from the board’s traditional job of dissecting the causes of fatal plane accidents and serious incidents, and then months – or years – later recommending ways to prevent repeats.

In today’s fast-paced society, by the time recommendations are presented, particularly if the timeline is 18-24 months post-accident, an organisation has already moved on. Many of the successful programs I’ve worked with across different industries have only met stakeholder needs if they’ve delivered timely outcomes.

I also propose the premise of proactive hazard identification is a missing link for regulators. They too need to move well beyond traditional surveillance to consider new models for enacting their requirement to regulate industry and to ensure operators have the capacity to deliver the standards necessary to provide safe, effective operations required by the fare-paying public.

Another solution is bright spot thinking. The aim is to avoid focusing on the negatives and to instead look for solutions that could be in plain view, including the opportunity to innovate better ways of doing business. It’s about spending more time identifying, cloning and sharing good industry standards and practices.

I believe it’s time to have an independent group perform a complete review of the existing practices of CASA and the ATSB – with a view to looking at opportunities for innovation.

This could help to identify what’s working well and why; to better understand and consider industry needs from a business perspective. Perhaps it’s about creating enhanced efficiency and effectiveness for business success or the re-alignment of existing resources to deliver enhanced outcomes for the benefit of the whole of industry.

Time and again we’ve heard the same promises: the regulatory reforms will be prioritised, accident investigations will be completed faster, but little has changed.

So isn’t it time for an independent and innovative review of how to get the best we can from both the ATSB and CASA?

Consider this: Some regulators establish relationships with airlines to rotate personnel through inspectorate roles, with clear policy and procedures to avoid conflicts of interest.

The benefit is access to industry personnel with recent, relevant experience for a two to four year placement. Aircrew and engineers gain valuable insights into the role of the regulator, with an ability to transfer those skills back to the airline. This could equally be applied by investigatory bodies. This may not be the correct answer for our industry, but it demonstrates how we can think outside the box.

Some other suggestions for rebuilding trust include:

>> Delivery: Deliver what you say you’re going to deliver and performance manage personnel who cannot demonstrate a genuine contribution to your core business, particularly those lacking trust or respect by industry. They tarnish brands. Meet industry expectations and hold your own personnel accountable.

>> Industry risk profiles: Establish industry risk profiles (work is ongoing in this space) and reconsider the classification of various operations to ensure CASA and ATSB resources are utilised for best effect. With limited resources, they must be utilised across sectors that will genuinely enhance and protect the broader population.

This also allows regulations and acceptable means of compliance to be tailored to match the nature of the industry profile, and for some sectors the outcome might even be enhanced through self-regulation.

>> Regulatory reform: Keep the rules simple and aligned to industry risk profiles. The regulatory requirements considered suitable for high capacity organisations such as Qantas and Virgin Australia need to be much different to those that will support smaller family businesses, such as aerial application and flying training organisations.

>> More safety promotion: Both CASA and the ATSB have delivered outstanding proactive support to industry including the establishment of aviation safety advisors, the delivery of safety promotion products (eg Safety Behaviours Human Factors for Pilots) that have received international praise, and training courses (eg ATSB Human Factors for Transport Safety Investigators) that are recognised and oversubscribed by industry seeking placement. It’s time to take this model to the next level.

>> Collaborative investment: Promote high training standards and outcomes, rather than every operator trying to deliver a minimum standard. Why not establish larger training centres within regions of high training activity (Moorabbin, Parafield, Bankstown, Jandakot etc) focused on delivery of modules such as non-technical skills training, accident investigation, human factors for operators, and applied fatigue management? This could be achieved through use of Aviation Safety Advisors, ATSB investigators, industry experts and aviation universities working in collaboration with a focus on train-the-trainer. Some of our smaller organisations, particularly the flying training industry, require greater assistance to keep their businesses viable. While a one-hour presentation at a local flying club on situational awareness by an Aviation Safety Advisor might be interesting, wouldn’t it be better to deliver longer courses that genuinely upskill future trainers to allow them to deliver enhanced standards and professional practices?

It’s back to bright spots – taking what we’ve already got and delivering better outcomes aligned with industry needs. This will help build a more trustworthy, collaborative and reliable industry.



Timeliness is a critical factor

still impacting on investigative
processes. atsb

In conclusion

I would like to thank you for taking this journey with me. For those who have read all five articles, we’ve covered much ground including the impact of egos, trust, professionalism, fatigue, inconsistencies with systemic investigation, and the powerful impact of organisational culture.

I hope you’ve gained some practical tips that you can apply within your own aviation operations.

MTF...P2 

[Peetwo]

How things have changed? NOT! -  


References:

Update: Via the Oz today.

Dick Smith urges small airfare levy to fund new MH370 search



Dick Smith. Picture: Jonathan Ng
ROBYN IRONSIDE
AVIATION WRITER
@ironsider

12:00AM FEBRUARY 27, 2019
11 COMMENTS
Veteran aviator Dick Smith has used the launch of a new book on the MH370 mystery to call for airlines to introduce a small levy on fares to raise money for another search.

Launching The Hunt for MH370 by The Australian’s Ean Higgins, Mr Smith said it was almost unbelievable that the Boeing 777-200ER remained missing almost five years after it disappeared en route from Kuala Lumpur to Beijing.

There were 239 people on board the Malaysia Airlines flight, including six Australians, but all that has been found of the jet is a dozen or so pieces of debris.


Mr Smith said a levy of just 10c a fare could raise as much as $350 million towards a new ocean search, given 3.5 billion people travelled by air each year.

“I just simply can’t believe that the safety regulators around the world have said nothing about the need to find MH370,” he said.

“I’m not at all convinced we know what happened and because of that, it is imperative we find the aircraft and the black boxes so if it was a design fault (with the aircraft) we can fix it and save lives in the future.”

Mr Smith said if there had not been an extended search for Air France flight 447 in the Atlantic Ocean, information about why the plane crashed would remain unknown.

“They spent the extra money and found the flight data recorder which revealed one of the flight crew held the side stick controller in the stall position,” Mr Smith said.

“No one would’ve guessed that but now every pilot is taught not to do that.”

Higgins said all the families he had spoken to in the course of researching and writing his book were desperate to know what happened to their loved ones and deserved answers.

“I think it’s more a matter of will than money that’s lacking in renewing the search,” he said. “Boeing recently reported $US100 billion in sales and it could, as Airbus did for Air France 447, put up some money to fund a new hunt.

“So could, and so should, China whose nationals accounted for two-thirds of the passengers on the aircraft.”

The International Air Transport Association, which represents 293 airlines worldwide, was unable to support Mr Smith’s call for an airfare levy to fund a new MH370 search.

Assistant director of corporate communications Albert Tjoeng said there was already a well established process for accident investigation, included in Inter­national Civil Aviation Organ­isation’s annex 13.

“There is nothing in the ICAO annexes that would establish a precedent for the kind of funding mechanism being suggested, nor would IATA support such a mechanism,” Mr Tjoeng said.

Mr Smith said that without knowing what happened to MH370 there would always be some doubt about the safety of air travel. “This situation hasn’t occurred before and we have to change that for the confidence of the airline industry,” he said.

“Every passenger who flies now must be concerned.”

And from UP thread:

The utter dishonesty of the Canberra system – MH370
Many will know that the Deputy Prime Minister Michael McCormack has proposed a legislative change in Parliament which reinforces the unique Civil Aviation Act and the words “CASA must regard the safety of air navigation as the most important consideration.”

Of course, this means that safety is more important than anything else, including cost.

If that is true, can I ask a simple question? Why isn’t the Deputy Prime Minister pushing for the search to be reinstated for MH370?

You got it! Because the powers that be have decided that the extra cost is more important than the extra safety they may gained by finding out what actually happened!

It is clear that not only were eight Australians killed, but Australians are flying all the time on the Boeing 777, which could have an inherent fault. Only yesterday, a Qantas pilot said to me that he does not believe in the murder/suicide theory and believes there is an airworthiness problem with the aircraft – it is tied up with an oxygen cylinder that could blow up.

Of course, we see the utter hypocrisy of Canberra – not one word from Mr Carmody (the Director of Aviation Safety) and not one word from the Deputy Prime Minister or his Chief of Staff, or his head of PR.

I have called for a small levy to be put on air tickets. Ten cents would raise $270 million from the 2.7 billion passengers, so the search could continue and the aircraft to be found. After all, small fortunes were spent in finding the African Airways 747 in the Indian Ocean and the Air France Airbus A330 in the Atlantic.

Once the flight data recorders were found, safety was improved. It is unlikely that form of accident would happen again.

Yes, I know, lots of readers here believe it was a simple (if you could call it that) murder/suicide and nothing will be learnt from finding the aircraft. However, anyone who flies, and anyone who has relatives who fly, should be very wary. There is a chance that the Qantas pilot is correct and there is a problem with the aircraft.

I ask everyone to support me in a campaign to get the search going again (this time probably in the correct area would be a good idea), find the flight data recorders, and show that we are really interested in passenger safety.

No, of course! I have suddenly realised – this won’t be paid for by general aviation. Ten cents on an air ticket could mean ten cents less profit per air ticket by the airlines, so they will completely stop this from happening.

I wonder if the Minister will stand up to the powerful and truely put safety as the most important consideration ?

 

The international MH370 social media crew were slow to react to the Dick Smith comments but one long time loyal MH370 follower and super sleuth Julie Nihonmama did not miss the irony or opportunity to make a very valid Elephant in the room point - 

Julie
‏


@nihonmama

"Why isn’t the Deputy PM pushing for the search to be reinstated for #MH370?

...anyone who flies, and anyone who has relatives who fly, should be very wary. There is a chance that the Qantas pilot is correct and there is a problem with the aircraft."

https://www.pprune.org/australia-new-zea...st10401515 …

However what really caught my attention was Julie's next tweet which posthumously referenced a Ben Sandiland's Planetalking blast from the past - RIP BEN!  

☝️  "CASA clearly considers that cost is clearly more important than the safety improvement that can be made." (2019)

"The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report" (2014) ?

https://twitter.com/PlaneTalking/status/...7478363137 …

RIP Ben. #MH370

---

AIR SAFETY


Call for ATSB chief’s removal over Pel-Air report fiasco

Senior mandarins in aviation tried to lock their Minister, Warren Truss, into a position he no longer wants to be in. A very bad career move

BEN SANDILANDS
 
DEC 03, 2014


SENATOR NICK XENOPHON CALLING FOR DOLAN'S REMOVAL FROM ATSB

The scope for major changes in Australia’s air safety investigator, the ATSB,  its aviation regulator, CASA,  and their administrator the department of Infrastructure and Regional Development looms large following the Minister’s abrupt call for a fresh look at the Pel-Air crash inquiry report.

A great deal of political and administrative capital was invested in producing and defending  the vindictive, unfair and inadequate final report that the ATSB issued, and subsequently defended, concerning the Pel-Air crash of a Westwind corporate jet doing a medical charter into the sea near Norfolk Island on 18 November, 2009.

In what might prove a critical development in the public administration of air safety in this country, that report, released after many delays on 30 August 2012, seems set to be undone, or redone.

As might prove to be the case for  Martin Dolan, the discredited ATSB chief commissioner whose testimony before a Senate hearing into the investigator’s botched processes over its Pel-Air findings was rejected by an all party committee.

Independent SA Senator, Nick Xenophon, lost no time in calling for Dolan’s removal  “and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and CASA.”

The human suffering aspect of what at first glance seems like a minor hull loss in the middle of the night is difficult to discuss for legal reasons at present. However it was anything but minor for the six people onboard when it was ditched in the sea because it had reached its intended refueling stop at Norfolk Island, on its way from Apia to Melbourne, when it discovered the weather advice it had received was wrong, it was unable to land, and it no reserves to reach an alternate.

Pel-Air, the operator was a mess. It grounded its surviving Westwinds voluntarily after the crash. Its deputy chairman and former coalition aviation minister John Sharp, even gave a media interview in which he admitted there ‘was no plan B’.  The operator didn’t even have a written oceanic fueling policy.  It was an appalling state of affairs, all seemingly brushed under the carpet by two safety authorities and a federal department.

One of those people on the flight was quite seriously injured, yet more than five years later, she is being appallingly treated, even gloated over by some parties on the basis that Australia’s air regulations in respect of such accidents were so lax/ or non-existent, that anyone using them had no legal protection whatsoever.  (Which may not prove to be the case, of course.)

That regulatory vacuum persists to this day, despite lies from CASA under previous management as to how promptly it was going to fix the situation, and an apparent paralysis of that organization under a recently departed head of safety when it came to actually reforming or performing any of its obligations to aviation stakeholders and the public.

However the testimony of Dolan to the Senate, and the tale of administrative incompetence and lack of clear management on his watch during the bungled Pel-Air inquiry that is set out by the TSBC peer review ought to have him out of the door on skates.

The identification of the secretary for Infrastructure and Regional Development, Mike Mrdak with the Dolan, ATSB and CASA positions on the Pel-Air inquiry places him in a difficult position. Mr Mrdak took his Minister, Mr Truss, to a place where the Minister no longer wants to be, which is always in hindsight, a bad, bad move.

It was Mrdak’s department that told Truss to reject earlier calls, including from the Senate committee inquiring into the ATSB, to recover the flight data recorder from the Pel-Air wreckage and redo the findings, which were essentially a lazy and incomplete scapegoating of the pilot in charge of the Westwind.

The privileged Hansard records of the testimony of Dolan, the then director of air safety for CASA, John McCormick, and Mrdak are substantially incompatible with the findings of the TSBC.

It was Mrdak’s department that wrote the original position taken by Minister Truss that there was no point in retrieving the flight data recorder or correcting the accident report.  It will be interesting to see if Mrdak can perform the necessary U-turn, and repudiate his previous words, while remaining on top in Infrastructure.

When Minister Truss’s Air Safety Regulation Review panel, chaired by David Forsyth, reported at the end of May this year it anticipated that the TSBC report would be both critical and released in the near future.

It was however, repeatedly delayed, to the point where some feared it mightn’t even see the light of day, given reported resistance to its contents within the ATSB.

The report released on Monday was written in a manner likely to put a casual reader into a coma.  But for those who read the full document, it proved highly critical of the ATSB, setting out comprehensive failings in terms of collecting and assessing information.

There was dissent within the investigating team, to the point where a ‘coach’ appointed to assist in the inquiry, sought, eventually successfully, to be relieved of his role.

The TSBC dealt deeply with the disruption caused in the investigation by uncertainty over the appropriate relationship with CASA, which conducted parallel inquiries, including an audit that was withheld from the ATSB, into the Pel-Air Westwind operation subsequent to the crash.

As reported earlier in Plane Talking and examined by a Senate committee into the ATSB’s procedures in relation to Pel-Air, CASA suppressed an audit that found that the crash could have been prevented had the regulator carried out its own duties of oversight over the Westwind operation.

The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report, in which the committee took that rare if not unprecedented step of giving a section of their findings to their lack of confidence in the testimony and conduct of the chief commissioner of the ATSB, Martin Dolan.

Today’s decision to have ‘another look’, which to be clear, is a direction not a suggestion, reflects poorly on Truss’s Labor predecessor Anthony Albanese.

Mr Albanese broke several commitments to deal with the adverse Senate findings into the ATSB, and was ineffectual or unwilling in relation to the Pel-Air issues, which first arose on his watch with ample opportunity for ministerial direction or intervention.

Mr Truss has not escaped criticism in this portfolio either, and not just from Plane Talking.  But something has changed, this damaging and disgraceful report will be ‘fixed’ in its procedural or methodological shortcomings, there is already a new Director of Air Safety at CASA, and there may well be further changes for the better in the administration of air safety.

How things have changed? NOT! - MTF...P2 

[Gobbledock]

P2;

How things have changed? NOT! - MTF...P2 Angry

One could say that it’s all tautological?

[Peetwo]

The lessons of 1st PelAir final report; obfuscated and forgotten a decade on?? -   

Reference: A decade of obfuscating an open safety loop??

And in particular this 'supposedly' adequately addressed/closed ATSB Safety Issue: https://www.atsb.gov.au/publications/inv...190-si-14/  

Issue status justification: The ATSB is satisfied that CASA has undertaken action to address this issue since November 2009.

Safety issue description
The Civil Aviation Safety Authority’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.

Proactive Action

Action number: AO-2014-190-NSA-040
Action organisation: Civil Aviation Safety Authority
Date: 23 November 2017
Action status: Closed

In August 2017 (after receiving the draft ATSB report for the reopened investigation), CASA advised the ATSB:

CASA implemented a national approach to surveillance in 2012 with the introduction of the CASA Surveillance Framework which is documented in the CASA Surveillance Manual (CSM). The CSM identifies possible systems and system elements for holders of each authorisation type, and necessitates that those elements relevant to a particular authorisation holder are identified when preparing for a surveillance event—including noting areas of potential system vulnerability.

In the preparation process, inspectors are required to review a range of information—including the authorisation holder's policy and procedures manuals—and identify specific areas and risks to be assessed or reviewed. The information, data and history known about the authorisation holder assists in determining the scope and depth of each surveillance event.

CASA has developed safety risk profiles for a number of sectors of the aviation industry, and is continuing to develop safety risk profiles for the remaining sectors. These sector safety risk profiles enable a shared understanding between CASA and industry of hazards that sector participants must address in order to manage their risks and enhance safety outcomes for the sector. CASA is working to enhance the use of sector safety risk data to inform the scoping of surveillance activities.

CASA is currently developing and implementing a National Surveillance Selection Process (NSSP), which will be an enhanced systematic approach to the prioritisation of CASA's surveillance activities. This will include improved authorisation holder risk and performance profile capabilities, including integration of relevant sector information. The NSSP is expected to be fully deployed by June 2018.

Then this reference to the now discontinued investigation into the VARA SMS and CASA oversight of that SMS:

The ATSB notes the surveillance planning and scoping form provided by CASA to its inspectors is still the same as the form used from 2004–2009, and this form does not refer to 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.

Nevertheless, the ATSB acknowledges CASA’s surveillance processes have undergone significant evolution since 2009, and that it is continuing to review and develop its surveillance processes. It should also be noted that the ATSB will review CASA’s oversight processes since the introduction of the CSM in 2012 during the course of other investigations, including investigation AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion).

 
So after reading any of the above waffle does any reasonably intelligent, rational person honestly believe that the safety issues highlighted by the PelAir (cover-up) ditching investigation (x2) and the damning VARA (cover-up) accident investigation (In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014) have actually been adequately addressed - anyone?? -        

Which brings me to the following (related) CASA Additional Estimates AQON (remembering that PelAir is a subsidiary company of Rex Airlines):

Senator Malarndirri McCarthy asked:

Senator McCARTHY: The Australian Licensed Aircraft Engineers Association has raised the issue of another Rex engineer who has been treated in a way that is contrary to the principles of just culture. I'm talking about an engineer who was subject to disciplinary action after the aircraft he was taxiing clipped a bin. The engineering investigation found that the line markings on the tarmac for taxiing were in the wrong place and had been incorrectly marked, and no fault was attributed to the engineer. The Rex general manager, however, ordered an investigation be conducted by human resources and determined that the engineer was professionally negligent. Has this been reported to CASA and are you aware of this?
Ms Spence: I'm not aware of it. I will have to take on notice whether it was reported to CASA.
Senator McCARTHY: I do understand that the association has reported it.
Ms Spence: I'm just not aware of it, I'm sorry.

Answer:

On 27 May 2019, the Australian Licensed Aircraft Engineers Association (ALAEA) informed the Civil Aviation Safety Authority (CASA) Chief Executive Officer/Director of Aviation Safety, Mr Shane Carmody, by email of concerns relating to Regional Express (Rex) Approved Maintenance Organisation (AMO). These complaints related to the Safety Management System (SMS), the discouraging of reporting maintenance errors or defects, and Just Culture.

Included in this letter were incidents relating to a single engineer, including the taxi incident.

CASA contacted Rex about the allegations and conducted two surveillance events in July and October 2019 at the Rex’s Wagga Wagga maintenance facility, and Rex’s Sydney Head Office, with a focus on safety culture and the reporting of defects and maintenance errors by engineers.

The intent of both audits was to establish whether the alleged safety-related risks identified in the ALAEA letter had any foundation, ascertain what follow up of the events had been carried out, the operational effectiveness of the Just Culture within the Rex AMO, and for CASA to be satisfied with the level of operational aviation safety in the Rex operation.

As reflected in its Regulatory Philosophy, CASA defines ‘Just Culture’ as follows.

CASA embraces, and encourages the development throughout the aviation community of, a 'just culture' as an organisational culture in which people are not punished for actions, omissions or decisions taken by them that are commensurate with their experience, qualifications and training, but where gross negligence, recklessness, wilful violations and destructive acts are not tolerated.

Interviews were held with four engineers. Some were selected at random from a shift roster during the Wagga Wagga visit on 4 July and some volunteered for an interview following the Sydney visit of 28 August. From the interviews conducted the engineer cohort were seen to have an understanding of Just Culture in the organisational and individual context.

As a result of the two surveillance activities, the audit team were satisfied that the Rex SMS was operating and effective in the areas examined. The Accountable Executive and the senior management team were aware of the safety risks faced by the organisation. SMS principles, including Just Culture, were found to be implemented throughout the organisation.

The evidence produced or discovered during the 2019 audits did not result in any Safety Findings or Safety Observations.

  
Hmm...I wonder if CASA (as per the ATSB/CASA MOU) shared the findings of their 2019 investigations/audits with the ATSB?  - 

Maybe they did and maybe that is why the ATSB decided to discontinue the VARA SMS investigation:

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation. The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations.

v

Regulatory surveillance – scoping of audits

The Civil Aviation Safety Authority’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.

Safety issue details
Issue number: AO-2014-190-SI-14
Who it affects: All operators
Status: Adequately addressed

Reference - safety issues: https://www.atsb.gov.au/publications/inv...-2009-072/

Much MTF...P2 

[Peetwo]

Chillit renames the TSI Act??  - 

Via murderatzenith.net : 

CYA With Australia’s TSI Act

February 15, 2023 by admin

Australia’s TSI Act is the mechanism that allows that nation to hide transportation-related screwups, including well-documented failures to conduct intelligent, responsible searches for Pel-Air in 2009 and again for MH370 in 2014 and beyond ad infinitum. So inept is the organization as a whole that Canberra had to ask Canada, another Commonwealth Nation, to intervene to correct blunders made in Canberra during the 2009 Pel-Air accident investigation.

The Act, referred to as the “TSI Act,” does not require Australia to have a single sniff-test reason for hiding screwups. In its wisdom, Canberra does not have a “no bull*hit threshold” when invoking the Dome of Silence over yet another ATSB-caused disaster. Whenever someone with a little authority gets tired of seeing screwups in newspapers, they reach for the Act outlined below.

Fortunately or unfortunately, the Act’s primary advantage for the rest of the world is that it helps highlight the incredibly low level of expertise in Australia’s transportation sector. Travel to Australia, and you are on your own.

Keep in mind that were it not for Canadian forensic expert Larry Vance, most would still believe MH370 was lost somewhere in the Southern Ocean in a high-speed dive. That did not happen. MH370 is a mere 2,760 kilometers south of its departure airport at Kuala Lumpur and was set down “softly” by the hijacking pilot.

Australia appears to be so ashamed of the mess it made during a four-year search that was closer to the South Pole than to the departure airport that it secretly forked over big bucks to US firm, Ocean Infinity, to simply give the appearance that the plane was “unfindable.” Actually, MH370’s terminal location had been known and documented by Canberra long before Ocean Infinity arrived on the scene. And it appears from all available evidence that Ocean Infinity fully understood that the plane’s location was already well known in 2018 when it deliberately cut its “showboat search” short just as it approached the already confirmed debris field.

There are probably some who consider the TSI Act sensible. Especially for dictatorships. Others may find it the ultimate “Cover Your Ass” nonsense by a tin pot government masquerading as a democracy.

This is the Act that permits Australia to deny Freedom of Information requests made in good faith by families of Chinese victims. This is what allows Canberra to tell the entire world to “buzz off” when it comes to learning what is known about the fate of MH370, its passengers, and crew.

Australia is currently seeking input on how best to amend and update this Act. Perhaps, savvy reader, you can think of suggestions? If so, here are two telephone numbers and an email address. There are more at this link: ATSB Contact Options Page

International inquiries:

1800 020 616 (option 2, then option 3)
International: +61 2 6122 1600
Email: international@atsb.gov.au
National telephone translation service: 131 450

Excellent stuff MC...love it - 

MTF...P2 

[Peetwo]

Tenth Anniversary of the Senate PelAir report and what's changed??

Via Joining Dots:

How the tragedy of Young's Monarch plane crash paved the way for safer skies

11 June 2023 | Edwina Mason



Police officers at the scene of the Monarch Airlines crash near Young 30 years ago. Image: National Library of Australia.

---

Thirty years ago on this day – June 11 – a small 10-seater Piper PA31-350 Navajo Chieftain attempted several landings from the south of Young’s airport around 7:10 pm.

Travelling from Sydney – the Monarch Airlines flight OB301 flight carried seven occupants, including the two pilots.

It was a bleak moonless night, so characteristic of June in the NSW South West Slopes, one where low cloud and darkness conspired with blowy, icy conditions and undulating tree-scattered terrain to challenge any pilot flying into the small aerodrome.

Two flights were scheduled for arrival. Waiting families and friends huddled in the small stark aerodrome building.

From above, the only sign of life below was the light from that building and tarmac lights. From below, the unmistakable drone of an engine, flashing small wing lights as the craft circled the airport.

One aircraft landed that night. The other didn’t.

Searching beyond the rain-shrouded landing strip on a hill, a light was sighted. It remained stationary.

That light was a fireball; the result of Monarch Airlines flight crashing into a hill on approach, first hitting three successive trees, leaving what remained – the fuselage – to land on a boulder, split in two, one part landing on the plane’s already severed right wing before incinerating in a fire fed from an estimated 366 litres of aviation fuel.

Everybody on board died as a result of the impact and fire. One not immediately.

One survivor had been thrown from the plane. She was discovered near the wreckage around 8 pm. The following morning in Sydney’s Camperdown Children’s Hospital she succumbed to her injuries.

She was one of three Pymble Ladies College students – Allanda Clark, 16, Jane Gay, 14, and Prudence Papworth, 14, – homeward bound from boarding school on a flight that included popular Cootamundra councillor Stephen Ward, 42, and Queens Counsel William (Bill) Caldwell, 45, whose farming family have long been connected with the district.

Also killed were the pilot Wayne Gorham, 42 and co-pilot Brynley David Baker, 24.

Today a bronze plaque fixed to a granite rock atop that hill memorialises those seven killed. But the anguish is still lugged around in the hearts and memories of those whose recollections of that crash remain undimmed.

One of those people was John Sharpe.

Away with his wife celebrating their anniversary – he took an early morning call from a friend to see if he was still alive.

“I said “yes, why do you ask,” and the caller said the local radio was saying a politician was killed in that crash last night,” John told Region.

John had notched up nine years with the Nationals representing Gilmore which had been redistributed into Hume.

He’d grown up beside and overlooking Young airport – his sister and he with their parents on a historic property called “Clifton”. Also a pilot, he was a member of the Young Aero Club.

“So I knew that the airport runway in the surrounding territory pretty well, and I knew about that hill,” he said.

Bar the co-pilot, he also knew everybody on that flight.



Days after the crash, the MP who was also the federal shadow transport minister, stood at the site with an overpowering sense of responsibility in finding answers.

“Yes, it was personal – I knew most people on that flight and their families, I was standing on the burnt grass trying to work out, like everyone else, how this had happened”.

Time froze as news of the crash reverberated around the district – to this day, most recall with unmistakable clarity what they were doing when they heard.

“The feeling in the community at the time was obviously very overpowering because we’d lost six people from the local area. Many of them young kids, high school kids coming home for a long weekend,” he said.

“I made it my mission to pursue the reason why this crash had occurred.”

Thirteen months later, the Bureau of Air Safety Investigation’s (BASI) official report said the final uncommanded descent was merely a culminating factor. Weather and climate were implicated. The weather evident; the climate less visible but equally real: the priorities, assumptions and values under which the airline and its regulator operated.

Missing instruments, inadequate training and commercial priorities; the airline had been red flagged six weeks earlier but remained operational.

The day following the crash, John said, bizarrely, it continued flying into Young.

“What I couldn’t work out was how this could occur right under the very nose of the then Civil Aviation Authority (CAA) when they were literally almost next door to Monarch’s offices and building and all these things were going on right under their nose.”

“As somebody who’s been a pilot, you understand these things moderately – you sort of say to yourself this surely couldn’t have happened if the safety regulator was doing its job.”

Also buried beneath Monarch’s wreckage, rattling revelations about national airline safety regulation, showing systemic failures in the CAA’s safety surveillance operations.

“People were coming to me with all sorts of stories about what was going on and how the rules were being bypassed and airlines were operating unsafely,” John said.

“The more I learned, the more incensed I became, and the more motivated to make changes. I became emboldened,” John said, “because when you make these claims publicly, you get criticized by all sorts of people – they really hop into you and they call you all sorts of things, but you get to get involved because you think ‘you can say all that, but guess what?'”

“People die when you get it wrong. And you’ve got it wrong, and people are dead. And to me, that’s completely unacceptable. And we can’t let it happen again. And I’ll do my best to make sure it doesn’t.”

One CAA whistleblower would bleed official files concealed in rolled-up copies of The Canberra Times to John’s chief of staff, also carrying a rolled-up copy of the paper, at Woden Bus Interchange.

With this, John had the ammunition necessary to campaign against the CAA with parliament as his platform.

On 4 May 1994, he warned parliament of an airline operating so dangerously it was putting people’s lives at risk if it continued to fly.

John said it gave him no satisfaction that those concerns were most sadly proven correct by the Seaview crash in October that year.

By July 1995, the CAA had been split into an airspace management organisation called Airservices Australia, and an aviation safety authority, the Civil Aviation Safety Authority (CASA).

In 1996 John became federal transport and regional development minister, initiating a complete rewrite of the CASA’s regulations with robust powers still enforced today.

“I’d like to think we’ve reduced the risk of flying, reduced the accidents,” he said.

William Caldwell’s wife Hilary became a founding member of the Airline Passenger Safety Association, was a consumer representative on CASA’s Program Advisory Panel (PAP) and, in 2000, was appointed to a new consultative body, the Aviation Safety Forum, formed to provide strategic advice to the Civil Aviation Safety Authority (CASA).

“I wanted her there to oversight operations so at least they have somebody who knows what it’s like when you get it wrong,” John said.

“Monarch was a tragedy that should never have happened, as was Seaview and I look back and I think, because of all that things are safer, we’ve fixed a lot of those problems and the effort was worth it,” John said, “nothing will bring those people back you realise, nothing’s ever going to bring them back”.

Original Article published by Edwina Mason on About Regional.

    

All those noteworthy comments from John Sharpe and yet 16 years on when the PelAir Norfolk Island ditching occurred JS (now in the real commercial aviation world) flipped flopped from the 'pilot was a hero' to the 'pilot ducked up, operator PelAir err...nothing to see here!!' Then the slight of hand Rex 250k donation to the Labor Party?? - Ref: https://auntypru.com/what-will-a-quarter-buy-you/ & ATSB search for IP remains elusive    

In the end this led to Albo ducking making any timely Ministerial and Govt response to the disturbing, factually overwhelming evidence and clinical findings of the Senate RRAT Committee PelAir (AAI) Inquiry - cue MSM CH7 legend Chris Reason shirtfronting Albo...  :

A decade on and what have we got?? Now PM Albo ducking and weaving, spinning and lying about anything remotely resembling being accountable or transparent on any of the growing list of his Government's economically detrimental policies...  

The guy has had form for a very long time, starting with a policy setting that began the final decimation of a once vibrant GA industry punching well above it's weight. And remember he was the dude that in his own self-interest (IE protecting ministerial rump) decided in 2009 to make the ATSB an independent statutory authority - hmm and how's that worked out since??    

MTF...P2