[Sandy Reith]

K, you are on the right right tram but maybe jumped off in frustration before terminal conclusion. This is a place that has glittering prizes provided one can eschew and forgo the mind lolly comfort stations. Don't we grumble about government planners but in the end acquiesce and succumb to the keepers of Crown Privilege? Then there's the discomfort to perceive the vast money flows guided not by Adam Smith's invisible hand of free enterprise but by political influence.

Australians rail against Authority but cry "there should be a law against that". We foolishly accepted that we were recipients of a government gifted "privilege" to fly. We accepted Aviation Mediclals and huge piles of regulations and everyone has an opinion about how everyone else should technique their job.

We set up Canberra, our biggest mistake. A model capital without that messy free enterprise stuff. A souless city of stratified socialist control, near 400,000 that must extol the necessity of planning and the virtue of deleting risk from life. Guess who pays the bill? Where a $600,000pa public servant can walk out of his five year contract after less than two years with no explanation to taxpayer or industry. He was head of his excruciatingly named Tiger Team, the Exemption inventors for the $300 million dollar new and unworkable aviation rules.

Melbourne said to be the World's most liveable city, how smug can you be? Yes fine if you already own a piece of it and accept the traffic jams and grotty bits of planner frozen wastelands. You have your little piece of dirt, your number one asset;  value artificially pushed up by "planning", read government control, to stratospheric levels thus bloating banks with mountains of mortgage moneys and leaving the not so well off and new comers out in the cold with little to do but take the dole, make trouble and wonder how previous waves of migrants did so well (ie. Before Planning). To you younger people yes BP was a time. In the 50s, 60s you could make an airstrip where you wanted. I bought seaside building blocks for $400 each realising, correctly, that the artificial land zoning would create a price hiking shortage. There was practically no unemployment. You could by a house in Brighton for $16,000. Before Planning, early 70s, really started to bite we made it to USD$1.50 for one of ours. Imagine shopping in the US at that rate. We've become so stupid that we think, like Glenn Stevens, that it's a good thing our dollar is devalued. Everything in Australia is worth less to the world than it was before, even your cups and saucers. How's that for clever country?

We have to get past the ifs and buts, freedom works, great prosperity, better environment (EPA laws are good) is within reach if we go for property rights and cause government to relinquish its mindset of micro management by institutionalized bureaucracy. We can't afford the present trajectory, something has to give, it can go well if we try, otherwise we continue to muddle along downhill.

'K' - Edit - Choc Frog Sandy.

[Gobbledock]

The economic ship is listing.....abandon ship abandon ship

Sandy, well said. Top points.
However sadly, history is born to repeat itself. It's the dent in our DNA cake tin - no matter how hard people try to bake the perfect cake, it always comes out with the same dent in it. Financially, each cycle lasts around 40 years give or take, then it's Shitsville! We are at that cusp again.

Look at this pathetic world. Three examples only;

1. Start with Germany. Thought they had learned from the currency collapse and hyperinflation of 1923? Nope. Frau Merkel, who has spent years promulgating the 'too big to fail' Deutsche Bank and how it is the worlds strongest banking institution is now realising how wrong she has been. Not long now til Deutsche Bank runs out of printer ink and can no longer keep it's Ponzi going. Too bad for the German sheeple the
morning after the inevitable 'bank holiday' and they wake up to the realisation that all those electronic digits that make up their bank accounts are gone! Tick tock the time bomb is coming.

2. Surprise surprise, roughly 40 years later, another continent and more shennanigans. For our American friends 1971 was one of the most significant in history in which the unilateral cancellation of the direct international convertibility of the United States dollar to gold. Gold standard Goooone! The Central Banks pulled puppet Richard Nixon's strings and the rest as they say is history. The Banksters will forever do their utmost  to rid the world of precious metal value because you can't fake it, print it, replace it with digital numbers on a computer. Do the USSA get a tick tock? They sure do. That treasonous act back in 71 has set the framework for where we are today. Again roughly 40 years between the destruction of the gold standard and GFC 2008 (which incidentally was just the precursor bubble to the big bubble sitting out our doorstep). Tick tock, you got that right.

3. That brings us to 2016. Dear oh dear, what an abhorrent mess. As Sandy pointed out, Australia is itself evidence of a broken corrupt system. Medium price range for a city shitbox in Sydney - $1m. Say no more! But I will. Toronto house prices  crashing up to 60% in the past two months, New York (yes the worlds greatest city) with an increase in the homeless by 23% in the past 12 months. The great USSA where the average wage is $30k and 99% of the wealth created in the past 8 years under Obama has gone to the 1%, the worlds richest.

And not to forget the final desperate move of the rule changers who rig the system and keep the Ponzi scheme going - Abenomics! Yes, that nifty idea out of Japan called 'negative interest rates'. That's right, you, the little person get to put your money in the (not so safe) bank, and you pay THEM for the privelege by copping negative interest rates! Yes, it costs you money to let them look after your worthless paper. What an effing farce!

So let's see what the next year or two bring under the stewardship of Goldman Sachs Turnbull and his conga line of silver spoon millionaire ministers. But from where I sit the global wrecking ball has gathered immense speed and the pain has yet to begin.

TICK TICK. Christ yes.

P2 on thread drift - Due the significance of the last three posts in the 'State of the Nation' (& Aviation), I have copied across to the Mandarin thread - Ministers, Mandarins & Minions: The road to dusty ruin - which IMO is the most applicable board for this fascinating debate...cheers P2

[Peetwo]

Aviation Safety: All roads (should) lead to Montreal -

 As I read the Ferryman SR - which IMO summarised quite nicely Australia's 'Nanny State' conundrum where governments of all persuasions seemingly have this endless love affair with layers & layers of bollocks rules, regulations & red tape - my 1st thought was has P9 lost his marbles posting in a thread dealing with international aviation safety standards and Australia's indifference (non-harmonisation) to those standards???

But then the penny dropped; it is actually more to do with how our convoluted, voluminous & hugely prescriptive regulations and aviation safety standards are totally out of step with the performance based regulation and aviation safety standards philosophy set by ICAO and being enthusiastically adopted by rest of the 'sane' aviation world.    

The following will hopefully shine a light on the huge impediments being inflicted on our aviation industry, by an out of control aviation safety bureaucracy, which is increasingly out of sync and merely paying lip-service to ICAO accepted standards. 

Most of the ICAO signatory states, including those who have been red-flagged, are proactively seeking to adopt a philosophy on aviation safety standards that is based on 'performance based regulation' and a strong adherence to the ICAO SARPs (Annexures).

The following is an extract from the AP 'international accidents' thread:

ICAO: Nepalese State AAI no improvement in 3 years.

According to ICAO Nepal is literally the most dangerous place to fly and since the last 2013 ICAO audit the Nepalese AAI (Annex 13) standards are not improving...

Nepal’s aviation on a wing and a prayer
ICAO says no improvement in air accident investigation in the past three years
Published: September 08, 2016 6:01 am
Rajan Pokhrel

Now here is a 'heads up' for Chester, Murky & his minions:

"..According to him, the key takeaway from the Tokyo meeting was the independence of the investigation process. He added that to ensure total objectivity and impartiality, ICAO had stipulated that the investigation authority should not report to the same minister responsible for the regulation and/or safety oversight of civil aviation, a practice that is not being followed by Nepal..."

Such a damning indictment of the Nepalese AAI standards compared to the acceptable standards, as outlined in ICAO Annex 13, got me thinking on how bad their investigations and final reports could possibly be compared to our much internationally maligned ATSB..

Air Kasthamandap crash caused by engine failure: Probe report
- SANGAM PRASAIN, Kathmandu




Sep 18, 2016

The crash of an Air Kasthamandap plane at Chilkhaya in Kalikot last February was caused by engine failure, a probe report has revealed. Both pilots were killed while the nine passengers on the charter flight survived...

...The report said that engine failure was not the sole reason behind the crash. “Although single-engine aircraft can glide a fair distance after losing power to execute a safe force landing, the route lacks proper landing spots,” said Hari Bahadur Khadka, member-secretary of the commission.

The crew had flown for nearly 15 km searching for a suitable landing spot after the engine shut down. “There should be a force landing spot for every three minutes of flying distance, but no such spots were designated,” said Khadka, adding that the civil aviation regulator had also not followed up on this issue.  

P2 - Note the part in bold. This suggests to me that the Nepal CAA has some form of adaption of the ASETPA rules. However the only reference I can find is in a 2009 version of the Nepalese regulations - see HERE.

 5.3 Additional requirements for operations of single-engine turbine-powered aeroplanes at night and/or in Instrument Meteorological Conditions (IMC)

5.3.1 Operation by single-engine turbine-powered aeroplanes at night and/or in
IMC, an Operator shall ensure that the airworthiness certification of the
aeroplane is appropriate and that the overall level of safety intended by the
provisions of:

a) the reliability of the turbine engine;
b) the operator’s maintenance procedures, operating practices, flight
dispatch procedures and crew training programmes; and
c) equipment and other requirements provided in accordance with
Appendix 3 (insert reference).

The report said that the accident "could also be the result of the financial health of the airline”. Khadka said, “Due to the deteriorating financial condition of the company, it was unable to conduct proper monitoring of the operation. It had not been able to retain technical manpower due to financial stress.”

Meanwhile, the investigation committee has concluded that the Civil Aviation Authority of Nepal has not been able to oversee the use of different types of aircraft due to capacity constraints. This has affected efficient monitoring of the Nepali skies, it added...

Considering Nepal is one of the least developed and under resourced nations in the world, with huge topographical and infrastructure issues, IMO they have done remarkably well to address and improve on all but one (i.e. AAI) of the eight ICAO critical elements.

In an endeavour to track down where the 2016 figures, compared to the 2013/14 audit figures, were sourced from I made an interesting but somewhat perplexing and disturbing discovery.

The following is the ICAO reference webpage where those figures for Nepal are listed:

Safety Audit Information

Page Content

This information has been updated and relocated from the ICAO Flight Safety Information Exchange (FSIX) website. You can use the search box to find a State and then compare the result of its last USOAP CMA activity with the global average or any other State on the list. The Effective Implementation (EI) of each Audit Area is rated from 0% to 100%, with 0% being "Not Implemented" and 100% being "Fully Implemented". The EI score represents the percentage of satisfactory USOAP protocol questions applicable for a given State.

For developers, the EI scores can also be accessed via the iSTARS API Data Service.
 
Please note: A significant safety concern (SSC) does not necessarily indicate a particular safety deficiency in the air navigation service providers, airlines (air operators), aircraft or aerodrome; but, rather, indicates that the State is not providing sufficient safety oversight to ensure the effective implementation of applicable ICAO Standards. Full technical details of the ICAO findings have been made available to the State to guide rectification, as well as to all ICAO Member States to facilitate any actions that they may consider necessary to ensure safety. The State has undertaken to regularly report progress on this matter to ICAO. Read more
 
Other links related to USOAP CMA:
 

• Video on Youtube (2 min) on The Launch of CMA 
  
• CMA Interactive Presentations in all ICAO languages>
  
• Frequently Asked Questions (FAQs) on CMA
  
• CMA Forum
  

Now if you click on the link provided you will see that it is possible to review the current status for any signatory State on all of the 8 critical audit categories against the ICAO Global average.

It is also possible to compare individual signatory states against each other. For our purposes click on compare for Australia and then Nepal. Now go to the graph with the mouse pointer and hover it over the brown graph (Nepal) for accident investigation. You will see that the 20.41% 2016 figure (as above) is replicated.

Now go to the purple graph (Australia) for AI and you will see there is a totally UDB bollocks figure of 96.97% (3.03% percentile points off a 100% compliance... ).

But how can that be when we have, on the record, very damning recent evidence of very substantial failings of the effectiveness of the State AAI (i.e. the ATSB)? 

Examples:

• The TSBC peer review report.
  
• The Senate PelAir cover-up report.  
  
• The nearly 2 year PelAir re-investigation which has a IIC that has a proven conflict of interest with there being a fully independent, without fear nor favour final report being produced.
  
• The production of totally useless and seemingly Annex 13 conflicted final reports for several significant, potentially politically sensitive, serious incidents and/or accidents (e.g. Mildura Fog duck-up, ATR VARA birdstrike cover-up).
  

Basically our State AAI is a total basket case that is IMO in direct conflict (non-compliance) with the ICAO Annex 13 & 19...

Therefore one has to question the veracity of the ICAO (2016) figure of 96.97 percentile points of compliance, especially considering the last time the Australian aviation safety system was properly audited by ICAO was in 2008??

Digging a little deeper what I've been able to establish is that the figures, as listed for Australia, are based on what is fundamentally a desktop (ICAO CMA) questionnaire answered by Murky's department and the applicable agencies.

Therefore this is the equivalent of an ICAO tick-a-box survey, which basically asks for an individual State's perception of where they feel they sit on the 8 critical audit categories.

Now here is the rub, from what I have been able to establish the ICAO (CMA) questionnaire is the 'heads up' that there is an ICAO USOAP audit imminent...

Watch and absorb the following:

Hmm...miniscule DDD, Murky (& his minions), better get those ducks in a row....tick..tick..tick..tick - 




MTF...P2


     

[Gobbledock]

The ICAO 39th Triennial Apple Bobbing From A Trough Party has kicked off in Montreal, September 27 to October 7, 2016.

They will be even having the aptly named 'Sky Talks'! Woohoo, how exciting. After all, they just loooooove to talk;

http://www.icao.int/Meetings/a39/Pages/default.aspx

The greatest congregation of aviation wankers to be gathered in one place. They even had extra long name tags made so that acronyms such as Dr, or PHD, or AVM and DIPSHIT can be accommodated on the badge. Most important.

Now I don't know if Australia's representatives for the 'wank word extravaganza' will include Herr Skates, or whether it will be Wingnut, Dazzling Dazza or Pumpkin Head, but I'm sure other wordsmiths like Dr Voodoo, Brooks, Hutton, Flyingfiend and additional cling-on's will make an appearance.

So step right up folks, bob for an apple or spin a wheel because everyone is a winner, all attendees win a door prize and the skiing is magnificent this time of year. Take your throat lozenges and knee-pads because there will be lots of blah blah blah, plenty of gadding about, many hypothesis to discuss and endless wristies dished out to those who get aroused by legal talk, policy promulgation and out of touch bureaucracies!!

"Safe USOAP on a rope for all"

[185skywagon]

The list of attendees can be found at www.icao.int under the delegates section. We are even sending a climate change rep. 

The ICAO 39th Triennial Apple Bobbing From A Trough Party has kicked off in Montreal, September 27 to October 7, 2016.  

They will be even having the aptly named 'Sky Talks'! Woohoo, how exciting. After all, they just loooooove to talk;

http://www.icao.int/Meetings/a39/Pages/default.aspx - HERE.

The greatest congregation of aviation wankers to be gathered in one place. They even had extra long name tags made so that acronyms such as Dr, or PHD, or AVM and DIPSHIT can be accommodated on the badge. Most important.

Now I don't know if Australia's representatives for the 'wank word extravaganza' will include Herr Skates, or whether it will be Wingnut, Dazzling Dazza or Pumpkin Head, but I'm sure other wordsmiths like Dr Voodoo, Brooks, Hutton, Flyingfiend and additional cling-on's will make an appearance.

So step right up folks, bob for an apple or spin a wheel because everyone is a winner, all attendees win a door prize and the skiing is magnificent this time of year. Take your throat lozenges and knee-pads because there will be lots of blah blah blah, plenty of gadding about, many hypothesis to discuss and endless wristies dished out to those who get aroused by legal talk, policy promulgation and out of touch bureaucracies!!

"Safe USOAP on a rope for all"

Who's got the soap ?

[Peetwo]

The list of attendees can be found at www.icao.int under the delegates section. We are even sending a climate change rep. 

P2 - And if you really want to be indefinitely comatose here is the live streaming YouTube link:

AUSTRALIA
 
CARMODY, Shane Patrick
CHIEF DELEGATE
DEPUTY SECRETARY
 
MACAULAY, Kerryn Maree
ALTERNATE CHIEF DELEGATE
AUSTRALIAN COUNCIL REPRESENTATIVE TO ICAO
 
SPENCE, Philippa Jillian
ALTERNATE CHIEF DELEGATE
EXECUTIVE DIRECTOR, AVIATION AND AIRPORTS DIVISION
 

ALECK, Jonathan
DELEGATE
GENERAL MANAGER, LEGAL AFFAIRS, REGULATORY POLICY AND INTERNATIONAL STRATEGY BRANCH

P2 - Besides the fact that it makes me feel ill seeing this smug narcissistic, sociopathic, parasite on the list, it does make you laugh when you get two confessions in one job title description.

Here is the man that IMO has singlehandedly inflicted more damage, for the better part of 3 decades, on the Australian aviation industry through the setting of a totally archaic prescriptive regulatory reform policy, that has cost over $300 million so far and is still years off completion.

On top of that this is the man that as the manager of the 'international strategy (weasel word) branch', was responsible for oversighting the addition of some 3000 odd notified differences to ICAO SARPs, leaving Australia in the most unenviable position as being the most non-compliant 1st world signatory State to ICAO. 

BOLLARD, Jeffrey Ronald
DELEGATE
AIR NAVIGATION COMMISSIONER

LUCAS, Samuel Campbell
DELEGATE
ALTERNATE AUSTRALIAN COUNCIL REPRESENTATIVE TO ICAO

SMITH, Gilon Chaim
DELEGATE
ACTING DIRECTOR, INTERNATIONAL STANDARDS SECTION

SOMMERVILLE, Alison Catherine
DELEGATE
DIRECTOR, AVIATION SECURITY BRANCH, OFFICE OF TRANSPORT SECURITY

STREET, Jeffrey James
DELEGATE
SENIOR POLICY OFFICER, INTERNATIONAL RELATIONS

XIE, Ken Kai
DELEGATE
SENIOR CLIMATE POLICY OFFICER, SUSTAINABILITY AND CLIMATE CHANGE BRANCH

WHEELENS, Anthony John
ADVISOR EXECUTIVE MANAGER - INTERNATIONAL AND REGULATORY AFFAIRS

WOOD, Robert John Gregory
ADVISOR HEAD OF SUSTAINABILITY

The ICAO 39th Triennial Apple Bobbing From A Trough Party has kicked off in Montreal, September 27 to October 7, 2016.  

They will be even having the aptly named 'Sky Talks'! Woohoo, how exciting. After all, they just loooooove to talk;

http://www.icao.int/Meetings/a39/Pages/default.aspx - HERE.

The greatest congregation of aviation wankers to be gathered in one place. They even had extra long name tags made so that acronyms such as Dr, or PHD, or AVM and DIPSHIT can be accommodated on the badge. Most important.

Now I don't know if Australia's representatives for the 'wank word extravaganza' will include Herr Skates, or whether it will be Wingnut, Dazzling Dazza or Pumpkin Head, but I'm sure other wordsmiths like Dr Voodoo, Brooks, Hutton, Flyingfiend and additional cling-on's will make an appearance.

So step right up folks, bob for an apple or spin a wheel because everyone is a winner, all attendees win a door prize and the skiing is magnificent this time of year. Take your throat lozenges and knee-pads because there will be lots of blah blah blah, plenty of gadding about, many hypothesis to discuss and endless wristies dished out to those who get aroused by legal talk, policy promulgation and out of touch bureaucracies!!

"Safe USOAP on a rope for all"

Who's got the soap ?

[thorn bird]

Good grief P2, considering the cost alone I hope Australia's credit rating holds up.

But one question, who's steering the ship with all those "managers" off quaffing champagne and caviar?

Maybe old smart Alec will have a desk in the foyer for book signing his new tome
"Destroying an industry for dummies"

[Peetwo]

Good grief P2, considering the cost alone I hope Australia's credit rating holds up.

But one question, who's steering the ship with all those "managers" off quaffing champagne and caviar?

Maybe old smart Alec will have a desk in the foyer for book signing his new book
"Destroying an industry for dummies"

  Well thorny according to the latest CASA missive it would appear Herr Skates is holding the Fort...

Still on Dr A and as we approach the 2nd anniversary of the PelAir re-investigation, please refer to this blog piece:  PelAir – ‘Lest we forget’ Part III

Ok back to ToRs and setting the scene for...  

PAIN/IOS audit of Australia's SSP (ICAO Annex 19) 




Part I: Critical element Accident Investigation.

Before we get started note that of the original ICAO eight critical elements of a USOAP Safety Audit, 'Accident Investigation' has I believe taken over the previously listed 'resolution of safety concerns' critical element. The reason ICAO have changed the element reflects the introduction (2012) of Annex 19 and the importance ICAO places on the State AAI, according to Annex 13, to the integrity and compliance of an effective State Safety Program (SSP). 

While we review the Australian aviation 'accident investigation' system we have several handy points of historical reference:

1) ICAO 2004 ATSB audit

2) Final report - 2008 ICAO USOAP audit of Australia

3) Senate AAI Inquiry - Final Report

4) ASRR (Forsyth review) Final Report.

5) TSBC peer review report of the ATSB.


So to begin for a comparison to the Nepalese 20.41 % (above pic) and Australian 96.97 %(post #23) for 2016  AI critical element figures, let us refer to Appendix 2 of the 2008 ICAO USOAP audit of Australia, final report:



First thing we can see is that the global average for 'resolution of safety concerns' (now accident investigation) 6.62 %, or .83 of a percentile point a year for the last 8 years. All in all a good progressive achievement by ICAO possibly reflecting the effective implementation and adoption of Annex 19 by most signatory States.

However, despite all the evidence to the contrary (see references 1 thru 5  above), this achievement was totally eclipsed by the Australian aviation safety bureaucracy who managed to lift the critical element statistics for accident investigation/resolution of safety concerns above the global average by a whopping 89.42 percentile points, or a touch over 11% for each of the last 8 years. - Yeah right   

One word BOLLOCKS!- But now time to prove it...  


Much MTF...P2

[Gobbledock]

Safe troughs for all

So here is a very rough breakdown regarding the waste of taxpayer money on the pointless ICAO folly as follows in this very 'general' guesstimate;

Total of around 11 attendees (trough swillers) from Australia;

- Airfares are business class at around $11k each, = $110k
- 7 days accommodation at around $4k pp = $28k
- Meals, entertainment, vehicles and fiddles are approx $2k pp = $14k
- Salaries. Each attendee earns between $200k - $800k p/a. If you take a medium of $350k, divide that by 52 weeks they average around $6,730 per week. Times that by 11 = $74k

Total = $226,000 AUD for this farce.

Correct, a quarter of a million dollars for a group of drips to sit around for a week talking shit and achieving SFA. What a disgrace. What a waste of money. Why don't you stick em in the Formule One Motel in Nudgee Brisbane for a week and get them to use Skype or video conferencing?

Nope, just another opportunity for oxygen thieves and money burners to tickle their egos dribbling bollocks at a conference that achieves nothing but produce piss and wind with no tangible results or actual outcomes, and certainly adds no value to Australian aviation.

Listening to Dr Voodoo extoll his fantasies and giving his interpretation of law in his droning, monotone voice is as exciting as watching two turtles hump each other or watching Darren Chester comb his hair. Or is as useful as trying to paddle across the Pacific Ocean on a clump of dried out elephant shit!

Lunchtime on Day 1 in Montreal;

Oink oink

[Kharon]

Sometimes it's instructive to go back to basic principles, we should be schooled in how society causes civilisation, bearing directly on how much governing do we really require.

One notable architect of the American revolution being Thomas Paine. Architect in the sense that he wrote forceful essays which inspired the American colonists. The following excerpt courtesy the Foundation for Economic Education, a US libertarian think tank.

Quote:

"In The Rights of Man, fifteen years later, he wrote that the

great part of that order which reigns among mankind is not the effect of government. It has its origin in the principles of society and the natural constitution of man. It existed prior to government, and would exist if the formality of government was abolished. The mutual dependence and reciprocal interest which man has upon man, and all the parts of civilised community upon each other, create that great chain of connection which holds it together. The landholder, the farmer, the manufacturer, the merchant, the tradesman, and every occupation, prospers by the aid which each receives from the other, and from the whole. Common interest regulates their concerns, and forms their law; and the laws which common usage ordains, have a greater influence than the laws of government. In fine, society performs for itself almost everything which is ascribed to government.

By way of example, Paine pointed out that

for upwards of two years from the commencement of the American War, and to a longer period in several of the American States, there were no established forms of government. The old governments had been abolished, and the country was too much occupied in defence to employ its attention in establishing new governments; yet during this interval order and harmony were preserved as inviolate as in any country in Europe.… The instant formal government is abolished, society begins to act: a general association takes place, and common interest produces common security.

It is not true, according to Paine, “that the abolition of any formal government is the dissolution of society,” for in fact the abolition of formal government “acts by a contrary impulse, and brings [society] the closer together.” For

it is but few general laws that civilised life requires, and those of such common usefulness, that whether they are enforced by the forms of government or not, the effect will be nearly the same.

To no one's surprise, The Rights of Man was suppressed by the English government. By the beginning of 1792, it had become a crime to be found with a copy of The Rights of Man in one's possession. A warrant was issued for Paine's arrest."

End quote.

A "few general laws" would do very well in aviation remembering that in regard to safety, by the statistics, by far the greatest general rule is recency. In other words the more that an individual flys his safety increase exponentially. Therefore Government get off our backs.

"K" edit - Nicely done Sandy - rings my bells, it says exactly what I tried to say and more. Here, have a Tim Tam. Cheers.

[Kharon]

One word BOLLOCKS!- But now time to prove it...  

P2 - "However, despite all the evidence to the contrary (see references 1 thru 5  above), this achievement was totally eclipsed by the Australian aviation safety bureaucracy who managed to lift the critical element statistics for accident investigation/resolution of safety concerns above the global average by a whopping 89.42 percentile points, or a touch over 11% for each of the last 8 years. - Yeah right."

That, master P2 smacks of upcoming weekend research and head scratching.  But it is a valid point; how can Au possibly claim to have achieved near perfection.  It beggars belief.  What it does prove is that Aleck and Walker are ‘masters of the game’ when it comes to meeting ICAO audit ‘compliance’.  The ‘Beyond all sensible Reason' method and the wretched MoU keep the agencies well away from any possible scrutiny with artful creative manipulation of the numbers.

Met a bloke, years back who said, accountants come in three flavours – those who crunch the numbers; those who make numbers jump through hoops and those who create the hoops for the numbers to jump through. Seems we have quite a team doing ours.

Ayup, count me in, I’ll play.

[Gobbledock]

Skiddies intent - pure?

I'm actually reasonably confident that Mr Skidmore's intentions when he took on the DAS poison chalice were somewhat pure and genuine. The bloke is known to be a reasonable sort of chap, unlike his sociopathic predecessor, however the black hats reign supreme.

Mark, you can't turn back 3 decades of malfeasance, bullying and pineappling in 20 months, probably not even in 20 years with the amount of destruction that has and still is being inflicted on our industry. When you finally acknowledge, even understand that a large part of the root cause has been, and still is allowed to flourish for decades and still remains firmly entrenched and empowered to unleash the same level of bullshit on us you will get where we are coming from.

And yes, this shit gets personal, very personal - businesses, families, careers, finances, health and futures have been destroyed out of spite, vindictiveness, ego and apathy towards fairness and respect.

Skiddies replacement should he/she have genuine good intent and actually be allowed to flex their testicles, could earn some quick wins and grasp some low hanging fruit for starters. Everyone knows where to begin, how to really restructure/clean up CAsA - who to axe, what regs and laws to repeal, white private Parts to scrap or at least 'get them right'.

A fare playing field Brother Skates, that's all we've ever asked for....

Tick tock mate

[Kharon]

CASA and ATSB; an unholy union?

It really is a hellish tangle. Layer upon layer of obfuscation, work-shopped denial, artful justification and more hyperbole than you could shake a stick at.  I am of course referring to the ATSB confection of investigation; the sweet delights found in the Beyond all Sensible Reason approach. I can’t, not with the best will in the world, do the research and reading for you. Neither can I tell you  how to ‘read’ the material. It is as stultifying, mind numbing, tedious and eye glazing, as it is intended to be.  Practical folk, like pilots (particularly) don’t read the published works of ICAO or the glossy, lengthy dribble published by the ‘agencies’; not in the way a lawyer or a judge would and certainly not in the way ICAO would. These documents are writ in different language, the language of the bureaucrat, the diplomat and the policy maker. So, one needs to dig deep and do some head scratching to translate the offerings.  Not many practical folk will– I flatly refuse to, unless there is a need. The Pel-Air report provides that need, the concerns of the Senate Standing Committee (SSC) drive that need and, IMO the industry, the minister and the travelling public need to be made aware of the dreadful state not just the ATSB is in; but the whole sorry saga of the Australian aviation oversight system, despite the ‘feel good’ rhetoric.  Shall we begin by taking a brief look at history, (the exit? - second on the left).

The ICAO Audit – ATSB - June 2004 found the organization in ‘good shape’. Sure, there were a few niggles – it was an audit after all; but essentially Kim Byls and his crew had done a good job and the Reason model was used effectively. The number of Safety Recommendations was on a par with the worlds best; the reports were of benefit to all and the safety lessons and messages were making improvements, as and where required. Then the hoary spectre of Lockhart River enters the fray.  It was a watershed, much changed both during and after that event; a great much.  It was also about the time Doc Walker pitched up and his academic, no shame, no blame, beyond all reason model was grabbed as it suited both parties; CASA and ATSB both delighted to ‘lockout’ the organizational links in the chain. If ever there were ‘organizational’ links in the causal chain, the Lockhart CFIT had them; in Spades.  FWIW, PAIN did a brief analysis of the Lockhart accident – HERE, from the AP library.

The excerpt below takes us to the year of our lord 2007 and is from the Queensland State Coroners findings on the Lockhart tragedy.

“[In] my view, the validity of such a benchmark can be challenged from at least two other perspectives. Firstly, to suggest that the accuracy of deductive reasoning or even speculative assessments to which the approach will be applied can be gauged with such precision is, in my view, misconceived. A calibration that may be ideally suited to measuring tangible items or the outcomes of chemical or physical processes may have no application to the vagaries of human behaviour.

Further, there seems no good basis for requiring the same level of certainty in  relation to all possible contributing causes in all cases and seeking it solely from within the evidence gathered during an investigation. Lawyers apply what is referred to as the Briginshaw principle whereby the level of persuasion or conviction required and the evidence necessary to establish it may vary, having regard to the seriousness of the issue under consideration; the gravity of its consequences and inherent likelihood of it occurring.

The ATSB should perhaps heed the warning of Justice Dixon (as he then was) who, when discussing the level of persuasion necessary to find a fact proven said “It can not be found as a result of a mere mechanical comparison of probabilities independently of any belief in its reality.”

Water off the proverbial duck’s back; no, they heard it alright.  The words simply pointed to an opening, a potential breach, which was almost immediately plugged, to prevent the unthinkable at an indecent speed.

History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve.

The next ‘report’ on the reading list is the ICAO – SOAP final report 2008.  It is interesting in that it subtly but clearly defines the paradigm shift away for Reason and the gradual emergence of the ‘academic’ approach – without the need to examine ‘organizational’ firewalls.  In fact the report almost defines the firewall and cut out circuit breakers between ‘agency’ and operator; which of course suits. The report does get a little more interesting about the Appendix 1-6-01 mark.

‘We’ need to break down the barriers; Aleck as master of the ICAO exemption scam working in concert with Walker, master of no blame game through the MoU have very neatly and quite legally, removed their agencies far from any hint of ‘organizational’ or institutional involvement in not only accident investigation but have managed to detach our aviation oversight from not only reality, but any semblance of responsibility. When you add that to being completely and totally ’above the law’ and utterly unaccountable, an ugly picture appears.

Pel-Air was no aberration; it is the norm. It is however a real life look at how far removed the aviation agencies have become from being accountable and how they are failing the nations air travellers.  The simple fact that the SSC, Forsyth and the TSBC all recognised this as an existing normalized deviance – there is no tangible evidence that any criticism has permeated the isolated, rarefied atmosphere of aviation by academia. They’re all sitting about in Canada, at our expense, selling the same snake oil, to the same gullible people, those who chose to believed it all last time around; despite empirical evidence to the contrary.

P2 – I will keep at it; but right now, I need a breath of fresh air – handing over.

Toot – slightly bemused – toot.

[Peetwo]

CASA and ATSB; an unholy union?

It really is a hellish tangle. Layer upon layer of obfuscation, work-shopped denial, artful justification and more hyperbole than you could shake a stick at.  I am of course referring to the ATSB confection of investigation; the sweet delights found in the Beyond all Sensible Reason approach. I can’t, not with the best will in the world, do the research and reading for you. Neither can I tell you  how to ‘read’ the material. It is as stultifying, mind numbing, tedious and eye glazing, as it is intended to be.  Practical folk, like pilots (particularly) don’t read the published works of ICAO or the glossy, lengthy dribble published by the ‘agencies’; not in the way a lawyer or a judge would and certainly not in the way ICAO would. These documents are writ in different language, the language of the bureaucrat, the diplomat and the policy maker. So, one needs to dig deep and do some head scratching to translate the offerings.  Not many practical folk will– I flatly refuse to, unless there is a need. The Pel-Air report provides that need, the concerns of the Senate Standing Committee (SSC) drive that need and, IMO the industry, the minister and the travelling public need to be made aware of the dreadful state not just the ATSB is in; but the whole sorry saga of the Australian aviation oversight system, despite the ‘feel good’ rhetoric.  Shall we begin by taking a brief look at history, (the exit? - second on the left).

The ICAO Audit – ATSB - June 2004 found the organization in ‘good shape’. Sure, there were a few niggles – it was an audit after all; but essentially Kim Byls and his crew had done a good job and the Reason model was used effectively. The number of Safety Recommendations was on a par with the worlds best; the reports were of benefit to all and the safety lessons and messages were making improvements, as and where required. Then the hoary spectre of Lockhart River enters the fray.  It was a watershed, much changed both during and after that event; a great much.  It was also about the time Doc Walker pitched up and his academic, no shame, no blame, beyond all reason model was grabbed as it suited both parties; CASA and ATSB both delighted to ‘lockout’ the organizational links in the chain. If ever there were ‘organizational’ links in the causal chain, the Lockhart CFIT had them; in Spades.  FWIW, PAIN did a brief analysis of the Lockhart accident – HERE, from the AP library.

The excerpt below takes us to the year of our lord 2007 and is from the Queensland State Coroners findings on the Lockhart tragedy.

“[In] my view, the validity of such a benchmark can be challenged from at least two other perspectives. Firstly, to suggest that the accuracy of deductive reasoning or even speculative assessments to which the approach will be applied can be gauged with such precision is, in my view, misconceived. A calibration that may be ideally suited to measuring tangible items or the outcomes of chemical or physical processes may have no application to the vagaries of human behaviour.

Further, there seems no good basis for requiring the same level of certainty in  relation to all possible contributing causes in all cases and seeking it solely from within the evidence gathered during an investigation. Lawyers apply what is referred to as the Briginshaw principle whereby the level of persuasion or conviction required and the evidence necessary to establish it may vary, having regard to the seriousness of the issue under consideration; the gravity of its consequences and inherent likelihood of it occurring.

The ATSB should perhaps heed the warning of Justice Dixon (as he then was) who, when discussing the level of persuasion necessary to find a fact proven said “It can not be found as a result of a mere mechanical comparison of probabilities independently of any belief in its reality.”

Water off the proverbial duck’s back; no, they heard it alright.  The words simply pointed to an opening, a potential breach, which was almost immediately plugged, to prevent the unthinkable at an indecent speed.

History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve.

The next ‘report’ on the reading list is the ICAO – SOAP final report 2008.  It is interesting in that it subtly but clearly defines the paradigm shift away for Reason and the gradual emergence of the ‘academic’ approach – without the need to examine ‘organizational’ firewalls.  In fact the report almost defines the firewall and cut out circuit breakers between ‘agency’ and operator; which of course suits. The report does get a little more interesting about the Appendix 1-6-01 mark.

‘We’ need to break down the barriers; Aleck as master of the ICAO exemption scam working in concert with Walker, master of no blame game through the MoU have very neatly and quite legally, removed their agencies far from any hint of ‘organizational’ or institutional involvement in not only accident investigation but have managed to detach our aviation oversight from not only reality, but any semblance of responsibility. When you add that to being completely and totally ’above the law’ and utterly unaccountable, an ugly picture appears.

Pel-Air was no aberration; it is the norm. It is however a real life look at how far removed the aviation agencies have become from being accountable and how they are failing the nations air travellers.  The simple fact that the SSC, Forsyth and the TSBC all recognised this as an existing normalized deviance – there is no tangible evidence that any criticism has permeated the isolated, rarefied atmosphere of aviation by academia. They’re all sitting about in Canada, at our expense, selling the same snake oil, to the same gullible people, those who chose to believed it all last time around; despite empirical evidence to the contrary.

P2 – I will keep at it; but right now, I need a breath of fresh air – handing over.

Toot – slightly bemused – toot.

- P2: Tim Tam quality post that one "K", now all I've got to do is come in behind join the dots and colour in the picture...  

However before I do here is a contrary World View on the State of the Oz (Aviation) Nation -  

P2 - "However, despite all the evidence to the contrary (see references 1 thru 5  above), this achievement was totally eclipsed by the Australian aviation safety bureaucracy who managed to lift the critical element statistics for accident investigation/resolution of safety concerns above the global average by a whopping 89.42 percentile points, or a touch over 11% for each of the last 8 years. - Yeah right."

On the one hand: We have the current ICAO wank-fest where once again Dr Aleck is spinning the bollocks that aviation Downunda is just fine & dandy; despite some 3000 (down from 4000 odd) NCN/ notified differences and a festering PelAir re-investigation that Walker, Sangston, Walsh (& apparently the invisible Manning) are desperately trying to put the lid back on and quietly slide into the ATSB (O&O BASR) 'Hall of Shame' archive.

Then on the other hand: Totally unencumbered from the diplomatic bureaucratic back-slapping, trough-feeding currently going on in the ICAO Star Chamber; with a realistic, Reasoned fully independent World view we have the following timely blog piece from Mike (Legend) Chillit...  

Captain's Log - DOI archive entry 01.10.2016 

Via Chillit's 7th Arc blog... :

Australia’s Struggle With Insanity
Posted on September 30, 2016 by Mike Chillit 



The critical “7th Arc”, where MH370 is believed to have crashed, is 4,000 km long in the Indian Ocean, and stretches from Java, Indonesia to -40° South. The 7th Arc appears to be reasonably correct, but less than 25% of it has been searched by Australia’s ATSB, which has lead investigative authority. In spite of not finding anything in the original 60,000 square kilometers, Australia has repeatedly refused to search any other portion of the 3,000 km that remain unsearched.

I will have all vessel AIS information for a 300 km strip on each side of the entire Indian Ocean’s 7th Arc sometime next week. Both “Satellite-AIS” and “Terrestrial-AIS” versions for a 4,000 km strip of ocean. Everything. Deliverables for the now awarded RFP posted one week ago include a graphic of vessel locations between midnight March 5, 2014 and midnight March 10 / 11, 2014. I will also use accompanying digital information to prepare graphics in my own format, but the contractor’s effort to provide its own version is greatly appreciated.

Separately, I will encourage one or two research analysts I trust to conduct their own review of the data. More eyes are better than fewer eyes in all complex analyses, from my point of view. The goal, of course is to identify vessel positions that might help determine where best to look for the missing plane. I continue to place a fair amount of trust in the “7th Arc”. It’s one of the meager bits of information we have that seems to actually be helpful. I have tried to find fatal problems with the 7th Arc construct, and one or more may yet emerge, but so far I have always come back to it as one of the few fairly useful metrics we have.

As readers will know if they follow my mumblings on Twitter and here, the commercial cargo vessel “Stella” was within 150 km of ATSB’s “crash location” at 00:19 UTC March 8, 2014 when ATSB claims the plane crashed in “Penguinville”. And Stella was headed directly into the plane’s descending flight path. If the plane had been anywhere in the area, it would have been seen to within a gnat’s eyelash of absolute certainty. Yet, to my knowledge, no one connected to any Australian entity has attempted to speak to the ship’s Captain or owners to determine if anything was seen. There were thin patchy clouds overhead, but it was daylight in the early morning hours of Autumn in the Southern Hemisphere.

The obvious explanation for the absence of reports from the Stella crew about a crashing airliner is that it did not crash anywhere near where Australia has been searching for nearly three years. There is no other plausible explanation.

If you are in charge of an important investigation, how do you justify closing your mind and all of your senses to the things that were going on at the time you believe such an important event happened? How can you do your job when you close yourself to everything that is at odds with what you prefer to believe? It’s known as being DELUSIONAL.

    
"I'll be back" - with much MTF...P2

[Peetwo]

Ticking boxes & joining dots -


Okay to begin to put this in perspective, sometimes pictures (or in this case graphs) paint a thousand words:



The blue from the 2008 graph was the full & frank ICAO audit team assessment, of where 'we', as an ICAO signatory nation, were at in comparison to the global average, on what was then considered eight critical elements of the FAA/USOAP audit process. You can see that not one single element surpassed or equalled the global average. 

In the 2nd graph purple represents where we are assessed at being now (2016) after our aviation safety bureaucrats (Murky & his minions) have carefully filled out and ticked the boxes in the ICAO USOAP CMA questionnaire/self-assessment process...    

K said - The ICAO Audit – ATSB - June 2004 found the organization in ‘good shape’...
Reference Executive Summary of the 2004 audit report paragraph 4.1 to 4.6:

4.1 The ICAO audit team commended the positive and professional approach of the ATSB in proactively seeking the audit. The team was highly satisfied with the legislative and organizational framework established by Australia and the ATSB enabling the conduct of aircraft accident and incident investigations. Nevertheless, the audit focussed on all areas related to accident and incident investigation and found possible areas of improvement...

...Sure, there were a few niggles – it was an audit after all; but essentially Kim Byls and his crew had done a good job and the Reason model was used effectively...

And with two notable exceptions - what a team , reference paragraph 1.5 2004 audit:  

ATSB officials contacted

Mr. Kym Bills Executive Director

Mr. Rob Graham Director Safety Investigations Branch

Mr. Alan Stray Deputy Director Aviation Safety Investigation

Mr. Patrick Hornby Legal Advisor

Mr. Lawrie Brown Team Leader, Quality and Audit

Mr. Christopher Filor Deputy Director Surface Safety Investigation

Mr. Ian Sangston Senior Transport Safety Investigator

Mr. Phil Robertson Senior Transport Safety Investigator

Mr. Julian Walsh Acting Team Leader, Technical Analysis and

Notification

Mr. Joe Hattley Team Leader, Aviation Investigations

Mr. Greg Walsh Notifications Officer

Mr. Steve Young OASIS Data Administrator

Mr. Andrew Roberton Senior Transport Safety Investigator

Mr. Rodney Newnham Senior Transport Safety Investigator

Mr. William Fry Senior Transport Safety Investigator

Note that the services of Herr Walker - guru of all things beyond Reason - was not called upon - wonder why?

The number of Safety Recommendations was on a par with the worlds best; the reports were of benefit to all and the safety lessons and messages were making improvements, as and where required.

Now this is where, IMO, the true divergence by the ATSB from (a) Annex 13 & recognised World's best practice/methodology in effective AAI; and (b) minimalising the overall iinfluence of 'organisational factors' in the causal (Reason model) chain of accidents/incidents truly becomes apparent.

Reference2004 audit:

..para 1.3.1..The audit was carried out with the objective of ascertaining the capability of the ATSB of Australia and to ensure that it is in conformity with ICAO Standards and Recommended Practices (SARPs), as contained in Annex 13 to the Convention on International Civil Aviation (Chicago Convention), guidance material and relevant safety-related practices in general use in the aviation industry as referred to in such material.

---

2.1 The audit was carried out following the standard auditing procedures provided for in ICAO Doc 9735 — Safety Oversight Audit Manual with the objective of reviewing the relevant activities conducted by the ATSB to determine whether the SARPs of Annex 13 and associated guidance material were being followed. The objective was also to offer advice, as applicable, to the ATSB in implementing these provisions.

2.2 The ICAO audit team reviewed the ATSB compliance with the SARPs set out in Annex 13 and other relevant procedures, and adherence to guidance material and relevant safety-related practices in general use in the aviation industry, as referred to in such material. The ICAO audit team also reviewed whether the ATSB had the organizational structure and the legal status necessary to carry out its obligations.

 
And on Safety Recommendations the report said:

4.6 Safety recommendations are issued by the ATSB in conformity with Annex 13 requirements....

As "K" said, everything was going along swimmingly until the terrible tragedy of Lockhart River...

After that there was a bizarre pendulum shift that IMO saw all the positives, acclaims and transparency of that ICAO audit be almost totally reversed in the negative. One of the indicators that clearly shows this reversal IMO is in the decimation of the 'safety recommendation'.

The following is a link for a short PAIN opinion paper, part of which dealt with the decline of the safety recommendation: Opinion :-ATSB since 2003.

TBC...P2


Ps For the Murky Mandarin ventriloquist dummy, miniscule DDDD (Dumb Dancing Dazzling Dazza), to while away the time in the Chairman's Lounge, preening himself & waiting for his next set of weasel word lines to prattle out on cue from M&M - Simply join the dots DDDD to find what is in the picture...

[Gobbledock]

The good, the bad and the ugly

Love those graphs. They really highlight Australia's past, present and future in brief, nauseating fashion.

Some interesting things that have occurred during that period of time in question; 2004 to 2016. A bit of the good, the bad and the ugly;

POSITIVES
• Kym Bills was high level ATsB
• Alan Stray was high level ATsB
• No stupid ass CAsA/ATsB MOU was in play
• Sangers and Walsh had less power
• Dr Voodoo had less power

NEGATIVES
• The era of McComick arrived
• The era of the Beaker arrived
• Lockhart clusterfu#k
• Pell air clusterfu#k
• The rise and rise of Pumpkin Head
• The rise of Dr Voodoo
• Possibly the worst agreement (MOU) in aviation history was formed between CAsA ad the ATsB.

In reality ICAO's approach is as follows;

2004: good audit. Minor snags, nothing systemic or intolerable. TICK. Good work lads, keep progressing forward.

2008: getting a bit messy now, this Lockhart thing raises a few red flags, numerous deficiencies, and an appearance that some wheels are starting to fall off.

2016: no sign of ICAO, but there is a hint of them in the wind. Australia has now completely slipped backward to the point that it is outshone by Indonesia, yes them of the Garuda and a multitude of other aircraft crash shame. Not to be left out, ASA also takes a huge backward step under Russell, Staib, Electric Blue and Sir An(g)us.
The ATsB implosion is complete and Beaker departs, CAsA undergoes supposed 'transformation' and it's short lived CEO gets punted. If ever a colonic hose was to be inserted into the Australian governments ass now is the right time.

The final oddity is that Wingnut Carmody, overlooked for DAS when Bwuce Bywon left and the Screaming Skull of CX Star Chamber fame turned up, is now sitting in the DAS chair, for now!

You know it's quite ironic that people like CAsA and the ATsB are always banging on about 'root cause'. I wonder what ICAO or FAA would put down the root cause of the complete implosion of Australia's alphabet soup agencies in the past 8 years to?


TICK TOCK

[Kharon]

An evening twiddle.

Good shot GD. Top post P2; dots neatly joining up to form a picture, its nearly there. There are a couple of ‘troubling’ sidebars to that ‘Dorian Grey’ portrait which may not, without some thought, be immediately apparent.  I shall try, in my left handed manner to explain – con su permiso.

What is not glaringly obvious is the cynical, devious ‘grab’ at the offered bait Walker dangled.  Dolan, dumb as a hammer and; ‘obliging’ to boot, saw an easy, cheap way out of having to continue the ATSB farrago with CASA.  History and court records clearly, unequivocally and totally show the constant up-hill battle to get Safety Recommendations up and running.  The Coroners court reports clearly define the on going battle.  CASA denied, or equivocated; or ignored; or worked around the ATSB ‘safety recommendations’.  There is a score card somewhere in the archives; (I may even seek it out). But, to paraphrase; the ATSB bowling average was not stellar. The ATSB crews must have had a guts-full; decades of being told yes – meaning ‘piss off’.  Now Byls and Stray would have continued the good fight – Dolan had neither the balls to fight, nor the brains to see the train wreck. Walker’s Beyond all Reason substantiated ‘excuses’, which provided an ‘academically’ certified, easily accessed back door, and slotted in neatly with the Aleck smoke and mirrors. It did not rock too many boats and was philosophically seen as the answer to a maidens prayer. That is, lots of and as often as possible.  Saved a fortune, spared the horses and made everyone’s life ‘easier’.  Due to the ‘academic’ accolades. It was an easy task to convince a disinterested minister to go along with the charade. A ‘scientific’, awarded program and an ethos which removed any and all ‘organisational’ matters from the ‘Beyond any Culpable Reason’ equation.  Bloody marvellous. Hands rubbed in glee and ‘all aboard’ the honeymoon cruise.

The only thing suffering was industry – but what the hell – tendentious bloggers and the ills of society, all. Not the only bonus on offer though; no Siree. The big end of town saw the value too. You see children; the ‘game’ is set up so that no matter whatever happens, the minister does not, ever, have to worry. The rules are set up so that no matter what the ATSB ‘renegades’ come up with, CASA had no part in the accident and the ATSB has met its ‘ministerial obligations’ i.e. ‘done a report’. The pay-out was always visible – no problems for the government and, the ‘blame’ could always be allayed, sheeted to either the pilot; or the operators feet; or a whim of fate.  CASA even stage managed ‘prosecutions’ to reinforce that notion in the ministerial mind. Many great snake-oil salesmen lost to the world of spin, hyperbole and bollocks then.

And so, without a whimper of protest; the ‘soft edge’ weapon of Beyond all Reason was foisted on industry.  The fact that ATSB have not issued, let alone carried trough an ‘organisational’ Safety Recommendation, for almost a decade, to a satisfactory result, where industry gained ‘safety enhancing knowledge’ is at the very heart of this shameless, cynical, self promoting pantomime.

The list of aberrations is long; the cost is manifold in terms of safety and oversight. One day – something will occur which will rock the cosy little boat and there will be no escape for CASA or the ATSB.  Pel_air a clarion call to wake up; Mildura a signal rocket.  Make no mistake, there will no hiding from the international condemnation.  You can, indeed, fool some of the people, some of the time etc.  

Australia’s air safety oversight is a sham.  A cynical manipulation to avoid responsibility. By using the spirit and intent of ICAO tenets in a very Cavalier, underhand, deceitful, premeditated manner may seem fair enough. Until the wheels come off. If the uninformed public, ever learn and understand exactly how little the government value their lives, it is a popular opinion that the fall of a government will result.  Anyone who thinks holistic ‘safety’ is an expensive, moveable feast, is deluded, mad or lying through their teeth. Wait for an accident, then count the cost. Up to you what you care to believe - .  

Selah.

[Peetwo]

"There's a hole in the cheese dear Liza, dear Liza??"

Who'd of thought? The Ferryman doing 'an evening twiddle' just short of the 'witching hour' on a Sunday night? Maybe like the rest of us mere mortals, this bollocks daylight savings has disturbed his evening routine..

Anyway job well done Mr "K"...   (Ps & TY for the edit I was bit rushed with my last - )

Ok onwards & downwards with the dot joining...

Quote from: Opinion :-ATSB since 2003.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they provide further examples of compromised ATSB Final Reports.

In case you need a reminder of the circumstances of the Darwin Brasilia accident, here is a disturbing ATSB simulator animation of that tragic C&T accident: 

From earlier post#33 "K" said:

..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...

And just before the Senate PelAir inquiry, on the 6th August 2012, a certain 'senior' ATSB Transport Safety Investigator (who I believe was actually Dr (BASR) Walker), said this about the Braz tragedy:


{P2 comment - To put this in context this was just prior to the release of the original nearly 3 year, totally shambolic, politically & bureaucratically obfuscated VH-NGA ditching investigation final report}

Now in an effort to track down the 'unflattering comments' that so offended Dr (BASR) Ghost-Who-Walks, I raided the UP archives based on the timing and this is (much to my amusement..) was what I discovered: Air North Brasilia Crash in Darwin (Merged) #446

Without this diverging into a mixture vs closed throttle vs Flight idle vs zero thrust debate has anyone noticed the gradual decay of the quality of investigation reports coming out of the ATSB?

Besides the Hempel Inquest, where the ATSB appears to have abrogated all responsibility to investigate at all, the ATSB report into the Brasilia accident in Darwin is nothing short of totally spare in its conclusions!

There also appears to be no 'Safety Recommendations' generated from a training accident that I think we could have all learnt a lot more from.

Take a look at a couple of extracts from the report:

Quote:
Terminology used in training and checking
The operator’s documentation did not contain any specific terminology for discontinuing a manoeuvre, but did provide clear instruction as to how control of an aircraft was to be changed between crew members.
To take over control from the pilot flying, or for the pilot flying to relinquish control to the other pilot in a multi-crew aircraft, very specific terminology was used. To avoid any confusion as to which pilot was manipulating the controls, the operator’s General Policy and Procedures Manual, section 4.7.2.2 Crew Communication - Handing Over and Taking Over stated:
The process of handing over control of the aircraft shall always be conducted in a positive manner. To minimise confusion or operational risk, the following terminology shall be used.
To assume control, the pilot monitoring shall call "taking over". To relinquish control, the pilot flying shall call "handing over".
Control of the aircraft cannot be handed over until the pilot monitoring has called "taking over"...
The term ‘disengage’ that was used by the PIC during this simulated engine failure was not standard phraseology. Other EMB-120 pilots reported that they had never heard the term ‘disengage’ used for any action other than deselecting the autopilot/yaw damper and had never heard it used to discontinue a manoeuvre.
They also reported that if a training or check pilot decided to discontinue a simulated engine failure procedure, they would expect that check pilot to restore power to the ‘failed’ engine. Alternately, if the training or check pilot wanted to assume control of the aircraft, they would expect to hear the term ‘taking over’.

Which is pretty basic stuff in a multi-crew aircraft....and then in regards to the Yaw Damper....

Quote:
The operator’s flight operations manual for the EMB-120 stated that the yaw damper was not to be used for takeoff or landing, and that the minimum speed for its use during one engine inoperative (OEI) flight was 120 kts indicated airspeed (KIAS).

.....and then more in relation to the apparent Yaw Damper activation...

Quote:
The use of the yaw damper during asymmetric flight was introduced to the simulator testing following consideration of the cockpit voice recording references to the PIC’s command ‘disengage’ and the pilot under check’s response, ‘yeah, disengaging’. It was assumed that the reference was to the yaw damper and not the autopilot because the chime that sounds when the autopilot was disengaged was not heard on the CVR recording. Additionally, the simulator instructor reported having previously observed pilots engage the yaw damper during simulated engine failures in the EMB-120 in response to pilots ‘overcontrolling’ rudder and aileron following a simulated engine failure.

All of the above is all good factual investigative methodology a lot of which points to a number of operational issues (company SOPs etc) and regulator oversight issues....right?? Wrong, take a look at the first paragraph of the ATSB conclusion.

Quote:
No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified as a result of this investigation.

Maybe this conclusion is a result of the regulator putting in place the Mandatory Simulator program and subsequent NPRM leading to the current NFRM, but does it excuse glossing over what was a particularly significant training accident event that, although tragic, we could all have learnt from!

ps ....and what gives with the no 'Safety Recommendations' issued!

http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf

With "K" in tow, the discussion went on down the page:

Now I'm curious

---

I find I am once again forced to read between the lines of an ATSB report. Technically it's spot on; for example, reading the time line analysis, there is a temptation to question the rudder v aileron input, however this is clearly resolved in the computer simulation graphics. Not having operated a Braz – there are a couple of points of interest which perhaps can be explained by someone who has.
Disengage ?? –could this refer to the Flight Director or is it the Yaw Damper ?. I note the AFM mentions –(paraphrased) FD Before take off (SET), expanded to PF select GA and check 7° pitch up; and, that the AP or YD may not be engaged during TOFF and LAND manoeuvres.

Has it been SOP for the PF to engage the YD as part of an EFATO or was this a recent innovation ?.

The V1, Vr and V2, V2 +10, etc. schedule. The AFM seems to be clear about the speed schedule and the acceleration to V2 +, then flaps up then Vfs (paraphrased). There appears to be a deliberate reduction from V2 + 4 (at – 23 seconds) to V2 (at -20.7 seconds). Is this a norm for the type or a new innovation ?.

Is the un monitored management of the OE, the over torque (124%) and the corresponding rudder/aileron excursions normal for the airborne exercise being conducted ?.

It is suggested by the ATSB final analysis that the BASI recommendations made after an investigation into the Flight Idle v Zero thrust (auto feather) scenario have been ignored. There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

P.S. Categorically not having a pot shot at the crew, the company or the simulator. Just seeking a satisfactory explanation of why and how this 'abnormal' chain of events occurred. If this was a new ME instructor and an initial twin conversion, perhaps this event may have occurred, but it wasn't – was it.

   
Which I followed with:

Quote:
It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

A lot of what was covered in the ATSB report touched on the areas of operational concern and hinted to several differences in history where the Check Pilot had started to diverge from his 'norm'. This quote from page 54 of the report is significant:

Quote:
Two of the pilots who were recently assessed by the PIC reported that he selected flight idle (zero torque) to simulate an engine failure after takeoff in their check flights. It was possible that the PIC had decided to deviate from the operator’s approved procedure in order to test the recognition by the candidate of the additional failure of the autofeather, before setting zero thrust.

 
However it isn't clear whether this 'divergence' from his 'norm' started after he had been to the simulator or before. If it was after then one may suggest that he was operating in a 'simulator induced complacency' manner i.e. it was proven that Flight idle (aircraft) or 'Autofeather Failed' engine failure (simulator) could be successfully recovered from while conducting a V1 cut.

This also appears to have been an area of concern for the regulator, as they used this accident as an example in Annex A of the NFRM for Mandatory Simulator, see here:

Quote:
From CASA NFRM Mandatory Simulator training Annex A:

COMMENT 1.2
Some respondents proposed adding wording to allow training and checking to occur in the aircraft provided the exercise had been conducted by all pilots in a simulator in the preceding 12 months.
CASA Response
CASA is firmly of the view that where a qualified STD is available for aircraft of this size, this should be used for all training and checking activities. The ATSB has reported that the training captain of the aircraft involved in an accident in Darwin in March 2010 had undergone training and checking in a flight simulator, however the actions by the training captain in simulating an engine failure in the actual aircraft during the accident flight was not consistent with the training received during the simulator course. This suggests that doing one session of training and one check per year in an STD (with the subsequent session/check in an actual aircraft) does not satisfactorily address the risk of conducting non-normal exercises in an actual aircraft.

If the Check Captain was inducing this scenario (FI V1 cuts) prior to having gone to the simulator, whereas previously he always only induced a Zero Thrust EFATO scenario, then there must have been input from somewhere/someone to change him to suddenly start breaching the company T&C SOPs??

As 'K' suggests there has been many takes, ambiguity and debate..etc..etc..on the regulatory requirements of CAO 40.1.0:

Quote:
There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

Maybe there is an element of rogue FOI's, that lack the necessary industry experience, that insist on adhering to the letter of the law in CAO 40.1.0. Instead of applying practical safeguards and risk management to high risk training and checking scenarios!!

 
So am I offended that 'his nibs' Dr W#*ker believes that I have no idea about what an "..organisational issue actually is, and when it is, or is not important.?"  - Not on your life I luv it... 


MTF...P2

[Kharon]

Milestones along the road to Pel-Air.

Beaker's Mum – “Oh Martin dear, the garden is looking so lovely, how do you do it?”

Beaker – “Easy Mum, quality fertilizer; the boys gave me cartloads of top grade bullshit to bring home from Canberra”.

BM – “Well after all that hard work, we’d better have a cup of tea; I’ll put the kettle on”.

B – “Great, you will read my tea leaves afterwards”.

BM – “Don’t I always”.

That was about all the conversation GD could capture and anyway, the stench from the big pile at the bottom of the garden was making him nauseous, so he packed up. But the information, used properly, is of value if we are to follow the road to Pel-Air.

Some of the BRB feel that we did Beaker a disservice; others disagree. It is a ‘quiet’, academic discussion, ruminative rather than combative. I expect you are confused by now; what’s the fool rabbiting about? Well it goes like this.

Many of us who watched, listened and studied ‘Beaker-speak’ at estimates and inquiry could not fathom the disconnects.  Clearly, the man was a dumb as a bag of hammers even clearer was he had NFI (whatsoever) about ‘matters aeronautical’ or accident investigation.  He could trot out the ‘scripted’ lines, but deeper questioning produced the ‘disconnect’ between rehearsed, work-shopped weasel words and ‘in-depth’ knowledge of his subject. In short, many believed his Mum’s tea leaf readings were his guide.  But that is obviously not the case. Being malleable, obliging, not too sharp and beholden made him a perfect foil. Add to that an accountants narrow minded purview and things become clearer. Real Accident Investigators (AI) live and breathe their profession; their bible Annexe 13 their only goal – solutions and providing reports which prevent a reoccurrence. There is no way a career public servant, with a ‘spotty’ record could grasp that passion and so the ‘disconnect’, once again, became apparent. Which of course led to much criticism. A soulless public servant mentality could never understand, not properly, what a 'real' accident report means to aviators.  I digress.  

P2 has done well to fill on the gaps, join up some of the dots and set the stage to tell the tale of our long, weary journey from the 2004 ‘first rate’, world class status to the pitiful, crippled thing we have today.  Many believe Lockhart was the watershed; almost as many reach back to Seaview and Staunton; it is, I believe, academic.  Seaview certainly changed the dynamic and shifted the perception of ‘blame’; Lockhart was the catalyst for real change.  There was a battle for supremacy, power, money and kudos, but that was a sub-plot; the real battle was to decide who’s version of why the holes in Reason's famous cheese lined up that day.  ATSB lost the fight and were relegated to a subservient role; handmaiden and arse wiper to CASA.

Progressive MoU which bastardised the Morrison report ensured that slowly, but surely ATSB was subsumed, the independent power base eroded and those that wanted to kick that bucket were quietly informed that there were not too many jobs for ‘specialist’ accident investigators out in the cold, hard world.  There were pockets of resistance and for a while, every accident or incident provided a new skirmish and opened the golden  gates to criticism of the minister and CASA – intolerable. There was an urgent need to find a way to get CASA and by extension, the minister –‘off the hook’.

Enter the dragon: Doc Walker and his ‘cloud’ diagrams; they all look like ‘little balls’ floating in space; (you can draw whiskers on ‘em and they look like hairy little balls i.e. bollocks) which placed ‘regulatory oversight’ on the top line and organizational matters in a subsidiary role.  Well that suited everyone just fine, all that was needed was an obliging Muppet with NFI to carry the message and make it all work.  Aye, Dolan was not selected by accident children – a front man was required, one who could be controlled by strings, from behind the curtain of safety mystique.

CASA thought this a wonderful thing and ‘regulatory oversight’ gained ascension, the bonus of ‘no operational issues’ being included; a goose which laid it’s golden eggs as/ when required.  McComic took liberties with the system and allowed some of the known thugs free rein to dictate and ‘enforce’ their own ideas, under ‘black letter’ law wherever it pleased, with full back up.  One of the classic exponents of this art is still ‘at it’ to this day, still operating under the McComic system, still creating mayhem, still bullying aircrew and operators alike; rejoicing in a track record which has brought many a pilot and operator to an impotent boiling point.

When you place this type of mentality in an atmosphere of no accountability, support it with the full resources of the CASA and a belief that the ‘law’ cannot touch them; you have created a monster which has, can and will continue to do much harm. When that monster is turned loose without organizational constraint or accountability there is no recourse as the government and minister like the peace and quiet the system produces and all is well until there is an accident. No matter you say – the ATSB will get to the bottom of it and we shall find out why a Brasilia with two experienced pilots ploughed in and killed them both.  We shall discover why two perished at Canley Vale, we shall determine why two jets nearly ran out of noise and luck at the same time; we will have the truth of the Melbourne incidents; and, many other incidents with organizational links in the causal chain.

No, you won’t.  Not while we have a minister who’s aviation interests are centred on publishing pictures of the DPM taking a leak. Not while we have a whipped ATSB who will not examine an accident and include the full story in a report with teeth. Not while we have a CASA so mired in deceit and obfuscation that no one dare let the fell truth be known, especially to ICAO or the public.

The absolute, very best we can hope for; offer prayers to any pagan god who’ll listen, is a clean sheet. Start again; from the beginning; let the past lay. The organizations and the minister are in too deep; they dare not take the lid off and it is their lid. Let’s hope for a new broom DAS who will remove the Worthless rubbish from the CASA corridors, an ATSB commissioner who can put aside the Walker bollocks diagram and a minister who can take at least a pissing interest in the well being of an industry and the travelling public.

Enough – finish ‘em off P2 – I'm off to buy a new bucket; the old one is just about buggered.

Selah.

[Peetwo]

P2 armed with spak-filla -  

K said - "..Enough – finish ‘em off P2 – I'm off to buy a new bucket; the old one is just about buggered..."

...Some of the BRB feel that we did Beaker a disservice; others disagree. It is a ‘quiet’, academic discussion, ruminative rather than combative. I expect you are confused by now; what’s the fool rabbiting about? Well it goes like this.

Many of us who watched, listened and studied ‘Beaker-speak’ at estimates and inquiry could not fathom the disconnects.  Clearly, the man was a dumb as a bag of hammers even clearer was he had NFI (whatsoever) about ‘matters aeronautical’ or accident investigation...

Senate AAI Public Hearing Hansard 22/10/12:

Senator FAWCETT: With the process you are describing whereby you use a process, and risk and consequence and all the good tables I have seen in your submission, do you consider balancing that against the cost of action? I will take for example the New Zealand flight information service where, in Australia, if there is a deteriorating weather situation they have an obligation to update the pilot and alert them to the fact that something is occurring, or the Unicom operator who was not legally allowed to use the HF radio to talk. But if either of them had said, 'The situation is getting worse,' as Unicom did to the New Zealand FIS who chose not to pass it on, surely, even including that kind of thing, there should be a recommendation that the Australian government should talk to the New Zealand government and ask for cooperation for safety reasons. Even if it is only for one in 1,000 flights and your probability of occurrence is very low, given the cost of action is also very low, why does your process exclude consideration of something that to the common man in the street seems like common sense? Why are we not seeing logical, reasonable recommendations coming out of ATSB reports to an address in this case two things, either of which probably would have prevented the accident?

Mr Dolan : There are two things there and I will go to the question of recommendations before I get to the specifics of your question. The ATSB at the point where it became independent of the Department of Infrastructure and Transport also got a shift in its powers in relation to the making of recommendations which raised the ante with recommendations and their significance. There is a legal requirement to respond to each of the recommendations we make. In recognition of that we set up the system of identifying safety issues that said there needs to be a critical or a significant safety issue before we will explicitly use that power to make a recommendation and require a response, and we would generally limits recommendations to those sorts of things. What you are talking about we would in our normal framework, given what you said about likelihood and consequence, deal with as a safety issue without going to recommendation. That is the context: it is still there but your question remains.

The answer is we assessed the facts of the information made available in the course of the flight, the number of opportunities to receive information and to absorb it. We said that that did not seem to indicate that there needed to be any change to the system. That is a matter that others based on those facts could form different views on, but the view we formed was we did not see anything that needed to be done to enhance that system.

Senator FAWCETT: With all due respect, to have a process that deliberately closes the door to suggestions that another agency, if they wished to say they would respond to that recommendation by saying no but if they chose to say yes may have saved this flight and may potentially save another flight, I suggest is process that is extremely poorly misplaced and prioritised.

Mr Dolan : I accept you can suggest that to me. As I said, we as an organisation were trying to look at this on a systemic level rather than an individual detail level. We looked at the overall components of the current system to deal with the risks that go with operation to remote islands and the particular case we were dealing with which was the situation where the weather forecast on departure was for weather suitable for landing at the destination and that changed en route. That seemed to us the key issue. There was also an issue about what happened in pre-flight planning and so on, but for us as we say in our report the key issue was, having left, how to deal with the situation where things change in flight. What we tend to do in identifying safety issues is rather than specifying a precise solution to the issue we try and draw the issue to the attention of those who are best placed to do something about it and for them to take steps to deal with it.

We could certainly have a discussion about this, but it is the methodology we currently use. Rather saying precisely there is a problem explicitly with the issue of the proactive provision of weather information by air traffic control, we focused on the general framework to support information, the seeking of information and the provision of information, and decision-making en route. We left it as a general issue rather than coming up with a precise set of answers and making those a requirement. That is the way we normally do the business: we try to leave it to the organisation best positioned—in this case, the Civil Aviation Safety Authority principally—to decide how best to deal with the issue and to tell us what is being done to address the issue, which is the safety action part of our report.

Senator FAWCETT: Mr Dolan, I think you have probably heard a number of the witnesses this morning indicate that in their view ATSB in the past has taken a far more proactive approach to identifying issues and being prepared to make a recommendation. The general consensus from witnesses has been that that is a far more value-adding document. With a technical issue, for example an A330 off the North West Shelf with a software glitch that causes the aircraft to plunge, in terms of probabilities it was very remote that that would never happen again. But there was a report, recommendations and the OEM put a fleet-wide alert out to look at a software reload or whatever. If that approach is taken on something that almost led to the loss of an aircraft, here we have the loss of an aircraft. Why did you take such a conservative approach as opposed to saying any information, any opportunity to preclude a further incident by including all of the regulatory and systemic issues in terms of the organisation, their training, they check-in training, the lack of control, the lack of standardisation around fuel planning—all the things that led to this occurrence—should be canvassed in the report? I have heard your process, but putting the process aside, is the process wise when after three years we end up with a report that deals quite narrowly with one element of the things that led to this incident?

Mr Dolan : As I said earlier in my general reflection on what I have been hearing through the submissions and today, there are two elements to this. The first is that there was a range of lines of inquiry that we went down. We satisfied ourselves that there was not a safety issue involved in it. Among the massive documentation we have provided to you, there is a range of lines of inquiry that clearly we went down. We did not reflect that process in our report and on reflection that is not ideal. That is the first issue. On some of the things you are concerned about, our view is we did take a look at them and formed the view that they were not directly relevant to the issues we needed to address in the report.

...He could trot out the ‘scripted’ lines, but deeper questioning produced the ‘disconnect’ between rehearsed, work-shopped weasel words and ‘in-depth’ knowledge of his subject. In short, many believed his Mum’s tea leaf readings were his guide.  But that is obviously not the case. Being malleable, obliging, not too sharp and beholden made him a perfect foil. Add to that an accountants narrow minded purview and things become clearer. Real Accident Investigators (AI) live and breathe their profession; their bible Annexe 13 their only goal – solutions and providing reports which prevent a reoccurrence. There is no way a career public servant, with a ‘spotty’ record could grasp that passion and so the ‘disconnect’, once again, became apparent. Which of course led to much criticism. A soulless public servant mentality could never understand, not properly, what a 'real' accident report means to aviators.  I digress.
 

Reference 28/02/2013 Senate AAI Public Hearing: RRAT AAI Inquiry Hansard

Note the following extract from the 28/02/13 Inquiry Hansard where Dolan refers to his BASR Guru  :

Mr Dolan : ...That is a simplification of the purpose of that table. We will do a risk assessment of an identified safety factor. This is not about assessment of evidence, this is about assessment of safety issues—a safety factor that is seen to have a continuing effect on risk to assess the likelihood and the consequence of that factor coming into play in the future. That is our basis for establishing the significance of a safety issue. It is not the basis on which we will assess evidence.

If you are looking for the philosophical underpinnings of how we deal with evidence and a range of other things, there is a document, Analysis, causality and proof in safety investigations, which was a publication of Dr Walker and Mr Bills in 2008. That shows the philosophical underpinnings of how we deal with facts, evidence, analysis and so on. It is reflected in our policies and procedures in the organisation. The risk assessments largely draw on or are compressed versions of international safety organisation risk management standards. We are trying to bring all that to bear on a diverse range of operations, while bearing in mind the guidance from the government that our attention should primarily be on the safety of the travelling public...

P2 has done well to fill on the gaps, join up some of the dots and set the stage to tell the tale of our long, weary journey from the 2004 ‘first rate’, world class status to the pitiful, crippled thing we have today.  Many believe Lockhart was the watershed; almost as many reach back to Seaview and Staunton; it is, I believe, academic.  Seaview certainly changed the dynamic and shifted the perception of ‘blame’; Lockhart was the catalyst for real change.  There was a battle for supremacy, power, money and kudos, but that was a sub-plot; the real battle was to decide who’s version of why the holes in Reason's famous cheese lined up that day.  ATSB lost the fight and were relegated to a subservient role; handmaiden and arse wiper to CASA.

Progressive MoU which bastardised the Morrison report ensured that slowly, but surely ATSB was subsumed, the independent power base eroded and those that wanted to kick that bucket were quietly informed that there were not too many jobs for ‘specialist’ accident investigators out in the cold, hard world...

Reference 15/02/2013 Senate AAI Public Hearing: RRAT AAI Inquiry Hansard

  
...There were pockets of resistance and for a while, every accident or incident provided a new skirmish and opened the golden  gates to criticism of the minister and CASA – intolerable. There was an urgent need to find a way to get CASA and by extension, the minister –‘off the hook’.

Enter the dragon: Doc Walker and his ‘cloud’ diagrams; they all look like ‘little balls’ floating in space; (you can draw whiskers on ‘em and they look like hairy little balls i.e. bollocks) which placed ‘regulatory oversight’ on the top line and organizational matters in a subsidiary role.  Well that suited everyone just fine, all that was needed was an obliging Muppet with NFI to carry the message and make it all work.  Aye, Dolan was not selected by accident children – a front man was required, one who could be controlled by strings, from behind the curtain of safety mystique.

2.5 years on from the Senate PelAir cover-up report and the Timeline of Beyond all Sensible Reason & Embuggerance:

Reference Aunty Pru blog: PelAir – ‘Lest we forget’ Part III

From CASA Hansard:

Senator FAWCETT:  …In coming back to your regulatory philosophy, you are saying that CASA is committed to maintaining the trust of the Australian aviation community. One of the biggest breaches of trust recently was the ATSB investigation into the Pel-Air report where CASA maintained that the internal investigation, the Chambers report, the fatigue risk management report and the special audit were not necessarily pertinent. I think the term was they were a private, internal report. Now that ATSB has reopened that investigation could you assure the committee that it is your intention to share all that information about the inadequacies of CASA’s oversight at the time with the team so that the new report reflects not just the actions of the pilot but the inadequate supervision of the organisation and the self-identified inadequacies of CASA at the time?

 Mr Skidmore : I think it is fair to say that we have provided all the information that the ATSB has requested of us and we will take into account any recommendations that come out of the investigation.

Senator FAWCETT: Would it be your view that a report like the Chambers report should have been provided to ATSB voluntarily?

Mr Skidmore : I was not there at the time. It is very unfair for me to be making a statement of the organisation of the past.

Mr Aleck : One of the significant amendments we have made to the MOU with the ATSB is to put beyond doubt the kind of information that can and should be provided on request, or sometimes voluntarily. As you may recall, the existence of the Chambers report was conveyed to the ATSB. The circumstances under which that happened probably were not as concrete as they certainly will be in future.

Senator FAWCETT: Mr Aleck, I think you might recall Mr Dolan found out about it 30 minutes before he appeared before the Senate committee because he had overheard the evidence where we had dug it out of half a truck load of cardboard boxes that CASA had dumped on our doorstep. I do not accept the contention that they knew about it before the report was issued; in fact, the Canadian peer review confirms that was not the case.

Mr Aleck : I will not challenge that except to say that I believe the former director gave evidence that he had mentioned this to Mr Dolan. Now, he might not have mentioned it by the term Chambers report, because that was a term that came into existence afterwards, but I think the information about some inquiry having been made internally had been conveyed. I guess the major point is that that kind of thing should not happen again under the new arrangements.

Senator FAWCETT: I am very pleased to hear that…

CASA thought this a wonderful thing and ‘regulatory oversight’ gained ascension, the bonus of ‘no operational issues’ being included; a goose which laid it’s golden eggs as/ when required.  McComic took liberties with the system and allowed some of the known thugs free rein to dictate and ‘enforce’ their own ideas, under ‘black letter’ law wherever it pleased, with full back up.  One of the classic exponents of this art is still ‘at it’ to this day, still operating under the McComic system, still creating mayhem, still bullying aircrew and operators alike; rejoicing in a track record which has brought many a pilot and operator to an impotent boiling point.

When you place this type of mentality in an atmosphere of no accountability, support it with the full resources of the CASA and a belief that the ‘law’ cannot touch them; you have created a monster which has, can and will continue to do much harm. When that monster is turned loose without organizational constraint or accountability there is no recourse as the government and minister like the peace and quiet the system produces and all is well until there is an accident. No matter you say – the ATSB will get to the bottom of it and we shall find out why a Brasilia with two experienced pilots ploughed in and killed them both.  We shall discover why two perished at Canley Vale, we shall determine why two jets nearly ran out of noise and luck at the same time; we will have the truth of the Melbourne incidents; and, many other incidents with organizational links in the causal chain.

Reference Aunty Pru blog: PelAir – ‘Lest we forget’ Part III

From ATSB Hansard:

Senator FAWCETT: I would like to go to the information-gathering stage. Going back to an answer to a question on notice that you took at the time of the original investigation, you said:

… the Chambers Report does not contain any new evidence that organisational factors were likely to have contributed to the accident...

 You go on to say:

… the Chambers Report reflected what was separately reported (and available to the ATSB) in the reports of CASA’s accident investigation and of its special audit …

I challenged that at the time, and so did your Canadian peers ,who have done an independent peer review and who have made numerous comments in their report that in actual fact regulatory systemic issues to the organisation and oversight of the organisation by CASA were significant and were omitted. They go into some detail about the process within your organisation that resulted in those being omitted even though they were significant. Can you provide me with an assurance that the rework of this report will be considering the quite detailed information contained not only in the special audit but in the Chambers report and in the fatigue report that go to the heart of how the individual ended up having that accident?

Mr Dolan : Yes, I can give you that assurance. We have acquired from CASA not just the various reports but the core material they relied on to prepare those reports as part of the process of undertaking the reopened investigation.

Senator FAWCETT: I am pleased to hear that cooperation. Could you also comment on whether you still stand by the remarks that you made in the questions on notice?

Mr Dolan : I am not in a position to comment on that until I see the results of the reopened investigation. It is entirely possible. The Canadians have already alluded to the fact that we did not give sufficient weighting as an organisation to the organisational aspects of this investigation, and that is what we hope we can determine through the reopened investigation.

Senator FAWCETT: There are a couple of points that come out of this. There is one about the trust of industry in the organisations that are supposed to be having an oversight around safety and regulation, but the other is a very real impact on people. At the time, the committee were concerned about what we saw as a breakdown in the relationship between you and CASA and the inadequacies of the report. Subsequent to the Canadian peer review, which was quite scathing about the fact that there were very clear systemic issues which were not addressed, people who have been affected by this accident—being the pilot involved and potentially the nurse—have sought some remedy for the situation they find themselves in as a result of this report. In the pilot’s case, correspondence I have seen from him has indicated that that report has essentially finished his aviation career. My understanding is that even after the Canadian report, when he has sought an act of grace payment from the Department of Finance, ATSB’s recommendation is: ‘Don’t pay it. It was his fault.’ Can you confirm that was the case?

Mr Dolan : I recall that there was some information sought from the Department of Finance in relation to an act-of-grace payment. We provided the facts as we understood them. It is not a purpose of our organisation to assign blame, and we would not have said that to the Department of Finance.

Senator XENOPHON: Can you provide the advice that Senator Fawcett has asked you for?

Mr Dolan : I beg your pardon?

Senator XENOPHON: Can you table that advice?

Mr Dolan : I cannot see any reason why we should not, so I will obtain it and table it for the committee.

Senator FAWCETT: In the light of the Canadian report, which indicates there were very clear systemic failures on the part of the company and in terms of CASA’s oversight, the whole concept of systems safety is that whilst the pilot was the last link in the chain these other considerations had a significant impact, which was borne out by the fact that the company had to cease operations after these investigations until remedial measures were put in place. With that now on the public record, with this new focus, would you consider providing the Department of Finance with alternative advice if he were to come back and seek some compensation for the fact that as a direct result of the report that your organisation issued, with all of the failings and how that was put together, his career has essentially been finished and all the financial loss that has gone with that?

Mr Dolan : That is not a matter that I can answer on the spot here. I am happy to turn my mind to that if any such request comes forward.

Senator FAWCETT: That would be very useful. I look forward to the report

No, you won’t.  Not while we have a minister who’s aviation interests are centred on publishing pictures of the DPM taking a leak...

...Not while we have a whipped ATSB who will not examine an accident and include the full story in a report with teeth. Not while we have a CASA so mired in deceit and obfuscation that no one dare let the fell truth be known, especially to ICAO or the public.

The absolute, very best we can hope for; offer prayers to any pagan god who’ll listen, is a clean sheet. Start again; from the beginning; let the past lay. The organizations and the minister are in too deep; they dare not take the lid off and it is their lid. Let’s hope for a new broom DAS who will remove the Worthless rubbish from the CASA corridors, an ATSB commissioner who can put aside the Walker bollocks diagram and a minister who can take at least a pissing interest in the well being of an industry and the travelling public.

Back to you..Dear Ferryman, Dear Ferryman..back to you - P2