[Peetwo]

ANAO wet lettuce report? - Not a good look for the Hooded Canary...  

Ref - O&O thread:

[b]O&O AAI: AO-2017-057 -[/b][b] UPDATE[/b]

Interesting legislation which came out a year after the Rossair crash in which CASA were testing the chief pilot for check and training and the chief pilot was checking an inductee pilot. Which comes first - the chicken or the egg?
https://www.legislation.gov.au/Details/F...ntrol+seat

Via the Adelaide Advertiser: https://www.adelaidenow.com.au/news/sout...405eabe119

Widow Terri Hutchinson says ATSB has treated families of pilots killed in Renmark Rossair crash as ‘worthless entities’



The family of a pilot killed in a plane crash near Renmark says her family has been treated like “worthless entities” by the aviation safety watchdog investigating the incident.


The comments come as the Australian Transport Safety Bureau (ATSB) confirmed the estimated release date for the report into the crash which killed three experienced pilots had been pushed back another six months.

Terri Hutchinson, the widow of Rossair chief pilot Martin Scott, said the ongoing delays and the justifications made by the ATSB were meant to placate the families of the dead pilots.

Mr Scott, 48, was alongside experienced pilot Paul Daw, 65, and Civil Aviation Safety Authority officer Stephen Guerin, 56, in a nine-seat Rossair aircraft when it crashed into scrubland 4km from Renmark Aerodrome on May 30, 2017.

The pilots were completing an evaluation flight for Mr Daw who was planning to join the ranks of Rossair.

The plane was only in the air between 60 and 90 seconds before plummeting into the ground nose first, killing all three occupants on impact.

“To say that I am more than disappointed would be a huge understatement,” Ms Hutchinson told The Advertiser.

“In my opinion, this investigation has been flawed from the outset.”

Mrs Hutchinson said the ATSB had “not bothered to tell those involved” that the publication of the report had been pushed back.

“In fact, the last push-back came after I received an email from the Chief Commissioner of the ATSB saying they would take ‘extra care to keep me informed’.

“That is clearly rubbish and I must say, the latest development has made it seem as though those who lost so much that day are treated as worthless entities.

“To date, Martin’s father and I have been advised that we would receive a draft copy of the final report one month prior to public release.

“(In an email received earlier this week) they have now said that there could be a ‘number of months’ in between the draft report and the final publication.

An ATSB spokesman confirmed the final report is expected to be published in the final quarter of 2019 — more than double the 12 month target for air crash investigations.

“It is important to note that investigations are complex and dynamic, and the priority of the ATSB is always the thoroughness of an investigation to ensure that any systemic safety issues are identified and addressed,” he said.

“This means that complex investigations can take longer, if necessary, in order to ensure a robust investigation with the appropriate third party input and reviews.

“Should a critical safety issue be identified during the course of any investigation, the ATSB immediately notifies relevant parties to ensure safety action is taken.”

With little to no fanfare the ANAO yesterday tabled their audit report into the 'Efficiency of the Investigation of Transport Accidents and Safety Occurrences':  https://www.anao.gov.au/sites/default/fi...019_29.pdf

The objective of this audit was to examine the efficiency of the Australian Transport Safety Bureau’s (ATSB’s) investigation of transport accidents and safety occurrences.

Conclusion

10. The efficiency with which the ATSB investigates transport accidents and safety occurrences has been declining. The ATSB has recently been focussing its attention on reducing the backlog of old investigations, improving investigation timeframes and taking steps to benchmark its performance against transport investigation entities in some other countries.

11. The ATSB has established key elements of an overall framework to promote efficient investigation processes. There is a focus on clearing the backlog of investigations that have been underway for some time, applying sound processes to decide which notifications merit a safety investigation, and adjusting key performance indicators to identify more realistic completion timeframes for the more complex investigations. The ATSB has also taken a number of actions to give greater attention to the efficiency with which it undertakes transport safety investigations.

12. The efficiency of the ATSB’s investigation activities has declined over time both in relation to the length of time taken to complete investigations, and the amount of investigation resources required. The ATSB has recently started taking steps to benchmark its performance against transport safety investigators in some other countries. Analysis of the available data indicates that averaged across the last three years the ATSB has performed well in comparison to the selected countries on a range of efficiency metrics. On an annualised trend basis, the analysis indicates that the ATSB’s efficiency has been declining relative to the selected comparators, particularly in relation to resource efficiency.

Supporting findings


Measuring and supporting operational efficiency

13. The ATSB has performance measures in place addressing time efficiency. Timeframe targets have not been achieved by the ATSB, and work is underway to develop more realistic timeframe targets. The ATSB does not publicly report on its resource efficiency.

14. The ATSB collects a range of information that can be used to inform an assessment of its investigation efficiency. Work is underway within the ATSB to improve its collection and analysis of data for this purpose.

15. The assessment and prioritisation processes support the ATSB focussing its investigation resources in the areas that are most likely to result in safety improvements. Action is underway to enhance the way those processes take into account the extent to which investigator resources are available.

16. Organisational change programs have been initiated and opportunities to improve investigatory processes have been identified and are being pursued.

17. The ATSB has had quality controls and processes in place, however they have not been conducive to the timely completion and review of investigations. Since 2017, the ATSB has implemented key review points earlier in the investigations process. As a result, the ATSB has identified improvements in quality and a reduction in the amount of rework required through the various review stages.

Comparing operational efficiency

18. The ATSB has undertaken limited analysis of changes in its investigation efficiency over time. This analysis has focussed on timeliness and the work effort required to complete an investigation.

19. Efficiency has declined over time. Over the last five years, the time taken and resources required by the ATSB to complete investigations has increased significantly.

20. Prior to 2018, the ATSB had not compared its investigation efficiency to other relevant transport safety investigation organisations. Steps are now being taken to benchmark performance against international comparators.

21. Data obtained in connection with this ANAO performance audit indicates that, averaged across the last three years, the ATSB is performing comparably across a range of efficiency metrics. On an annualised basis, the ATSB’s efficiency has been declining particularly in terms of resource efficiency where it has fallen behind two of the three countries examined for which data was available.

---

Recommendations


22. Any findings in the report which the audit team feel warrant Executive accountability to remedy should be included as a recommendation.

Recommendation no.1
Paragraph 2.8
The ATSB implement strategies that address the decline in the timely completion of short investigations.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.2
Paragraph 2.18
The ATSB report on the efficiency with which it uses resources in undertaking investigations.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.3
Paragraph 3.5
The ATSB establish more realistic targets for investigation timeframes addressing both calendar and investigator (effort) days.
Australian Transport Safety Bureau response: Agreed.

Recommendation no.4
Paragraph 3.21
The ATSB continue to progress actions that it has recently commenced to benchmark its investigation performance against relevant international comparators and use the results to identify strategies to improve its performance.
Australian Transport Safety Bureau response: Agreed.

     


As expected, with such limited ToR, the ANAO have printed the hard copy on 46 soggy wet lettuce leaves. That said, coupled with the O&O post above, it is still not a glowing assessment of the ATSB Avery under the Hooded Canary's tenure...  

  
MTF...P2