[Peetwo]

So why the delay? -

Slowly working my way through the full report, I do understand that there was a considerable lack of hard facts and recorded information which makes the job of the IIC particularly complex because the investigators have to delve into the area of high probabilities against subject matter expert opinion and experience.

Referring back to the prelim report - https://www.atsb.gov.au/publications/inv..._2_content - the FR is basically an expanded version of the prelim report. 


Which is why I still can't get my head around why this high profile investigation could possibly take nearly 3 years to complete...  

With that question in mind I just had to skip forward (sorry "K") to the 'safety issues and actions' section which I believe starts to go the cause of such considerable delay - read and absorb:

Safety issues and actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action taken by the Civil Aviation Safety Authority in response to this occurrence.

Following the accident, CASA issued temporary management instruction (TMI) 2017-004 to provide interim instructions to CASA officers tasked to conduct in-aircraft activity as a CASA employee. These instructions were issued with the caveat that CASA did not know the contributing factors to this accident. The instruction’s intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).

The operating requirements differed, based on whether the CASA FOI was occupying a control or non-control seat in the aircraft. For key personnel and check pilot assessments when the FOI was in a position other than a control seat, the TMI required:

• Emergencies were not to be simulated below 1000 ft above ground level and initiated at VYSE + 10 kt.
• The assessment could only be conducted if the non-control seat was in the immediate vicinity of the operating crew, suitable communication existed and a pre-flight briefing was conducted.
• The CASA FOI had to have evidence of each person at the controls meeting the requirements of Civil Aviation Safety Regulation 1998 Regulation 61.385 – General pilot competency requirements in relation to the manoeuvres intended to be conducted and recover from the above manoeuvres in the event of mishandling. For example, a person who does not regularly (and recently) operate the aircraft may be unable to demonstrate the general competency requirements to the satisfaction of a CASA officer.
• The FOI had to have evidence that the person under check had been trained and considered competent / recommended by someone other than themselves. The time between the competency recommendation and the assessment flight could be no more than 28 days.

The temporary management instruction published on the CASA website expired in June 2018. This was reissued as an amended internal document in June 2018 and November 2019, with an expiry of May 2020. One additional relevant inclusion in the amended versions was a requirement for CASA officers to ensure the requirements of the new CASA exemption 58/18 - Carriage of passengers on proficiency check and flight test flight instrument (updated to 58/19 in May 2019).

As of April 2020, the TMI conditions had not been incorporated into regulation.

Remember that the above TMI was initiated within months of the accident occurring - now note the expiry of the TMI and the comment down the bottom:

This was reissued as an amended internal document in June 2018 and November 2019, with an expiry of May 2020...

...As of April 2020, the TMI conditions had not been incorporated into regulation.

MTF...P2