[Peetwo]

RossAir Cover-up: An insight of CASA's toxic culture within? -    

Quote from Tony Kern's - Cultural Threat Detection: Business Intelligence for the 21st Century:

Whatever wars are being waged in your organization between your strategic objectives and your actual outcomes, your culture tips the scales for the winning side

A McKinsey survey of some 3,000 executives found that two out of three organizational change efforts fail—the majority due to cultural resistance. Recognizing this threat, some organizations seek to first move the culture into alignment with the planned organizational change strategy. These fare somewhat better, but still fail more than 50% of the time. This isn’t because something else trumped culture in these situations. Rather, it’s likely due to the organization being unable to successfully change the culture to align with their new objectives—so they quit trying.

Have now reading (several times) the bollocks PC'd ATSB final report into the tragic Renmark C441 RossAir accident (plus other less publicly available documentation) and in the context of the Senate RRAT committee GA/CASA inquiry, IMHO the good Senators would do well to forensically examine all available documentation and request witness presentation before the committee of all key personnel and directly interested parties to this latest aviation safety bureaucratic cover-up. The reason being that like the Tony Kern quoted extract above highlights, there is much evidence to suggest that despite the efforts of David Forsyth and his fellow ASRR panel members to put forward proactive recommendations to address the toxic culture within CASA, that culture is alive and well, at least in the CASA flight operations inspectorate -       
 
Ref: #SBG 24/05/20: Liar, liar, hair on fire. 

AAAA - “CASA officer interpretations – an issue that was at the core of the ASRR Report findings and recommendations - individual officers within CASA continue to make interpretations that are not bound by regulatory heads of power, consistency, experience, sector knowledge or specific safety risks. It is opinion parading as policy – and frequently ill-informed opinion. CASA continues to lack a coherent, centralised policy interpretation and expertise centre to standardise regulation. Different offices have different interpretations, and generally CASA is not troubled by using subject matter experts that it may have on staff – as there is no centralised policy development system. In a modern regulator that had this pointed out to them in an independent review (the ASRR), serious questions must be raised about why this situation is perpetuated by senior management.” 

Indeed serious questions do need to be asked and perhaps the RossAir cover-up properly examined could be the catalyst to finally force serious reform within the Halls of Aviation House?

Could I also suggest to a certain South Australian Senator, that before this matter is shuffled from the SA Coroner's 'still pending' in tray to the 'no further action' out tray, that he should be making representations and FOI requests on behalf of the victims families, friends and directly effected constituents of SA.   

Enough said back to the dots and dashes -   

Previous reference from Accidents -Domestic:    

P2 OBS: Dots, dashes and passing strange disconnections??? -   

While the BRB continue to mull over the IMO obvious (for whatever reason??) top-cover edited version of the final report, I intend to go off on a slightly different toot...

Ref: https://www.atsb.gov.au/media/5777738/ao..._final.pdf

Throughout the report there are several references to a pratice flight conducted a week before the accident flight - initial  reference from page 21:

...In preparation for the occurrence check flight, a practice flight covering similar sequences was conducted in XMJ the week before with the chief pilot and inductee pilot. That flight also had an observer on board with extensive Cessna 441 check pilot experience. The practice flight was not conducted as a training flight, but rather a private flight with two licenced and experienced pilots on board, preparing for their respective roles during the CASA check flight.

The observer advised that during the practice flight, the engine failure was simulated by the chief pilot reducing the power lever but not all the way to the flight idle stop. He further recalled that once the inductee pilot completed the initial response actions, the chief pilot partially advanced the power lever. The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation...

Page 26:

In assessing personal competency under this regulation, CASA recommended that ‘pilots should seek advice and consider refresher training or practice before commencing an operation they haven’t carried out for a while’. Although the pilot is already licenced and current on the class of aircraft, training for general competency can only be given by a pilot who holds an instructor rating and appropriate training endorsements.

The check flight briefing (see the section titled Check flight sequences) prepared for the flight had a series of questions at the end of the briefing for the inductee pilot to answer, consistent with the areas of competency identified above. Additionally, the practice flight conducted by the two pilots the week prior was an opportunity to practice the handling skills in this aircraft rather than other aircraft flown by each of the pilots...

Page 34:

...The chief pilot completed two flights as a check pilot in the year since being judged ready for assessment (Cessna 441 fleet manager’s OPC and a line check) and the practice test flight the week prior...

Page 35:

...Other than during the practice flight the week prior, the inductee pilot had not managed an engine failure in the Cessna 441 in over two and a half years, and the chief pilot had not had the opportunity to set an engine failure in almost a year. It is unclear from the chief pilot’s training records if he had ever been required to demonstrate a recovery from a mishandled engine failure after take-off in a Cessna 441.

The Cessna 441 check pilot observer who was present on the practice flight the week before described that flight as ‘messy’, with the inductee pilot appearing to be ‘rusty’. Specifically he recalled that the inductee:

•had to make reference to the checklist as he was unfamiliar with the memory items and wastherefore ‘well behind’ the aircraft
•adopted a steep pitch attitude that resulted in a lower than normal climb airspeed.

The observer further advised that there were also omissions by the chief pilot during the flight including that the:

•pre-flight briefing did not cover the procedure for transferring control of the aircraft between the two pilots
•incorrect use of the engine anti-ice system was not identified.

He also stated that the practice engine failure simulation after take-off from Renmark was ‘quite safe’ and that he debriefed both pilots on his observations...

..The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise...

P2 questions? 

1) To begin I wonder if there is a Flight Radar 24 &/or GPS record of the 'practice flight' from the week before? If so it would be interesting to see if the flight profile did indeed mimic the accident flight profile?
2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a pax and; b) the Chief Pilot didn't yet have CASA approval to conduct an OPC as a 'Check Pilot' on the C441, wouldn't that necessarily deem any simulated/practice asymmetric (OEI) as illegal, despite the fact the observer had extensive Cessna 441 check pilot experience? 
  
Quote: "..The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation..."

Now note the following from page 7:

Part 1 of the aircraft’s Log Book Statement specified that the aircraft was to be maintained in accordance with the AE Charter Services system of maintenance and all applicable airworthiness directives. The following summarises the maintenance activities conducted on XMJ leading up to the accident.

• On 31 August 2016 a number of parts, including both the left and right engines were removed for use on other company aircraft. These engines were reinstalled on 24 November 2016 and had operated for 385.2 hours on XMJ since this time.
• On 30 April 2017, the installed fuel control unit (FCU) from the aircraft’s left engine was replaced by an FCU borrowed from a third party maintenance organisation.
• On 4 May 2017, the aircraft was erroneously released to service prior to in-flight FCU set-ups having occurred, with an endorsement in the deferred defect list that the left engine had to be operated in manual mode until the FCU set-up had been completed but could continue in service until no later than 14 May 2017 without the set-up being completed.
• The Rossair chief pilot raised a concern on 8 May 2017 about the aircraft being released into service without the in-flight set-ups being completed, as the aircraft was more difficult than normal to operate with one engine in manual mode. Further maintenance work was performed on the aircraft, and, on 10 May, the aircraft was released into service, with both engines operating in normal (automatic) mode.
• The aircraft subsequently flew 28 flights, totalling 32.6 hours with no reported issues.
• On 26 May 2017, the original FCU that was removed on the 30 April 2017 was reinstalled onto the left engine of XMJ following removal, cleaning and reinstallation of the FCU’s manual mode control valve.
• A certification regarding a wing de-icing system unserviceability was made on 26 May 2017. It stated ‘No action was carried out at this time. Aircraft unavailable due to flying requirements. Customer notified.’ There was no entry in the defect field of the current maintenance release Part 3.
• Between 26 May and 30 May, the aircraft flew 6.9 hours without reported issue, including 4.5 hours across five sectors on the morning of the accident.

So the observer had prior experience conducting simulated/practice OEI in the accident aircraft to the extent that he/she could remember to the ft/lb what was required to be set in order to achieve zero thrust.  
3) Was the observer's experience with the accident aircraft before or after any of the listed maintenance to the engines (and in particular the LH engine)?

In relation to the above, I note the following from page 49 of the report:

 The self-recommendation made by the chief pilot on his training records was for CASA to assess him in checking other check pilots, that is, just the Cessna 441 fleet manager, rather than checking all line pilots. Following that recommendation, a CASA FOI (who was on the accident flight) observed the Cessna 441 check pilot’s OPC, which was conducted by the chief pilot in the right-hand seat.

The OPC of the Fleet Manager, conducted by the CP and observed by the accident flight FOI, occurred in May 2016:
4) Did the FOI have de-brief notes on that flight? If so did he make mention of the procedure and possibly the setting of zero thrust of the Chief Pilot? I also wonder if there was a Flight Radar 24 record for that flight?

5) I wonder if it would be worth requesting through FOI (or Senate order) a copy of the ATSB interview transcript of the practice flight observer who had extensive check pilot experience on the C441?

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P2 - Q&A.

I'll have two bobs worth of that please.

To that I'll add a link to this document: CASA RSR - VH-XMJ - REDACTED (28.10.19)

Keeping in mind the above extracts from the ATSB topcover edited report and then read and absorb the following from page 3 of the CASA RSR - 

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"Once investigations are finalised..etc..etc.." - Hmm...wonder what the hold up is - 

MTF? - Definitely...P2