[Peetwo]

Coroner distrust and ATSB disconnect with investigation AO-2018-078 -   

As we begin to try and join the dots-n-dashes to yet another (IMO) cocked up (vs covered up) ATSB investigation, let us 1st consider the only (refer HERE) MoU agreement between the ATSB and an Australian State or Territory Coroner's office/jurisdiction: https://www.atsb.gov.au/media/48048/tas_coroner.pdf 

2 PURPOSE

2.1 The purpose of this MoU is to maximi se the effectivene ss of both parties
in carrying out their respective roles in the event of a fatal transport safety
accident by:

(a) recognising the similarity of goals of the Bureau and Coroners in
improving the safety of the public while at the same time
acknowledging the different methods used by the parties to achieve
those goals; and
(b) minimising unnecessary duplication of effort and the potential for
conflict without compromising the independence and function of
either party and to encourage a spirit of consultation and
cooperation directed to ensure both parties are able to carry out a
proper investigation.

2.2 The Bureau and Coroners acknowledge that this MoU cannot legally
restrict the statutory discretion and powers of either party under relevant
legislation.

2.3 It is not the intention of the parties to this MoU to create any legal
obligations between them as to the matters set out in it.

As far as I can gather, this 18 year old MoU represents the only such agreement between a Coroner and the ATSB still in force today?? Which brings me to the next point of interest, which perhaps helps to explain why the TAS Coroner dumped so heavily on the ATSB in his inquest report into the death of Nikita Walker - 

The following is a link to a report that involved the same operator, from the same Coroner, into another fatal aviation accident that occurred in 2014: https://www.magistratescourt.tas.gov.au/..._Peter.pdf

Comments and Recommendations:

I extend my appreciation to investigating officer, Senior Constable Michael Barber, for his investigation and report.
The circumstances of both deaths are not such as to require me to make any recommendations pursuant to Section 28 of the Coroners Act 1995.

The ATSB investigators were provided, at my direction, with every assistance by Tasmania Police investigating this tragic accident.

The subsequent decision by the ATSB to refuse my request for copies of witness statements obtained in the course of its investigation was, in such circumstances, both surprising and disappointing. The ATSB made the obvious point in its reasons for refusal that “ATSB investigations and [C]oronial investigations/Inquests [sic] fulfil separate statutory functions”. However, the common, and crucially important, statutory function of both the ATSB and the Coroner is the investigation of fatalities with a view, inter alia, to endeavouring where possible to prevent avoidable deaths occurring in similar circumstances in the future. The ATSB acknowledged as much.

The coronial investigation of the deaths of Mr Langford and Mr Jones proceeded on the basis that it was unnecessary to interview witnesses that had already been interviewed by the ATSB because it was understood, wrongly it would appear, that the ATSB would provide copies of those statements to the Coronial Division. The request for the statements was made after the ATSB had concluded its investigation and after it had released its report publicly.

In refusing to provide the requested statements the ATSB relied upon section 60 of the Transport Safety Investigation Act 2003 (Cth). That section prohibits the provision of restricted information. The expression ‘witness statement’ is included in the definition of that term. However, the prohibition is subject to section 60(5) which empowers the ATSB to issue a certificate authorising the release of witness statements where the ‘disclosure of the information is not likely to interfere with any investigation’.

Despite this provision the ATSB still refused the request, when there was no rational impediment, at all, to the provision of the requested statements and its investigation was complete.

In concluding I convey my sincere condolences to the family and loved ones of Samuel Langford and Timothy Jones.

Dated 21 July 2017 at Hobart in the State of Tasmania.

Simon Cooper Coroner

            
Hmm...it would seem to me that Coroner Cooper had duly respected the terms and conditions of the MoU and expected that same respect would be forth coming from the ATSB and yet that clearly did not occur. Then with his next dealings with the ATSB he found the same disrespect and dodgy disconnect, subsequently (inappropriately or not?) he vented his displeasure in his Nikita Walker inquest report -      

Next I make the following OBS from the AO-2018-078 report: 

(From under 'Bureau of Meteorology' - 'Forecasts', note the parts in bold)

A Bureau of Meteorology (BoM) graphical area forecast was issued at 0342 and was valid for the period 0400 to 1000, encompassing the accident flight. The forecast was applicable for all of Tasmania. The BoM reported that the forecast included mist (visibility reduced to 2,000 m) and broken[6] stratus cloud with a base of 200 ft above mean sea level (AMSL) for areas within 20 NM (37 km) of the coast (encompassing the Bathurst Harbour ALA),[7] associated with the low‑level moist onshore flow. The forecast also included areas of scattered light rain (visibility reduced to 7,000 m) throughout the entire area from a layer of broken altocumulus/altostratus cloud at 9,000 ft, and scattered stratus cloud between 500 ft and 1,000 ft. The forecast indicated that severe turbulence below 8,000 ft and widespread sea fog was expected.

The subsequent graphical area forecast issued at 0348 and valid from 1000 to 1600 was divided into two regions and showed a deterioration in the conditions in the south-west. Broken cumulus and stratocumulus cloud was between 2,000 ft and 8,000 ft, and visibility reduced to 7,000 m in scattered light rain.

The search and rescue helicopter pilot advised that the forecast on the day:

…was quite unusual (I have not seen one like it to date) which had broad brushed the entire state. This made me wonder if there was a technological issue behind it…

As a result, the pilot contacted the BoM who advised that the:

forecast for the South West region was poor, as the weather would be pushing inland from the south west and there was a high probability of low cloud but they could not quantify an accurate cloud base.

The closest aerodrome forecasts[8] (TAF) were available at Strahan (about 145 km north-west of the accident site) and Hobart (about 100 km east-north-east of the accident site).

The TAF for Hobart, issued at 0405, indicated 8 kt winds from the west and CAVOK [9] conditions, with a 30 per cent probability of deteriorations of less than 30 minutes due to thunderstorms and rain until 0900. From this time, the TAF indicated a change to the prevailing weather conditions, with a reduction in visibility, and increasing rain and cloud. 

The Strahan TAF was issued at 1737 (the day before the accident) and indicated that the conditions were deteriorating at 0300 the next day. The cloud base was broken stratus cloud with a base at 500 ft. It was subsequently updated at 0005 showing a deterioration at 0400, with broken stratus cloud with a base of 200 ft. A special report of the meteorological conditions at Strahan, issued at 0800 and 0830 on 8 December 2018, indicated that there was overcast cloud at 1,300 ft above ground level (AGL). At 0900, the cloud had deteriorated to include broken cloud at 600 ft.

Analysis of the conditions

There were no recorded observations of the conditions at the location of the accident. The BoM provided the following analysis based on satellite imagery, forecasts, and observations. Specifically, they noted that:

On the night of 7 December 2018, Tasmania was under a very moist north-easterly airstream, with dew point temperatures in excess of sea surface temperature thus sea fog, coastal mist and very low cloud were expected to develop around the coastal areas of Tasmania. A surface trough moving over the southwest in the morning of 8 December 2018 was expected to extend low cloud over southern Tasmania during the morning.

The satellite images showed that there was an ‘extensive layer of middle and high cloud associated with the passage of the trough’. Similarly, high-resolution images also indicated the presence of low-level cloud in the area, including the accident location (Figure 4).

Figure 4: Visible satellite image at 0800 showing the approximate accident location



Source: Bureau of Meteorology, annotated by the ATSB

The aerological diagram from Hobart indicated ‘a likelihood that cloud would form via orographic ascent[10] on the windward side of ranges’. Likewise, the relative humidity at other nearby locations was also high during the morning.

The nearest cloud and visibility observation sites to the accident location were at Hobart (100 km to the north-east) and Strahan Airports. However, Strahan Airport was considered to be more representative of the onshore flow at the accident site in the wake of the trough. Between 0345 and 0840, the cloud base at Strahan was between 1,000 ft and 2,000 ft. After this time, the cloud base lowered to below 1,000 ft, before gradually lifting later in the day. In addition, there were several instances where the visibility reduced to below 5,000 m during the night and morning, likely associated with areas of mist.

In summary, the BoM concluded that:

Conditions on the morning of 8 December 2018 were characterised by coastal sea fog and mist, low orographic cloud developing and the passage of a mid-level cloud band with light rain and virga.[11]

The relevant forecasts were consistent with the weather conditions in the area of the incident.

 
(Also refer pg 12 para 48 of the Coroner's report)  

Hmm...where's a copy of the 0342 GAF report; and why is this aberration not more closely examined as would normally be required under the ToR for a full blown systemic investigation?

Systemic

Systemic investigations can involve in‑the‑field activity, and a range of ATSB and possibly external resources. They have a broad scope and involve a significant effort collecting evidence across many areas. The breadth of the investigation will often cover multiple organisations. Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes.

In addition to investigating failed and missing risk controls, systemic investigations may also investigate the organisational processes, systems, cultures and other factors that relate to those risk controls, including from the operator, regulator, certifying and standards authorities. Systemic investigations result in substantial reports, often with several safety issues identified.

Systemic investigations were previously known as 'complex' investigations. The change in terminology more accurately reflects the broad scope and systems-level complexities involved in these investigations.

Which brings me to some extracts from both the AO-2018-078 prelim and update reports: (click on the applicable links: https://www.atsb.gov.au/publications/inv...-2018-078/ )

Prelim report:

Ongoing investigation

The investigation is continuing and will include examination of the following:

• recovered components and available electronic data
  
• aircraft maintenance documentation
  
• weather conditions
  
• pilot qualifications and experience
  
• operator procedures
  
• research and previous occurrences.
  

 
Update:

Updated: 6 December 2019 

The investigation into the collision with terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018 is continuing. A preliminary report outlining the then known facts of the investigation was published on 4 February 2019.

Since the publication of the preliminary report, the investigation team has gathered information from, or related to the accident, to build a detailed picture of the event including:

• recovered aircraft components and available electronic data
  
• aircraft maintenance documentation
  
• weather conditions
  
• pilot qualifications and experience
  
• operator procedures
  
• research and similar occurrences.
  

The investigation team is currently examining and reviewing the evidence to determine its relevance, validity, credibility and relationship to the accident and other pieces of evidence. Based on this analysis, the team is developing and testing a series of hypotheses to determine the safety factors that could have contributed to the accident or increased the risk of the accident occurring and will form the basis of the ATSB final report.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant stakeholders so appropriate and timely safety action can be taken.

Hmm...so one year in and it was still considered an investigation defined by the dot points above: 

Defined

Defined investigations seek to identify systematic safety issues that reveal underlying cause of the accident. They involve several ATSB resources and may involve in-the-field activity or be an office-based investigation. Evidence collected can include recorded flight and event information, multiple interviews, analysis of similar occurrences, and a review of procedures and other risk controls related to the occurrence.

Defined investigations result in a report of up to 20 pages and look at transport safety accidents and incidents of a more complex nature than short investigations. They include an expanded analysis to support the broader set of findings within the report and may include safety factors not relating directly to the occurrence. Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. The report also identifies safety issues, along with proactive safety action taken by industry and ATSB safety recommendations.

Q/ So what changed and when did the ATSB make the decision to escalate (and commit the significant extra resources) to define this investigation as 'systemic'? Q/ Why didn't the Coroner/Police investigations note any significant organisational issues/deficiencies within the operator and/or CASA regional office?

On a final note, which I believe is definitely related, has anyone else checked out the bizarre, totally disconnected safety issue addressed to CASA, that was subsequently escalated to a very rare Safety Recommendation??

Regulatory management of repeat safety findings

The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.

---

Safety recommendation
Action number: AO-2018-078-SR-01
Action organisation: Civil Aviation Safety Authority
Date: 20 December 2021
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority amend its acquittal process for repeat safety findings to ensure it is effective in ensuring that all previous findings of a similar nature are also appropriately assessed prior to the current and all associated safety findings being acquitted.

Hmm...anyone else understand that gobbledygook -   

Response by Civil Aviation Safety Authority

The Civil Aviation Safety Authority did not provide a response concerning its intention to address this safety issue.

If I was the CASA Regional Manager, supposedly tasked with responding to that bollocks SR, I wouldn't  be providing a response either?? - FDS!        

MTF...P2