[Peetwo]

Popinjay and Hoody taking the piss on ICAO Annex 13 final report compliance??

Via the Dicky King thread:

Chalk & Cheese: S is for? - Surveillance.

As a clear chalk and cheese comparison, I refer to another ATSB systemic investigation - AO-2018-078. In regards to CASA oversight, the following is the overview summary (page 29):

The Civil Aviation Safety Authority (CASA) had two primary means of oversighting a specific operator’s aviation activities: regulatory services and conducting surveillance of its activities. They also used a scale of prioritisation, based on risk, to determine where to focus resources. This prioritisation was based on several factors, such as the sector of operation, organisational changes and challenges.

To maintain oversight across Australian operators (authorisation holders), CASA had a number of certificate management teams in different locations, made up of CASA officers, including flying operations inspectors, safety systems inspectors, and airworthiness inspectors. Each of these teams oversighted multiple authorisation holders. At the time of the accident, the team responsible for the oversight of Airlines of Tasmania comprised of one certificate team manager, three flying operations inspectors, four airworthiness inspectors and one safety system inspector. The team had oversight of 58 AOC holders, 50 aviation maintenance organisations and four delegates.

This oversight summary is strangely remiss in the AO-2022-009 report, despite (I would have thought) being equally applicable??

In the meantime from the BRB, here is the 'King Aviation Swiss Cheese' model for the Miniscule to refer...

In reference to the 'Previous investigations with surveillance and hazard identification findings', listed in the  AO-2018-078 investigation, I checked for the applicable section for 'CASA Oversight': 

AO-2017-057: 

 

Regulatory oversight

Overview

The stated mission of the Civil Aviation Safety Authority (CASA) is ‘To promote a positive and collaborative safety culture through a fair, effective and efficient aviation safety regulatory system, supporting our aviation community.’

CASA was responsible, under Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia, including by:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

CASA had documented a regulatory philosophy that included maintaining a risk-based approach to decision making, and being consultative and collaborative with industry, while balancing consistency with flexibility in its work.

CASA had two primary means of oversighting a specific operator’s aviation activities:

• regulatory services, by assessing applications for the issue or variations to its AOC and associated approvals (including approvals of key personnel)
  
• conducting surveillance of its activities.
  

CASA used a scale of prioritisation based on risk to determine where to focus resources. This prioritisation was based on a number of factors, such as the sector of operation, organisational changes and challenges.

In order to maintain oversight across Australian operators, CASA had a number of certificate management teams (CMTs), made up of CASA officers, including flying operations inspectors (FOIs) and airworthiness inspectors (AWIs), in different regions of Australia. Each of these teams oversighted a number of AOC holders. The majority of the oversight of Rossair was conducted by an Adelaide-based team.

AO-2017-005:

Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section 9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

The two primary means of oversighting a specific operator’s aviation activities were:

• assessing applications for the issue of or variations to its AOC and associated approvals (including approvals of key personnel)
  
• conducting surveillance of its activities.
  

AO-2009-072:

Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the
safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section
9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;
(d) developing effective enforcement strategies to secure compliance with aviation safety standards;
(da) administering Part IV (about drug and alcohol management plans and testing);
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance, including assessment of safety‐related
decisions taken by industry management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in order to monitor the safety
performance of the aviation industry, to identify safety‐related trends and risk factors and to promote
the development and improvement of the system;
(h) conducting regular and timely assessment of international safety developments.

The two primary means of oversighting a specific operator’s aviation activities were:

 assessing applications for the issue of or variations to its AOC and associated approvals
(including key personnel and the training and checking organisation)
 conducting surveillance of its activities on a regular basis.

Up until 2004, CASA oversight of the operator’s jet AOC was conducted by the Bankstown
general aviation (GA) field office276 and oversight for the operator’s turboprop operation was
conducted by the Brisbane air transport office. In August 2004, responsibility for oversighting the
turboprop AOC was transferred to the Bankstown office. The Bankstown office retained oversight
responsibility for the operator when the two AOCs were merged in October 2006.

This section briefly overviews the processes involved in assessing variations and conducting
surveillance, and then discusses CASA’s oversight of specific aspects of the operator’s activities.
The section focusses on CASA’s oversight of flight operations activities conducted under the
operator’s AOC during 2005–2009, with some events prior to 2005 discussed when relevant.

Curious to how far back this standard format for the 'CASA Oversight' summary in ATSB systemic operator investigations, I went to the biggest CFIT investigation in this century IE 'Collision with Terrain - Fairchild Metro 23 aircraft, VH-TFU 11km NW Lockhart River Aerodrome, Qld 7 May 2005'

1.18 Regulatory oversight of Transair and Aero-Tropics

1.18.1 The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act
1988, for the regulation of aviation safety in Australia. Section 9 of the Act
included the following:

(1) CASA has the function of conducting the safety regulation of the
following, in accordance with this Act and the regulations:

(a) civil air operations in Australian territory;
(b) the operation of Australian aircraft outside Australian territory;
by means that include the following:
© developing and promulgating appropriate, clear and concise
aviation safety standards;
(d) developing effective enforcement strategies to secure compliance
with aviation safety standards;
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance,
including assessment of safety-related decisions taken by industry
management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in
order to monitor the safety performance of the aviation industry, to
identify safety — related trends and risk factors and to promote the
development and improvement of the system;
(h) conducting regular and timely assessment of international safety
developments.

The two primary means of oversighting an operator’s aviation activities were
assessing applications for the issue of or variations to its Air Operator’s Certificate
(AOC) and associated approvals (including key personnel and training and
checking organisation), and conducting surveillance of its activities on a regular
basis.

The only exceptions to this standard format that I have been able to find so far are Croc-o-shite and the VARA ATR broken tail accident reports:

Anyone else see the ironies of the examples that the ATSB has picked on?? Wonder why they didn't include the VARA ATR-72 broken tail accident?? Oh that's right they farmed that part of the investigation off to a 'Case study: implementation and oversight of an airline's safety management system during rapid expansion':  Update: ATSB PC accident investigation AO-2014-032

Overview of the investigation

As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems.

The ATSB collected a significant amount of evidence and conducted an in‑depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

As part of its investigation, the ATSB:

interviewed current and former staff members of the operator, regulator and other associated bodies
examined reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
reviewed other investigations and references where similar themes have been explored.

This stitched up Hooded Canary investigation waffled along aimlessly for 3 years until it was subsequently discontinued: 

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

"...The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations..." - Unless of course you're the 'Croc Wrangler'??? - 

Before we move on from the Hooded Canary's successful cover-up of the flawed CASA oversight of the VARA ATR operation, remember this? Ref:  Update: ATSB PC accident investigation AO-2014-032 

 

It is interesting to note that in the rather lengthy 1st interim report, the following was stated:

Investigation activities to date
To date, the ATSB has collected information about, and analysed the following:

• the sequence of events before and after the pitch disconnect, including the post-occurrence maintenance and initial investigation by Virgin Australia Regional Airlines (VARA) and ATR
  
• flight and cabin crew training, qualifications, and experience
  
• the meteorological conditions
  
• VARA policy and procedures
  
• VARA training courses
  
• VARA’s safety management system
  
• VARA’s maintenance program
  
• the aircraft’s systems
  
• the relationship between VARA and the maintenance organisation
  
• maintenance engineer training, qualifications, and experience
  
• the maintenance organisation’s policy and procedures
  
• the maintenance organisation’s training courses
  
• the maintenance organisation’s quality and safety management
  
• the Civil Aviation Safety Authority’s (CASA) surveillance of VARA
  
• CASA’s approvals granted to VARA
  
• CASA’s surveillance of the maintenance organisation
  
• CASA’s approvals granted to the maintenance organisation
  
• ATR’s flight crew type training
  
• ATR’s maintenance engineer type training
  
• ATR’s maintenance instructions for continuing airworthiness
  
• known worldwide in-flight pitch disconnect occurrences involving ATR 42/72 aircraft.
  

So the CASA Oversight had been completed and apparently analysed, yet the findings and analysis were not included in the final report...

Back to the 'Croc-o-shite' report and the bizarre omission of the 'CASA Oversight' standard format. The following is a very alarming Oz article (TY CW -   ) from 14 July this year:

Accusations of safety breaches show failure to rein in Outback Wrangler Matt Wright



The Civil Aviation Safety Authority had investigated scores of incidents involving celebrity croc-wrangler Matt Wright and his company Helibrook in the decade preceding the fatal chopper crash that killed Netflix star Chris Wilson.

The Australian has obtained, under Freedom of Information laws, CASA documents which – despite being heavily redacted – reveal the regulator has been aware of suspected safety breaches involving Helibrook for about 12 years.

Wright burst onto CASA’s radar after the first series of his reality television show Outback Wrangler hit screens in 2011.

When those first four episodes – produced for National Geographic and bankrolled by Screen NSW – were broadcast, a member of the Northern Territory Government’s crocodile management program contacted CASA and “raised concerns” about Wright’s “aviation operations”.

After reviewing the footage, investigators alleged Wright and his co-star Michael Burbidge had possibly committed up to 14 safety breaches, during a six-week period, while filming in late 2010.

That assessment was based solely on what CASA could see in the final cuts.



The possible offences – involving five different choppers – included reckless operation of an aircraft, low flying, carrying firearms, carrying live animals, not wearing seatbelts, not restraining cargo, unapproved modifications and conducting commercial operations without an air operator‘s certificate.

But before the ink was dry on CASA’s report Wright was back in the spotlight after the NT News published a front-page photo of what was alleged to be someone shooting a crocodile from a helicopter he was flying.

CASA did not investigate the April 2013 incident but NT Parks and Wildlife did.

A witness alleged that shots were fired from the helicopter as it hovered over the mouth of Shady Camp, 110km southeast of Darwin, which is known for its high concentration of crocodiles.

‘‘(I) spotted these guys about a kilometre away shooting a croc outside the river mouth, winching it up and flying to shore and land,” he told the newspaper.

But Wright, who said he was taking a client heli-fishing and on an adventure tour, denied they had shot towards the water, adding that there might have been a few gunshots heard earlier when they were shooting pigs over land.

‘‘We were just flying over looking at all the boats on the water,’’ he said.



‘‘We saw a barra caught in the shallows and he (the client) jumped out and grabbed it, and we flew to the bank to secure it.’’

The client, David Blanck, refused to comment on the gunshots but said he had jumped out to grab the fish.

‘‘We saw a barra and I asked Matt what he thought, and he said ‘jump in and get it’, and that is pretty much what we tried to do,’’ he said.

‘‘I jumped down, got it and tied it to the skid with a bungee cord, and flew to the bank and took photos.”

The Parks and Wildlife Commission investigated but cleared the men of any wrongdoing after seeing a picture of a barramundi they had caught.



When the story was published, Wright was angry and Burbidge, who owned the chopper, allegedly stormed into the NT News building and had a go at the paper’s editor.

A year later, in a separate alleged shooting incident, the owner of a fishing charter business reported seeing two R44 helicopters flying low, near the mouth of the Finniss River, while those on-board discharged what appeared to be automatic firearms. The man alleged to police that one of the pilots was Wright.

He said the choppers were hovering and circling around as if looking for something, possibly pigs, and firing volleys of shots in quick succession.

He further claims that bullets were landing within 100m of him and others who were fishing in the area, causing them to fear for their lives.

When the fisherman called triple-zero the operator said that she also could hear the shots being fired.

“He could hear the whizzing of bullets and they ducked their heads into the boat,” CASA recorded.

Police contacted Wright to arrange an interview but his travel schedule made it hard.

When CASA contacted him, he said the complaint was “untrue”, “didn‘t happen” and that he “had no knowledge of this incident”.

Wright said his log book was not up to date and he couldn’t remember his movements that day but if he was in the area, he would have been 10 nautical miles back from the Finniss River and that the fisherman “complains about that sort of thing all the time”.

“As soon as he sees helicopters and hears shots he brings him (Wright) into it,” the investigator recorded Wright as saying.

“It is bullshit and he is sick of it.

“This is not helping his AOC application and he does not need this.”

CASA decided there was insufficient evidence of wrongdoing.

In the midst of these accusations the rising star was having a blast with his Hollywood actor mate Gerard Butler who was Down Under filming Gods of Egypt.

In March 2014 Wright took the star of 300 on a bespoke outback adventure that involved buffalo hunting, heli-fishing and airboat rides.

When Butler returned to the US, he giddily shared a home video of Wright’s wild chopper flying during an appearance on Jimmy Kimmel Live.

The 20-second clip shows Wright’s black Robinson R44 hurtling towards Butler and others, before aiming its rotor towards the men and spinning above their heads for a terrifying few seconds before landing a few metres away on the beach.

“This guy is quite a famous adventurer in Australia,” the Scottish actor told Kimmel.

“I don’t want to say his name because it was … There was a lot of stuff I couldn’t even put on this video by the way. This is the tame stuff.”

As the footage began to roll, Butler told the host “this is how we were flying about”.

“We didn’t even upload the best bit of this where we were spinning around at 70 miles per hour and him in the chopper right above us,” he said.

Sources close to the incident say that when the footage, filmed at the Peron Islands, was made public, Wright was “wild” that Butler had shared the private clip.

Experienced helicopter pilots have told The Australian that the chopper’s perceived proximity to the people on the beach appeared to breach CASA regulations and that for several seconds the chopper was within “the dead man’s curve”.

“Any cough or splutter from the engine would’ve killed them all,” a source said.

But after reviewing the footage and interviewing Wright, CASA found no breaches had occurred.



In any case, by the time CASA became aware of Butler’s video, investigators had their hands full with another alleged incident involving that same chopper, registered VH-MEB, after receiving a tip-off that it had drowned.

“Yes that is correct that MEB did go underwater the other day when I was on my way back to the shack,” Wright emailed a CASA investigator in June 2014.

“Wasn‘t a good weekend that one as I also had a major on the airboat about three days earlier.

“But with MEB I had landed on the beach to have a quick flick before starting work that afternoon.”

Wright said that when he went to start the chopper again, there was “no power”.

“It was a diode of the starter relay that had stopped working so by the time the engineer got there it was too late with the incoming tide and water was lapping up around the belly and we could not get it started at that stage.

“I know this isn‘t going to help my current investigation but there wasn’t much I could do to prevent this one Pete and I’ve lost my machine that I still have to pay (Mick Burns) out for it as the insurance didn’t cover the total cost, so this one has hurt a bit.”



Wright told CASA that he was alone when it happened and that the helicopter’s Maintenance Release – where flying time is recorded – had floated away.

Burbidge flew out to retrieve the wreckage via sling load beneath his Squirrel.

Days later Wright sold the written-off chopper to his mentor, cattle baron and former reality television star Milton Jones, who later changed its registration to VH-NTH.

A year before MEB went underwater, Wright had slung a 23-year-old man with cancer – Jett Brewster – beneath it “for some sightseeing”.

CASA was alerted when the November 2013 edition of North Australian Fishing and Outdoors magazine published a story about it with photos.

The article, written by his Outback Wrangler co-star Wilson, said that “Jett dangled airborne below the chopper for more than 30 minutes as Matt flew across some of the vast landscapes of the Top End”.

When CASA interviewed Wright and Brewster, who passed away last month, both said the slinging had only been for five minutes along the shoreline and Wright said he didn’t think he needed authorisation because it was a “private operation”.

“He had done it because Jett wanted to experience what he (Wright) did for work,” the CASA investigator recorded of his conversation with Wright.

“He (Wright) thought ‘why not as Jett did not have long to live’.”

In August 2015 CASA asked Wright to show cause why it should not – in light of previous incidents including the Butler video – vary, suspend or cancel his Air Transport Pilot Licence or Commercial Pilot Licence.

In March 2016, CASA decided – after considering Wright’s response and representations made on his behalf – not to vary, cancel or suspend his licenses.

“Rather, in this instance, I have decided to counsel you,” the acting regional manager wrote in a 10-page Notice of Counselling letter.

Only two pages of this letter were not redacted before it was released to The Australian.



“Therefore the purpose of this letter is to formally record that you have been counselled during our face-to-face meeting in the Darwin CASA office on 9 March 2016,” it concluded.



But Wright’s aviation issues were far from over.

In April 2017, a helicopter sub-hired from Wright’s mate and former business partner Troy Thomas crashed in Western Australia, injuring passengers and sparking CASA and Australian Transport Safety Bureau investigations.

The Robinson R44, registered VH-SCM, crashed into the water after taking off for a charter flight from the top of a boat at Talbot Bay.

Thomas’s company Horizontal Falls Seaplane Adventures owned the chopper but was operating under Wright’s AOC.

The pilot and two passengers, who suffered minor injuries, had to exit the helicopter underwater and swim 50m to shore before being treated at hospital.

Then in August 2017, pilot Jock Purcell crashed one of Helibrook’s Robinson R44s, registered VH-LGN, in the NT with three passengers on board.

In December that year, CASA called Wright again after the newlywed regaled the Herald Sun with a story, about how he had told his wife Kaia to jump from a hovering helicopter to chase a pig, which was then printed in an article about their outback romance.

In 2018, CASA launched a noncompliance investigation into Helibrook after receiving complaints about five alleged incidents of “unsafe behaviour” in helicopters associated with Broome-based Horizontal Falls Seaplane Adventures, which was still operating under Wright’s AOC.

The complaints to CASA included reports and videos of “deliberate and systematic low-flying and vessel-harassment”, unsafe behaviour by a helicopter in relation to a seaplane, an illegal landing on Cockatoo Island and reports of a helicopter departing Broome in thick fog.

“This organisation is conducting itself in a manner which demonstrates a systemic and belligerent disregard of legal and safety obligations over an extended period,” one complaint alleged.

A pilot, with “several thousand hours of experience” told CASA he was “aghast” when he saw a helicopter take off from Broome with “zero visibility”.

“Other pilots were watching and shaking their heads,” he wrote. “I have photographs of this morning that proves the conditions were nowhere near legal.”

WA National Parks and Wildlife had also ordered one of the pilots to attend mediation with them.

CASA said the activity in the videos “depicted helicopters engaging in manoeuvres which placed the aircraft in situations of varying risk profiles” but ultimately concluded that the complaints could not be substantiated.

In late 2018, Wright turned up at Airwork Helicopters in Caboolture, north of Brisbane, where he reportedly told students that “CASA had sent him back to flight school”.



In May 2019 CASA sent Wright a “notice of decision to vary commercial pilot licence”.

A couple of months later, CASA sent him a “notice of decision to vary conditions on commercial pilot licence”.

Both letters were fully redacted before being released to The Australian.



At the turn of the decade, in 2020, Helibrook’s affairs took a turn for the worse, after a seemingly benign incident involving an R44 with the registration VH-XHB.

In August 2020, Helibrook reported to CASA and the ATSB that “while repositioning for refuel, the helicopter landed hard” at Wright’s Top End Safari Camp and that the pilot was the only person on board.

“The pilot was not injured and the helicopter sustained moderate damage to the undercarriage,” a CASA report from September 2020 states.

As a consequence, CASA deemed that “no further CASA action is recommended with respect to the company” and did not investigate further.

Nothing more would have come of it if it had not been for Wilson’s fatal crash two years later.

On February 28 last year, Wilson was killed when Helibrook’s VH-IDW, which he was slinging beneath, crashed during a crocodile egg collecting mission at West Arnhem Land. Pilot Sebastian Robinson was critically injured and is still recovering from severe spinal injuries.
During their investigation NT Police publicly appealed for anyone who had flown on board the destroyed chopper, which was also used for charter flights, to submit their photos and footage.



Lo and behold tourists who had been on VH-XHB when it crashed in 2020 also came forward and reported that an alarm sounded before the chopper fell about 10 metres and made a hard landing.

At the time Wright, who was not the pilot, was informed one of the tourists had recorded a video of the incident.

It will be alleged that after viewing the footage, Wright asked the tourist not to share it with anyone, before providing the passengers involved in the incident with free alcohol and refreshments.

Since Wilson’s death, which is still under intense scrutiny, CASA has launched another five investigations into Helibrook.

Of those, one is about the fatal crash and another relates to alleged “unsafe behaviour reports”.

Helibrook’s operations were voluntarily suspended last year but Wright, who still has his pilot licence, is still flying.

CASA said it was inappropriate to comment “noting other ongoing matters under investigation”.

Wright declined to comment.

If you believe it is remotely possible that the ATSB was not aware of any of these disturbing tales of regulatory safety breaches involving both the Matt Wright and Troy Thomas commercial, airwork and private operations - I've got a lovely bridge in Sydney Harbour going cheap...  

Why go to such lengths to cover up the CASA negligence to properly oversight the Matt Wright and Troy Thomas cowboy outfits?

The following is one BRB hypothesis doing the rounds. Under ICAO Annex 13, APPENDIX I - FORMAT OF THE REPORT, para 1.17 it states:

1.17 Organizational and management information.

Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator. the air traffic services, airway. aerodrome and weather service agencies: and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices. and regulatory framework.

It then says under 'Analysis':

2. ANALYSIS

Analyse, as appropriate, only the information documented in I. - Factual information and which is relevant to the determination of conclusions and causes.

From a legal perspective, by the ATSB leaving out 'CASA Oversight' in the context section, means that there is no need to properly analyse the obvious complete lack of surveillance of the Helibrook AOC and approvals.

Why they would do this? Possibly to avoid any embarrassment when the report and safety issues are reviewed by ICAO?

Incidentally the safety issues from the Croc-o-shite report are still yet to be given an issue date and/or to listed on the ATSB safety issues and actions database - WTD? 

MTF...P2