A new Broome?
Not a bad idea; they say a new one sweeps clean. After carefully reading the ATSB report (twice) – HERE - 'The Australian's' article – HERE -a lot more times; there are some pretty big questions left lingering in the dark corners. In order to strip back the C310 event 'we' (if we are serious about it) need to venture all the way back to the grass roots, to the core issues, those that matter.
Where does 'operational safety' control begin and where should it end? There is a clearly defined structure within any flying operation detailing the legal and operational 'responsibility' of each 'key' element; corporate, operator, chief pilot, check and training, engineering & etc. In theory, any one of those elements can (and are obliged) to raise the red flag. There are no legal excuses for failing to do so: none. In the 'real life' situation i.e. a prang; the buck is passed around at dizzying speed. Where it stops is usually at the feet of the pilot operating the flight.
“The Auditors fluttered anxiously. And, as always happens in their species when something goes radically wrong and needs fixing instantly, they settled down to try to work how who was to blame.”
'We' have the same problem; the event happened, C310 + fuel starvation. Where is the radical cause? Where to begin? The aircraft is a good place. This particular C310 has operated many thousands of hours over the years; safely completing many tasks and operated by many pilots; none of whom managed to run out of juice, or mismanage the 'system'. The venerable C310 alongside the PA30 (twin com) have trained countless pilots to operate their first 'multi-engine' air-frame, usually coincidental with their instrument rating. Almost 100% of those pilots will 'study' the manuals, learn the 'systems' and the performance limitations; thoroughly and ask many questions. Good trainers will devote at least a day in the 'classroom' working through the manuals and answering the questions after study, before examination. So item 1: did our pilot have a 'proper' structured, approved ground course, proper instruction on how to manage the awkward fuel system and a solid company policy for clear guidance? If not, why not?
“During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.” ATSB..
The 'Findings' section of the ATSB report is an important section. Each individual 'note' standing alone shouts a clear message; collectively they are damning. They speak loudly of a 'lip-service' approach to the demands of a 'modern' safety culture. From both the operator and the CASA. The 'system' implodes and becomes a mockery when:-
“Following a complaint by a former Broome Aviation pilot regarding management pressure on pilots to operate un-serviceable aircraft, CASA conducted a level 2 surveillance activity on the operator in early June 2023 and following further complaints, a level 1 audit in August 2023, with key scope elements being to evaluate the complaints. Despite that, the surveillance activities and the associated reports did not assess the subject of the complaints.” ATSB.
Cast your memory back to being the brand new hire on your first line flying job. Hired to operate single engine machinery with the promise of perhaps a multi engine 'command'. Head down, mouth shut and absolutely no 'boat rocking' in an operation where the 'culture' is as described by the ATSB. There is powerful motivation to just tow the line; rack up some hours and keep applying to other operators in the hope of a greener pasture and better conditions elsewhere. That is what everyone else is doing. Operators are fully aware of this; some look on it benignly and wish you well; others however can, will and do take advantage of this. There is no 'safe' conduit to raise concerns through and have those concerns rectified. 'Senior pilots' are (mostly) on the same trajectory or, reporting to management in the hope of a glowing reference come airline interview time. Often, they either cannot, nor will not step up for fear of the jungle drums and the 'poisoned' telephone calls. So, what options does a newbie have? Hobson's Choice is what.
“The search for a scapegoat is the easiest of all hunting expeditions.”
I could probably bang on for another page; but the best way to finish this is to point at the radical and ask the question. What in the seven Hells is CASA playing at in the top end? There is now quite the list of 'aberrations', smashed up aircraft and bodies scattered across the NW of Top End; the Broome fatal fiasco; the Croc Eggs debacle; the G8 lucky escape and now the C310 near fatal. It is all very well for CASA acquitting themselves 'on paper' and scampering back to the more sybaritic, salubrious surrounds; they ain't 'responsible'. But it won't serve. Nope, it just won't do. CASA have 'dropped the hammer' on much less injurious operations; crucified operators for much less than we have witnessed in these events.
“There are no secrets to success. It is the result of preparation, hard work, and learning from failure”.
“It’s all very well to make findings in hindsight, and we look at how our findings are likely to lead to a safer system in the future, as opposed to just hammering a regulator because we found evidence to be critical,” said Mr Mitchell.
The 'cost' of the ATSB investigation and report added to the cost of the CASA audits added to the astronomical cost of the re-writing of regulation and avoiding ICAO compliance; and 'easy' blame allotment; and, with no real threat of 'prosecution';and, written, enforced, abrogation of all responsibility is staggering. Yet for all that, junior pilots are left 'vulnerable' and in this case, unprotected by the HOFO or Chief Pilot. or CASA. One has to wonder what the Hell are they playing at and who's running the clown show?
“Like any other big government department, it looks good on paper but is an utter shambles. Petty infighting and political agendas, arrogance and sheer bloody-mindedness almost guarantees that the left hand doesn't know what the right is doing.”
Amen to that; it must be time for Spence to be rid of those clinging to her voluminous skirts and 'get to grips with it': that or bugger off back to the clerical world, before CASA become a mocked, universal pariah. Get some folk 'up North' who know their work, can sort out the mess and ring in some real changes, before there is a blood bath. Oh, it is on the cards. Soon or late the big questions will demand answers, exposing both minister and a 'do little' hands off government.
“The final ATSB report found the pilot was not familiar with the aircraft’s relatively complex fuel system after transitioning from a Cessna 210 and getting little supervision or support from employer Broome Aviation.”. ATSB.
Well, I'm over it; if 'industry' does not drag CASA kicking and screeching back to the reality of their remit then we can all look forward to traveling through the morass until we reach the abyss aptly named as 'more of the same' with better cover and more insidious, draconian regulation as a defence against culpability. No? Well watch as history repeats itself – again.
“There was an abyss. And books contained magical incantations to raise what was hidden there, all the great mysteries.”
That's it: time to return to the stable workshop and the quiet sanity of animals, good clean timber and sharp tools; Aye; there's balm for the soul right there.
Selah..
Not a bad idea; they say a new one sweeps clean. After carefully reading the ATSB report (twice) – HERE - 'The Australian's' article – HERE -a lot more times; there are some pretty big questions left lingering in the dark corners. In order to strip back the C310 event 'we' (if we are serious about it) need to venture all the way back to the grass roots, to the core issues, those that matter.
Where does 'operational safety' control begin and where should it end? There is a clearly defined structure within any flying operation detailing the legal and operational 'responsibility' of each 'key' element; corporate, operator, chief pilot, check and training, engineering & etc. In theory, any one of those elements can (and are obliged) to raise the red flag. There are no legal excuses for failing to do so: none. In the 'real life' situation i.e. a prang; the buck is passed around at dizzying speed. Where it stops is usually at the feet of the pilot operating the flight.
“The Auditors fluttered anxiously. And, as always happens in their species when something goes radically wrong and needs fixing instantly, they settled down to try to work how who was to blame.”
'We' have the same problem; the event happened, C310 + fuel starvation. Where is the radical cause? Where to begin? The aircraft is a good place. This particular C310 has operated many thousands of hours over the years; safely completing many tasks and operated by many pilots; none of whom managed to run out of juice, or mismanage the 'system'. The venerable C310 alongside the PA30 (twin com) have trained countless pilots to operate their first 'multi-engine' air-frame, usually coincidental with their instrument rating. Almost 100% of those pilots will 'study' the manuals, learn the 'systems' and the performance limitations; thoroughly and ask many questions. Good trainers will devote at least a day in the 'classroom' working through the manuals and answering the questions after study, before examination. So item 1: did our pilot have a 'proper' structured, approved ground course, proper instruction on how to manage the awkward fuel system and a solid company policy for clear guidance? If not, why not?
“During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.” ATSB..
The 'Findings' section of the ATSB report is an important section. Each individual 'note' standing alone shouts a clear message; collectively they are damning. They speak loudly of a 'lip-service' approach to the demands of a 'modern' safety culture. From both the operator and the CASA. The 'system' implodes and becomes a mockery when:-
“Following a complaint by a former Broome Aviation pilot regarding management pressure on pilots to operate un-serviceable aircraft, CASA conducted a level 2 surveillance activity on the operator in early June 2023 and following further complaints, a level 1 audit in August 2023, with key scope elements being to evaluate the complaints. Despite that, the surveillance activities and the associated reports did not assess the subject of the complaints.” ATSB.
Cast your memory back to being the brand new hire on your first line flying job. Hired to operate single engine machinery with the promise of perhaps a multi engine 'command'. Head down, mouth shut and absolutely no 'boat rocking' in an operation where the 'culture' is as described by the ATSB. There is powerful motivation to just tow the line; rack up some hours and keep applying to other operators in the hope of a greener pasture and better conditions elsewhere. That is what everyone else is doing. Operators are fully aware of this; some look on it benignly and wish you well; others however can, will and do take advantage of this. There is no 'safe' conduit to raise concerns through and have those concerns rectified. 'Senior pilots' are (mostly) on the same trajectory or, reporting to management in the hope of a glowing reference come airline interview time. Often, they either cannot, nor will not step up for fear of the jungle drums and the 'poisoned' telephone calls. So, what options does a newbie have? Hobson's Choice is what.
“The search for a scapegoat is the easiest of all hunting expeditions.”
I could probably bang on for another page; but the best way to finish this is to point at the radical and ask the question. What in the seven Hells is CASA playing at in the top end? There is now quite the list of 'aberrations', smashed up aircraft and bodies scattered across the NW of Top End; the Broome fatal fiasco; the Croc Eggs debacle; the G8 lucky escape and now the C310 near fatal. It is all very well for CASA acquitting themselves 'on paper' and scampering back to the more sybaritic, salubrious surrounds; they ain't 'responsible'. But it won't serve. Nope, it just won't do. CASA have 'dropped the hammer' on much less injurious operations; crucified operators for much less than we have witnessed in these events.
“There are no secrets to success. It is the result of preparation, hard work, and learning from failure”.
“It’s all very well to make findings in hindsight, and we look at how our findings are likely to lead to a safer system in the future, as opposed to just hammering a regulator because we found evidence to be critical,” said Mr Mitchell.
The 'cost' of the ATSB investigation and report added to the cost of the CASA audits added to the astronomical cost of the re-writing of regulation and avoiding ICAO compliance; and 'easy' blame allotment; and, with no real threat of 'prosecution';and, written, enforced, abrogation of all responsibility is staggering. Yet for all that, junior pilots are left 'vulnerable' and in this case, unprotected by the HOFO or Chief Pilot. or CASA. One has to wonder what the Hell are they playing at and who's running the clown show?
“Like any other big government department, it looks good on paper but is an utter shambles. Petty infighting and political agendas, arrogance and sheer bloody-mindedness almost guarantees that the left hand doesn't know what the right is doing.”
Amen to that; it must be time for Spence to be rid of those clinging to her voluminous skirts and 'get to grips with it': that or bugger off back to the clerical world, before CASA become a mocked, universal pariah. Get some folk 'up North' who know their work, can sort out the mess and ring in some real changes, before there is a blood bath. Oh, it is on the cards. Soon or late the big questions will demand answers, exposing both minister and a 'do little' hands off government.
“The final ATSB report found the pilot was not familiar with the aircraft’s relatively complex fuel system after transitioning from a Cessna 210 and getting little supervision or support from employer Broome Aviation.”. ATSB.
Well, I'm over it; if 'industry' does not drag CASA kicking and screeching back to the reality of their remit then we can all look forward to traveling through the morass until we reach the abyss aptly named as 'more of the same' with better cover and more insidious, draconian regulation as a defence against culpability. No? Well watch as history repeats itself – again.
“There was an abyss. And books contained magical incantations to raise what was hidden there, all the great mysteries.”
That's it: time to return to the stable workshop and the quiet sanity of animals, good clean timber and sharp tools; Aye; there's balm for the soul right there.
Selah..