12-10-2015, 09:36 AM
(12-10-2015, 06:52 AM)kharon Wrote: Well, a good place to start is with ‘incidents’ which could, potentially, develop into accidents. Take the recent Jetstar ‘incidents’ as example, where incorrect weights were provided, it’s a simple example of how things can and do, on occasion, go wrong. No one died, but through error, the percentage risk factor increased. That risk could have been mitigated had the crew been aware; the risk factor would have increased had any one of a number of things ‘gone wrong’. The radical – root cause – of the increased risk factor must be eliminated if the ‘risk equation’ is to be returned to the ‘norm’.
SSP?- Overdue & Obfuscated.

Quote from this post - Turbulent times for Tiger country
Quote:..Although the findings of the QZ8501 final report could be seen as a set back for the stated Indonesian effort above, it should also be recognised that the NTSC have proven their effectiveness as a properly independent & compliant State AAI (Annex 13). This integrity & independence is fundamental to the implementation of a proper ICAO Annex 19 SSP. Sadly the same cannot be said for our State AAI, the currently much maligned ATSB..
The parallels are stark, on the one hand we have a first class final report into Indonesia's second worst aviation disaster - see HERE - completed within a year. Then we get 2 related occurrences - same airline, same safety issue i.e. load control errors - classified as 'serious', which would have gone unnoticed, unreported on and possibly not investigated if not brought to the attention of Ben Sandilands from PlaneTalking.
What is worse is that the notification of the ATSB to investigate these incidents occurred over a month after the second incident (29 October), was supposedly first submitted. I say the second incident because the first incident does not appear to be recorded (even though classified as serious) on the ATSB Aviation occurrence database - see HERE.
{Note: It should also be noted - from that Excel spreadsheet - the 29 Oct 'serious incident' original record shows a zero in the 'ATSB Investigation' box}
Due to the attention drawn to these incidents - somewhat ironically - CASA have been forced to notify the intention for a 'parallel investigation'. Yet more than a week after this notification not a word; or at least transparency of possible enforcement; or management action plans to address the initial highlighted safety issues.
Now compare this to the NTSC QZ8501 investigation, quote from safety actions section of FR:
Quote:4.1 Aircraft operator
As a result of this accident, the aircraft operator informed the KNKT of safety actions that they had taken.
At meetings between the aircraft operator and the KNKT, the operator advised that the safety actions had been generated from the preliminary recommendations that were published by the KNKT in the Preliminary Report...
'preliminary recommendations' - yes that's right the State AAI under Annex 13 can issue recommendations at anytime in the course of an investigation when significant safety issues are identified.
This fact has sadly been forgotten in the elongated (2.5 yrs so far -

Incidentally ATSB investigation AO-2013-100 was recently (discretely

Quote:Updated: 25 November 2015
The draft investigation report is in the final stages of review by the ATSB Commission prior to it’s release to directly involved parties (DIP) for comment in December 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in March 2016.
Spot the difference??- Not hard is it..

P9:
Quote:Exeunt stage left, mildly cursing all and sundry from P1 to P1066…....
...
Ahh...Ferryman you love it -
