[Peetwo]

Many may not be aware but PAIN is currently on a mission (reference - RE: The Xenophon end game.):

...But Manning is taking on a role, the MH 370 show runs out of money in May and the Senate committee is now watching the Be-a-cur performance, as we all are, with some interest.  It will be great deal of fun to compare the PAIN investigation report against the ATSB second attempt.  The Senate will get that just before the ATSB present; we have had five years to do our research and investigate.  The comparisons will be of interest as we have gone deep into the murky realms of power, money and influence; starting with who paid for the resurrection of the failed Ansett feeder lines Kendell and Hazelton Airlines, which morphed into the now Singapore owned Rex.  This is where any sensible investigation must begin, if the true reasons behind the appalling travesty that was the Pel-Air investigation are to be examined.  It is quite a tale... 

 
I have been tasked with following the PelAir cover-up chronological trail of embuggerance to help create a timeline to factually back up the PAIN Final Report. Well in the process of reviewing the TSBC peer review report & comparing to all other publicly available (& some not publicly available) information, which includes the excellent Senate AAI report, I have already noted some discrepancies that will need further investigation??

The chronology is still very much a work in progress and necessarily needs to be completed before properly writing the organisational factors that were contributory to the VH-NGA ditching. However I can reveal certain dots & dashes that I have discovered so far for those with a bent for forensic examination of documented evidence.

To begin I have spent some time examining the much convoluted trail of the original Critical Safety Issue:

26 February 2010

Accident Investigation Liaison Unit
Civil Aviation Safety Authority
GPO Box 2005
Canberra ACT 2601

Dear (blank)

A0-2009-072 - Ditching - 3 NM south-west of Norfolk Island Aerodrome - 18 November 2010 - Westwind, registered VH-NGA - Critical Safety issue

I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect of the lack of regulation or guidance for pilots when exposed to previously un-forecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.

Subsequently, on 12 February 2010, you rang the investigator in charge of the ATSB safety investigation, (blank) and requested a supporting letter that described the critical safety issue and requested CASA's assistance in its resolution. In later telephone calls to me, you suggested that the receipt of this letter would allow you to 'kick-start' CASA's consideration of, and response to the issue.

Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB' s initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA' s commitment to address the safety issue is appreciated.
Please don't hesitate to contact me (blank) (blank) on telephone should you have any questions or comments.
 
(Blank)
Director Aviation Safety Investigations
Australian Transport Safety Bureau

          
Okay we all know who the DASI (above) was (& last I heard still is... ) i.e. Sangston; so from this letter it would appear that Sangston - & therefore Dolan - were very much in support of the Investigator In Charge (IIC) assessment that the identified safety issue was of a "critical" nature (quote from attachment One)...

"...Safety issues are broadly classified in terms of their level of risk. A critical safety issue is associated with an intolerable level of risk, and generally leads to the immediate issue of a safety recommendation unless corrective safety action has already been taken..."

Which leaves the open question of when exactly did the executive & middle management change their tune on this identified safety issue (ref: Attachment One):

Safety issue
There were no regulations or other guidance for application by flight crews when
making in-flight, weather-related decisions in a changing meteorological environment.
That reduced the reliability of in-flight decision making, and increased the risk of an
aircraft arriving at a destination with insufficient fuel to continue to an alternate
aerodrome, if the weather at the intended destination has deteriorated below its landing
minima.

Initial safety action by the ATSB
In accordance with its preference to encourage relevant organisation(s) to initiate
proactive safety action to address any identified safety issues, and in recognition of the
criticality of the above safety issue, a meeting was convened by the ATSB with Civil
Aviation Safety Authority (CASA) officers on 3 February 2010 to highlight the
identified issue. In addition, the A TSB sought an understanding of the potential for
safety action by CASA.

Initial safety action by CASA
During the 3 February 2010 meeting, CASA officers indicated that they understood the
issue, and that it should be progressed with CASA management.

As I mentioned I have been reviewing firstly the TSBC peer review report, as it is supposedly based on all the ATSB documented chain of evidence in relation to the PelAir investigation. Therefore it should be accurate & the veracity of the information should not be questionable...true or false?? {Ps: Still holding judgement but so far it is not looking good for the ATSB senior management}

Anyway the following is what I have been able to glean from the TSBC report in regards to the progression of the above identified (& embarrassingly still outstanding) safety issue..  

01 Feb '10: "On 01 February 2010, the team leader and the general manager (GM) decided to provide CASA with a briefing on the perceived safety issue.

The briefing was held by video conference on 03 February 2010. On 12 February, the primary contact at CASA followed up with a phone call to the IIC asking the ATSB to send a letter describing the safety issue.

Around this time, several meetings and discussions on the signing of a new memorandum of understanding (MOU) between CASA and the ATSB were documented. The MOU, which was signed on 09 February 2010, reflected the ATSB approach favouring proactive safety action over recommendations. By taking this approach, the ATSB aimed to track action taken by stakeholders on all issues determined to have a systemic impact (known as safety issues) and to issue recommendations only as a last resort when an unacceptable risk persisted.
CASA was reported to be supportive of this and to be anticipating that the Norfolk Island investigation would generate safety action. At the same time, CASA was clear that it intended to pursue regulatory action against the pilot. This was the subject of several e-mail exchanges between the IIC and the Chief Commissioner on the two agencies' differing perspectives and approaches."

26 Feb '10: "On 26 February 2010, the ATSB sent a letter to CASA outlining the “critical” safety issue (see attach). The issue, based on the preliminary analysis, was described as a lack of regulation or guidance for pilots exposed to meteorological conditions that had not been forecast previously when on long flights to destinations with no nearby alternate aerodromes.

CASA sent a written response to the ATSB on 26 March 2010, agreeing that the then-current regulations were not prescriptive, but pointing out that weather-related decision making was part of all pilot training syllabi, beginning with the day-VFR (visual flight rules) syllabus. CASA expressed the view that the current published guidance material should allow pilots to make appropriate in-flight decisions, but said it was reviewing the regulations to determine whether amendments were needed."

18 Mar '10:  "On 18 May 2010, a critical investigation review was held and an analysis coach was appointed to help prepare the analysis section of the report."

27 July - 06 Aug '10: "The analysis coach and the IIC worked together for a period of time, much of which was devoted to refining fuel calculations for the occurrence flight. Both the coach and the IIC found the process frustrating. The IIC felt that the coach's focus on the performance of the flight crew prevented the coach from seeing the systemic issues that the IIC considered important. The coach felt that insufficient data had been collected to identify systemic issues.

A progress meeting involving the IIC, the analysis coach, the team leader, and the GM took place on 27 July 2010. On 06 August, the coach, citing an inability to make progress on the analysis due to a lack of supporting data, asked to be, and ultimately was, removed from the investigation.

In the summer of 2010, there was a change in team leader responsible for the investigation: the original team leader was appointed to the position of assistant GM at the beginning of July, but remained involved in the Norfolk Island investigation until the handover to the new team leader was complete in mid-August. It was in the context of this handover that the inability to make progress with the analysis coaching arose. No action was taken to provide further assistance with the analysis.

The IIC continued to develop the analysis and draft report independently." 

Comment: What is interesting was that it was around this time that the end of another email chain occurred over at CASA HQ (see attached & note email from Farquharson 22 July 2010), plus there was the July 2010 CAO 82.0 NPRM which was still open for comment - http://www.casa.gov.au/wcmswr/_assets/ma...1003os.pdf . 

18 Feb'11: "...the team leader forwarded the MS Word document containing the second peer reviewer's comments to the IIC and asked that they be considered."

15 Mar '11: "...the IIC and the human factors investigator (the only remaining members of the investigation team) agreed that the report was ready for the team leader's review, and they submitted it the same day."

02 May '11: "...the IIC asked the team leader how to expedite the investigation..."

04 June '11: "...the team leader completed the review and returned the report to the IIC for response. The IIC made the requested modifications to the report and on 05 July, after another review by the team leader, the report was sent to the GM for review.

At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations. (NB It would appear that the IIC was still under the impression that 1) was still a CSI) 

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues. (NB But the GM Sangston should have already signed off on the analysis of the CSI back before 01 Feb '10??)

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation. They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.

During this period, the GM was working through a backlog of reports, many of which required considerable revision and editing. The GM was making these revisions himself, and he did the same for the draft Norfolk Island report. It was in the course of this work that the GM concluded that the available data did not substantiate classifying the safety issue on guidance for en-route weather-related decision making as significant, and modified the report to recast it as a minor safety issue. The report, with revisions and comments from the GM, was returned to the IIC, who reworked sections of the report and returned it for another review by the GM.

Passing strange that Sangston re-cast the CSI to minor in approximately September 2011 yet he did not notify CASA of this till August 2012. This was despite several formal & informal opportunities to bring the matter to CASA's attention. Including prior to the release of the 2nd  anniversary interim report where it would seem CASA were expecting further mention of the identified safety issue: 

Hansard AAI Inquiry 15 Feb '12:

Senator XENOPHON: That is a summary of what you said. I want to be fair about that. Yet the minutes talk about, 'Talk to ATSB to work through the implications of the safety issue identified by ATSB in relation to the Norfolk Island ditching. Mr Farquharson contacted Ian Sangston. Mr Sangston will indicate if there are any changes to the ATSB position.' There was a change to the ATSB position, wasn't there, after that contact?


[ltr]Mr Farquharson : The date was 2011?[/ltr]

[ltr]Senator XENOPHON: It was 18 November 2011.

Mr Farquharson : My understanding is that the downgrading occurred on 16 August 2012.

Senator XENOPHON: Yes, but there was a lead-up to that. The downgrading occurred as a result of a number of representations. How many times did you meet with the ATSB to discuss CASA's views about whether it should be a critical safety issue or not? It was clearly the view of CASA that it should not be a critical safety issue. Is that right?

Mr Farquharson : The CASA view was that the legislative approach the ATSB were proposing at the time could not be achieved and in our responses we pointed out to them an amount of information and that these decisions come down to airmanship and the responsibilities of the captain when airborne. They were the two positions taken.

Beyond that the next we heard, that I am aware of, was when the safety issue was formally downgraded by the commission on 16 August 2012— [/ltr]

Hmm...interim reports?? Going through the records it would appear that there was never any interim reports issued for the PelAir ditching investigation?

Annex 13 Para 6.6 states  -  "If the report cannot be made publicly available within twelve months, the State conducting the investigation shall make an interim statement publicly available on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised.

 IMO this is important if you consider that the significant safety issue was still very much outstanding (and still classified as critical prior to the 1st & 2nd anniversary) & in any normal course of events would have meant the promulgation (prior to an interim report release) of a safety recommendation:

Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend in a dated transmittal correspondence to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.


Note.— Precedence for the issuance of safety recommendations from an accident or incident investigation should be given to the State conducting the investigation; however, in the interest of safety, other States participating in the investigation may issue safety recommendations after coordinating with the State conducting the investigation.


6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety
recommendations arising out of its investigations in a dated transmittal correspondence to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.

Note.— When Final Reports contain safety recommendations addressed to ICAO, because ICAO documents are involved, these reports must be accompanied by a letter outlining the specific action proposed.

Despite Sangston's clearly bad memory the safety issue was not officially recognised or downgraded till 16 August 2012.

It should be remembered that CASA had put out a NPRM on a proposed rule change to CAO 82.0 in July 2010 - Carriage of Fuel on Flights to
a Remote Island – 
CAO 82.0 http://www.casa.gov.au/wcmswr/_assets/ma...1003os.pdf ( http://auntypru.com/whodunnit-why-chapte...gator-toe/ ) - 

which for some bizarre reason dropped off the radar till it was again resurfaced in August last year - 

http://www.casa.gov.au/wcmswr/_assets/ma...1413os.pdf

Which means of course that the identified safety issue has effectively not been properly mitigated (still) in over five years....

MTF...P2