[Peetwo]

Skidmore & the continued culture of DWK -

P9 - A very similar situation was researched which occurred in WA where suspect parts were involved in a fatal accident investigation.   The loop was as open then as it is today; there are others.  It is of great concern that the potential for preventable accidents to repeat is allowed to continue.  It is of greater concern the CEO of the Civil Aviation Safety Authority allows the practice of diminishing, then dismissing legitimate Safety Recommendations (SR) from the ATSB.

This was the original ATSB Final Report to which the Ferryman (above) is referring - Cessna Aircraft Company 404, VH-ANV 200303579.

From the 'Significant Factors' section of that report:

1. The material specification contained in the engineering order for replacing the pump

bushing of the engine driven fuel pump (EDFP) fitted to the right engine was not

appropriate.

Strangely there was no mention of this in the 'Safety Action' section of the FR, therefore at that stage it was not considered a 'significant safety issue'. 

However then the Coroners findings were handed down. Extract reference page 16 of PAIN report - Response to Coronial inquiry-Fatal air accidents.:

Coroner Hope.

Relevant Quote: “While the Memorandum of Understanding between CASA and the ATSB
which is currently in effect dated 20 September 2004, only requires CASA to respond to
the ATSB in writing, such response to contain clear statements of acceptance, partial
acceptance or rejection of each recommendation, it is unfortunate that the above CASA
responses do not identify any research conducted by CASA or information obtained,
particularly when CASA has not accepted ATSB recommendations.

The air safety system in Australia depends on interaction between the regulator (CASA)
and the investigator (ASTB). The investigator does not have the power to require that any
safety recommendations be implemented and in that context it is particularly important
that the regulator should respond adequately and appropriately to the recommendations of the investigator.”

Coroner Recommendations.

1. That in future CASA ensure that reasonably comprehensive audits are in fact conducted n respect of all CAR 30 organisations and CAR 35 authorised persons on a regular basis of no more than 24 months duration.

2. That CASA require its CAR 30 design organisations and CAR 35 authorised persons to ensure that engineering orders contain sufficient information in each case to provide a clear indication as to the basis of the engineering order and specify whether the engineering order is proposing a “like for like” replacement or the construction of an
entirely new item. In the event that an engineering order is approving a material change,
the relevant file should contain a metallurgical report providing information in relation to
the material in question.

3. That in the event that CAR 35 authorised persons or CAR 30 design organisations do not prepare engineering orders containing sufficient information, then consideration should be given to not permitting those persons or organisations to continue to exercise those functions...

With the Coroners findings, & with another example of a reconditioned Continental engine fuel pump failure, to the credit of the ATSB they revisited their original VH-ANV investigation and conducted a further investigation in 2005. The ATSB findings were published in report - 200501462:

On 7 April 2005, shortly after the release of the VH-ANV report, the ATSB became aware of the existence of another engineering order, issued by a CAR 35 authorised individual, which provided for the replacement of specific EDFP bearings with an aluminium bronze alloy, similar to that which contributed to the failure of the VHANV pump. In concert with actions by CASA and the ATSB to identify and remove from service any bearings produced to that EO, the ATSB initiated an investigation into the circumstances surrounding the issue of that second EO and the associated material selection processes.

&..

..An inquest into the loss of life resulting from the VH-ANV accident was convened by the State Coroner for Western Australia on 18 April 2005, with the inquest findings delivered in December 2005. As part of its scope, the inquest closely investigated the circumstances surrounding the inception and content of the EO for the fuel pump bearing replacement...

 
This led to the ATSB identifying a 'safety issue' associated with CASA regulatory oversight:

Less definitively, in terms of direct contribution to a reduction in safety, was the frequency and thoroughness of CASA audits undertaken of approved organisations and individuals. The evidence suggests that oversight by a central authority (in this case CASA) is important in ensuring consistency and technical adequacy, with infrequent or shallow audits potentially leading to variability in the quality of engineering outputs.

Now keep in mind that the ATSB report 200501462 was published a decade ago?? Now re-read the CASA response from almost a year ago:

..CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised persons and concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.


In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated...

 
Followed by the CASA SOP - 'sheer bastardry', 'up yours', 'nothing to see here', 'no action required'- response...  

"...Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue..."

Yet again we have a well documented trail of an identified significant safety issue, that has been blatantly ignored & repeatedly obfuscated by our so called 'safety authority' for more than a decade - UFB? Nope true to form...TICK bloody TOCK!


MTF...P2