10-01-2016, 08:40 AM
(This post was last modified: 10-01-2016, 12:39 PM by Kharon.
Edit Reason: E&OE running late - again
)
CASA and ATSB; an unholy union?
It really is a hellish tangle. Layer upon layer of obfuscation, work-shopped denial, artful justification and more hyperbole than you could shake a stick at. I am of course referring to the ATSB confection of investigation; the sweet delights found in the Beyond all Sensible Reason approach. I can’t, not with the best will in the world, do the research and reading for you. Neither can I tell you how to ‘read’ the material. It is as stultifying, mind numbing, tedious and eye glazing, as it is intended to be. Practical folk, like pilots (particularly) don’t read the published works of ICAO or the glossy, lengthy dribble published by the ‘agencies’; not in the way a lawyer or a judge would and certainly not in the way ICAO would. These documents are writ in different language, the language of the bureaucrat, the diplomat and the policy maker. So, one needs to dig deep and do some head scratching to translate the offerings. Not many practical folk will– I flatly refuse to, unless there is a need. The Pel-Air report provides that need, the concerns of the Senate Standing Committee (SSC) drive that need and, IMO the industry, the minister and the travelling public need to be made aware of the dreadful state not just the ATSB is in; but the whole sorry saga of the Australian aviation oversight system, despite the ‘feel good’ rhetoric. Shall we begin by taking a brief look at history, (the exit? - second on the left).
The ICAO Audit – ATSB - June 2004 found the organization in ‘good shape’. Sure, there were a few niggles – it was an audit after all; but essentially Kim Byls and his crew had done a good job and the Reason model was used effectively. The number of Safety Recommendations was on a par with the worlds best; the reports were of benefit to all and the safety lessons and messages were making improvements, as and where required. Then the hoary spectre of Lockhart River enters the fray. It was a watershed, much changed both during and after that event; a great much. It was also about the time Doc Walker pitched up and his academic, no shame, no blame, beyond all reason model was grabbed as it suited both parties; CASA and ATSB both delighted to ‘lockout’ the organizational links in the chain. If ever there were ‘organizational’ links in the causal chain, the Lockhart CFIT had them; in Spades. FWIW, PAIN did a brief analysis of the Lockhart accident – HERE, from the AP library.
The excerpt below takes us to the year of our lord 2007 and is from the Queensland State Coroners findings on the Lockhart tragedy.
“[In] my view, the validity of such a benchmark can be challenged from at least two other perspectives. Firstly, to suggest that the accuracy of deductive reasoning or even speculative assessments to which the approach will be applied can be gauged with such precision is, in my view, misconceived. A calibration that may be ideally suited to measuring tangible items or the outcomes of chemical or physical processes may have no application to the vagaries of human behaviour.
Further, there seems no good basis for requiring the same level of certainty in relation to all possible contributing causes in all cases and seeking it solely from within the evidence gathered during an investigation. Lawyers apply what is referred to as the Briginshaw principle whereby the level of persuasion or conviction required and the evidence necessary to establish it may vary, having regard to the seriousness of the issue under consideration; the gravity of its consequences and inherent likelihood of it occurring.
The ATSB should perhaps heed the warning of Justice Dixon (as he then was) who, when discussing the level of persuasion necessary to find a fact proven said “It can not be found as a result of a mere mechanical comparison of probabilities independently of any belief in its reality.”
Water off the proverbial duck’s back; no, they heard it alright. The words simply pointed to an opening, a potential breach, which was almost immediately plugged, to prevent the unthinkable at an indecent speed.
History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script. In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve.
The next ‘report’ on the reading list is the ICAO – SOAP final report 2008. It is interesting in that it subtly but clearly defines the paradigm shift away for Reason and the gradual emergence of the ‘academic’ approach – without the need to examine ‘organizational’ firewalls. In fact the report almost defines the firewall and cut out circuit breakers between ‘agency’ and operator; which of course suits. The report does get a little more interesting about the Appendix 1-6-01 mark.
‘We’ need to break down the barriers; Aleck as master of the ICAO exemption scam working in concert with Walker, master of no blame game through the MoU have very neatly and quite legally, removed their agencies far from any hint of ‘organizational’ or institutional involvement in not only accident investigation but have managed to detach our aviation oversight from not only reality, but any semblance of responsibility. When you add that to being completely and totally ’above the law’ and utterly unaccountable, an ugly picture appears.
Pel-Air was no aberration; it is the norm. It is however a real life look at how far removed the aviation agencies have become from being accountable and how they are failing the nations air travellers. The simple fact that the SSC, Forsyth and the TSBC all recognised this as an existing normalized deviance – there is no tangible evidence that any criticism has permeated the isolated, rarefied atmosphere of aviation by academia. They’re all sitting about in Canada, at our expense, selling the same snake oil, to the same gullible people, those who chose to believed it all last time around; despite empirical evidence to the contrary.
P2 – I will keep at it; but right now, I need a breath of fresh air – handing over.
Toot – slightly bemused – toot.
It really is a hellish tangle. Layer upon layer of obfuscation, work-shopped denial, artful justification and more hyperbole than you could shake a stick at. I am of course referring to the ATSB confection of investigation; the sweet delights found in the Beyond all Sensible Reason approach. I can’t, not with the best will in the world, do the research and reading for you. Neither can I tell you how to ‘read’ the material. It is as stultifying, mind numbing, tedious and eye glazing, as it is intended to be. Practical folk, like pilots (particularly) don’t read the published works of ICAO or the glossy, lengthy dribble published by the ‘agencies’; not in the way a lawyer or a judge would and certainly not in the way ICAO would. These documents are writ in different language, the language of the bureaucrat, the diplomat and the policy maker. So, one needs to dig deep and do some head scratching to translate the offerings. Not many practical folk will– I flatly refuse to, unless there is a need. The Pel-Air report provides that need, the concerns of the Senate Standing Committee (SSC) drive that need and, IMO the industry, the minister and the travelling public need to be made aware of the dreadful state not just the ATSB is in; but the whole sorry saga of the Australian aviation oversight system, despite the ‘feel good’ rhetoric. Shall we begin by taking a brief look at history, (the exit? - second on the left).
The ICAO Audit – ATSB - June 2004 found the organization in ‘good shape’. Sure, there were a few niggles – it was an audit after all; but essentially Kim Byls and his crew had done a good job and the Reason model was used effectively. The number of Safety Recommendations was on a par with the worlds best; the reports were of benefit to all and the safety lessons and messages were making improvements, as and where required. Then the hoary spectre of Lockhart River enters the fray. It was a watershed, much changed both during and after that event; a great much. It was also about the time Doc Walker pitched up and his academic, no shame, no blame, beyond all reason model was grabbed as it suited both parties; CASA and ATSB both delighted to ‘lockout’ the organizational links in the chain. If ever there were ‘organizational’ links in the causal chain, the Lockhart CFIT had them; in Spades. FWIW, PAIN did a brief analysis of the Lockhart accident – HERE, from the AP library.
The excerpt below takes us to the year of our lord 2007 and is from the Queensland State Coroners findings on the Lockhart tragedy.
“[In] my view, the validity of such a benchmark can be challenged from at least two other perspectives. Firstly, to suggest that the accuracy of deductive reasoning or even speculative assessments to which the approach will be applied can be gauged with such precision is, in my view, misconceived. A calibration that may be ideally suited to measuring tangible items or the outcomes of chemical or physical processes may have no application to the vagaries of human behaviour.
Further, there seems no good basis for requiring the same level of certainty in relation to all possible contributing causes in all cases and seeking it solely from within the evidence gathered during an investigation. Lawyers apply what is referred to as the Briginshaw principle whereby the level of persuasion or conviction required and the evidence necessary to establish it may vary, having regard to the seriousness of the issue under consideration; the gravity of its consequences and inherent likelihood of it occurring.
The ATSB should perhaps heed the warning of Justice Dixon (as he then was) who, when discussing the level of persuasion necessary to find a fact proven said “It can not be found as a result of a mere mechanical comparison of probabilities independently of any belief in its reality.”
Water off the proverbial duck’s back; no, they heard it alright. The words simply pointed to an opening, a potential breach, which was almost immediately plugged, to prevent the unthinkable at an indecent speed.
History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script. In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve.
The next ‘report’ on the reading list is the ICAO – SOAP final report 2008. It is interesting in that it subtly but clearly defines the paradigm shift away for Reason and the gradual emergence of the ‘academic’ approach – without the need to examine ‘organizational’ firewalls. In fact the report almost defines the firewall and cut out circuit breakers between ‘agency’ and operator; which of course suits. The report does get a little more interesting about the Appendix 1-6-01 mark.
‘We’ need to break down the barriers; Aleck as master of the ICAO exemption scam working in concert with Walker, master of no blame game through the MoU have very neatly and quite legally, removed their agencies far from any hint of ‘organizational’ or institutional involvement in not only accident investigation but have managed to detach our aviation oversight from not only reality, but any semblance of responsibility. When you add that to being completely and totally ’above the law’ and utterly unaccountable, an ugly picture appears.
Pel-Air was no aberration; it is the norm. It is however a real life look at how far removed the aviation agencies have become from being accountable and how they are failing the nations air travellers. The simple fact that the SSC, Forsyth and the TSBC all recognised this as an existing normalized deviance – there is no tangible evidence that any criticism has permeated the isolated, rarefied atmosphere of aviation by academia. They’re all sitting about in Canada, at our expense, selling the same snake oil, to the same gullible people, those who chose to believed it all last time around; despite empirical evidence to the contrary.
P2 – I will keep at it; but right now, I need a breath of fresh air – handing over.
Toot – slightly bemused – toot.