[Peetwo]

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.

- P2: Tim Tam quality post that one "K", now all I've got to do is come in behind join the dots and colour in the picture...  

However before I do here is a contrary World View on the State of the Oz (Aviation) Nation -  

P2 - "However, despite all the evidence to the contrary (see references 1 thru 5  above), this achievement was totally eclipsed by the Australian aviation safety bureaucracy who managed to lift the critical element statistics for accident investigation/resolution of safety concerns above the global average by a whopping 89.42 percentile points, or a touch over 11% for each of the last 8 years. - Yeah right."

On the one hand: We have the current ICAO wank-fest where once again Dr Aleck is spinning the bollocks that aviation Downunda is just fine & dandy; despite some 3000 (down from 4000 odd) NCN/ notified differences and a festering PelAir re-investigation that Walker, Sangston, Walsh (& apparently the invisible Manning) are desperately trying to put the lid back on and quietly slide into the ATSB (O&O BASR) 'Hall of Shame' archive.

Then on the other hand: Totally unencumbered from the diplomatic bureaucratic back-slapping, trough-feeding currently going on in the ICAO Star Chamber; with a realistic, Reasoned fully independent World view we have the following timely blog piece from Mike (Legend) Chillit...  

Captain's Log - DOI archive entry 01.10.2016 

Via Chillit's 7th Arc blog... :

Australia’s Struggle With Insanity
Posted on September 30, 2016 by Mike Chillit 



The critical “7th Arc”, where MH370 is believed to have crashed, is 4,000 km long in the Indian Ocean, and stretches from Java, Indonesia to -40° South. The 7th Arc appears to be reasonably correct, but less than 25% of it has been searched by Australia’s ATSB, which has lead investigative authority. In spite of not finding anything in the original 60,000 square kilometers, Australia has repeatedly refused to search any other portion of the 3,000 km that remain unsearched.

I will have all vessel AIS information for a 300 km strip on each side of the entire Indian Ocean’s 7th Arc sometime next week. Both “Satellite-AIS” and “Terrestrial-AIS” versions for a 4,000 km strip of ocean. Everything. Deliverables for the now awarded RFP posted one week ago include a graphic of vessel locations between midnight March 5, 2014 and midnight March 10 / 11, 2014. I will also use accompanying digital information to prepare graphics in my own format, but the contractor’s effort to provide its own version is greatly appreciated.

Separately, I will encourage one or two research analysts I trust to conduct their own review of the data. More eyes are better than fewer eyes in all complex analyses, from my point of view. The goal, of course is to identify vessel positions that might help determine where best to look for the missing plane. I continue to place a fair amount of trust in the “7th Arc”. It’s one of the meager bits of information we have that seems to actually be helpful. I have tried to find fatal problems with the 7th Arc construct, and one or more may yet emerge, but so far I have always come back to it as one of the few fairly useful metrics we have.

As readers will know if they follow my mumblings on Twitter and here, the commercial cargo vessel “Stella” was within 150 km of ATSB’s “crash location” at 00:19 UTC March 8, 2014 when ATSB claims the plane crashed in “Penguinville”. And Stella was headed directly into the plane’s descending flight path. If the plane had been anywhere in the area, it would have been seen to within a gnat’s eyelash of absolute certainty. Yet, to my knowledge, no one connected to any Australian entity has attempted to speak to the ship’s Captain or owners to determine if anything was seen. There were thin patchy clouds overhead, but it was daylight in the early morning hours of Autumn in the Southern Hemisphere.

The obvious explanation for the absence of reports from the Stella crew about a crashing airliner is that it did not crash anywhere near where Australia has been searching for nearly three years. There is no other plausible explanation.

If you are in charge of an important investigation, how do you justify closing your mind and all of your senses to the things that were going on at the time you believe such an important event happened? How can you do your job when you close yourself to everything that is at odds with what you prefer to believe? It’s known as being DELUSIONAL.

    
"I'll be back" - with much MTF...P2