[Peetwo]

P2 armed with spak-filla -  

K said - "..Enough – finish ‘em off P2 – I'm off to buy a new bucket; the old one is just about buggered..."

...Some of the BRB feel that we did Beaker a disservice; others disagree. It is a ‘quiet’, academic discussion, ruminative rather than combative. I expect you are confused by now; what’s the fool rabbiting about? Well it goes like this.

Many of us who watched, listened and studied ‘Beaker-speak’ at estimates and inquiry could not fathom the disconnects.  Clearly, the man was a dumb as a bag of hammers even clearer was he had NFI (whatsoever) about ‘matters aeronautical’ or accident investigation...

Senate AAI Public Hearing Hansard 22/10/12:

Senator FAWCETT: With the process you are describing whereby you use a process, and risk and consequence and all the good tables I have seen in your submission, do you consider balancing that against the cost of action? I will take for example the New Zealand flight information service where, in Australia, if there is a deteriorating weather situation they have an obligation to update the pilot and alert them to the fact that something is occurring, or the Unicom operator who was not legally allowed to use the HF radio to talk. But if either of them had said, 'The situation is getting worse,' as Unicom did to the New Zealand FIS who chose not to pass it on, surely, even including that kind of thing, there should be a recommendation that the Australian government should talk to the New Zealand government and ask for cooperation for safety reasons. Even if it is only for one in 1,000 flights and your probability of occurrence is very low, given the cost of action is also very low, why does your process exclude consideration of something that to the common man in the street seems like common sense? Why are we not seeing logical, reasonable recommendations coming out of ATSB reports to an address in this case two things, either of which probably would have prevented the accident?

Mr Dolan : There are two things there and I will go to the question of recommendations before I get to the specifics of your question. The ATSB at the point where it became independent of the Department of Infrastructure and Transport also got a shift in its powers in relation to the making of recommendations which raised the ante with recommendations and their significance. There is a legal requirement to respond to each of the recommendations we make. In recognition of that we set up the system of identifying safety issues that said there needs to be a critical or a significant safety issue before we will explicitly use that power to make a recommendation and require a response, and we would generally limits recommendations to those sorts of things. What you are talking about we would in our normal framework, given what you said about likelihood and consequence, deal with as a safety issue without going to recommendation. That is the context: it is still there but your question remains.

The answer is we assessed the facts of the information made available in the course of the flight, the number of opportunities to receive information and to absorb it. We said that that did not seem to indicate that there needed to be any change to the system. That is a matter that others based on those facts could form different views on, but the view we formed was we did not see anything that needed to be done to enhance that system.

Senator FAWCETT: With all due respect, to have a process that deliberately closes the door to suggestions that another agency, if they wished to say they would respond to that recommendation by saying no but if they chose to say yes may have saved this flight and may potentially save another flight, I suggest is process that is extremely poorly misplaced and prioritised.

Mr Dolan : I accept you can suggest that to me. As I said, we as an organisation were trying to look at this on a systemic level rather than an individual detail level. We looked at the overall components of the current system to deal with the risks that go with operation to remote islands and the particular case we were dealing with which was the situation where the weather forecast on departure was for weather suitable for landing at the destination and that changed en route. That seemed to us the key issue. There was also an issue about what happened in pre-flight planning and so on, but for us as we say in our report the key issue was, having left, how to deal with the situation where things change in flight. What we tend to do in identifying safety issues is rather than specifying a precise solution to the issue we try and draw the issue to the attention of those who are best placed to do something about it and for them to take steps to deal with it.

We could certainly have a discussion about this, but it is the methodology we currently use. Rather saying precisely there is a problem explicitly with the issue of the proactive provision of weather information by air traffic control, we focused on the general framework to support information, the seeking of information and the provision of information, and decision-making en route. We left it as a general issue rather than coming up with a precise set of answers and making those a requirement. That is the way we normally do the business: we try to leave it to the organisation best positioned—in this case, the Civil Aviation Safety Authority principally—to decide how best to deal with the issue and to tell us what is being done to address the issue, which is the safety action part of our report.

Senator FAWCETT: Mr Dolan, I think you have probably heard a number of the witnesses this morning indicate that in their view ATSB in the past has taken a far more proactive approach to identifying issues and being prepared to make a recommendation. The general consensus from witnesses has been that that is a far more value-adding document. With a technical issue, for example an A330 off the North West Shelf with a software glitch that causes the aircraft to plunge, in terms of probabilities it was very remote that that would never happen again. But there was a report, recommendations and the OEM put a fleet-wide alert out to look at a software reload or whatever. If that approach is taken on something that almost led to the loss of an aircraft, here we have the loss of an aircraft. Why did you take such a conservative approach as opposed to saying any information, any opportunity to preclude a further incident by including all of the regulatory and systemic issues in terms of the organisation, their training, they check-in training, the lack of control, the lack of standardisation around fuel planning—all the things that led to this occurrence—should be canvassed in the report? I have heard your process, but putting the process aside, is the process wise when after three years we end up with a report that deals quite narrowly with one element of the things that led to this incident?

Mr Dolan : As I said earlier in my general reflection on what I have been hearing through the submissions and today, there are two elements to this. The first is that there was a range of lines of inquiry that we went down. We satisfied ourselves that there was not a safety issue involved in it. Among the massive documentation we have provided to you, there is a range of lines of inquiry that clearly we went down. We did not reflect that process in our report and on reflection that is not ideal. That is the first issue. On some of the things you are concerned about, our view is we did take a look at them and formed the view that they were not directly relevant to the issues we needed to address in the report.

...He could trot out the ‘scripted’ lines, but deeper questioning produced the ‘disconnect’ between rehearsed, work-shopped weasel words and ‘in-depth’ knowledge of his subject. In short, many believed his Mum’s tea leaf readings were his guide.  But that is obviously not the case. Being malleable, obliging, not too sharp and beholden made him a perfect foil. Add to that an accountants narrow minded purview and things become clearer. Real Accident Investigators (AI) live and breathe their profession; their bible Annexe 13 their only goal – solutions and providing reports which prevent a reoccurrence. There is no way a career public servant, with a ‘spotty’ record could grasp that passion and so the ‘disconnect’, once again, became apparent. Which of course led to much criticism. A soulless public servant mentality could never understand, not properly, what a 'real' accident report means to aviators.  I digress.
 

Reference 28/02/2013 Senate AAI Public Hearing: RRAT AAI Inquiry Hansard

Note the following extract from the 28/02/13 Inquiry Hansard where Dolan refers to his BASR Guru  :

Mr Dolan : ...That is a simplification of the purpose of that table. We will do a risk assessment of an identified safety factor. This is not about assessment of evidence, this is about assessment of safety issues—a safety factor that is seen to have a continuing effect on risk to assess the likelihood and the consequence of that factor coming into play in the future. That is our basis for establishing the significance of a safety issue. It is not the basis on which we will assess evidence.

If you are looking for the philosophical underpinnings of how we deal with evidence and a range of other things, there is a document, Analysis, causality and proof in safety investigations, which was a publication of Dr Walker and Mr Bills in 2008. That shows the philosophical underpinnings of how we deal with facts, evidence, analysis and so on. It is reflected in our policies and procedures in the organisation. The risk assessments largely draw on or are compressed versions of international safety organisation risk management standards. We are trying to bring all that to bear on a diverse range of operations, while bearing in mind the guidance from the government that our attention should primarily be on the safety of the travelling public...

P2 has done well to fill on the gaps, join up some of the dots and set the stage to tell the tale of our long, weary journey from the 2004 ‘first rate’, world class status to the pitiful, crippled thing we have today.  Many believe Lockhart was the watershed; almost as many reach back to Seaview and Staunton; it is, I believe, academic.  Seaview certainly changed the dynamic and shifted the perception of ‘blame’; Lockhart was the catalyst for real change.  There was a battle for supremacy, power, money and kudos, but that was a sub-plot; the real battle was to decide who’s version of why the holes in Reason's famous cheese lined up that day.  ATSB lost the fight and were relegated to a subservient role; handmaiden and arse wiper to CASA.

Progressive MoU which bastardised the Morrison report ensured that slowly, but surely ATSB was subsumed, the independent power base eroded and those that wanted to kick that bucket were quietly informed that there were not too many jobs for ‘specialist’ accident investigators out in the cold, hard world...

Reference 15/02/2013 Senate AAI Public Hearing: RRAT AAI Inquiry Hansard

  
...There were pockets of resistance and for a while, every accident or incident provided a new skirmish and opened the golden  gates to criticism of the minister and CASA – intolerable. There was an urgent need to find a way to get CASA and by extension, the minister –‘off the hook’.

Enter the dragon: Doc Walker and his ‘cloud’ diagrams; they all look like ‘little balls’ floating in space; (you can draw whiskers on ‘em and they look like hairy little balls i.e. bollocks) which placed ‘regulatory oversight’ on the top line and organizational matters in a subsidiary role.  Well that suited everyone just fine, all that was needed was an obliging Muppet with NFI to carry the message and make it all work.  Aye, Dolan was not selected by accident children – a front man was required, one who could be controlled by strings, from behind the curtain of safety mystique.

2.5 years on from the Senate PelAir cover-up report and the Timeline of Beyond all Sensible Reason & Embuggerance:

Reference Aunty Pru blog: PelAir – ‘Lest we forget’ Part III

From CASA Hansard:

Senator FAWCETT:  …In coming back to your regulatory philosophy, you are saying that CASA is committed to maintaining the trust of the Australian aviation community. One of the biggest breaches of trust recently was the ATSB investigation into the Pel-Air report where CASA maintained that the internal investigation, the Chambers report, the fatigue risk management report and the special audit were not necessarily pertinent. I think the term was they were a private, internal report. Now that ATSB has reopened that investigation could you assure the committee that it is your intention to share all that information about the inadequacies of CASA’s oversight at the time with the team so that the new report reflects not just the actions of the pilot but the inadequate supervision of the organisation and the self-identified inadequacies of CASA at the time?

 Mr Skidmore : I think it is fair to say that we have provided all the information that the ATSB has requested of us and we will take into account any recommendations that come out of the investigation.

Senator FAWCETT: Would it be your view that a report like the Chambers report should have been provided to ATSB voluntarily?

Mr Skidmore : I was not there at the time. It is very unfair for me to be making a statement of the organisation of the past.

Mr Aleck : One of the significant amendments we have made to the MOU with the ATSB is to put beyond doubt the kind of information that can and should be provided on request, or sometimes voluntarily. As you may recall, the existence of the Chambers report was conveyed to the ATSB. The circumstances under which that happened probably were not as concrete as they certainly will be in future.

Senator FAWCETT: Mr Aleck, I think you might recall Mr Dolan found out about it 30 minutes before he appeared before the Senate committee because he had overheard the evidence where we had dug it out of half a truck load of cardboard boxes that CASA had dumped on our doorstep. I do not accept the contention that they knew about it before the report was issued; in fact, the Canadian peer review confirms that was not the case.

Mr Aleck : I will not challenge that except to say that I believe the former director gave evidence that he had mentioned this to Mr Dolan. Now, he might not have mentioned it by the term Chambers report, because that was a term that came into existence afterwards, but I think the information about some inquiry having been made internally had been conveyed. I guess the major point is that that kind of thing should not happen again under the new arrangements.

Senator FAWCETT: I am very pleased to hear that…

CASA thought this a wonderful thing and ‘regulatory oversight’ gained ascension, the bonus of ‘no operational issues’ being included; a goose which laid it’s golden eggs as/ when required.  McComic took liberties with the system and allowed some of the known thugs free rein to dictate and ‘enforce’ their own ideas, under ‘black letter’ law wherever it pleased, with full back up.  One of the classic exponents of this art is still ‘at it’ to this day, still operating under the McComic system, still creating mayhem, still bullying aircrew and operators alike; rejoicing in a track record which has brought many a pilot and operator to an impotent boiling point.

When you place this type of mentality in an atmosphere of no accountability, support it with the full resources of the CASA and a belief that the ‘law’ cannot touch them; you have created a monster which has, can and will continue to do much harm. When that monster is turned loose without organizational constraint or accountability there is no recourse as the government and minister like the peace and quiet the system produces and all is well until there is an accident. No matter you say – the ATSB will get to the bottom of it and we shall find out why a Brasilia with two experienced pilots ploughed in and killed them both.  We shall discover why two perished at Canley Vale, we shall determine why two jets nearly ran out of noise and luck at the same time; we will have the truth of the Melbourne incidents; and, many other incidents with organizational links in the causal chain.

Reference Aunty Pru blog: PelAir – ‘Lest we forget’ Part III

From ATSB Hansard:

Senator FAWCETT: I would like to go to the information-gathering stage. Going back to an answer to a question on notice that you took at the time of the original investigation, you said:

… the Chambers Report does not contain any new evidence that organisational factors were likely to have contributed to the accident...

 You go on to say:

… the Chambers Report reflected what was separately reported (and available to the ATSB) in the reports of CASA’s accident investigation and of its special audit …

I challenged that at the time, and so did your Canadian peers ,who have done an independent peer review and who have made numerous comments in their report that in actual fact regulatory systemic issues to the organisation and oversight of the organisation by CASA were significant and were omitted. They go into some detail about the process within your organisation that resulted in those being omitted even though they were significant. Can you provide me with an assurance that the rework of this report will be considering the quite detailed information contained not only in the special audit but in the Chambers report and in the fatigue report that go to the heart of how the individual ended up having that accident?

Mr Dolan : Yes, I can give you that assurance. We have acquired from CASA not just the various reports but the core material they relied on to prepare those reports as part of the process of undertaking the reopened investigation.

Senator FAWCETT: I am pleased to hear that cooperation. Could you also comment on whether you still stand by the remarks that you made in the questions on notice?

Mr Dolan : I am not in a position to comment on that until I see the results of the reopened investigation. It is entirely possible. The Canadians have already alluded to the fact that we did not give sufficient weighting as an organisation to the organisational aspects of this investigation, and that is what we hope we can determine through the reopened investigation.

Senator FAWCETT: There are a couple of points that come out of this. There is one about the trust of industry in the organisations that are supposed to be having an oversight around safety and regulation, but the other is a very real impact on people. At the time, the committee were concerned about what we saw as a breakdown in the relationship between you and CASA and the inadequacies of the report. Subsequent to the Canadian peer review, which was quite scathing about the fact that there were very clear systemic issues which were not addressed, people who have been affected by this accident—being the pilot involved and potentially the nurse—have sought some remedy for the situation they find themselves in as a result of this report. In the pilot’s case, correspondence I have seen from him has indicated that that report has essentially finished his aviation career. My understanding is that even after the Canadian report, when he has sought an act of grace payment from the Department of Finance, ATSB’s recommendation is: ‘Don’t pay it. It was his fault.’ Can you confirm that was the case?

Mr Dolan : I recall that there was some information sought from the Department of Finance in relation to an act-of-grace payment. We provided the facts as we understood them. It is not a purpose of our organisation to assign blame, and we would not have said that to the Department of Finance.

Senator XENOPHON: Can you provide the advice that Senator Fawcett has asked you for?

Mr Dolan : I beg your pardon?

Senator XENOPHON: Can you table that advice?

Mr Dolan : I cannot see any reason why we should not, so I will obtain it and table it for the committee.

Senator FAWCETT: In the light of the Canadian report, which indicates there were very clear systemic failures on the part of the company and in terms of CASA’s oversight, the whole concept of systems safety is that whilst the pilot was the last link in the chain these other considerations had a significant impact, which was borne out by the fact that the company had to cease operations after these investigations until remedial measures were put in place. With that now on the public record, with this new focus, would you consider providing the Department of Finance with alternative advice if he were to come back and seek some compensation for the fact that as a direct result of the report that your organisation issued, with all of the failings and how that was put together, his career has essentially been finished and all the financial loss that has gone with that?

Mr Dolan : That is not a matter that I can answer on the spot here. I am happy to turn my mind to that if any such request comes forward.

Senator FAWCETT: That would be very useful. I look forward to the report

No, you won’t.  Not while we have a minister who’s aviation interests are centred on publishing pictures of the DPM taking a leak...

...Not while we have a whipped ATSB who will not examine an accident and include the full story in a report with teeth. Not while we have a CASA so mired in deceit and obfuscation that no one dare let the fell truth be known, especially to ICAO or the public.

The absolute, very best we can hope for; offer prayers to any pagan god who’ll listen, is a clean sheet. Start again; from the beginning; let the past lay. The organizations and the minister are in too deep; they dare not take the lid off and it is their lid. Let’s hope for a new broom DAS who will remove the Worthless rubbish from the CASA corridors, an ATSB commissioner who can put aside the Walker bollocks diagram and a minister who can take at least a pissing interest in the well being of an industry and the travelling public.

Back to you..Dear Ferryman, Dear Ferryman..back to you - P2