[Peetwo]

#PelAir cover-up: The 'for instances' continued - 

...why it was PAIN had major disagreement when the ATSB first announce the re-investigation of their VH-NGA cover-up investigation... : O&O #2

PelAir & beyond - 'Lest we forget'

The PelAir Norfolk Island ditching came so close to being our first international aviation fatal accident. All on-board miraculously survived and therefore the accident never ended up in the Coroner's Court. However there was still much to be learnt - or there should have been much to be learnt - from one of the rarest survived aviation occurrences, that is a night ditching in open sea conditions of an aircraft. 

However IMO the PelAir cover-up highlights perfectly how our aviation safety system (Annex 19 SSP) is currently so fundamentally & reprehensively broken.

As a reminder of how far we have drifted from the ICAO principles for an effective State SSP, one need not go past the following post from Ziggy...  - The tale of Karen Casey #post65  

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PelAir - 'Lest we forget' Part II

I note that in the very entertaining Estimate's session on Monday, that there was several references to the PelAir cover-up & indeed the "Chambers Report"...
  

Before we move onto more 'for instances' that question the veracity, independence and ongoing mendacity of the continued O&O'd ATSB PelAir cover-up (re)-investigation,  it is worth reflecting on the now historical 'we told you so' PAIN supplementary Senate RRAT submission - PA_Review   

Executive summary.

1) The purpose of this report is to draw to the attention of the Aviation Accident

Investigation (AAI) Senate Committee members, who participated in the Pel-Air

inquiry several matters of grave concern raised from within the PAIN network.


2) In short, we are certain that the committee is very aware that the Australian

Transport Safety Bureau (ATSB) has grudgingly condescended to re-open the

investigation into the 'report' of that incident. The following are of concern:-

a) That the ATSB have elected to utilise Dr. Michael Walker of the ATSB to lead the

investigation. We believe that to be effective, any investigation should be

conducted independently and not involve ATSB, the commissioners or staff if only to

preclude any suspicion of 'internal' influence or external bias being raised.

b) The terms of reference cited by Mr. Sangston are narrow and only mention the

'report' itself. Whilst the industry acknowledges that the report was substandard,

there is little doubt that the investigators conducted their work with integrity and

within the prescribed guidelines. Indeed, the early stages of the ATSB report were

exemplary and clearly directed toward serious safety recommendations being made.

We believe little will gained by utilising scarce resources re-investigating the original

ATSB investigative 'reports'.


3) Our greatest concern is that a deliberate, calculated manipulation of the national

aviation safety system was attempted. It is not a 'one off' aberration. We firmly

believe that the subsequent actions of both the Civil Aviation Safety Authority (CASA)

and the ATSB were proven, by the AAI committee, to grossly pervert the conclusions

of the ATSB investigation to suit a clearly predetermined outcome, thus denying

industry valuable, safety related knowledge and information.


4) It is the process by which these subsequent events occurred which demands an

independent investigation conducted transparently in public. We believe the Senate

Committee is the right reporting and oversight platform for that investigation. The

committee Senators are well briefed, informed and have a firm, current understanding

of what transpired during the events subsequent to the Pel-Air aircraft ditching off

Norfolk Island. Further, the Estimates committee is very clearly 'awake' to the

machinations of the various aviation oversight bodies and will not easily be misled or

confounded by 'technical' issues.


5) We submit that any other form of investigation will not withstand the scrutiny of

industry experts; as the initial premise is fatally flawed. The potential for further

disingenuous obfuscation is obvious. This will, ultimately, be detrimental, not only to

the travelling public and industry, but to the government which allowed one authority

to investigate it's own wrong doings, but avoided investigating those agencies and

their officers, which aided and abetted the travesty, which was the Pel-Air accident

investigation became.

Ok back to the 'for instances'...

CASA discombobulating & the PelAir tick-a-box SMS -

With the ATSB now 2 plus year re-investigation, it should be safe to assume that there will more a proactive review of the historical CASA oversight/audit of the significant elements of the pre-ditching CASA approved PelAir AOC.

Therefore for the benefit of readers, the first publicly available document that can be reviewed is a May 2008 PelAir CASA CAR 217/T&C audit report - see HERE - in particular the 'audit summary' pages 3 thru 7.

'Evaluation' extracts... :

 
In terms of aviation safety, by definition such elements as T&C (CAR 217), FRMS and even 'fuel policy', all fall under the CASA approved PelAir Safety Management System (SMS). The  CASA Special Audit report examines the PelAir SMS from page 38 to 42:

    
Keeping the 2008 audit report in mind take note of some of the disturbing findings on page 42.. :

Now compare the findings of both the 2008 & 2009 CASA audits to the findings, causal factors/contributory safety factors & conclusions sections of CAIR 09/3 (pdf pg 77-81) and ATSB VH-NGA original final report (pages 43-44):

Contributing safety factors

• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Other safety factors

• The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert. [Minor safety issue]
• Given the forecast in-flight weather, aircraft performance and regulatory requirements, the flight crew departed Apia with less fuel than required for the flight in case of one engine inoperative or depressurised operations.
• The flight crew’s advice to Norfolk Island Unicom of the intention to ditch did not include the intended location, resulting in the rescue services initially proceeding to an incorrect search datum and potentially delaying the recovery of any survivors.
• The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands. [Minor safety issue]

Other key findings

• At the time of flight planning, there were no weather or other requirements that required the nomination of an alternate aerodrome, or the carriage of additional fuel to reach an alternate.
• The aircraft carried sufficient fuel for the flight in the case of normal operations.
• A number of the flight crew and medical personnel reported that their underwater escape training facilitated their exit from the aircraft following the ditching.
• The use by the flight crew of the aircraft’s radar altimeter to flare at an appropriate height probably contributed to a survivable first contact with the sea.
• The observation of the pilot in command’s torch re-directed the search to the correct area and facilitated the timely arrival of the rescue craft.

Hmm...can anyone else spot the disconnect...


MTF...P2