[Peetwo]

Of delay and denial.

"Mistakes are not always the result of someone's ineptitude."

The report above intrigues me: 1352 days invested in a report which changes nothing. Why bother. Quick turn around and ‘on time performance’ are management and PR tools, nothing whatsoever to do with ‘aircrew’ duties and responsibilities. Now if the air crew are too worried about ‘pressure’ there is a union to complain to: but, and most importantly, there is a Safety Management System (SMS), which is legally binding and fully auditable.

A report in the SMS system demands attention; an incident, like the one mentioned above should have an open ‘action’ trail, in which the response from ‘management’ may be clearly seen and the ‘remedy’ examined.

An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place. The company SMS in a perfect world would have identified, much more quickly than the ATSB where the problem lay and been able to quickly effect a solution – which the ATSB have failed (again) to provide. The company can, in a heartbeat, issue ‘orders’ to change an anomaly in their system; ATSB cannot. So why even involve the ATSB in any way except as an ‘auditor’ of the SMS?

Tiger SMS team are obliged, by law, to investigate – there would be a paper trail. All ATSB need to do is send in a couple of auditors to check that all has been attended to – correctly and that should be the end of the story. We either trust and use the SMS; or, save the company the cost.  This double up, where there are no effective cross checks or balances is ridiculous. Why not let Tiger sort out the problem, audit their response and ‘order’ any changes ATSB deemed necessary. Would save some time and money; we’d probably even get an accurate, valuable ‘report’ back in 13 days, not 1300.

The way the ATSB present this latest load of Tommy-Rot suggest that the aircrew need to back to planning their own fuel burns – for indeed they are ultimately responsible. But the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure.

[we] are not ill provided but use what we have wastefully.”

Toot toot.

Excellent post "K"...

I to am bemused by this report and still trying to fathom why this particular incident was investigated at all. Especially when you consider that the ATSB has chosen to discontinue many other on par investigations, stating lack of available resources and/or higher priority (i.e. serious incident) investigations as reasons for discontinuing...

Q/ So why did this particular non-event, & supposedly proactively addressed by airline occurrence, require the ATSB to instigate a topcover O&O investigation?

 P9 - "..An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place..."

Maybe "K" that it is where the problem lies? Could it be that at that particular time the Tiger SMS was simply a tick-a-box routine that on paper met the CASA regulatory and oversight requirements but in actual fact was ineffectual in identifying and mitigating serious safety issues?

After all it wouldn't be the first time that an AOC holder, operating under a CASA approved SMS, was found to be operating with significant safety deficiencies that the SMS failed to identify and/or effectively risk mitigate.

"..the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure..."

Yes the classic example of a failed 'in operation' SMS is of course PelAir.

The following is an extract from former CASA Manager of Human Factors Ben Cook's Special Audit report of PelAir's FRMS (reference: CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012; (PDF 5428KB) ):

 
Note that Ben Cook highlights that the 'special audit' was a 'systemic investigation' and that he took steps to de-identify company personnel in order to not jeopardise the Rex position on positively fostering a 'just' internal safety culture.

When you consider the ongoing embuggerance of DJ it is kind of ironic that a former CASA officer was taking such steps to protect the fundamental concepts of a 'just culture' that is integral to the effective operation of a company SMS (i.e. you don't have 'just culture', you don't have an SMS).

Reference search 4 IP post: Update: ATSB PC accident investigation AO-2014-032

Then about a week ago the following new investigation was initiated (note new investigation No.) that was bizarrely co-joined to the ongoing ATR broken tail investigation -

Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 

• Tab - Summary
  

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
• reviewing other investigations and references where similar themes have been explored.
  

So maybe the ATSB investigators and HF experts on the coalface have come to realise there are some serious deficiencies in the CASA regulated and oversighted SMS of some of our major operators and SSP defined service providers (e.g Airservices, BOM) -

Naturally it would then follow that Hoody and his fellow commissioners, in the interest of political correctness and not embarrassing the minister, have developed an O&O campaign to allow the commercially and/or politically sensitive DIPs time to get their shit together and shred the negative evidence of SMS/SSP complacency - Just surmising...   


MTF? Definitely...P2