[Peetwo]

ATSB with an up yours to former DPM/Minister Truss -  

Remember this?

Via Oz Aviation:

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Truss calls for fresh look at Pel-Air ditching
December 3, 2014 by australianaviation.com.au
Westwind VH-NGA ditched off Norfolk Island in 2009. (ATSB)

Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss wants the Australian Transport Safety Bureau (ATSB) to take another look at the Pel-Air Westwind corporate jet ditching off the coast of Norfolk Island in 2009.

Truss told parliament a review of the ATSB’s investigation of the accident by the Transportation Safety Board of Canada (TSB) found “there were errors made”.

“I am concerned that the TSB report raises some concerns about the application of ATSB methodologies in the investigation into the ditching of a Pel-Air aircraft off Norfolk Island in 2009,” Truss told parliament in a ministerial statement on Wednesday.

“As a consequence, I have asked the ATSB Commission to give serious consideration to reopening the investigation.

“I have asked that the fresh review of the Pel-Air accident should take into account the findings of the TSB’s report.”

The TSB report, released on Tuesday, said the ATSB did not follow proper process and had poor oversight during an investigation into the ditching.

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Couple that with the commitment by the ATSB to give due regard to not only the findings of the TSBC but also the Forsyth (ASRR) review and the Senate AAI inquiry:

 ...On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation... - From the MKII final report.

Therefore it should be natural to assume that the new ATSB investigation should have had at their disposal all the documents that under the spirit and intent of the 2010 MOU, under para 4.1 (Parallel Investigations) and sub-paragraph 4.4.6 of the 2010 MOU,... 

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..CASA agrees that if a CASA Officer is known to have information that could assist the ATSB in the performance of its investigative functions, CASA will undertake to advise the ATSB of the existence of the information...

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...CASA should have released but never did in the original parallel investigation. The classic examples were both the Chambers Report and what would soon be referred to as the 'Cook Report' (PelAir FRMS Special Audit Report).

Of course the former DAS McCormick and his executive minions contentiously argued over and over again that CASA had not breached the spirit and intent of the 2010 MOU by withholding the Cook and Chambers reports.

Extracts from 15 February 2013 AAI Inquiry Hansard:

Senator XENOPHON:  On its plain language, you have breached the MOU.

Mr McCormick : No, I do not think we have.

Senator XENOPHON:  But, for whatever reason, you withheld the Chambers report from the ATSB.

Mr McCormick : The Chambers report is an internal CASA document.

Senator XENOPHON:  I am sorry; the memorandum of understanding states:

CASA agrees that if a CASA Officer is known to have information that could assist the ATSB in the performance of its investigative functions, CASA will undertake to advise the ATSB of the existence of the information.

Are you saying this report would not have assisted the ATSB?

Mr McCormick : What I would say is that the Chambers report was not done until we had completed our investigations. In our interactions with the ATSB, we did not give the ATSB any information, on the deliberate point, as I think is under 4.1 of the MOU, that we do not influence their investigation. We completed ours in 2010; it took until 2012 for the ATSB to—

Senator XENOPHON:  That is a curious and bizarre interpretation of 4.4.6 of the MOU, but I will hand back to Senator Fawcett and ask you more questions about that later.

Senator FAWCETT:  Going to that exact point, if you go to 4.1 of the Chambers report, it states that it is likely that many of the deficiencies identified after the accident would have been detectable through interviews with line pilots and through the conduct of operational surveillance of line crews in addition to the surveillance, the management checks.

It strikes me that the Chambers report is quite specific, and that is only one example. There are a number of other areas where it is fairly clear that there were deficiencies in the oversight that had they been addressed through effective audit the accident may well have been prevented. The point though, Mr McCormick, is not so much to say that the surveillance was deficient therefore the world is about to end. Commissioning the Chambers report was commendable upon your taking control of the organisation. The point is, for the public to have confidence that there is transparency and due process, where there is a report in existence, a formal report conducted by a senior manager, it would be the expectation of the public—and indeed, as Senator Xenophon has pointed out, it is clearly highlighted in the MOU—that the information pertinent to an investigation by ATSB would be made available.

With the concept of a systems approach, whereby not only the operator and the piloting command but also the regulator are key parts of the safety system, where there is written evidence in the possession of one department prior to the publication—in fact, prior to even the review of the draft report coming out—it seems inappropriate to the committee that the spirit and letter of the MOU was not implemented to make that information available.

Mr McCormick : As I said, the CASA Chambers report was a report that I started. It did not even require to be done. It was not something that was in our normal procedures. Following the MOU—

Senator FAWCETT:  We appreciate the fact that you started it. Our concern is the fact that, having initiated the report and having it in your possession, the report was not then made available—as required by the MOU, in writing let alone in spirit—to assist the ATSB with their subsequent investigation.

Senator FAWCETT:  We will come later to the issues of collaboration—I will use that word as opposed to 'cooperation'—between the ATSB and CASA.

But there is evidence and there are documents, which we will discuss, that indicate there was relatively frequent and open discussion about the content of reports and alignment between the two organisations, and yet a report that (a) would obviously embarrass CASA was not made available, despite other interactions that go contrary to what you have just stated; and (b) the ATSB report, for example on the issue of fatigue, almost discounts fatigue because they say 'there is a lack of evidence that this is a serious safety concern'—and they take the fact that there have been audits done of the FRMS system used by the company. In the audit that CASA put together, it said:

… it is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during the surveillance audit of March 08 were never appropriately actioned.  

There is a lack of any clear evidence to support corrective actions have been implemented, confirmed by CASA or that there were effective. If this process is indicative of broader practices of CASA, it is considered that CASA is exposed to unnecessary risk, particularly if required to provide evidence to support how it approved and operated a system, in this case their FRMS …

Given that the ATSB chose to ignore the whole issue of fatigue and how that might have affected the errors that were made by the pilot, because of a lack of evidence, and CASA had a formal report within their system dealing with the issue of fatigue and chose not to disclose that to the ATSB as required by the MOU, I think you would have to agree Mr McCormick that that would seem a little unusual to the reasonable man on the street.

Mr McCormick : The issue of FRMS, or the issue of fatigue, at the time was in its infancy, shall we say—even today, the FRMS rules, where they lie and how we are going forward is a matter we can discuss at some length; we are in a regulatory development process at the moment for fatigue risk management. Put in one score forward from a FAID system, which I believe Pel-Air were using, and which is used by many others around the world, gives an answer. Using some other esoteric system, or some other mathematically based system, may give you another answer. Mathematically based systems have not been proven to be accurate in any way, shape or form. I think the important thing is, on page 21 of the Pel-Air Aviation Safety Audit Report from CASA, where we interviewed Pel-Air pilots, under the 'Policy and application of fatigue practices', it says:

All crew interviewed stated that they felt that would be no issues in stating that they were fatigued and pulling out of duty, but also felt that they had limited opportunities to fly and had to take these opportunities when they arose.

I fully agree that Pel-Air could have done more to assist in this flight. We said that from the start. The issue is that, in the end, fatigue—and I think this is in our supplementary submission as well—comes down to two parts: the operator rostering people appropriately so they are not unnecessarily fatigued, to the best of their knowledge; and the last line of defence of the crew not operating. Pel-Air crew have indicated to us that they felt no restrictions about operating. In this particular case of Mr James and the amount of rest he achieved, I think there were three different answers—four hours, eight hours and a couple of hours—to the Four Corners interview. I do not know to this day how much fatigue was induced in Mr James by that operation; only he will know. And so far, with three different answers, the only question we have to ask is which one is correct and which two are the lies.

Senator FAWCETT: With all due respect, Mr McCormick, that complete answer had no relevance to the point that I raised. Everything you have said is quite possibly correct, but it has no relevance to the point that your own internal investigation indicated that CASA's oversight of the Fatigue Risk Management System at Pel-Air was inadequate. And other parts of the document go to their training and implementation and the lack of effectiveness. That is surely a crucial part of the safety information that the ATSB should have considered in its inquiry as to why the error was made. That information was held by CASA—in fact, withheld by CASA, despite the requirement of the MOU to release any relevant parallel investigation that went to a matter that was been investigated by ATSB.

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&..

Senator FAWCETT:  Mr McCormick, two points: (1) the report I was just talking about was in fact the Special Audit of Pel-Air Fatigue Risk Management System of December 2009, a separate CASA report almost a year ahead of the Chambers report that you are referring to; and (2) this report, and Chambers, that are different to other internal CASA reports—which I accept any good learning organisation will do; some of them will be embarrassing, and there is no requirement, in the normal course of events, for CASA to release internal reports. But, where they are directly relevant to the causation of an accident that is being investigated by the ATSB, there is clearly an expectation of disclosure by the public, and indeed by your own organisation and the government, because it is articulated in the MOU that 'wherever CASA conducts a parallel investigation into a transport safety matter the ATSB is also investigating, CASA will provide the ATSB with a copy of the CASA investigation as soon as it is practicable to do so.' Given that this was tabled in December 2009, is there any reason why this was not provided to the ATSB in accordance with the MOU?

Mr McCormick : If I could make two points on that. If you look at the Chambers report—and I will go away and confirm this—to my knowledge the points raised in there are points that are also covered in our special audit report and our accident report. In other words, they are not raising new information; they are raising information about how internal processes in CASA were carried out. As I said, I will check that on notice, if I can; but I think you will find that there is nothing raised in the Chambers report that is not reflected in our accident report. So if you ask have we given the information, as I said: we gave the information that we were required to give, that the ATSB asked for, we assisted where we could within the confines of the MOU and confidentiality and our differing aims and opinions—and, when it comes to the Chambers report, to me it shows what is behind those points. But I think you will find all those points are raised.

To turn to that report you have in your hand, Senator: in actual fact the major elements in it are, to my knowledge, are incorporated in the accident report as well. I had not seen that report before today, I might add; and you will notice from the front cover that I am not actually an addressee. That is not me trying to sidestep it, but you will find it has not actually been signed by anybody. There were two human-factor specialists involved in that investigation, and to my knowledge their comments were incorporated in the report. I might ask Mr Hood if he can expand a bit of the background of that.

Mr Hood : The findings in relation to Pel-Air in the special audit report of fatigue were lifted and directly placed into the special audit report that was made available to the operator.  - PING! That's a Canary dot...

Senator FAWCETT:  I accept the fact that the detail, if you like, of some of the issues that were found with the operator ended up in the reports.

The issue here, as you correctly point out in most of your written and oral evidence, is that the pilot is the last line of defence and is a key part. The operator is another one. As you correctly point out, many of those things made their way into the report. But the oversight by the regulator is a third tier and that is what is missing from the ATSB report.

It is clear that CASA had in its possession, through these reports—and this is where the Chambers report differs from the special audit. The Chambers report is CASA's own assessment of how it performed its oversight role, which is why, to use your term, it appears 'passing strange' to the committee that there should be such strong rebuttal against witnesses who say we do not think the surveillance was adequate. There was very strong rebuttal, in a public space, saying 'CASA rejects that', when you know your own internal investigations by senior managers are saying that your oversight was inadequate.

We are happy that you are taking steps to correct it. Surely it is in the public interest, rather than us having to drag it out through a committee process like this. There were inadequate processes. The ATSB should be provided with that information so the public have confidence that you recognise there are problems internal that contributed to our culture, environment and practices by pilots that led to an error and an accident. The public should have confidence that, regarding the organisational characteristics and culture as such, (a) you are learning—and yes, that is good and (b) that you are also transparent and will say 'ATSB: yes, we were making mistakes in the past and we are addressing it, but here is a report of our own assessment.' For you to say in things like this rebuttal, in quite strong language and with absolutely no hint of compromise, that you reject any assertion that your oversight may have been inadequate when your own internal reports are damning in that area, is surely not in the public interest, nor does it inspire public confidence.

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Or in pictures...

Keeping a focus on what IMO was the more important CASA withheld document, i.e. the Cook report, let's fast forward to the Beaker section of the Hansard...

Senator FAWCETT:  Mr Dolan, can I go to the issue of the scope and content of the report. I have just been flicking through—I have not actually counted the pages, but there is clearly a bulk of the report that examines in quite some detail the sequence of the pilot's fuel planning, obtaining the weather, decisions he makes et cetera, and it leads through to the fact that he ended up having to ditch the aircraft. You go to a number of issues about that decision and why or why not some of those consequences occurred. There appears to be very little inquiry in the report about why was the pilot in a position where he felt his decisions were reasonable. There are two issues that come out of that: one is the issue of the culture and the practice of the operator and the oversight of CASA—we will come back to that in a minute—and the other one is fatigue. Did any of your own staff, or any of the directly interested parties, raise the issue of fatigue during the drafting of the report?

Mr Dolan : Yes.

Senator FAWCETT:  There are two very short paragraphs that touch on the hours with respect to fatigue, but that is about it. Can you explain why the issue of fatigue was not pursued in any more detail by the ATSB?

Mr Dolan : This goes to discussions I have had with the committee earlier, which are that there is a lot more work behind this investigation than is necessarily reflected in this report. So we did a quite reasonable amount of work on assessing the relevance of fatigue issues to this accident. Where we came out, as a result of that assessment and reassessment, was a position where it was not possible on the basis of what was available to us to form the view that fatigue was a significant issue in the formation of this accident. That is what were reflected in the report.

There are two possible assessments, which we also reflect in shorthand in the report, one of which relies on the initial report to us of the amount of rest that was available to the pilot, and the second is an alternative report of the amount of rest available that he made to CASA. The reconsideration we did in the process was to try and assess the second of those, less sleep of the order of four hours, rather than making use of most of the available eight hours of rest time. What difference would this have made at the key points? We satisfied ourselves that it was unlikely but always possible that fatigue was contributing, but we did not see it as a major contributing factor.

Senator FAWCETT:  To the point where in one of the emails you provide to us, one of your officers indicates that, 'We will put a comment about fatigue in just to deter or deflect any criticism about the report.' I am happy for you, in any subsequent submission, to give this some background on that.

Mr Dolan : If I could, Senator, I would not want there to be a misunderstanding of the intent of that comment. The concern that has been reflected there is the concern that others would form the assessment that we had not seriously considered fatigue issues in the context of the information available to us. We did. So we are including in the report those references, best assessments, as to the fact that fatigue did not seem to be a significant issue in play in the formation of this accident. Organisationally we were not seeing any basis for having a long discussion in the report of how we arrived at the conclusion.

Senator FAWCETT:  If you had—in your initial evidence base that you keep coming back to about the facts—in that factual base, information that a peer regulator—in this case the UK—had looked at the patterns of sleep and cycle and said that under their system it would not have been acceptable, if you had in your facts base that CASA had done an audit of the operator and CASA's own oversight of the management system. I will quote from the report: 'It is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during the surveillance were never appropriately actioned. There is a lack of any clear evidence to support corrective action had been implemented and confirmed by CASA that they were effective. If the process is indicative of broader practices by CASA it is considered that CASA is exposed to unnecessary risk particularly if the requirement to provide evidence to support how it approves an operator system, in this case the FRMS.' If you had that in your evidence base, the fact that a competent body said. 'We think the fatigue would have been beyond us letting the person fly,' and the fact that the operator clearly had some problems and the fact that the regulator had recognised themselves that the oversight was not adequate of that, do you think you would have gone a little bit further in your report than just saying, 'Perhaps fatigue was a factor but we cannot actually assess it, so we will discarded it'?

Mr Dolan : The principal purpose of our investigation into an accident is to understand those factors that contributed to the accident and particularly those contributing factors that indicate a level of increased risk in the system of safety. On that basis, having carefully looked at contribution in relation to fatigue, we did not form the view that it was something we needed to highlight as a contributing factor that illustrated a heightened level of risk in the system.

Senator FAWCETT:  Mr Dolan, sorry to cut you off. I hear what you did to. My question is: if you had had this additional information would it most likely have made a difference?

Mr Dolan : I was going on to answer the second part of that, Senator.

Senator FAWCETT:  My apologies.

Mr Dolan : I understand you wish to cut through. The other opportunity available to us in the course of investigation is to highlight what we call 'other safety factors'. The focus is on what contributes, understand that and see whether something needs to be done to prevent a recurrence. In the course of investigation sometimes we will identify other factors that are of interest and that may represent an increased level of risk or an inappropriate level of risk in the system.

It is possible—we are dealing to some extent with hypothesis here—that, had a range of other information been available to us that had been acquired in the course of our investigation, we would have formed a view about another safety issue in this case. But it was not the primary focus of our investigation.

UDB! - To this day that response and load of BASR bollocks by Beaker, still leaves me gobsmacked...

However I have diverged enough so to the question - Q/ Did the ATSB stick to the Truss ToR and/or their own commitment to review and/or utilise the findings of the TSBC, the ASRR and the Senate AAI inquiry in the re-investigation of the VH-NGA ditching?

Answer: Using the examples of the comprehensive, scientifically based Cook - Special Audit of Pel-Air Fatigue Risk Management System - Report and the Chambers Report it should be a simple matter of referencing the 'Sources and submissions' section under 'references' of the MKII report (refer pages 389 - 391) - however there is no reference to either report. Nor is there any reference to the TSBC peer review report, the ASRR or Senate AAI Inquiry reports. Nor is there any attributable references to any of the abovementioned reports in the large Appendices, or in the contextual sections of the body of the report. Therefore the answer is NO! 

Hmm...wonder how much ATP (Australian Taxpayer) money has now been spent simply for the aviation safety bureaucracy to once again thumb their noses at the former minister, the current minister, the Australian Senate, the TSBC, the Reverend Forsyth panel members, the industry stakeholders and indeed the travelling public - UDB!


MTF...P2

Ps Another Canary PING! moment from that infamous 15 February AAI inquiry Hansard:

Mr McCormick : This unfortunate accident occurred in 2009. I commenced here in March 2009. In 2009, we introduced a new board, in July, and we were in the middle of a restructure in reporting lines and around our policies, processes and procedures. At the time of this incident, November 2009, we were very much still in the mode we had been in for the previous four or five years. On the Chambers report, I directed operations—


Senator XENOPHON: You say were in the same mode as you had been for four or five years—what mode was that?

Mr McCormick : I mean that the way we were conducting surveillance, the way we were organised and the way our offices were put in place—our policies, processes and procedures—was very much the legacy of our previous years. We did not have much fundamental change in the seven months after I arrived, before this accident had occurred.

CHAIR: Does that imply that they were faulty?

Mr McCormick : No, I do not think they were. As I said at estimates in, from memory, May 2009, in the previous years I think there had been a bit of neglect in the way we went about our business, in that we were not necessarily organised in the best way to go forward and we relied very much on subject matter experts. That is not to say that was wrong; in that respect, we were very much like other NAAs around the world, all of which undergo continual renewal. CASA is an organisation that we had to put onto the correct footing. We had to move forward, build on the things that were right and correct the things that we did not think were working particularly well. At the same time, there were numerous other issues which we were dealing with.

To get back to the Chambers report, I directed Mr Hood, who was then the executive manager of operations, to get an independent internal view of CASA, for my information—a view of how the organisation worked, the efficiency of our procedures and how we were undertaking them. The Chambers report dates from August 2010. We had to wait for the entire investigation to be finished before we did the Chambers report. That report was actually intended for me, and I did say at the time that I wanted warts and all. I certainly did not want any holding back in finding out where we were going and how we were going forward. Many of the issues that were raised in the Chambers report we can discuss individually, if you wish, but, if we go back to the accident—and I am cognisant, Senator Fawcett, that the committee has reached a position in regard to the pilot of the aircraft—the report still does not indicate anything that would have affected the outcome of the accident. What it indicates is that our procedures and way we went about doing some things needed revision, and we were in the process of doing that. We are a different organisation from what we were in those days.