[Peetwo]

HVH reckons ATSB will be more transparent -

From the ATSB spokesperson HVH: 

ATSB provides increased visibility into investigations
The ATSB is providing further insight into its investigation processes with the release of real-time investigation status information for all of its active investigations.


In addition to releasing the status of an investigation on its dedicated investigation web pages, the ATSB has also made available detailed information about its investigation phases and methodology.

ATSB Chief Commissioner Greg Hood said the changes were designed to provide a greater level of transparency into the work of the national transport safety investigator.

'The ATSB is a world class transport safety investigator and all of our investigations are undertaken in a meticulous and thorough manner, in accordance with both national and international legislation and standards. While our legislative obligations prohibit the release of restricted information during an active investigation, we strive to provide as much transparency as possible during an investigation.'

Mr Hood noted that the ATSB has traditionally provided more insight into its investigations than many international counterparts, particularly regarding the provision of estimated timeframes for each investigation.

'The dynamic and multifaceted nature of investigations can affect timeframes, which are always provided as an estimation.

'We understand that the length of time it takes to conduct a thorough investigation can sometimes generate frustration and uncertainty for directly involved parties such as next-of-kin, and for the interested general public.

'Australia actually performs very well against international investigation timeframes, particularly with  aviation investigations where our overall completion timeframes were assessed by the International Civil Aviation Organization as being around half of the global average.'[/url]

Mr Hood said investigation timeframes are impacted by two primary factors—available resourcing and the unpredictable and often complicated nature of serious incidents and accidents.

'It is important to note that, even if the timeframe of an investigation is extended, if the ATSB discovers a critical safety issue during an investigation we immediately bring it to the attention of relevant parties to be addressed.'

To better reflect the dynamic and multifaceted nature of investigations, the ATSB has now amended its web pages to reflect an expected completion date as a quarter, rather than a month.

Those who would like to be kept informed of ATSB releases can subscribe via [url=https://www.atsb.gov.au/subscriptions/]the ATSB website.
 



Last update 28 February 2018 

Note that this revelation was revealed 2 days after HVH got very sensitive and defensive at Senate Estimates when questioned about one of the world's longest aviation accident investigations where initially all the occupants survived and the aircraft and black-boxes were eventually recovered...

Mr Hood : I wouldn't mind making a few overarching statements about the report, if I can, and then I might hand over to Mr Hornby, who has a much greater and more detailed knowledge of the report.

Senator PATRICK: Sure.

Mr Hood : The report was released on 23 November 2017. It's the largest and most thorough report ever undertaken by the ATSB—in excess of 500 pages. We're very cognisant of the fact of the history. Obviously, the first time round, it led to a Senate inquiry, which led to David Forsyth's regulatory and safety review of ATSB and CASA and to a review of the ATSB's methodologies by the Transport Safety Board of Canada. It reopened investigation of where we went back to Norfolk Island and recovered the cockpit voice recorder and flight data recorder, at the cost of some $500,000 to $600,000. And then, of course, the reopened report includes an additional 30 interviews et cetera the second time round.

Like all of the investigations, the findings in the report are not meant to apportion blame or liability to anybody or any particular organisation or individual. The captain's individual actions with respect to flight planning and fuel management are included in the report as some of the contributing factors. The actions of the captain and other parties are explained in an organisational context, examining the risk controls of the operator and the regulatory framework. So we went to great pains to have a look at the whole chain of events, from regulatory oversight to the ownership of the company and the processes and procedures in the company and then, of course, to the individual factors. So we think it's a thorough report.

In terms of the detail, I don't think anybody at this table or at the back has been involved in the investigation team. The investigator in charge is based in Brisbane. I'll refer to Mr Hornby for specifics on any of your questions....

...Senator PATRICK: We're looking at a number of incidents now that are dealing with weather related concerns. Surely that's something you might turn your mind to in the context of that.

Mr Hood : In the Pel-Air accident report we devoted two full appendixes—H and J—to remote island weather and to Norfolk Island weather. I think out of the 500-odd-page report about 10 per cent, about 50 pages, are devoted specifically to weather. We certainly did have a pretty good look in the report at the weather factors. The other point you make is about general Australian weather. We do have a pretty good look at what we're seeing in Australia in relation to weather events. In most years we have around 12 to 15 reports of unforecast weather where aircraft have been faced with decision-making in relation to diversion because of unforecast weather. That reduced in 2017. We had eight of those. So we are actually looking very carefully. We don't think there's a systemic issue in Australia in relation to weather events currently, but it is certainly under watch.

 
Seems as if Commissioner Manning has thrown on his invisibility cloak once again...

For the record the following is an appraisal of the PelAir MKII final report from a bona fide expert whose specialty lies in Human factors:

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Systemic Observations – Pel Air Report

There are many observations, which contribute to a less than adequate first and second Pel Air investigation report.

Bottom Line Up Front: If you don’t collect the right data and information in a timely manner as part of the preliminary investigation process then you have significant barriers in ever being able to produce a quality report aligned with the standards expected of an aviation investigatory organisation.

Furthermore, if you are aware of many shortcomings in the investigation process then you need to ensure other factors such as the influence of organisational culture have also been carefully considered prior to making recommendations specific to the active failures of the aircraft captain. In many respects, shortfalls are identified within the investigation report, yet the report continues to use incomplete ‘systemic’ evidence to make final decisions specific to the aircraft captain. Most of these issues are also identified in the Transport Canada (TC) Independent Review. Observations, including TC and final report extracts as follows:

• [b]Quality of the investigation process:[/b]
  • [i]The analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight were not effective because insufficient data was collected.[/i]
    
  • Poor data collection hampered the analysis of specific safety issues, particularly fuel management, company and regulatory oversight, and fatigue. A comprehensive sleep-wake history going back at least 72 hours and to the last two adequate periods of restorative sleep was not immediately obtained. [It should be noted in June 2008, the ATSB sent human performance representatives to attend a CASA run NTSB Fatigue Factors training course as well as an exchange of fatigue related investigation lessons. This included copies of the NTSB fatigue investigation checklist and provided an overview of effective fatigue investigation techniques and NTSB case studies.]
    
  • [i]Weakness in the application of the ATSB analysis framework. Analysis tools were not effectively used.[/i]
    
  • [i]Ineffective ATSB oversight of the investigation.[/i]
    
  • Inadequate data collection e.g. an informal survey of ATPL candidates regarding their understanding of decision making with forecast weather below alternate minima is not strictly valid i.e. what you learn at school can be significantly different to what actually occurs in practice based on company culture and norms. The sample of the survey was small (not valid) and did not include Pel Air pilots other than the occurrence crew. Yet, there was evidence suggesting the company practices (culture) involved a number of fuel planning deficiencies, including a lack of formal consideration to emergency scenarios (depressurization, single engine operations), which were specific normal practices for the majority of aircrew. The survey of operators, while not helpful in determining how widespread the practices observed in the occurrence were within Pel Air (clear limitations due to a lack of interviews with other Pel Air pilots).
    
  • The IIC concluded that pilots did not use a consistent approach to gathering weather information and making decisions in these circumstances (a systemic problem).
    
  • [i]Inadequate consideration to the CASA special audit report.[/i]
    
  • [i]Critical reviews were conducted periodically but did not identify specific shortcomings in the data collection or analysis.[/i]
    

 

• [b]Communication-misunderstandings:[/b]
  • The responsibilities of CASA and the ATSB were never resolved, even though the ATSB had become a separate statutory agency in July 2009. As a result the ATSB did not collect sufficient information from Pel Air.
    
  • The IIC understood that the investigation should not cover the same areas as CASA, which persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots at Pel Air. [A clear lack of evidence with considering the culture of Pel Air, which must be considered prior to casting punitive action towards the aircraft Captain – see next section].
    
  • In May 2010 a critical investigation review was held and an analysis coach was appointed. The IIC felt that the coach’s focus on the performance of the flight crew (cognitive bias) prevented the coach from seeing the systemic issues that the IIC considered important. The coach felt that insufficient data had been collected to identify systemic issues. Coaching broke down and the data quality issues were not resolved.
    
  • November 2010, a peer review identified concerns with the factual information presented, the safety factors analysis, the findings and the readability of the report. The team leader assigned a second peer review, which was not known by the IIC.
    
  • May 2011, GM review – a team leader raised concerns to the GM about the adequacy of the data and analysis to support the draft safety issues. The GM directed a third peer review, which identified the organizational issue within CASA’s investigation report were significant and needed to be developed further in the ATSB report.
    
  • July 2012, Commissioner review and concern there was insufficient factual information and analysis, including concern as to why the CASA special audit report had not been relied upon more extensively.
    
  • Inadequate communication between the IIC, the team leader and the GM, including a GM personally editing the report (ongoing pressure due to a backlog of other reports).
    
  • Some pilots noted they were aware of tensions between the chief pilot and the Westwind standards manager…..a Westwind check pilot reported there was a lack of clarity regarding the role standards manager.
     
    
• [b]A potential ongoing bias towards the captain (punitive approach) with inadequate consideration of the evidence (organisational culture, norms, routine versus exceptional violations, justification of the decision-making process of the ATSB investigators (e.g. just culture culpability chart)) to substantiate the actions of the accident captain:[/b]
  • While the investigation report and the TC independent review highlight many systemic issues, there is inadequate evidence to continue to provide such a direct focus on the aircraft captain. In many sections of the report there are inconsistencies with making an evidence based approach to the analysis.
    
  • For example, the report states ‘contrary to the consistent practice of the operator’s Westwind fleet for such flights, the flight departed with full main tanks rather than full main tanks and tip tanks. Yet the report highlights the accident captain in the past has regularly taken a more conservative approach i.e. carried more fuel. So the critical question – what was happening on this particular day, what were the observed behaviours and what could be eroding the normally conservative decision making of the captain? The obvious consideration from a human factors perspective is fatigue. Furthermore, the culture of Pel Air also remains a key area that warrants investigation but with such a limited number of interviews with other Pel Air pilots the ATSB does not have adequate evidence to draw further conclusions.
    
  • Many organisational issues are identified (inadequate risk controls from the operator including fatigue risk management, crew resource management and flight crew training; limitations with Australian regulatory requirements; a critical breakdown of communication between Air Traffic Services and the flight crew). Hence, there is inadequate evidence and visibility of the process utilised to continue attribute direct blame to the actions of the aircraft captain.
    
  • P9, there were no regulatory or operator specific requirements to carry sufficient fuel for a divert or hold for an extended period…However there was a requirement to carry sufficient fuel to allow for aircraft systems failures…The report due to the inadequacy of the investigation process, namely further interviews with Pel Air personnel, did not gather adequate evidence to determine whether this was a routine (normalised) practice from a whole of company perspective. If yes, within a just culpability framework this could be described as a routine violation that warrants a recommendation for the organisation, not the accident captain.
    
  • Further evidence of lax company processes, in this case crew resource management are identified in the report…the first officer did not participate in the flight planning or fuel planning, nor did the operator’s procedures require her to participate. Again, examples of less than adequate professional practices linked to the culture of the organisation, which is heavily influenced by senior leaders e.g. the fleet standards manager. Further evidence of internal issues with organisational culture that have not been discussed.
    
  • The operators OM did not provide any guidance to flight crew for flight or fuel planning in non RVSM equipped aircraft in RVSM airspace.
    
  • The OM did not provide any figures to use for speed or fuel flow from the CP for the remainder of the flight for a loss of pressurisation. Some Westwind pilots reported they did CP calculations…other pilots reported they did not. [organisational culture – behavioural; norms] – most carried additional discretionary fuel. It is not reasonable to consider an adhoc practice of carrying extra fuel as adequate in this accident to apportion blame to the pilot for the decision made this time.
    
  • The OM contained no specific fuel planning requirements for flights to remote islands.
    
  • There was no formal guidance in the OM about what to do if a pilot was having difficulties obtaining the required weather or briefing material.
    
  • All the above having been identified even though the Westwind standards manager had been exposed to a divert to Auckland due to adverse weather – more signs of a lack of corporate learning through enhanced OM policy and guidance. It was also known that a requirement to depart within two hours could make it difficult to do the fuel and flight planning, prepare the aircraft, and complete the relevant paperwork. This has the potential to create a culture where such attention to detail is routinely bypassed and considered acceptable behaviour to get the job done.
    
  • Some pilots reported that occasionally they had perceived subtle or implied pressure from the air ambulance provider or the operator to conduct a flight when they were not comfortable doing so (organisational pressure).
    
  • Accepting the guidance that most pilots carried extra fuel negates a necessary requirement for professional planning and the calculation of emergency CP’s, yet the investigation elects to focus on the method used by the accident captain. The report should stay focused on what is required and center their findings around those fuel figures. For example, if depressurised CP’s are necessary then this should be the focus, including investigation as to the root causes as to why aircrew were not routinely performing this activity (cultural norms).
    
  • There is a mixed response regarding the practices of the accident captain…The first officer of the accident flight said that, in her experience, the captain of the accident flight normally conducted thorough flight planning. She recalled a previous flight they had undertaken together to a remote aerodrome neither of them had been to before, and the captain made significant preparations prior to the flight. Some other pilots who flew with the captain reported they did not notice any significant differences between the captain of the accident flight and other captains in terms of their flight planning. However, some pilots stated the captain appeared to conduct flight planning tasks in a less thorough manner than some of the other captains employed by the operator. [Given the previously identified limitations of the first report i.e. a lack of interviews with Pel Air pilots, this information contradicts itself and is not adequate evidence to apportion as much attention to the inactions of the accident captain.]
    
  • There is an excessive focus on the data regarding fuel loading (p158) and flight times, which is too focused on the company norms and not what would be expected of an operator IAW the regulations. This is not evidence based but does have an emphasis to discredit the one of decision of the accident captain for this accident. Yet, the paragraph on p159 finds evidence that the accident captain has a history most of the time to depart with full fuel. Hence, the focus must by what influenced the aircraft captain this time to do something that is not consistent with his previous practices and norms.
    
  • 2009, a Westwind check pilot conducted a proficiency check on the Westwind standards manager – base check, line check and instrument rating renewal in 0.7 hours without a flight to another airport. Evidence of a culture of minimal compliance – in this case non-compliance including waivers. Again, the report must consider leadership, company culture and organisation norms to fully appreciate the behaviour of crews and use appropriate just culture frameworks in making decisions when apportioning blame.
    
  • No formal training for captains to cover the unique requirements of operating to remote aerodromes (again, indicative of lax standards).
     
    
• [b]Organisational and reporting culture:[/b]
  • There was evidence of information not being reported by Pel Air to the ATSB – why was this not reported. Warrants further investigation into the organisational culture and the role/influence of the Westwind standards manager.
    
  • Management and safety personnel stated the reporting culture within the operator had been problematic for many years. Why? What was driving these problems?
    
  • …other pilots stated they had never declined a duty, and some of these pilots stated they would have been reluctant to report they were fatigued.
    
  • …several Westwind pilots stated that at times they had been tired or fatigued….however, most of these events did not result in a fatigue occurrence report.
    
  • Sydney-based pilots stated there were no pilot meetings where they could raise issues of concern.
    
  • ..staff had not been receiving feedback regarding closed investigations.
    
  • The company’s executive management relied upon the Westwind Standards manager to apply company policy and procedures to ensure the standard of operations were conducted to the appropriate regulatory and safety levels. It was evident that this had not taken place to the regulatory or safety standard required.
     
    
• [b]Inadequate oversight:[/b]
  • Communications amongst commissioners indicated there was concern with the lack of analysis of the adequacy of the company and regulatory oversight, especially in light of the CASA special audit report, yet this concern did not result in changes to the report.
    
  • Limitations in CASA oversight and regulations for operations to remote aerodromes.
    
  • Westwind standards manager – most pilots, including the Captain of the accident flight, reported they did not use how-goes-it charts and had not been taught how to use them. There was no standard way to calculate PNRs and other captains could not recall how they did that task. There was no requirement in the OM for PNR’s to be cross-checked.
    
  • CASA audit May 2006, although the audit team (including the fatigue management specialist) intended to interview some pilots, this was not conducted given the advice of the (turboprop) chief pilot that this would not be productive given the current lack of faith that exists with an open and honest reporting system.
     
    
• [b]The importance of culture: The investigation fails to consider the impact of culture on the normal behaviour of PelAir aircrew. For example, extracts from the ICAO safety management systems manual clearly highlight the relevance of culture and organisational performance:[/b]
  • Latent conditions are those that exist in the aviation system well before a damaging outcome is experienced. The consequences of latent conditions may remain dormant for a long time. Initially, these latent conditions are not perceived as harmful, but will become evident once the system’s defences have been breached. These conditions are generally created by people far removed in time and space from the event. Latent conditions in the system may include those created by a lack of safety culture; poor equipment or procedural design; conflicting organizational goals; defective organizational systems or management decisions. The perspective underlying the organizational accident aims to identify and mitigate these latent conditions on a system-wide basis, rather than through localized efforts to minimize active failures by individuals.
    
  • A safety culture encompasses the commonly held perceptions and beliefs of an organization’s members pertaining to the public’s safety and can be a determinant of the behaviour of the members.
    
  • Organizational culture sets the boundaries for accepted executive and operational performance by establishing the norms and limits. Thus, organizational culture provides a cornerstone for managerial and employee decision making.
    
  • Through personnel selection, education, training, on-the-job experience and peer pressure, etc., professionals tend to adopt the value system and develop behaviour patterns consistent with their peers or predecessors.
    
• Furthermore, many aviation investigatory bodies have checklists for their investigators (e.g. NTSB) that provide relevant questions and guidance to ensure cultural issues, including the influence of senior leaders/executive are considered, particularly given their direct influence on individual and team performance (what is considered normal and expected behaviour regardless of the policy and procedures that exist).
  

In general, the final report is too long, contains too much extraneous information not directly related to the contributory factors, and lacks consideration of the impact of the Pel Air leadership and organisational culture and crew behaviour with consideration to norms and actual (rather than documented) corporate practices. Hence, there is limited discussion regarding how decisions were made with respect to routine (it’s what everyone does) versus exceptional violations (the person should know better). It is also the opinion of myself and an independent and former NTSN human performance investigator that fatigue did contribute to the accident (see the next section).


 
Fatigue and fatigue management section
This section has been reviewed by myself and independently by a former NTSB Human Performance Specialist who also served as the Chief of the NTSB Human Performance Division.
 
Some key findings:
 

• While there were clear failings to collect adequate fatigue related information in the early investigation the report fails to adequately consider the changes to the accident captain’s behaviour on the day of the accident. Hence, while there may not be adequate evidence to include, there is also a lack of analysis to not include fatigue as a factor.
  

 

• TC Review: In February 2010, an industry stakeholder contacted the ATSB GM suggesting the possibility fatigue should be considered. This was forwarded to the IIC, who in turn communicated with the human factors investigator. No fatigue analysis was prepared at this time. An analysis of fatigue data was not attempted until late in the investigation. By then, it was too late to address shortcomings in the available data.
   
  
• The ATSB examined alternative roster scenarios using FAID. What scores did they use to accommodate the identified limitations of FAID? Why are the results not discussed, including providing the FAID outputs used as part of the updated ATSB report? Why were other biomathematical models not considered for use (e.g. FAST, SAFE) that are known to have some advantages over FAID, particularly the use of aviation data and research. FAID was built using rail data.
   
  
• A culture of minimum compliance rather than applying the FRMS to achieve practical outcomes:
   
  • The Westwind operations manager had been shown how to use the extension of duty checklist and calculate an IFLS during her training. However, she had never applied it when assigning duties for the Westwind Fleet. Clear reliance on a FAID score of 75, which the ATSB report identifies as representing ‘extreme fatigue’ based on the US railroad report.
    
  • Pel Air pilots reported the FAID scores as being inconsistent with their perceptions of their own fatigue levels. The ATSB cannot underestimate or fail to consider the organisational cultural issues – pilots exposed to a system they don’t trust, that does not match their operational judgements but allowing the processes to become the accepted norm. This is a systemic process that allows inadequate FRMS processes to normalise (normalisation of deviance) with the resultant outcome and erosion of professional practices and standards.
    
  • There were unexplained breaches of the Pel Air policy – the operations manager reported the time off duty should have been 10 hours.
    
  • In march 2008, a CASA audit found the operator had not provided flight crew with annual FRMS training.
    
  • As far as could be determined, the operator never conducted a study or analysis to review the suitability of using a default FAID score of 75 for its operations.
     
    
• The ATSB report notes FAID scores between 70 to 80 can be associated with extreme fatigue. Yet, they use FAID to conduct their own analysis.
  

 

• It is considered that adequate evidence exists to substantiate fatigue as a factor. In particular, recent sleep is very low (the report states 3.5-4 hours, although applied sleep science indicates a poor ability for personnel to sleep during the day, which could put actual sleep as low as a couple of hours); the decision regarding the refuel occurred near the afternoon window of circadian low; total time awake remains high hence fatigue would be increasing during the duration of the flight; and there are clear behavioural signs associated with fatigue. For example, the report suggests in the past the Captain normally fills to full fuel. The investigation team should be asking what factors could be influencing the Captains decision-making on this flight? Some of the behavioural factors IAW the NTSB fatigue factors checklist:
  

 

• • Did the operator overlook or skip tasks or parts of tasks? Yes. For example, the captain subsequently reported that he did not recall hearing the words SPECI or special weather, or that there was overcast cloud at 1,100 ft.
    
  • Was there steering or speed variability? No
    
  • Did the operator focus on one task to the exclusion of more important information? Yes. Furthermore, fatigue and expectation bias (a belief from the previous night’s flight to Norfolk that actual conditions would not be as bad as what was being reported bt the AWS) has not been considered or discussed.
    
  • Was there evidence of delayed responses to stimuli or unresponsiveness? Yes
    
  • Was there evidence of impaired decision-making or an inability to adapt behaviour to accommodate new information? Yes
    

 
With consideration to the ATSB listed adverse influences on human performance:
 

• • Slowed reaction time: No
    
  • Decreased work efficiency? Yes
    
  • Reduced motivational drive? Yes
    
  • Increased variability in work performance? Yes
    
  • More lapses or errors of omission? Yes
    
  • Is something influencing decision making in a negative way? Yes
    
  • Is there a greater acceptance of increased risk? Yes
    
  • Obtaining less than 5 hours sleep in the previous 24 hours is inconsistent with a safe system of work.
    
  • Other research has indicated less than 6 hours sleep in the previous 24 hours can increase risk.
    

 
Lack of fatigue systemic recommendations
 

• The report identifies ongoing issues with the use of biomathematical fatigue models yet makes no recommendations on how to address.
  
• The report fails to consider the planned flight beyond the accident – a systemic review should be considering the fatigue risk profiles had the flight continued from Norfolk to Melbourne. This remains relevant to the limitations and systemic failings of the company FRMS and regulatory oversight. This remains relevant to many operators across the Australian aviation industry.
  

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And the following is a response from a former NTSB fatigue specialist regarding the above summary report:

Basically I agree with everything you say, especially in fatigue (where I have some claim of expertise).  I think the NTSB could reasonably conclude that fatigue was likely in the case of the captain, given that he only had an estimated 4.5 to 5 hours sleep maximum (where as little as 2 hours less sleep than normal can be associated with impairment), where the quality of sleep would likely have been limited based on the available time of day, and where critical trip planning occurred during a circadian low in the afternoon 1500-1700 period. Further, NTSB would conclude that fatigue likely affected the accident as shown in factors such as the captain's uncharacteristic failure to load extra fuel and failure to review options as they approached the point of no return.  I think that fatigue or likely fatigue on the part of the captain should be cited as part of the probable cause.  Certainly, it raises questions about the company FRMS program and corporate culture.


I was also struck by a footnote that the captain, in his initial interview with the ATSB, claimed misleadingly that he slept well (and only changed his story later).  Similarly, the first officer claimed that the fact she took a controlled rest on the flight (and yawned on the CVR) is simply part of operational procedure and does not indicate she was tired.  My understanding is that she would have been unable to sleep if she was actually well rested.  Finally, I find it disturbing that ATSB reports that the company was unable to explain why scheduled crew rest was less than 10 hours but the ATSB says nothing further about this shortcoming.  This type of avoiding fatigue issues is more unusual in the US, where our regulation of duty time is less stringent.  We respect Australia as a leader in FRMS, and it seems unfortunate to think that careful regulation might also bring about a tendency to ignore or misrepresent discussion of fatigue in practical investigation.

MTF...P2

Ps From Hansard:

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Senator PATRICK: Will you be presenting this particular report at the International Society of Air Safety Investigators conference this year?

Mr Hood : Not to my understanding.

Senator PATRICK: Normally you present significant reports to that conference. My understanding is the ATSB turns up and often makes presentations there.

Mr Hood : I'm looking at my budget currently in terms of whether we can send someone to the ISASI conference. But from time to time the ATSB presents detailed reports. It is not to my knowledge that we're preparing to present this one.

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So despite Hoody's statement...

"..It's the largest and most thorough report ever undertaken by the ATSB.."

...it doesn't appear that he wants to put it on display to the world as an example of excellence in aviation accident investigation reporting...