[Kharon]

Dancing on hot coals -ATSB style.

Although I use the word ‘style’ very loosely indeed; ‘cos there ain’t much of it on display in the Hotham report. This type of writing may very well be deliberate, an attempt to confuse the legal eagles. It is an awful hodge-podge of a tea time story with mother and a very technical appraisal which sounds too ‘complex’ for the layman to comprehend. Of course it is neither – it is simply of no practical value to any operations department trying to ensure that there is no repeat of a similar situation. There are lessons to be learnt here; for instance a standard company protocol written into an operations manual on how to behave when there are more than two aircraft arriving at an approach in instrument conditions. Doesn’t need to be complex, (a simple SOP) just a general ‘guide’ - advice if you will, to cover that rare occasion where, outside controlled airspace, in IMC there could be a conflict or distraction.

This report indicates that there was no technical appraisal made of the equipment functionality, yet the wording seems to confirm that the GPS unit was faulty: there is no published result of investigation into the GPS, the autopilot; or the GPS /auto-pilot coupling; let alone the pilot’s operating practice. RAIM fails to get a mention despite being of critical importance.

There is however much dancing around the airspace Daisies, to the point where feet get tangled and comedy becomes farce which, when aligned with the lack of Met data and no TAFOR – the report starts to look like another instance of a three year delay being used as standard top cover. ATSB knowing full well that time will dull memory and blunt interest. Except in this case, the ghosts of the Essendon tragedy are quietly awaiting their turn for a twirl around the dance floor with the ATSB Spin Meister to the tune of ‘Believe it if you like’.  

Toot -toot.

[Peetwo]

AA summary article of ATSB VH-OWN FR:

LACK OF ACCURATE POSITION REPORT BROADCASTS, INCORRECT MISSED APPROACH CONTRIBUTED TO KING AIR NEAR MISS – ATSB

written by Australianaviation.Com.Au June 29, 2018

Two Beech King Airs came within approximately 300ft vertically of each other on approach to Mount Hotham Airport as the pilot of one of the aircraft grappled with GPS and autopilot difficulties while flying in instrument meteorology conditions, an Australian Transport Safety Bureau (ATSB) final report has found.

In the September 3 2015 incident, King Air VH-OWN was found to have come within around 300ft vertically of another King Air, VH-LQR, that was also on approach to Mount Hotham Airport, which is located at 4,300ft above sea level in the Victorian alps.

The ATSB report found the pilot of VH-OWN, who was also the pilot of a King Air that crashed shortly after takeoff from Essendon Airport in February 2017, killing all five people on board, had descended the aircraft below the minimum altitude and exceeded the tracking tolerance of the approach to Mount Hotham after experiencing GPS and autopilot difficulties.

“The pilot twice climbed the aircraft without following the prescribed missed approach procedure and manoeuvred in the Mount Hotham area,” the ATSB report said.

“During this manoeuvring, the aircraft came into close proximity to another King Air, registered VH-LQR, which had commenced the same approach.”

The ATSB report said air traffic control had limited radar coverage of the area.

However, investigators sourced radar data from the Department of Defence (Defence controlled East Sale airspace lies to the south of Mount Hotham) which found VH-OWN passed 300ft below VH-LQR.

Further, the report said the actions of the pilot of VH-LQR, who stopped descent when confronted with inconsistent position information from VH-OWN, helped avoid a collision.

“After detecting inconsistencies in the position reports from the pilot of VH-OWN, the pilot of VH-LQR stopped his descent at 8,000ft,” the ATSB report said.

“As a result, the separation between the aircraft was around 300 ft, ± 150 ft, and a collision was likely avoided.”



ATSB SAYS VH-OWN PILOT EXPERIENCED HIGH WORKLOAD AND GPS/AUTOPILOT DIFFICULTIES

The ATSB report found the pilot of VH-OWN did not track via the prescribed missed approach and prescribed holding pattern when experiencing GPS/autopilot difficulties, and did not communicate this to the air traffic controller or other aircraft in the area.

“This increased the risk of a collision,” the ATSB report said.
“Due to high workload and difficulties with the operation of GPS/autopilot system, the pilot of VH-OWN did not broadcast accurate position reports, resulting in reduced separation, and a near-collision, with VH-LQR.

“The pilot’s ability to follow established tracks and accurately communicate the aircraft’s position was likely adversely affected by experiencing a high workload, due to factors including single-pilot IFR operations while conducting an area navigation (RNAV) global navigation satellite system (GNSS) approach, existing weather minimums and the reduced available flight automation.”

The ATSB report said the pilot of VH-OWN voluntarily suspended RNAV operations until he could undergo independent flight testing by the Civil Aviation Safety Authority (CASA).

“This testing by CASA then resulted in a recommendation that the pilot complete remedial training before undergoing a further flight test,” the report said.

“Following the second flight test, the pilot was deemed proficient and competent to resume operations.

“At no time during the two test flights were any anomalies with the GPS and/or autopilot recorded by either the occurrence pilot or the CASA-approved testing officers.

“CASA, however, advised that no formal testing of the aircraft or its equipment was conducted during those two flights beyond observation of functionality.”

The ATSB said in its safety message on the incident that “maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced.

“Additionally, as the responsibility for separation from other airspace users and terrain in Class G airspace lies with aircrew, it is imperative that pilots maintain the skills to navigate accurately, and interpret and utilise traffic information to maintain safe separation. “

While on the subject of O&O'd ATCB investigations and final reports, I note that yesterday HVH's minions released another 'bollocks' update to yet another Scair Asia occurrence investigation...   

The ATSB has released its preliminary investigation report into the operational non-compliance of an Airbus A320 at Perth Airport, in Western Australia, on 24 November 2017. Preliminary report:
https://www.atsb.gov.au/publications/inv...-2017-114/

---

Preliminary report published: 29 June 2018

Sequence of events

On 24 November 2017, at about 1200 Western Standard Time,[1] the crew of an Airbus A320 aircraft, registered PK-AZE and operated by AirAsia Indonesia, was being prepared to depart on a scheduled passenger service from Perth Airport, Western Australia for Denpasar (Bali) Airport, Indonesia. The captain was designated as the pilot monitoring and the first officer (FO) was designated as the pilot flying.[2]

While the captain was conducting the pre-flight walk around, the FO entered the flight plan into the flight management guidance computer (FMGC). Believing that they would be using runway 03 for take-off, as they had recently landed on this runway, he entered this into the FMGC. He then listened to the automatic terminal information service,[3] which indicated the runway-in-use was runway 21. When the captain returned to the fight deck, the FO completed the pre-flight and departures briefing using runway 03. At 1201, the crew received their clearance from air traffic control (ATC) to depart for Denpasar using the AVNEX TWO standard instrument departure (SID)[4] and to climb to 5,000 ft using the SID (Figure 1). At 1213, the crew commenced taxiing. The crew also received ATC clearances to taxi to, and line-up on runway 21, which was read back correctly by the crew.

Figure 1: AVNEX TWO standard instrument departure

Source: Naviga, modified by the ATSB

At 1220, the aircraft took off from runway 21. Shortly after take-off, the aircraft was turned left at 260 ft above mean sea level (AMSL) (Figure 2), which was contrary to the SID procedure and below the minimum safe altitude stipulated by the operator. The runway 21 SID required a right turn at or above 2,500 ft at waypoint[5] NAVEY (Figure 1) and the operator stipulated that turns should not be commenced below 400 ft above ground level.

After observing the aircraft turning left on radar, ATC re-cleared the crew onto an assigned radar heading. ATC later confirmed with the crew they were issued with the AVNEX TWO SID and asked if operations were normal. The crew reported operations normal and the aircraft was turned to intercept the flight planned route and continued to Denpasar without further incident.

Recorded data

The aircraft’s flight data recorder was downloaded and a copy was provided to the ATSB. A review of that recording found:

• 
  
• the waypoint MIDLA was the first selected waypoint in the flight management guidance computer, which was the first waypoint on the AVNEX TWO SID for runway 03 (Figure 1)
  
  
• when manually flown, the aircraft was turned left at 260 ft AMSL
  
  
• after multiple heading changes were made by the crew, waypoint SWANN was selected at 8,104 ft, which was the second waypoint on the runway 21 AVNEX TWO SID.
  

Ongoing investigation

The investigation is continuing and will consider the following:

• 
  
• operator pre-flight procedures and checklists
  
  
• crew training and qualifications
  
  
• aircraft systems.
  

This is clearly a 'something nothing' investigation, that by anyone's measure should have been discontinued (or possibly written up as a 'desktop' short investigation bulletin) well before now. 

The curious thing is this investigation update is listed as a 'preliminary report'. However we all know, that according to ICAO Annex 13, that a preliminary report should be completed and dispatched to ICAO and DIPs within 30 days of the occurrence (ref: Ch 7 para 7.4) not 7 months after the occurrence - 

Q/ Could it be we have a 'notified difference' to that requirement? 

Not according to the 11 page PDF on our NDs to Annex 13:  http://www.airservicesaustralia.com/aip/...gation.pdf

So again we have some unexplained aberration with yet another ATCB Scair Asia occurrence investigation. Coincidence? - Yeah right..  

TICK..TOCK miniscule, TICK..TOCK indeed...
        


MTF...P2 

[Peetwo]

O&O AAI: AO-2017-057

Via the Search 4 IP thread: http://www.auntypru.com/forum/thread-10-...ml#pid9447

Backlog for aviation investigators
ROBYN IRONSIDE

...As of June 30, there were 81 ongoing complex aviation investigations and 34 ongoing short ­investigations. These included more than a dozen investigations dating back more than a year, including the probe into three deaths in a Ross Air Cessna Conquest 2 crash at Renmark in South Australia, and an Angel Flight crash at Mount Gambier last June, which took three lives.

The ATSB is yet to deliver its final report on the Perth Skyshow crash that killed a pilot and his passenger on Australia Day 2017, or the in-flight engine failure on an AirAsia X A330 in June 2017....

Despite all Hoody's protestations to the contrary, it would appear that the standard top-cover methodology for the management of complex and potentially sensitive high profile aviation accident investigations is to O&O them.

Although technically not yet overdue the tragic Ross Air accident is showing all the signs of being yet another classic ATSB O&O top-cover investigation...    

However it would seem that this time the family members of the Ross Air Chief Pilot Martin Scott, who was killed in the accident, are not prepared to accept being O&O'd by the ATSB...     

Via the Adelaide Advertiser:

Family of Rossair Renmark plane crash victim wants ‘highly questionable’ training routine banned

Elizabeth Henson, The Advertiser
October 28, 2018 9:13pm

THE family of a pilot killed in the 2017 Renmark plane crash wants a training exercise they believe contributed to the accident to be banned.

Rossair chief pilot Martin Scott, 48, experienced pilot Paul Daw, 65, and Civil Aviation Safety Authority officer Stephen Guerin, 56, were on board a nine-seat Rossair aircraft when it crashed into scrubland 4km from the Renmark Aerodrome on May 30, 2017.

Mr Daw was performing an induction flight at the time of the incident.

The Australian Transport and Safety Bureau is investigating the crash and has previously revealed the Cessna Conquest plane was in the air for only 60 to 90 seconds and reached an altitude of about 150m before it plunged to the ground.

Mr Scott’s widow Terri Hutchinson, who is also a pilot, his father Joe and brother Nigel have raised concerns over a training routine they believe played a factor in the crash, saying it “should have been discontinued long ago”.

Details on the routine have not been released due to the matter still being under investigation.


Rossair chief pilot Martin Scott was killed in the Renmark crash.


Mr Scott’s widow Terri Hutchinson and son Andy with their dog Sumo. Picture: Naomi Jellicoe

In a statement issued to The Advertiser, they said it had “always been our sole purpose to ensure that lessons are learned from this (crash)”.

“We have spent considerable time and effort researching this, and similar training accidents worldwide, to attempt to come to some understanding as to why this accident occurred; and whether it could have been prevented,” they wrote.

“It seems without doubt that a major influence on this accident was the highly questionable training routine, which could and should have been discontinued long ago.

“It is our understanding that, to date, no safety notices have been issued in respect of this accident, which under the circumstances appears to be quite remarkable.”

The ATSB issues Safety Advisory Notices about incidents such as crashes to prevent recurrence.

ATSB Transport Safety Investigators at the crash site of the triple fatal Rossair plane crash near Renmark. Picture: Dylan Coker

“Sadly, it seems that apart from those directly affected by this accident, no one really seems to care. It would appear to be just another statistic for CASA, ATSB and the Australian Government to ponder on, but to do little to avoid such an accident ever happening again,” Mr Scott’s family said.

The family also expressed disappointment in the ATSB’s handling of its investigation into the crash.

“We are well aware of the issues surrounding confidentiality and ATSB’s requirement to ensure those involved are able to speak freely, without retribution, however by failing to provide us with even basic updates, we question the level of transparency and involvement which we can expect from them,” they said.

“All those concerned lost a great deal that day and it is disappointing to realise that the organisation we rely on to support us seem to be unable to deliver on their responsibilities. It is simply not good enough.”

They said they had not received regular updates on the inquiry and believed the investigation was both underfunded and under-resourced.

The ATSB had been expected to finalise its investigation into the crash in May this year however it announced at the time the report would not be ready until “early 2019.

The family said it found out “by accident” that it now may not be finalised until mid-2019.

“On raising the issue with ATSB, we were informed by the manager leading the investigation that the delay was due to the Investigator in Charge (IIC) requiring additional resources,” they said.


ATSB transport safety investigators at the crash site near Renmark. Picture: Dylan Coker

“The current IIC has been in place since April, yet only now does he consider he has insufficient staff to be able to complete the investigation within the anticipated time frame.

“There has been plenty of opportunity to ensure that sufficient personnel were in place, after all the accident occurred some 18 months ago, but clearly ATSB are simply not proactive enough for an investigation of this complexity.”

On Thursday afternoon, ATSB transport safety executive director Patrick Hornby said “the priority of the ATSB is always the thoroughness of an investigation to ensure that any safety issues are identified and addressed”.

“I regret this investigation has required additional time and I acknowledge that this can cause uncertainty for directly involved parties,” he said.

“The ATSB will continue to liaise with all directly involved parties.”

MTF...P2 

[Peetwo]

Hooded Canary's 2019 O&O investigations - Update.

Given that it is approaching February it should be safe to assume that the Hooded Canary and his minions are all back on deck. Therefore now would be a good time to start trolling through the ATSB Aviation investigation web page records to see where the higher profiled and complex O&O'd investigations are at.

Since it was the last post on here, let's start with the tragic Rossair Conquest training accident. Although the webpage lists a recent update visit - Last update 14 November 2018 -  there does not seem to be any added additional information since the prelim report - see here:  https://www.atsb.gov.au/publications/inv...-2017-057/- and the progress of the investigation is still listed as - Phase: Examination and analysis.

Examination and analysis phase

The cause of a transport safety occurrence or safety issue is often multilayered and complex. ATSB investigators aim to use the collected evidence to build a detailed understanding of the circumstances surrounding a transport safety occurrence or issue.

During this phase, evidence is reviewed and evaluated to determine its relevance, validity, credibility and relationship to other evidence and to the occurrence. ATSB investigators may:

- undertake detailed data analysis
- create simulations and reconstruct events
- examine company, vehicle, government and other records
- examine selected wreckage in the laboratory and test selected components and system
- research scientific literature related to human factors associated with the evidence
- review specialist reports (such as meteorology, component examination, post-mortem report and toxicology reports)
- conduct further interviews, and
- determine the sequence of events.

Examination and analysis requires reviewing complex sets of data, and available evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined, potentially adding to the length of an investigation.

Not sure what the hold-up could possibly be but unfortunately it is pretty safe to say that this AAI will pass by the 2nd anniversary of this tragic accident.

..On-site examination of the wreckage and surrounding ground markings indicated that the aircraft impacted terrain in a very steep (almost vertical) nose‑down attitude, and came to rest facing back towards the departure runway...

Note: While the ATSB (for whatever reasons) continues to O&O this accident, I have been informed that there are PAIN associates that are starting to ask serious questions about this accident and in particular what could have caused the aircraft to go from being in stable flight to inverted and diving near vertical from a height of 600ft AMSL.

Ref: Update 09 June 17: Byron Bailey OP.

P9 - Casa DICTATED ‘Blue line’ fever strikes again?  I know, I know, wait for the details; but this new ‘regime’ of stupidity – V2 + 10 or a nice fat sandwich of wriggle room – all gone.  When will they realise the SIM ain’t real.

10 minutes sin bin? – OK - sounds reasonable M’lud; thank you – bow – exeunt: at a good clip. .

 

There is also the rather large elephant in the sky surrounding the long standing safety issue of CASA FOI dictated procedures for EFATO/V1 cuts in the actual aircraft...think Darwin Brasilia...think Essendon DFO accident etc..etc.

Next on the O&O list another possibly partly CASA induced fatal GA accident which has just been updated with an 2nd anniversary interim statement: see - https://www.atsb.gov.au/publications/inv...-2017-013/

Updated: 25 January 2019

The investigation into the collision with water involving a Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 is continuing.

The final report has completed the drafting phase and is now undergoing an internal review.

Final ATSB investigation reports undergo a rigorous internal review process to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

Following the completion of the internal review, the report will be sent to directly involved parties for comment before the report is finalised and published.

Currently, the anticipated completion and publication date of the final report is during the first quarter of 2019.

Should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

---

Final report: Internal review
Final ATSB investigation reports undergo a rigorous internal review process to ensure the report adequately and accurately reflects the evidence collected, analysis, and agreed findings of the Safety Factor Review. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

If a review identifies any issues with a report, such as information that needs to be expanded or findings that need to be modified, investigators will look to collect new evidence or conduct additional examination and analysis of existing evidence. P2 - code for PC'ing the Final Report

Note: I have been reliably informed that there is a lot more than meets the eye and to play out with this accident investigation...     

 Finally from the Hooded Canary's top draw of high profile O&O'd accidents an update to the Birdstrike/broken tail VARA ATR accident, which saw the aircraft flying with a badly bent horizontal stabilizer for 5 days and 13 sectors after the accident flight   : https://www.atsb.gov.au/publications/inv...-2014-032/ 

Again the web page for this AAI was listed as being recently updated - Last update 20 November 2018 - . 

Final report: External review phase

To check factual accuracy and ensure natural justice, Directly Involved Parties (DIPs) are given the opportunity to comment on the final report before it is approved to ensure their input has been accurately reflected.

DIPs are individuals or organisations outside the ATSB who possess direct knowledge of the circumstances surrounding the incident or accident. DIPs can only comment on the factual accuracy of an investigation, not its analysis and findings.

This process is consistent with international transport safety investigation conventions, including those published by the International Civil Aviation Organization, International Maritime Organizationas well as the Transport Safety Investigation Act 2003. DIPs are provided from five to 28 days to provide their comment and present evidence in support of their comments. This timeframe can be extended to allow DIPs based overseas to provide comment.

Feedback from the DIPs could prompt an investigation to return to the evidence collection, examination and analysis, and report drafting phases of an investigation.

However the progress listing for the investigation seems to be eternally stuck in the 'Final report: External review' phase? Therefore, given the 4th anniversary for this accident is less than a month away, it is highly likely this AAI will go well into it's 4th year of being dormant but active at the same time - UDB!   



MTF...P2  

Ps P2 comment - When you consider that all three of the above investigations have passed (or shortly will pass) their 2 year anniversaries, kind of makes the bollocks, blame the pilot at all costs, YMEN DFO complex investigation final report an aberration and very, very suspect...

[Gobbledock]

P2;

However the progress listing for the investigation seems to be eternally stuck in the 'Final report: External review' phase? Therefore, given the 4th anniversary for this accident is less than a month away, it is highly likely this AAI will go well into it's 4th year of being dormant but active at the same time - UDB! Dodgy

By the time this investigation is closed the only ATR’s you will see will be in an aviation museum in the year 2079. That will be the same year the regulatory reform program will be finally completed and the only aircraft in existence will be pilotless drone style aircraft which use magnetic fields as their power source! Oh, and CAsA will have been rebranded several times, usually to coincide with each major air disaster on Australian soil.

I’m glad I won’t be here....

[Kharon]

Is this

“Sadly, it seems that apart from those directly affected by this accident, no one really seems to care. It would appear to be just another statistic for CASA, ATSB and the Australian Government to ponder on, but to do little to avoid such an accident ever happening again,” Mr Scott’s family said.

Very, very un-Australian Minister?

News Flash – it ain’t; it has become the ‘norm’ along with much other pony-pooh associated with government ‘responsibility’ for public safety. Lot’s of ‘genuine’ talk – little in the way of genuine improvement or even accountable investigation. But, I’m so glad you could interrupt a busy schedule to talk to the Essendon 4 – cup of coffee and a reassurance chat. All will be well, never fear, the man from Wagga-Wagga is here. Ah, the words of a genuine honest man; most reassuring. Bet the local kids could write a load of poems about that, to satisfy your desire for poetical, lyrical twiddles, writ by the local kids. You can give 'em an apple as a token of appreciation - then pray they do not go shopping with Mum in a DFO near you. Bloody Muppet.

On the blotter are several fatal accidents - arguably the direct responsibility of CASA' decisions and edicts. Not that you would understand the complex arguments - but; rest assured, the professional aviation world does. No matter, despite your excellent 'advice' on matters aeronautical to the contrary - those incidents will be examined by 'expert' eyes and a full report forwarded to the Senate RRAT committee in time for the election. The 'press' may even get a look-see before that. Won't that be fun?

P7 reckons you need to fix this, before it fixes your lack-luster 'career'  as a transport minuscule for ever. Albo is panting for the 'report' -I do wonder why though? Anyway......

Toot - (with a very Australian - Up your'es)  - Toot.

[Peetwo]

O&O AAI: AO-2017-057 - UPDATE

Ref:

Interesting legislation which came out a year after the Rossair crash in which CASA were testing the chief pilot for check and training and the chief pilot was checking an inductee pilot. Which comes first - the chicken or the egg?
https://www.legislation.gov.au/Details/F...ntrol+seat

Via the Adelaide Advertiser: https://www.adelaidenow.com.au/news/sout...405eabe119

Widow Terri Hutchinson says ATSB has treated families of pilots killed in Renmark Rossair crash as ‘worthless entities’



The family of a pilot killed in a plane crash near Renmark says her family has been treated like “worthless entities” by the aviation safety watchdog investigating the incident.


The comments come as the Australian Transport Safety Bureau (ATSB) confirmed the estimated release date for the report into the crash which killed three experienced pilots had been pushed back another six months.

Terri Hutchinson, the widow of Rossair chief pilot Martin Scott, said the ongoing delays and the justifications made by the ATSB were meant to placate the families of the dead pilots.

Mr Scott, 48, was alongside experienced pilot Paul Daw, 65, and Civil Aviation Safety Authority officer Stephen Guerin, 56, in a nine-seat Rossair aircraft when it crashed into scrubland 4km from Renmark Aerodrome on May 30, 2017.

The pilots were completing an evaluation flight for Mr Daw who was planning to join the ranks of Rossair.

The plane was only in the air between 60 and 90 seconds before plummeting into the ground nose first, killing all three occupants on impact.

“To say that I am more than disappointed would be a huge understatement,” Ms Hutchinson told The Advertiser.

“In my opinion, this investigation has been flawed from the outset.”

Mrs Hutchinson said the ATSB had “not bothered to tell those involved” that the publication of the report had been pushed back.

“In fact, the last push-back came after I received an email from the Chief Commissioner of the ATSB saying they would take ‘extra care to keep me informed’.

“That is clearly rubbish and I must say, the latest development has made it seem as though those who lost so much that day are treated as worthless entities.

“To date, Martin’s father and I have been advised that we would receive a draft copy of the final report one month prior to public release.

“(In an email received earlier this week) they have now said that there could be a ‘number of months’ in between the draft report and the final publication.

An ATSB spokesman confirmed the final report is expected to be published in the final quarter of 2019 — more than double the 12 month target for air crash investigations.

“It is important to note that investigations are complex and dynamic, and the priority of the ATSB is always the thoroughness of an investigation to ensure that any systemic safety issues are identified and addressed,” he said.

“This means that complex investigations can take longer, if necessary, in order to ensure a robust investigation with the appropriate third party input and reviews.

“Should a critical safety issue be identified during the course of any investigation, the ATSB immediately notifies relevant parties to ensure safety action is taken.”

MTF...P2 

[Choppagirl]

A recent article in the Adelaide Advertiser is titled '649 days after plane tragedy, fiancee still seeks answers'. I think that speaks for itself!

As the widow of one of the pilots killed I have maintained a high level of interest in this investigation. The ATSB have made it quite clear that outside involvement is most unwelcome on every level. At the beginning of this investigation I was free to communicate directly with the investigator in charge however he resigned, effective immediately, in April 2018. Since then, despite repeated requests, ATSB have resolutely refused to allow us to know the name of the person investigating this accident. Why should this be the case? Surely, having lost so much, I am entitled to know who is investigating the crash which left a little boy without his Daddy?

http://web.mit.edu/~alo/www/Papers/ntsb17.pdf

Perhaps ATSB should be looking at the NTSB model?

[Kharon]

CG - "Perhaps ATSB should be looking at the NTSB model?

Spend a little time - HERE - withe the ANAO report into ATSB. The devil in in the detail.

[Peetwo]

A recent article in the Adelaide Advertiser is titled '649 days after plane tragedy, fiancee still seeks answers'. I think that speaks for itself!

As the widow of one of the pilots killed I have maintained a high level of interest in this investigation. The ATSB have made it quite clear that outside involvement is most unwelcome on every level. At the beginning of this investigation I was free to communicate directly with the investigator in charge however he resigned, effective immediately, in April 2018. Since then, despite repeated requests, ATSB have resolutely refused to allow us to know the name of the person investigating this accident. Why should this be the case? Surely, having lost so much, I am entitled to know who is investigating the crash which left a little boy without his Daddy?

http://web.mit.edu/~alo/www/Papers/ntsb17.pdf

Perhaps ATSB should be looking at the NTSB model?

CG - "Perhaps ATSB should be looking at the NTSB model?

Spend a little time - HERE - withe the ANAO report into ATSB. The devil in in the detail.

In follow up to the "K" link please refer: ANAO wet lettuce report? - Not a good look for the Hooded Canary.

And from the "Government News" blog: https://www.governmentnews.com.au/nation...g-mid-air/

TRANSPORT Judy Skatssoon

Transport safety investigations stall

14 March, 2019



The ATSB is getting less efficient at investigating accidents and incidents, an audit has found.


The national transport safety agency is getting less efficient at investigating accidents and safety incidents as it  battles to reduce a backlog of cases, an audit has found.

The time taken and resources needed by the Australian Transport Safety Bureau (ATSB) to complete investigations “have increased significantly over the last five years,” according to a  report  by the Australian National Audit Office  (ANAO) tabled on Thursday.

“The efficiency with which the ATSB investigates transport accidents and safety occurrences has been declining … both in relation to the length of time taken to complete investigations, and the amount of investigation resources required,” it found.

The report found that the time taken on “short” investigations increased from an average of 131 days before 2018 to 236 days over the first six months of that year. “Complex” investigations meanwhile were taking nearly three years to complete in the first half of 2018 – more than twice as long as  in 2016.

The ANAO recommended that the ATSB does more to ensure short investigations are completed quickly, reviews its use of resources and sets more realistic investigation deadlines.

The report also notes that the reputation of the agency took a hit after it was criticised for a three year delay in investigating the ditching of an aircraft carrying a seriously ill patient off Norfolk Island in 2009, when it was forced to reopen the investigation after pressure from a senate inquiry.

“Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation,” the report states.
In 2017-18, 6,350 incidents came under consideration for investigation by the ATSB and by November last year it had 122 ongoing investigations. Since then, the agency has attempted to reduce the number of ongoing investigations and take on fewer new ones.

The auditor’s office said the ATSB receives an average of more than 15,000 notifications of incidents and accidents a year but the trend has been steadily increasing since 2010. It noted that Australia hasn’t experienced “a major catastrophic event” that has required a major investigation.

Improving efficiency

The ATSB has acknowledged the findings and says it was already working to improve efficiency before the audit, and has since been applying a project management approach to investigations.

“The ATSB will soon release a varied corporate plan with more suitable key performance indicators for timeliness and demand/capacity,” it added.

Funding for the ATSB, a Commonwealth body established in 2003 to improve safety and public confidence in air, sea and rail transportation, was increased by $11.9 million over five years in the 2017 budget to boost its workforce and meet technical and data needs.

And from the ANAO report itself, too which GN refers:

What controls does the ATSB have in place to assure itself that improvements in efficiency do not compromise the quality of its investigations?

The ATSB has had quality controls and processes in place, however they have not been conducive to the timely completion and review of investigations. Since 2017, the ATSB has implemented key review points earlier in the investigations process. As a result, the ATSB has identified improvements in quality and a reduction in the amount of rework required through the various review stages.

2.50 The ATSB was criticised for its investigation report into the 2009 ditching of an aircraft off Norfolk Island17, due to its delay (nearly three years after the accident) plus the lack of detailed analysis and useful recommendations for avoiding future incidents and accidents. Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation. Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible.

2.51 The ATSB has identified that its workflow processes have not been conducive to the timely completion and review of investigations and associated safety activities. The workflow processes incorporated high levels of quality control during the draft report review phase, but contained limited quality assurance measures within the earlier investigation phases.19 In May 2017, in an Executive Paper, the ATSB acknowledged that its own investigation workflow processes and practices had directly contributed to its output timeliness issues, principally due to extensive review and rework requirements which were necessary to ensure that a quality report was released.

2.52 Since the broader organisational change initiatives in 2017, and in particular through the SIRF project, there have been major changes to the workflow processes for ATSB investigations. This has seen the increase in controls within the review process where there are multiple layers of review to gain the required level of quality assurance to release an investigation report. The improved workflow process for stages of an investigation currently include:

• planning meetings to ensure appropriate scope and resources;
  
  
• required analysis processes;
  
  
• safety factor reviews with managers and directors;
  
  
• safety factor executive briefs;
  
  
• technical review of reports;
  
  
• administrative reviews;
  
  
• director reviews;
  
  
• Commission reviews; and
  
  
• external reviews.
  
  
  

2.53 The ATSB advised the ANAO in October 2018 that since these processes have been introduced, and although in the early stages of implementation and application to current investigations, there has been notable improvements in quality and a reduction in the amount of rework required through the various review stages.

2.54 The ATSB further advised the ANAO in October 2018 that it is committed to looking for improvements across the range of investigatory processes and practices to improve efficiency, transparency and to better enable management decisions. As part of the work being undertaken to introduce a program managed approach to investigations, there is also a planned focus on strengthening the assurance processes that support the investigation process. For example, the ATSB is planning to establish an Investigation Review Board to more closely manage quality, risk mitigation and delivery issues.

"..Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible..."

TSBC peer review references: PelAir - 'Lest we forget' Part III & [b]How things have changed? NOT!  [/b]

In December this year will mark five years since the TSBC peer review report and recommendations were released for public consumption: http://www.bst-tsb.gc.ca/eng/coll/2014/A...141201.asp 

Recommendations
The TSB Review is making 14 recommendations to the ATSB in four main areas:

• Ensuring the consistent application of existing methodologies and processes
  
  
• Improving investigation methodologies and processes where they were found to have deficiencies
  
  
• Improving the oversight and governance of investigations
  
  
• Managing communications challenges more effectively.
  

Recommendation #1: Given that the ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, the ATSB should continue efforts to ensure the consistent application and use of its methodology and tools.
Recommendation #2: The ATSB should consider adding mechanisms to its review process to ensure there is a response to each comment made by a reviewer, and that there is a second-level review to verify that the response addresses the comment adequately.
Recommendation #3: The ATSB should augment its DIP process to ensure the Commission is satisfied that each comment has been adequately addressed, and that a response describing actions taken by the ATSB is provided to the person who submitted it.
Recommendation #4: The ATSB should review its risk assessment methodology and the use of risk labels to ensure that risks are appropriately described, and that the use of the labels is not diverting attention away from mitigating the unsafe conditions identified in the investigation.
Recommendation #5: The ATSB should review its investigation schedules for the completion of various levels of investigation to ensure that realistic timelines are communicated to stakeholders.
Recommendation #6: The ATSB should take steps to ensure that a systematic, iterative, team approach to analysis is used in all investigations.
Recommendation #7: The ATSB should provide investigators with a specific tool to assist with the collection and analysis of data in the area of sleep-related fatigue.
Recommendation #8: The ATSB should review the quality assurance measures adopted by the new team leaders and incorporate them in SIQS to ensure that their continued use is not dependent on the initiative of specific individuals.
Recommendation #9: The ATSB should modify the Commission report review process so that the Commission sees the report at a point in the investigation when deficiencies can be addressed, and the Commission's feedback is clearly communicated to staff and systematically addressed.
Recommendation #10: The ATSB should undertake a review of the structure, role, and responsibilities of its Commission with a view to ensuring clearer accountability for timely and effective oversight of the ATSB's investigations and reports.
Recommendation #11: The ATSB should adjust the critical investigation review procedures to ensure that the process for making and documenting decisions about investigation scope and direction is clearly communicated and consistently applied.
Recommendation #12: The ATSB should take steps to ensure closure briefings are conducted for all investigations.
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Recommendation #14: The ATSB should implement a process to ensure that communications staff identify any issues or controversy that might arise when a report is released, and develop a suitable communications plan to address them.

Much like the Hooded Canary's commitment (pic above) to address the ANAO recommendations, Beaker made similar commitment to address the TSBC recommendations. However the overwhelming evidence from the ANAO report and the handling of several high profile investigations since (including the Rossair investigation), would point towards blatant disregard and mere lipservice by the HC's regime in regard to independent and peer review findings/recommendations. So why should industry stakeholders and the many concerned DIPs/NOK put any faith in the hollow words of the Hooded Canary et.al in promising to address properly and transparently the ANAO recommendations and DIP/NOK concerns?

MTF...P2 

[Choppagirl]

A recent article in the Adelaide Advertiser is titled '649 days after plane tragedy, fiancee still seeks answers'. I think that speaks for itself!

As the widow of one of the pilots killed I have maintained a high level of interest in this investigation. The ATSB have made it quite clear that outside involvement is most unwelcome on every level. At the beginning of this investigation I was free to communicate directly with the investigator in charge however he resigned, effective immediately, in April 2018. Since then, despite repeated requests, ATSB have resolutely refused to allow us to know the name of the person investigating this accident. Why should this be the case? Surely, having lost so much, I am entitled to know who is investigating the crash which left a little boy without his Daddy?

http://web.mit.edu/~alo/www/Papers/ntsb17.pdf

Perhaps ATSB should be looking at the NTSB model?

CG - "Perhaps ATSB should be looking at the NTSB model?

Spend a little time - HERE - withe the ANAO report into ATSB. The devil in in the detail.

In follow up to the "K" link please refer: ANAO wet lettuce report? - Not a good look for the Hooded Canary.

And from the "Government News" blog: https://www.governmentnews.com.au/nation...g-mid-air/

TRANSPORT Judy Skatssoon

Transport safety investigations stall

14 March, 2019



The ATSB is getting less efficient at investigating accidents and incidents, an audit has found.


The national transport safety agency is getting less efficient at investigating accidents and safety incidents as it  battles to reduce a backlog of cases, an audit has found.

The time taken and resources needed by the Australian Transport Safety Bureau (ATSB) to complete investigations “have increased significantly over the last five years,” according to a  report  by the Australian National Audit Office  (ANAO) tabled on Thursday.

“The efficiency with which the ATSB investigates transport accidents and safety occurrences has been declining … both in relation to the length of time taken to complete investigations, and the amount of investigation resources required,” it found.

The report found that the time taken on “short” investigations increased from an average of 131 days before 2018 to 236 days over the first six months of that year. “Complex” investigations meanwhile were taking nearly three years to complete in the first half of 2018 – more than twice as long as  in 2016.

The ANAO recommended that the ATSB does more to ensure short investigations are completed quickly, reviews its use of resources and sets more realistic investigation deadlines.

The report also notes that the reputation of the agency took a hit after it was criticised for a three year delay in investigating the ditching of an aircraft carrying a seriously ill patient off Norfolk Island in 2009, when it was forced to reopen the investigation after pressure from a senate inquiry.

“Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation,” the report states.
In 2017-18, 6,350 incidents came under consideration for investigation by the ATSB and by November last year it had 122 ongoing investigations. Since then, the agency has attempted to reduce the number of ongoing investigations and take on fewer new ones.

The auditor’s office said the ATSB receives an average of more than 15,000 notifications of incidents and accidents a year but the trend has been steadily increasing since 2010. It noted that Australia hasn’t experienced “a major catastrophic event” that has required a major investigation.

Improving efficiency

The ATSB has acknowledged the findings and says it was already working to improve efficiency before the audit, and has since been applying a project management approach to investigations.

“The ATSB will soon release a varied corporate plan with more suitable key performance indicators for timeliness and demand/capacity,” it added.

Funding for the ATSB, a Commonwealth body established in 2003 to improve safety and public confidence in air, sea and rail transportation, was increased by $11.9 million over five years in the 2017 budget to boost its workforce and meet technical and data needs.

And from the ANAO report itself, too which GN refers:

What controls does the ATSB have in place to assure itself that improvements in efficiency do not compromise the quality of its investigations?

The ATSB has had quality controls and processes in place, however they have not been conducive to the timely completion and review of investigations. Since 2017, the ATSB has implemented key review points earlier in the investigations process. As a result, the ATSB has identified improvements in quality and a reduction in the amount of rework required through the various review stages.

2.50 The ATSB was criticised for its investigation report into the 2009 ditching of an aircraft off Norfolk Island17, due to its delay (nearly three years after the accident) plus the lack of detailed analysis and useful recommendations for avoiding future incidents and accidents. Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation. Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible.

2.51 The ATSB has identified that its workflow processes have not been conducive to the timely completion and review of investigations and associated safety activities. The workflow processes incorporated high levels of quality control during the draft report review phase, but contained limited quality assurance measures within the earlier investigation phases.19 In May 2017, in an Executive Paper, the ATSB acknowledged that its own investigation workflow processes and practices had directly contributed to its output timeliness issues, principally due to extensive review and rework requirements which were necessary to ensure that a quality report was released.

2.52 Since the broader organisational change initiatives in 2017, and in particular through the SIRF project, there have been major changes to the workflow processes for ATSB investigations. This has seen the increase in controls within the review process where there are multiple layers of review to gain the required level of quality assurance to release an investigation report. The improved workflow process for stages of an investigation currently include:

• planning meetings to ensure appropriate scope and resources;
  
  
• required analysis processes;
  
  
• safety factor reviews with managers and directors;
  
  
• safety factor executive briefs;
  
  
• technical review of reports;
  
  
• administrative reviews;
  
  
• director reviews;
  
  
• Commission reviews; and
  
  
• external reviews.
  
  
  

2.53 The ATSB advised the ANAO in October 2018 that since these processes have been introduced, and although in the early stages of implementation and application to current investigations, there has been notable improvements in quality and a reduction in the amount of rework required through the various review stages.

2.54 The ATSB further advised the ANAO in October 2018 that it is committed to looking for improvements across the range of investigatory processes and practices to improve efficiency, transparency and to better enable management decisions. As part of the work being undertaken to introduce a program managed approach to investigations, there is also a planned focus on strengthening the assurance processes that support the investigation process. For example, the ATSB is planning to establish an Investigation Review Board to more closely manage quality, risk mitigation and delivery issues.

"..Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible..."

TSBC peer review references: PelAir - 'Lest we forget' Part III & [b]How things have changed? NOT!  [/b]

In December this year will mark five years since the TSBC peer review report and recommendations were released for public consumption: http://www.bst-tsb.gc.ca/eng/coll/2014/A...141201.asp 

Recommendations
The TSB Review is making 14 recommendations to the ATSB in four main areas:

• Ensuring the consistent application of existing methodologies and processes
  
  
• Improving investigation methodologies and processes where they were found to have deficiencies
  
  
• Improving the oversight and governance of investigations
  
  
• Managing communications challenges more effectively.
  

Recommendation #1: Given that the ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, the ATSB should continue efforts to ensure the consistent application and use of its methodology and tools.
Recommendation #2: The ATSB should consider adding mechanisms to its review process to ensure there is a response to each comment made by a reviewer, and that there is a second-level review to verify that the response addresses the comment adequately.
Recommendation #3: The ATSB should augment its DIP process to ensure the Commission is satisfied that each comment has been adequately addressed, and that a response describing actions taken by the ATSB is provided to the person who submitted it.
Recommendation #4: The ATSB should review its risk assessment methodology and the use of risk labels to ensure that risks are appropriately described, and that the use of the labels is not diverting attention away from mitigating the unsafe conditions identified in the investigation.
Recommendation #5: The ATSB should review its investigation schedules for the completion of various levels of investigation to ensure that realistic timelines are communicated to stakeholders.
Recommendation #6: The ATSB should take steps to ensure that a systematic, iterative, team approach to analysis is used in all investigations.
Recommendation #7: The ATSB should provide investigators with a specific tool to assist with the collection and analysis of data in the area of sleep-related fatigue.
Recommendation #8: The ATSB should review the quality assurance measures adopted by the new team leaders and incorporate them in SIQS to ensure that their continued use is not dependent on the initiative of specific individuals.
Recommendation #9: The ATSB should modify the Commission report review process so that the Commission sees the report at a point in the investigation when deficiencies can be addressed, and the Commission's feedback is clearly communicated to staff and systematically addressed.
Recommendation #10: The ATSB should undertake a review of the structure, role, and responsibilities of its Commission with a view to ensuring clearer accountability for timely and effective oversight of the ATSB's investigations and reports.
Recommendation #11: The ATSB should adjust the critical investigation review procedures to ensure that the process for making and documenting decisions about investigation scope and direction is clearly communicated and consistently applied.
Recommendation #12: The ATSB should take steps to ensure closure briefings are conducted for all investigations.
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Recommendation #14: The ATSB should implement a process to ensure that communications staff identify any issues or controversy that might arise when a report is released, and develop a suitable communications plan to address them.

Much like the Hooded Canary's commitment (pic above) to address the ANAO recommendations, Beaker made similar commitment to address the TSBC recommendations. However the overwhelming evidence from the ANAO report and the handling of several high profile investigations since (including the Rossair investigation), would point towards blatant disregard and mere lipservice by the HC's regime in regard to independent and peer review findings/recommendations. So why should industry stakeholders and the many concerned DIPs/NOK put any faith in the hollow words of the Hooded Canary et.al in promising to address properly and transparently the ANAO recommendations and DIP/NOK concerns?

MTF...P2 

Well, as a DIP, along with my father in law, we have absolutely no faith whatsoever. It's so disheartening.

[Kharon]

A twiddle - for wont of better.

You can readily understand the pain and fury of Choppagirl; we’ve seen it before; far too often for my liking. A while back, after one of the ‘big’ events reports was declared a total waste of time, a few of us started to discuss the ATSB performance. Not stellar – not since Lockhart River; something changed about then, or shortly thereafter. The romantic in me wants to say ‘heartbroken’, the realist wants to scream – ‘Ducked over’ by experts. The ATSB tried hard with the Lockhart accident, in fact it was about the last accident they seemed to put a big effort into. Any comparison between Lockhart and Pel-Air clearly defined the downward spiral; chalk and cheese.

Then we had the Dolan era and the infamous ‘Memorandums of Understanding’. Which served to make it clearly understood that ATSB should mind its manners and fall in line with the big guns. And, no surprise – it did. We were not too concerned with all that; what intrigued us all as much then as it does today is the ‘why’ of it all. Several good ideas were put forward, we occasionally drag ‘em out, much as medical student would do with a cadaver to refresh a new idea. Of course we get nowhere, except the routine anger remerges and the routine condemnation and cursing continues. We did however come up with some food for thought; for instance:-

a) Government (as in whatever clown is put up as minister) is quite convinced that Australia is he safest aviation nation ever. This ain’t true of course; but the minister of the day wants to believe it and is spoon fed, by his 'advice'  ‘facts’ to support this notion. It also helps that since the Seaview accident, heaven and a goodly chunk of Hell has been moved to ensure, categorically and absolutely that no minister will be held responsible for aviation safety. The system ensures remoteness from blame and credible deniability. Provided the budget is approved and the ministerial hands are clean – all is rosy.

b) ATSB and CASA were, about the time of Lockhart on an even footing. ATSB could and did point the finger at CASA and asked them to clean up their act. The Staunton report, after Seaview tried to do this – it backfired – then there was Millar; who’s logic was transmogrified into the twisted interpretation of MoU etc. CASA gained the ascendency, the political clout, the money and elevated themselves to almost god like status. – Aided and abetted by the DoIT they captured minister after minister; until it became accepted as ‘the norm’.

c) ATSB hit rock bottom when Dolan ran the shop. Any pissing competition between Dolan and McConvict could be equated to a mouse taking on a lion. Not mind you that Dolan would contemplate such a barny. CASA wanted to rule – Dolan had even less backbone than he had idea of what the ATSB should be; or, what it’s real role was. The hapless, infamous 'Beaker' known universally as the Uriah Heep of accident investigation, readily acquiesced. The rest = history.

There’s more, but you get the drift. Only idle speculation over a beer in the pub of course; but one of our research guru’s reckons this is all reflected in the ‘quality’ of ATSB reports; the lack of ‘sparkle’, the clear ring of truth muffled and the endless obfuscation all reflect an operation with a very low morale level, the courage beaten out of ‘em and low self esteem.

Which leaves us with a demoralised accident investigator, being run by Hi-Viz Hood – the caged Canary; who despite his love for ‘courage’ wrist straps seems to lack this essential element. Go along to get along; time will pass the bank balance grows and if the world and it’s wife thinks the ATSB is a second rate outfit – who cares; except those left behind, wondering what happened, why and how to prevent a reoccurrence.

That is as close to an explanation as I can put together Choppagirl. The thoughts, speculations and ramblings of a bunch of miscreants who despair of the ATSB decline into insignificance. We all (bar P2) stopped reading their musings a while ago now. Life is too short.

Toot – coffee - now – toot.  (Fast type).

[Choppagirl]

Thanks Kharon. There certainly does appear to be a word missing from the Australian Dictionary - ACCOUNTABILITY. I've looked hard but it is nowhere to be seen.

[Gobbledock]

ACCOUNTABILITY, THE FORBIDDEN FRUIT

Choppagirl, you mention a word that makes every Pollywaffler shudder, run for cover, hide behind their loyal spin doctors, contact legal, and speak in tongues, riddles and shanty’s - ACCOUNTABILITY.

For our Pollywafflers and their bureaucrats, minions and footstools, these silk suit wearing obsfucating guru’s of peddling Pooh laugh at the notion of being accountable. Why? They are slime... Lying, deceiving, selfish, disgusting conscienceless sociopaths. They do not promulgate fairness, justice or moral correctness. They care not about you or I, Choppagirl, never have and never will. But we trudge along, occasionally scoring a minor win, heating up their kitchen a little bit and living the dream that one day justice will prevail. It’s a small hope, a dream of sorts, dare I say even a fantasy, but one that we hope will come true.

So for now, this Dorothy is putting away his slip on shoes as all that heel clicking is achieving nought. The Styx River beckons as the waters are calm and their are many political fish on the bite after the full moon. I will have to beg the Captain to let me take the Houseboat for a spin and to try and catch one or two. I’m not greedy, just want to catch enough to satisfy myself and Choppagirl...... please Captain?

[Choppagirl]

Unfortunately, I have little faith that your fishing trip will satisfy me but good luck to you.

Who are CASA and ATSB accountable to? The Minister for Infrastructure? How much aviation knowledge would he acquire during his inevitably short reign in politics?

[Sandy Reith]

Labor Minister for Transport A. Albanese did the independent regulator transformation on the ATSB, 2009 I think, and therefore, like CASA, it lost the political imperatives and incentives that come with direct Departmental responsibility. Mr. Albanese was very clear in his reasoning to divest the Government, himself and Cabinet of the responsible oversight of ATSB. He claimed that it should be above politics and the change went through Parliament with barely a whisper of doubt from anyone as far as I remember.

It is some 30 years since CASA was afforded this independent status. Two important factors occur when this change is made.

Firstly, as Bill Hamilton pointed out to me many years ago, as a statutory body CASA can be sued, a Department cannot. Therefore CASA goes to great lengths to cover itself, the consequences of that process, the near destruction of what was a vibrant industry, is all too clear.

Secondly, the new structure lent itself to a large increase in salaries on the basis that they needed to pay commercial rates by virtue of being a corporation.

And so we have the incongruous situation that the fatuously titled Director of Air Safety (CASA CEO) is paid considerably more than his Minister.

What has happened without any debate is Parliament ridding itself of responsibility and accountability  in these two areas and many others. Our democracy is being undermined with the totally misguided concept that government can outsource to an independent corporation who will have only the highest motives to act in the public interest, but to act without having the public involved. Of course it doesn’t make sense. No wonder the public have little faith in politicians because through the millions of individual interactions with government instrumentalities its plain that the bureaucracies have the upper hand. The trend of population growth in Canberra is one measure, with Queanbeyan now 450,000 and at last count the Commonwealth runs over 1200 instrumentalities. Canberra remuneration is 40% higher than the the average for the remainder of Australia.

[Choppagirl]

If they are all getting paid so much, how come the ATSB had such a huge attrition rate last year? Why are all the investigators leaving?

[Kharon]

CG - Check your PM.  Let me answer your question – with a question. Pretend you are a ‘tin-kicker’ a qualified, trained professional with integrity. Then, one day when you are investigating a nasty fatal, accident you are provided with evidence which is part of a causal chain. Say that evidence, in report form, had been provided a twelve month prior to the accident – warning that this accident was inevitable unless things changed. Let’s say you subpoena that report and then get told to bury it – then what would you do?

Pretend that sort of thing happened to you personally a couple of times and over a beer with a colleague or two you discovered that they too had been ‘talked to’. Then what?

Or, suppose you wrote a very good, in depth report into an accident which ended up in front of a Senate committee and found that the report was played down? Then what?

Many believe that ASA, ATSB and the CASA should report and be directly responsible to the Senate. Of all the three agencies, the ATSB is of crucial importance. Accidents happen, how to prevent a reoccurrence is of great importance; how else are we to reduce the accident rate?

ATSB is shadow of its former self; been in decline for years and still leading the race to the bottom. No matter a Hi-Viz vest is the solution to safety matters – unless you live and work in France; where a ‘courage’ wrist strap may protect you. Right?

[Sandy Reith]

Choppergirl asks why are staff leaving ATSB? I certainly don’t know the answer, but I wouldn’t be surprised if the higher salaries are more pronounced in the higher echelons of management. Otherwise after the embarrassments of Pelair and MH370 perhaps some investigators would be looking for more professional opportunities.

[Choppagirl]

At the beginning of the Rossair investigation I was able to communicate freely with the investigator in charge. I then received an email from him to say that he was resigning his position, effective immediately. It certainly was effective immediately. His mobile phone was disconnected the same day and emails bounced back. To date we have never been allowed to know who the new investigator is and we have been given no reason other than to 'let them do their job'.