[Kharon]

PAIN is a funny old thing to be mixed up with, great fun but it's the scratching of my curiosity itch which keeps me at it.  That's why the Bar Room Barristers (BRB) indaba are important; puzzles, riddles and conundrums are all fair game.  It's not often we have a full dress pow-wow, but there is one coming up, darts and lampshades verboten (Thorny), until later.  My turn to write the agenda and I'm spoiled for choice; major accidents are off the menu due to a shortage of 'hard' data.  The 'cruise conversations' have dried up, leaving only carefully nurtured 'pet theory' behind and a fair amount of beers being bet; and, pay up night is always a next day off event.  So to the menu:-


Senate Estimates.  The estimates today are considered a 'crucial' yardstick.  

1) It has been almost two years since the Pel Air recommendations were published by a furious committee which lambasted Merdek, his department, the CASA and ATSB and yet nothing has changed; not on the surface anyway.  We shall see tonight whether Xenophon has, as is rumoured, turned away from the aviation soap box, focussing now on power and glory.  It would be a sad thing if true, but the pragmatists are betting that way.

2) The monopolistic, profitable Quango ASA provider of air traffic services got a fair old flogging last round, dodgy doings with large lumps of (AAFRS) money, holidays paid for under the guise of 'training courses and several other unsavoury matters, all of which demanded answers to written question.  The answers have been grossly delayed by Merdek and, as the committee was 'fairly cross' about this game last time around, no doubt they will displeased with a what? an eight week delay.  Heff is Chair and he did make mention of this tiresome game last time. 

Then of course there is the great credit card rort to deal with.  Much mystery surrounds one case which Stabbed in the Dark (Staib) insisted be dealt with in camera (sub rosa).  The problem is, despite trying to keep a lid on the worst kept secret, that the answers provided were 'disingenuous'.   Hells bells, the world and it's wife knows the story; remember the Purcell ditty "Nymphs and Shepherds come away" well, transpose those words to "lawyers and firemen play all day" and you'll get the picture.  The Navy is miffed, the credit card auditors are going nuts and because of the unholy mess left behind by previous and existing 'high rollers' the Senators are all over it.  Could be fun. 

3) We will be interested to see if the payments made, sorry, donations to political parties surfaces.  It is a matter which needs to be attended to, if anyone ever joins the dots and follows the money trail from when Ansett went down and took it's two feeder airlines out with it, there will political embarrassment all around.  Then what will Singapore say over G&T in the Iron Bar??: well, I'll leave that up to your imagination.  Political mutual benefit is an old notion; but where does the undue influence line get drawn?  Anyway – it's up for BRB discussion.  Betting is the Senate won't touch it.

4) The appointment of Manning to ATSB may assist Be-a-Cur step around the Merde, certainly a useful delaying tactic, time to settle the new boy into school.  It will be intersting to see how the Senators treat this as it will signpost their intentions.  Soft line and no more Heff thundering at his famous man at the back of the room; or will we get some sound, tinged with fury from the panel.  Time will tell.

5) It's Mark Skidmores' first rodeo and that will tell us a tale.  It will be of great interest to see who's there, who sits where and the body language will tell a better story than the rhetoric.  If rumour is true; the Farq-u-hardson school of McComical embuggerance has declared war on the Skidmore boys.  A classic white hat v black hat shoot out.  The body count and score card will matter a great deal to aviation in this country.  If you do nothing else tomorrow, try and watch the Hansard video for it will tell you if we are indeed ducked for all money or; can struggle on to fly another day.  Do not; not ever, allow the price of land for development to be far from your thoughts.  Watch carefully children.

That's enough PAIN secrets for one day; I expect there will be more tomorrow.  Aunt Pru takes an interest in such matters; and, as we must pay our rent we need to earn our humble corn.  MTF? probably.

Music to muse by.

Toot toot... ..

[slats11]

Talking of those one-off political donations.......

Check out Q 1a on top of page 2 of this disclosure return.

http://periodicdisclosures.aec.gov.au/Re.../RINU3.pdf

“Do you operate or conduct business under any other names?"

These donations were made in the name of Rex.

Given ATSB was conducting investigation of PelAir at the time, should Rex have answered Yes to this question and declared they also operated as PelAir?

Slats

PAIN is a funny old thing to be mixed up with, great fun but it's the scratching of my curiosity itch which keeps me at it.  That's why the Bar Room Barristers (BRB) indaba are important; puzzles, riddles and conundrums are all fair game.  It's not often we have a full dress pow-wow, but there is one coming up, darts and lampshades verboten (Thorny), until later.  My turn to write the agenda and I'm spoiled for choice; major accidents are off the menu due to a shortage of 'hard' data.  The 'cruise conversations' have dried up, leaving only carefully nurtured 'pet theory' behind and a fair amount of beers being bet; and, pay up night is always a next day off event.  So to the menu:-


Senate Estimates.  The estimates today are considered a 'crucial' yardstick.  

1) It has been almost two years since the Pel Air recommendations were published by a furious committee which lambasted Merdek, his department, the CASA and ATSB and yet nothing has changed; not on the surface anyway.  We shall see tonight whether Xenophon has, as is rumoured, turned away from the aviation soap box, focussing now on power and glory.  It would be a sad thing if true, but the pragmatists are betting that way.

2) The monopolistic, profitable Quango ASA provider of air traffic services got a fair old flogging last round, dodgy doings with large lumps of (AAFRS) money, holidays paid for under the guise of 'training courses and several other unsavoury matters, all of which demanded answers to written question.  The answers have been grossly delayed by Merdek and, as the committee was 'fairly cross' about this game last time around, no doubt they will displeased with a what? an eight week delay.  Heff is Chair and he did make mention of this tiresome game last time. 

Then of course there is the great credit card rort to deal with.  Much mystery surrounds one case which Stabbed in the Dark (Staib) insisted be dealt with in camera (sub rosa).  The problem is, despite trying to keep a lid on the worst kept secret, that the answers provided were 'disingenuous'.   Hells bells, the world and it's wife knows the story; remember the Purcell ditty "Nymphs and Shepherds come away" well, transpose those words to "lawyers and firemen play all day" and you'll get the picture.  The Navy is miffed, the credit card auditors are going nuts and because of the unholy mess left behind by previous and existing 'high rollers' the Senators are all over it.  Could be fun. 

3) We will be interested to see if the payments made, sorry, donations to political parties surfaces.  It is a matter which needs to be attended to, if anyone ever joins the dots and follows the money trail from when Ansett went down and took it's two feeder airlines out with it, there will political embarrassment all around.  Then what will Singapore say over G&T in the Iron Bar??: well, I'll leave that up to your imagination.  Political mutual benefit is an old notion; but where does the undue influence line get drawn?  Anyway – it's up for BRB discussion.  Betting is the Senate won't touch it.

4) The appointment of Manning to ATSB may assist Be-a-Cur step around the Merde, certainly a useful delaying tactic, time to settle the new boy into school.  It will be intersting to see how the Senators treat this as it will signpost their intentions.  Soft line and no more Heff thundering at his famous man at the back of the room; or will we get some sound, tinged with fury from the panel.  Time will tell.

5) It's Mark Skidmores' first rodeo and that will tell us a tale.  It will be of great interest to see who's there, who sits where and the body language will tell a better story than the rhetoric.  If rumour is true; the Farq-u-hardson school of McComical embuggerance has declared war on the Skidmore boys.  A classic white hat v black hat shoot out.  The body count and score card will matter a great deal to aviation in this country.  If you do nothing else tomorrow, try and watch the Hansard video for it will tell you if we are indeed ducked for all money or; can struggle on to fly another day.  Do not; not ever, allow the price of land for development to be far from your thoughts.  Watch carefully children.

That's enough PAIN secrets for one day; I expect there will be more tomorrow.  Aunt Pru takes an interest in such matters; and, as we must pay our rent we need to earn our humble corn.  MTF? probably.

Music to muse by.

Toot toot... ..

[Peetwo]

“Do you operate or conduct business under any other names?"


These donations were made in the name of Rex.

Given ATSB was conducting investigation of PelAir at the time, should Rex have answered Yes to this question and declared they also operated as PelAir?

Good question slats personally I would have thought so but in the corporate world there is all kinds of murky arrangements that you would expect not to pass muster but inexplicably do. Maybe it is a case of no-one having the balls to bring these discrepancies to the attention of the relevant authorities - in this case ASIC - except of course a certain independent Senator.. : Senator Xenophon queries political donations by regional airline Rex

INDEPENDENT senator Nick Xenophon has called large political donations by listed regional airline Rex “incredibly baffling” and said he would be buying shares in the company so he could press board members on why the donations were made.  

Mr Xenophon, who led a Senate committee inquiry into much criticised government investigation into the crash of a Rex-owned passenger plane off Norfolk Island, said the airline had an “obligation” to disclose why the donations were made.

Between July and November 2012 — amid a three-year inquiry into the Norfolk Island crash — Rex made a $250,000 donation to the ALP, $95,700 to the federal Nationals and $40,000 to the Liberal Party. This made the small airline one of the biggest political donors in the country.

“Rex is a public company and it had an obligation to explain whether even one (word) regarding the crash was spoken with any of the political parties,” Mr Xenophon told The Australian.

“This largesse to political parties is inexplicably baffling and I will be buying some shares in Rex and asking them to explain it.”

Rex spokeswoman Alicia Chapple has declined to respond to repeated questions from The Australian this week regarding the donations and other matters, saying that the airline did “not see the need to devote additional resources to this matter”.

The airline had earlier incorrectly claimed it had made no donations to the LNP; however, when shown otherwise, Ms Chapple said the airline had meant it had made no donations to the Queensland LNP.

Of particular interest was Rex’s $250,000 donation to the federal ALP given the airline was a highly vocal critic of the Labor government.
In 2013 Rex publicly said the ALP was “hellbent” on destroying regional aviation and “along with it pretty much the rest of the economy”.

Mr Xenophon said it appeared to defy reason why Rex would donate heavily to a government it would shortly afterwards describe as “destroying its industry”.

“Perhaps Rex had a case of Stockholm syndrome?” he said.

In 2009 a Rex aeroplane — operated under the group’s Pel-Air brand — ditched into the ocean with six passengers on board, badly injuring one.

A lengthy Australian Transport Safety Board investigation blamed the Pel-Air pilot involved in the crash but failed to mention 57 breaches or “serious deficiencies” at Pel-Air.

Mr Xenophon headed a Senate committee inquiry into that botched investigation, which led to the federal government last month calling on the ATSB to reopen the investigation.

Rex has also come under the spotlight after it was last year awarded a series of key Queensland government contracts which had previously been held by Cairns-based rival Skytrans.

   
Company Directors & Board members are also supposedly bound by similar declarations e.g.

1. POLICY

Directors are required to act in good faith to avoid conflicts of interest between the interests of the Company and their own personal, professional and business interests. To this end a Conflict of Interest Register is to be maintained by the Company Secretary to record all conflicts of interest.

 

i. outside interests:

a. a contract or transaction between the Company and a Director or an immediate relation (by blood or marriage) ("family member"*) of such Director; or

b. a contract, consultancy or transaction between the Company and a company, partnership, business or entity in which the Director, or any such family member of the Director, has a material financial interest or of which such person is a director, officer, agent, partner, associate or trustee.

So in the REX/PelAir case did a Director who was appointed in 2010 declare his interests (as per b. above), especially given that his company was singularly responsible for setting up the REX/PelAir SMS (which includes amongst other things the company FRMS) before taking up his appointment as a Director in a safety sensitive position??
MTF..P2

[Peetwo]

Many may not be aware but PAIN is currently on a mission (reference - RE: The Xenophon end game.):

...But Manning is taking on a role, the MH 370 show runs out of money in May and the Senate committee is now watching the Be-a-cur performance, as we all are, with some interest.  It will be great deal of fun to compare the PAIN investigation report against the ATSB second attempt.  The Senate will get that just before the ATSB present; we have had five years to do our research and investigate.  The comparisons will be of interest as we have gone deep into the murky realms of power, money and influence; starting with who paid for the resurrection of the failed Ansett feeder lines Kendell and Hazelton Airlines, which morphed into the now Singapore owned Rex.  This is where any sensible investigation must begin, if the true reasons behind the appalling travesty that was the Pel-Air investigation are to be examined.  It is quite a tale... 

 
I have been tasked with following the PelAir cover-up chronological trail of embuggerance to help create a timeline to factually back up the PAIN Final Report. Well in the process of reviewing the TSBC peer review report & comparing to all other publicly available (& some not publicly available) information, which includes the excellent Senate AAI report, I have already noted some discrepancies that will need further investigation??

The chronology is still very much a work in progress and necessarily needs to be completed before properly writing the organisational factors that were contributory to the VH-NGA ditching. However I can reveal certain dots & dashes that I have discovered so far for those with a bent for forensic examination of documented evidence.

To begin I have spent some time examining the much convoluted trail of the original Critical Safety Issue:

26 February 2010

Accident Investigation Liaison Unit
Civil Aviation Safety Authority
GPO Box 2005
Canberra ACT 2601

Dear (blank)

A0-2009-072 - Ditching - 3 NM south-west of Norfolk Island Aerodrome - 18 November 2010 - Westwind, registered VH-NGA - Critical Safety issue

I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect of the lack of regulation or guidance for pilots when exposed to previously un-forecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.

Subsequently, on 12 February 2010, you rang the investigator in charge of the ATSB safety investigation, (blank) and requested a supporting letter that described the critical safety issue and requested CASA's assistance in its resolution. In later telephone calls to me, you suggested that the receipt of this letter would allow you to 'kick-start' CASA's consideration of, and response to the issue.

Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB' s initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA' s commitment to address the safety issue is appreciated.
Please don't hesitate to contact me (blank) (blank) on telephone should you have any questions or comments.
 
(Blank)
Director Aviation Safety Investigations
Australian Transport Safety Bureau

          
Okay we all know who the DASI (above) was (& last I heard still is... ) i.e. Sangston; so from this letter it would appear that Sangston - & therefore Dolan - were very much in support of the Investigator In Charge (IIC) assessment that the identified safety issue was of a "critical" nature (quote from attachment One)...

"...Safety issues are broadly classified in terms of their level of risk. A critical safety issue is associated with an intolerable level of risk, and generally leads to the immediate issue of a safety recommendation unless corrective safety action has already been taken..."

Which leaves the open question of when exactly did the executive & middle management change their tune on this identified safety issue (ref: Attachment One):

Safety issue
There were no regulations or other guidance for application by flight crews when
making in-flight, weather-related decisions in a changing meteorological environment.
That reduced the reliability of in-flight decision making, and increased the risk of an
aircraft arriving at a destination with insufficient fuel to continue to an alternate
aerodrome, if the weather at the intended destination has deteriorated below its landing
minima.

Initial safety action by the ATSB
In accordance with its preference to encourage relevant organisation(s) to initiate
proactive safety action to address any identified safety issues, and in recognition of the
criticality of the above safety issue, a meeting was convened by the ATSB with Civil
Aviation Safety Authority (CASA) officers on 3 February 2010 to highlight the
identified issue. In addition, the A TSB sought an understanding of the potential for
safety action by CASA.

Initial safety action by CASA
During the 3 February 2010 meeting, CASA officers indicated that they understood the
issue, and that it should be progressed with CASA management.

As I mentioned I have been reviewing firstly the TSBC peer review report, as it is supposedly based on all the ATSB documented chain of evidence in relation to the PelAir investigation. Therefore it should be accurate & the veracity of the information should not be questionable...true or false?? {Ps: Still holding judgement but so far it is not looking good for the ATSB senior management}

Anyway the following is what I have been able to glean from the TSBC report in regards to the progression of the above identified (& embarrassingly still outstanding) safety issue..  

01 Feb '10: "On 01 February 2010, the team leader and the general manager (GM) decided to provide CASA with a briefing on the perceived safety issue.

The briefing was held by video conference on 03 February 2010. On 12 February, the primary contact at CASA followed up with a phone call to the IIC asking the ATSB to send a letter describing the safety issue.

Around this time, several meetings and discussions on the signing of a new memorandum of understanding (MOU) between CASA and the ATSB were documented. The MOU, which was signed on 09 February 2010, reflected the ATSB approach favouring proactive safety action over recommendations. By taking this approach, the ATSB aimed to track action taken by stakeholders on all issues determined to have a systemic impact (known as safety issues) and to issue recommendations only as a last resort when an unacceptable risk persisted.
CASA was reported to be supportive of this and to be anticipating that the Norfolk Island investigation would generate safety action. At the same time, CASA was clear that it intended to pursue regulatory action against the pilot. This was the subject of several e-mail exchanges between the IIC and the Chief Commissioner on the two agencies' differing perspectives and approaches."

26 Feb '10: "On 26 February 2010, the ATSB sent a letter to CASA outlining the “critical” safety issue (see attach). The issue, based on the preliminary analysis, was described as a lack of regulation or guidance for pilots exposed to meteorological conditions that had not been forecast previously when on long flights to destinations with no nearby alternate aerodromes.

CASA sent a written response to the ATSB on 26 March 2010, agreeing that the then-current regulations were not prescriptive, but pointing out that weather-related decision making was part of all pilot training syllabi, beginning with the day-VFR (visual flight rules) syllabus. CASA expressed the view that the current published guidance material should allow pilots to make appropriate in-flight decisions, but said it was reviewing the regulations to determine whether amendments were needed."

18 Mar '10:  "On 18 May 2010, a critical investigation review was held and an analysis coach was appointed to help prepare the analysis section of the report."

27 July - 06 Aug '10: "The analysis coach and the IIC worked together for a period of time, much of which was devoted to refining fuel calculations for the occurrence flight. Both the coach and the IIC found the process frustrating. The IIC felt that the coach's focus on the performance of the flight crew 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.

A progress meeting involving the IIC, the analysis coach, the team leader, and the GM took place on 27 July 2010. On 06 August, the coach, citing an inability to make progress on the analysis due to a lack of supporting data, asked to be, and ultimately was, removed from the investigation.

In the summer of 2010, there was a change in team leader responsible for the investigation: the original team leader was appointed to the position of assistant GM at the beginning of July, but remained involved in the Norfolk Island investigation until the handover to the new team leader was complete in mid-August. It was in the context of this handover that the inability to make progress with the analysis coaching arose. No action was taken to provide further assistance with the analysis.

The IIC continued to develop the analysis and draft report independently." 

Comment: What is interesting was that it was around this time that the end of another email chain occurred over at CASA HQ (see attached & note email from Farquharson 22 July 2010), plus there was the July 2010 CAO 82.0 NPRM which was still open for comment - http://www.casa.gov.au/wcmswr/_assets/ma...1003os.pdf . 

18 Feb'11: "...the team leader forwarded the MS Word document containing the second peer reviewer's comments to the IIC and asked that they be considered."

15 Mar '11: "...the IIC and the human factors investigator (the only remaining members of the investigation team) agreed that the report was ready for the team leader's review, and they submitted it the same day."

02 May '11: "...the IIC asked the team leader how to expedite the investigation..."

04 June '11: "...the team leader completed the review and returned the report to the IIC for response. The IIC made the requested modifications to the report and on 05 July, after another review by the team leader, the report was sent to the GM for review.

At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations. (NB It would appear that the IIC was still under the impression that 1) was still a CSI) 

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues. (NB But the GM Sangston should have already signed off on the analysis of the CSI back before 01 Feb '10??)

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation. They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.

During this period, the GM was working through a backlog of reports, many of which required considerable revision and editing. The GM was making these revisions himself, and he did the same for the draft Norfolk Island report. It was in the course of this work that the GM concluded that the available data did not substantiate classifying the safety issue on guidance for en-route weather-related decision making as significant, and modified the report to recast it as a minor safety issue. The report, with revisions and comments from the GM, was returned to the IIC, who reworked sections of the report and returned it for another review by the GM.

Passing strange that Sangston re-cast the CSI to minor in approximately September 2011 yet he did not notify CASA of this till August 2012. This was despite several formal & informal opportunities to bring the matter to CASA's attention. Including prior to the release of the 2nd  anniversary interim report where it would seem CASA were expecting further mention of the identified safety issue: 

Hansard AAI Inquiry 15 Feb '12:

Senator XENOPHON: That is a summary of what you said. I want to be fair about that. Yet the minutes talk about, 'Talk to ATSB to work through the implications of the safety issue identified by ATSB in relation to the Norfolk Island ditching. Mr Farquharson contacted Ian Sangston. Mr Sangston will indicate if there are any changes to the ATSB position.' There was a change to the ATSB position, wasn't there, after that contact?


[ltr]Mr Farquharson : The date was 2011?[/ltr]

[ltr]Senator XENOPHON: It was 18 November 2011.

Mr Farquharson : My understanding is that the downgrading occurred on 16 August 2012.

Senator XENOPHON: Yes, but there was a lead-up to that. The downgrading occurred as a result of a number of representations. How many times did you meet with the ATSB to discuss CASA's views about whether it should be a critical safety issue or not? It was clearly the view of CASA that it should not be a critical safety issue. Is that right?

Mr Farquharson : The CASA view was that the legislative approach the ATSB were proposing at the time could not be achieved and in our responses we pointed out to them an amount of information and that these decisions come down to airmanship and the responsibilities of the captain when airborne. They were the two positions taken.

Beyond that the next we heard, that I am aware of, was when the safety issue was formally downgraded by the commission on 16 August 2012— [/ltr]

Hmm...interim reports?? Going through the records it would appear that there was never any interim reports issued for the PelAir ditching investigation?

Annex 13 Para 6.6 states  -  "If the report cannot be made publicly available within twelve months, the State conducting the investigation shall make an interim statement publicly available on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised.

 IMO this is important if you consider that the significant safety issue was still very much outstanding (and still classified as critical prior to the 1st & 2nd anniversary) & in any normal course of events would have meant the promulgation (prior to an interim report release) of a safety recommendation:

Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend in a dated transmittal correspondence to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.


Note.— Precedence for the issuance of safety recommendations from an accident or incident investigation should be given to the State conducting the investigation; however, in the interest of safety, other States participating in the investigation may issue safety recommendations after coordinating with the State conducting the investigation.


6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety
recommendations arising out of its investigations in a dated transmittal correspondence to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.

Note.— When Final Reports contain safety recommendations addressed to ICAO, because ICAO documents are involved, these reports must be accompanied by a letter outlining the specific action proposed.

Despite Sangston's clearly bad memory the safety issue was not officially recognised or downgraded till 16 August 2012.

It should be remembered that CASA had put out a NPRM on a proposed rule change to CAO 82.0 in July 2010 - Carriage of Fuel on Flights to
a Remote Island – 
CAO 82.0 http://www.casa.gov.au/wcmswr/_assets/ma...1003os.pdf ( http://auntypru.com/whodunnit-why-chapte...gator-toe/ ) - 

which for some bizarre reason dropped off the radar till it was again resurfaced in August last year - 

http://www.casa.gov.au/wcmswr/_assets/ma...1413os.pdf

Which means of course that the identified safety issue has effectively not been properly mitigated (still) in over five years....

MTF...P2

[Kharon]

Of cats and hot tin roofs.

I don't think the 'industry' has, as yet fully appreciated the value or understood the benefits brought by one of the best gifts it has been given in many a long year, the new MoU.  You can see the dire effects of the 'old one' in the Pel-Air matter; clearly.  The NTSB would not be stuffing about in the manner indicated by P2 (above).  No Sir, they would run their own investigation, issue the CSI then, perhaps, as they have done in the past 'discuss' the ramifications with the FAA to achieve a positive, beneficial outcome; same-same in Canada and in most of the civilized world for that matter.   

CASA chose, for their own reasons (MMTF) to activate their Pel-Air investigation in parallel, through the AILU under a MoU which was not 'technically' valid and unsigned.  Now, should an operator have a new 'approval' pending, which was agreed, unsigned and not promulgated but went ahead anyway, 'in anticipation' of formalities being complete, the very roof would cave in.  But CASA went ahead on exactly that premise; in short they were bound to the existing MoU until such time as the 'new' MoU was ratified.  

This askance allowed much of the exhibitionism, latitude and obfuscation of 'fact' uncovered by the SI.   This may be clearly seen in the White scripted, Chambers aided, top floor abetted CAIR 09/03 abomination.  This report demonstrates the unprecedented latitude (wriggle room) provided by an unsigned, not in effect MoU.   For those who intend to force a predetermined outcome in order to cover their tracks and take full advantage, it was heaven sent opportunity.  It must be sincerely hoped that no 'legal' action taken against the pilot, or later used against the survivors relied, even in part on that very moody report.  

Anyway, thanks to the efforts of the Senators, Rev Forsyth and the TSBC much of the 'wriggle room' has been culled from the latest version MoU, certainly the chance to take the Mickey has been reduced, but not excluded (that comes down to the individual).  Perhaps, if we have another event, the cautions and lessons learnt from the old style of 'cooperation' will be remembered.  Perhaps Manning and Skidmore can come to a tacit agreement whereby the cobbler sticks to his last.  But no amount of paperwork will cure the intent to act dishonourably, it will come down to structural and moral integrity of the two top guys.

Meanwhile, thanks to the Senators and the Rev. Forsyth we now have a MoU which is much improved.  We don't need one, not many sane administrations do.  But if we must, then lets hope this iteration will prevent another Pel-Air fiasco.   

P2 - "Which means of course that the identified safety issue has effectively not been properly mitigated (still) in over five years.'

That the accident was allowed to happen is bad enough, but what followed was an absolute, total debacle; one with far reaching ramifications.  The problems still exist, unresolved with the loop, or noose if you like, still open, awaiting the next victim. 

Old Wazza and his sharp mates may think Pel-Air has all been neatly put away, finished tidy, back in it's box: WRONG. Only when, metaphorically speaking, the tar and feathers are on the right arses, and things are put to rights can the rehabilitation of CASA, ATSB and industry begin.   Hey Ho, such is life in the fast and loose lane. 

Toot toot. 

[Peetwo]

Eeny. meeny, miney, MoU.


Sometime ago I made a UP post (well several actually) on the MoU conundrum that IMO was massively exploited by CASA in the PelAir cover-up:

Sundy cogitation on ANA’s, MoU’s, DJ’s, TASRR & any other safety related matters.

---

Heard a rumour that the Feds investigation into PelAirgate has been stalled while various DIPs get all their ducks in a row & before the WLR panel start sniffing around....just a rumour but most disturbing if true…

Anyway moving on..
Part One: On watering potplants and MOUs

Kharon:
Quote:

Was the 2010 MOU used actually in play at the time of the incident? Did the AILU manager start a parallel investigation assuming that ?, he certainly cited it; but wouldn't the active 2004 MOU prohibited this ?. If so, then they seem to have run very close to the 'legal' wind there. I wonder what the AAT would make of the procedural integrity in that.

A gentle reminder that the 2010 MOU was officially commissioned/signed off on the 9th February 2010, however the MALIU states in the, now infamous hidden report, CAIR 09/3 synopsis…

It is well worth perusing parts of the various MOUs that were kindly submitted, but then mi..mi..minimised, by FF in their original PelAir inquiry submission.

In the 1996 version we had the following paragraph…



.. in 2001…



..and in 2004..




All good stuff clearly outlining the rules of engagement between FF & the bureau and also indicating that bureau investigations will look at the big picture in a holistic, systemic manner, whereas FF’s emphasis will be solely on matters of possible non-compliance.

The 2010 version however does away with (deletes) all that palaver and cuts straight to the chase with their newly headed section, which the MALIU dutifully refers to in the CAIR 09/3 synopsis, ‘Parallel Investigations’…



Gone are the good old days where the bureau held the ultimate trump card, where the singular objective was to learn from accidents/incidents to help mitigate safety risk and where we met our international obligations under the articles of the Chicago Convention.

IMO this disconnection with the real world perception of AAI best practice is quite well highlighted in paragraphs 5.16-5.20 of the 1996 MOU..

Oh what a conundrum..for the miniscule and his WLR panel…

Here’s and idea just scrap the 2010 MOU, go back to the drawing board and use the 1996 MOU as a blueprint for a new MOU…my 2 bob’s worth..


Q/ Hasn't the 2010 MOU now time expired?? Hmm..perfect opportunity perhaps..

Of course the excellent Forsyth & TSBC reports have since been released, both of which supported the original premise of my above post and to top it all off the MoU has now been re-written pretty much in the original spirit & intent of the 1996 MoU...  

But I want to focus on this line from the above UP post...

"...It is well worth perusing parts of the various MOUs that were kindly submitted, but then mi..mi..minimised, by FF in their original PelAir inquiry submission..."

What was it that I meant in that statement??

Well in the original submission from CASA to the Senate Committee for the PelAir inquiry they had an attachment that included all versions of the MoU from 1996 to 2010. This attachment also contained - discretely hidden & unlisted in the contents - the infamous CAIR 09/3 report a.k.a the ALIU report (i.e. Whitey's report)...    

For your convenience here is a link for the original MoU attachment -  http://auntypru.com/?attachment_id=822
You will see that the attachment pdf was 102 pages and included the '96, '01, '04 & 2010 MoUs. The following was the listed contents for Attachment B: 

According to my records I had downloaded the original CASA MoU document on the 18 October 2012 off the Senate Inquiry submissions page - Submissions received by the Committee.

On the 09 July 2013 - when I had further need to again review the CASA MoU attachment and not having access to my original file download - I revisited the Inquiry submission page and again downloaded the pdf attachment. However I was to discover that the attachment had shrunk by 20 pages (now 82 pages) and was now minus the 2004 MoU?? Here is the version that now exists on the Senate Inquiry submissions page - 
http://auntypru.com/?attachment_id=821

So sometime between 18/10/12 to 09/07/13 person(s) unknown and for reasons unknown (although I could hazard a guess), have altered a document held under parliamentary privilege! How bizarre?? The most amusing part is that although the current version of attachment B is now minus the '04 MoU it is still listed in the contents....

Attachment B

Memorandum of Understanding between

the Bureau of Air Safety Investigation and the Civil Aviation Safety Authority

(May 1996)

Memorandum of Understanding between

The Australian Transport Safety Bureau and the Civil Aviation Safety Authority

(June 2001)

Memorandum of Understanding between

The Australian Transport Safety Bureau and the Civil Aviation Safety Authority

(December 2004)

Oops...

Much..much MTF on this...P2

Ps From the TSBC report...

"...3.3.6 Information on regulatory oversight

Throughout the investigation, ATSB staff and management consulted or briefed CASA staff and management. Attachment A of the Memorandum of Understanding between the ATSB and CASA (October 2004) indicated that, upon agreement by both CASA and ATSB, a CASA officer might participate in the ATSB investigation. In this instance, no CASA officer was designated..."

"...Around this time, several meetings and discussions on the signing of a new memorandum of understanding (MOU) between CASA and the ATSB were documented. The MOU, which was signed on 09 February 2010, reflected the ATSB approach favouring proactive safety action over recommendations. By taking this approach, the ATSB aimed to track action taken by stakeholders on all issues determined to have a systemic impact (known as safety issues) and to issue recommendations only as a last resort when an unacceptable risk persisted..."

Hmm..think we need to have a close look at the 2004 MoU??   
 

[Kharon]

Howzat ! LBW methinks.
Tim Tam class post from P2...    

Big time; so let's just get this straight.  The original CASA submission of 102 pages goes to the Secretariat, with the operational 2004 MoU firmly attached.  Then a little while later 20 pages, coincidentally containing the MoU which was in effect at the time, have. mysteriously 'disappeared', but the table of content is unchanged.  Well, well, that's a bit naughty, ain't it?.... ...

It's either a very smart bluff, relying on the fact that few, if any would bother to check or read every page; or it's plain dumb. My two bob – on bluff: you can hear the word weasels:- 

"Oh, sorry Senator, been a clerical error here dontcha know (shrug); we'll take it on notice and find that wascally document".  "But no Senator, of course not, no significant differences; the '04 is pretty much the same as the rest; and yes, signing is a mere legal formality".

BOLLOCKS shouted the crowd at the back of the room; absolute BOLLOCKS.

[Peetwo]

Howzat ! LBW methinks.
Tim Tam class post from P2...    

Big time; so let's just get this straight.  The original CASA submission of 102 pages goes to the Secretariat, with the operational 2004 MoU firmly attached.  Then a little while later 20 pages, coincidentally containing the MoU which was in effect at the time, have. mysteriously 'disappeared', but the table of content is unchanged.  Well, well, that's a bit naughty, ain't it?.... ...

It's either a very smart bluff, relying on the fact that few, if any would bother to check or read every page; or it's plain dumb. My two bob – on bluff: you can hear the word weasels:- 

"Oh, sorry Senator, been a clerical error here dontcha know (shrug); we'll take it on notice and find that wascally document".  "But no Senator, of course not, no significant differences; the '04 is pretty much the same as the rest; and yes, signing is a mere legal formality".

BOLLOCKS shouted the crowd at the back of the room; absolute BOLLOCKS.

Oh but according to Doc Aleck the 2010 MoU (his creation) was a work of art that had righted the pendulum on the Ol' Aviation Safety Grandfather clock...TICK..TOCK   Now watch carefully as Hoodoo Voodoo weaves his spin & bulldust:

Considering the latest MoU has shrunk by some seven pages - & much of the previous 2010 MoU multi-interpretative legalese has been omitted - I'd say that the Doc has been somewhat sidelined from any major contribution this time around...   

One thing you will notice from that vid is that never at anytime does anyone reference the previous 2004 MoU?? This is despite the fact that it is the one that they should have been referencing. However in hindsight would it have made any difference to the eventual outcome of the 1st ATSB PelAir investigation & Final Report?? 

After closely comparing the two MoUs alongside each other, it is my opinion that if the '04 had been referred to in the proper conduct of the two agencies throughout the PelAir investigation their would have been a profound difference in the final outcome. As an example I refer to the safety action sections of the two MoUs - spot the differences??:

2010 - 5.3 Safety action

5.3.1 The ATSB understands actions may be taken by CASA in response to safety
issues during the course of an ATSB or CASA investigation, and the ATSB will
include this information in the investigation report to the extent it is
practicable to do so. The ATSB encourages safety action that obviates the
need to make safety recommendations.

5.3.2 In order to ensure that any safety action is properly acknowledged by the
ATSB, CASA will advise the ATSB of any safety action taken or intended to be
taken by CASA.

5.3.3 In making recommendations for safety action by CASA, the ATSB will clearly
and explicitly identify the safety issue(s) involved. The ATSB will consult with
CASA prior to a recommendation being made.

5.3.4 CASA response to safety recommendations- In accordance with section 25A of
the TSI Act, CASA will respond to the ATSB in writing within 90 days of the date
on which the report is published, and include in that response the information
required under section 25A. The CASA response should clearly identify which
part of the written response is intended for publication on the ATSB website
and/or in the final report.

5.3.5 Where consideration and implementation by CASA of an ATSB
recommendation is or may be protracted, CASA will inform the ATSB of
progress at regular intervals as agreed between the organisations.

5.3.6 CASA and the ATSB will seek to ensure that information posted about the
status of ATSB recommendations on their respective websites is consistent.

Note: This may be achieved via a link on the CASA website to the ATSB
website.

 2004 - 10 SAFETY ACTION

10.1 The ATSB will acknowledge safety actions taken, or intended to be taken, by
CASA, in response to safety deficiencies identified during the course of an
ATSB investigation and will include this information in the investigation report
to the extent reasonable and possible. The ATSB encourages safety action that
obviates the need to make safety recommendations.

In order to ensure that any related safety action is properly acknowledged, CASA
notes that the ATSB will formally request details of safety action taken or
intended to be taken by CASA at the time of issue of a draft investigation report
to CASA and prior to the release of the final report.

10.2 The ATSB may issue formal recommendations to CASA at any time during or at
the completion of an occurrence or data analysis or research investigation. In
making recommendations for action by CASA, the ATSB will identify as far as
practicable, only the desired outcome required. The ATSB will consult with
CASA prior to a recommendation being made.

10.3 When the ATSB considers it appropriate to include recommendations in the draft
final report, the ATSB agrees to consult with CASA prior to the report being released to DIPs.
In such cases, comment from CASA on the recommendations is encouraged, but unless
safety action is being taken or intended to be taken in accordance with paragraph 10.1,
a formal response is not expected until the final report is issued. Notwithstanding the
above, CASA may choose to formally respond to recommendations included in a draft report.

10.4 CASA Response - Unless othe1wise agreed, within 60 days of the issue of a
reconm1eudation, CASA agrees to respond to the ATSB in w1iting. The w1itten
response will contain clear statements of acceptance, pa1tial acceptance or
rejection of each recommendation. The written response may also contain
information detailing the timetable and procedures for implementing the
recommendations or part thereof; or provide a full explanation for the decision
not to implement any recommendation or part thereof, and identify any
alternative action proposed. The CASA response may also identify which part of
the written response is intended for publication.

10.5 The ATSB acknowledges that it has no authority to compel CASA to accept any
ATSB recommendation, and further acknowledges that CASA may choose not to
accept an ATSB recommendation that CASA does not believe is appropriate.

10.6 Where a recommendation is formally issued prior to the final report or where
CASA chooses to formally respond to recommendations contained in the draft
final report, the responses will be included in the final report where time permits
and to the extent appropriate. The ATSB will, as a minimum, publish a
summary of recommendations directed to CASA, including responses to those
recommendations, on the ATSB's web site.

10.7 Where consideration and implementation of a recommendation is protracted,
CASA will inform the ATSB of progress at regular intervals as agreed between
the parties.

IMO in the '04 MoU the ATSB definitely had the upper hand and there was very little wriggle room in interpretation of the wording, the same could not be said of the 2010 MoU...

Finally let's take a look at the freshly minted 2015 MoU... :

10 SAFETY ACTION

10.1 Where CASA takes safety action in relation to an aviation transport safety issue
under investigation by the ATSB, CASA will notify the ATSB as soon as
practicable. The ATSB will use its best endeavours to acknowledge in its final
report the safety action taken by CASA, where the ATSB is advised at least 20
days prior to publication.

10.2 Where the ATSB has identified a safety issue indicating the need for persons or
organisations within the aviation industry to take safety action, to the extent it
is authorised to do so, and subject to operational requirements and priorities,
CASA will monitor action taken in relation to the safety issue. Where CASA has
information indicating action or inaction by the person or organisation, CASA
will advise the ATSB as soon as practicable.

ATSB Safety recommendations

10.3 The ATSB will consult with CASA should any safety issues be identified that
affect CASA, and before making any formal recommendations for safety action
by CASA.

10.4 CASA will respond to any formal safety recommendations issued, in accordance
with section 25A of the TSI Act. Where consideration and implementation of
the recommendation may be protracted, CASA will provide the ATSB with
updates on its progress at least every 3 months from the date when the
recommendation was first issued, or otherwise as frequently as the parties
agree.

10.5 CASA acknowledges that the ATSB may publish some, or all, of CASA’s response
to a safety issue or recommendation.

Beside the reduced (weasel) word count you can really see the influence of the Senate Inquiry recommendations in the latest version...top stuff Senators Heff/Sterle/NX/DF & Co the key for the Tim Tam cupboard is in the mail...

MTF...P2  

[Kharon]

Spellbound? 

One of the more subtly dangerous effects of the hypnotic voodoo spell weavers art is the deaf, dumb and blind state. Once an unfortunate is lulled into a trance, the evil can be completed with ease.  The arcane ritual begins with mind numbing boredom, usually produced through reams of stultifying paper work, crafted to be unintelligible to the reader and masking the true nature of the evil spells cunningly interwoven.

The first rate (Choc frog class) research on MoU, provided by P2 in the post above provides a perfect example.  The silky, whispering, hypnotic repetition increases in frequency leading the reader to mindless place, where reassured by 'the voices' the subtle, evil changes pass by, unnoticed.  In 199?, there was a need, because of changes to the Act, for an 'agreement' of some sort to be hammered out.  Both tribes were independent, strong and intent on doing their jobs, to the best of their ability.  The public purse was, after all funding it's own safety during flight.  Then those who sought power, ease of responsibility and had ambitions to become 'the authority' saw an opportunity to grab more power, ease the burden and wriggle out of some serious obligations.  Enter the legal word weasels.  

Slowly, stealthily, but surely the flaws built (some say purposely) into the infamous Miller report were exploited, the even balance of power was cynically eroded until one agency gained the political supremacy and began to slowly choke it's rival sister agency.  All done neat and legal of course, gradually as nearly all the names changed the poison slowly spread; and, as the done deals were supported and accepted 'fait accompli' with the top layers of 'departmental' power fully backing the paradigm shift, until  slowly, but surely the hideous MoU anathema became 'the norm'.  There was some token resistance, at least until Uriah Heep was quietly added to the mix.  From there it has been downhill, fully assisted, cobbed throttles, all the way.  The 2004 MoU was the penultimate sword stroke; the final death strike and Coup de grâce to independance was delivered with the 2010 version.   

There is much to thank the hapless crew of the ditched Pel-Air medivac flight for.  The new MoU would not have been a remote possibility, had it not been for that unfortunate, avoidable incident.  The once independent ATSB would have become a catamite to the insanity of the despotic McComic, Albo sponsored era; the board a mere puppet and the Iron Ring left reigning supreme, without let, hindrance or challenge.  As it stands, without fanfare or red faces, the aberration has become, once again a docile, domestic animal used to facilitate a flaw in the Act.  A honest loophole, writ by men of good will, which has been ruthlessly, selfishly and, IMO corruptly exploited by those who through voodoo, smoke and mirrors, seek to control and manipulate, for their own self interest, the safety of the travelling public.   

Yes; it is tedious.  But the time taken to plough through, really 'read' and comprehend the P2 offering will provide a true horror story to keep the honest reader awake; the dishonest will of course seek ways to circumvent the spirit and intent, simply to renew the atrocity.  The video is a handy short road to understanding.  Aye, such is the never ending battle between dark and light.

But, if we see this change as an example of a Senate supported DAS and new ATSB leadership, perhaps the first, tentative steps on the road to rehabilitation have been taken.  Sure they are small, but bravely done and in the right direction.

Top marks, gold stars and Choc frogs all around.   Bravo.

And thus I clothe my naked villany
With odd old ends stol'n out of holy writ,
And seem a saint, when most I play the devil."

Selah.

[Kharon]

P2 + GD.

Boys – I've moved the last posts to the UP thread; Alas, I lost the trimmings in the process (must get that fixed) – I regret.

[Peetwo]

Unintentional but "K" had some finger trouble and with regret deleted my post off this thread. However beside the UP content my post is reinstated for posterity & discussion on yet another of the myriad of dots & dashes related to the PelAir cover-up scandal, to which I believe one I-ron-Bar is up to his eyeballs in...    

-----------------------------------------------------------------------------------------------------------------
My turn to raid the UP all boring till I came across the UITA initiated thread - Lockhart River.........10 years on . Despite the honourable intent of starting the thread on the 10th anniversary of the Lockhart River tragedy, I fear that due to a resident parasite troll that the thread will very shortly be closed - why? Well for the record see here...  : 

I-ron-Bar(tsch)

FFS not again. Attention all new generation pilots (neglectfully failing to reply) take heed! This is NOT the way to manage your multi crew aeroplane, or the way to fly an instrument approach. 

Serious doubts about the event? Here's your problem;

From the ATSB report. 

Contributing factors relating to the event and individual actions. 

• The crew commenced the Lockhart River Runway 12 RNAV (GNSS) approach, even though the crew were aware that the copilot did not have the appropriate endorsement and had limited experience to conduct this type of instrument approach.

• The descent speeds, approach speeds and rate of descent were greater than those specified for the aircraft in the Transair Operations Manual. The speeds and rate of descent also exceeded those appropriate for establishing a stabilised approach.

• During the approach, the aircraft descended below the segment minimum safe altitude for the aircraft’s position on the approach.

• The aircraft’s high rate of descent, and the descent below the segment minimum safe altitude, were not detected and/or corrected by the crew before the aircraft collided with terrain.

• The accident was almost certainly the result of controlled flight into terrain.
3.2.2 Contributing factors relating to local conditions

• The crew probably experienced a very high workload during the approach.

• The crew probably lost situational awareness about the aircraft’s position
along the approach.

• The pilot in command had a previous history of conducting RNAV (GNSS) approaches with crew without appropriate endorsements, and operating the aircraft at speeds higher than those specified in the Transair Operations Manual.

Desperately sad for all involved. So why not just leave it rest.

 
UITA

The whole story please 

---

Maybe a quote from the Coroners report is worthwhile, which doesn't seem to match your take*ronbar**:

.........associated with applications by air operators to vary their AOC to add new routes. Such applications required CASA field officers to apply the guidelines and provisions of a particular manual of air operator’s certification. In the case of Transair this involved considering the operator’s request, in 2001, to add Bamaga as its first mainland Australia regular public transport route (from Cairns), and subsequently in 2004 to seek the addition of Lockhart River.

In neither case did CASA require the operator to conduct a comprehensive or structured risk assessment of the proposed change. In particular, no such assessment was required in relation to Transair’s operating procedures, pilot experience or level of training, the rostering practices of Transair in relation to pilots who would be flying the routes involved and the pilot resources available to Transair. 

In short, it was not part of CASA’s processes to require Transair to undertake a formal risk assessment or make out a safety case for the inclusion of Lockhart River as a new port although it did require Transair to revise performance charts.

I find that senior CASA management failed to provide sufficient guidance to its staff to enable them to fully and effectively evaluate risk management issues associated with Transair’s application to add Lockhart River to its air operator’s certificate as an interim port on the Cairns – Bamaga route. That guidance may have been as straight forward as requiring Transair to engage an independent specialist to conduct an assessment of, and provide a report on, all safety issues that were pertinent to the operation proposed.

It is also strange that two sources of relevant information were apparently not accessed by the regulator. 

I refer to the newspaper articles indicating that an operator who did not have an appropriate AOC[Aerotropics(sic)] was about to commence an RPT passenger service into Bamaga and later, Lockhart River. I would have thought an agency as large and well funded as CASA would subscribe to a clipping service that would bring such information to its attention for routine checking. 

Similarly, it is of concern if CASA did not access the inquest findings and transcript in relation to the death of the pilot Mr Short. [Died at TI in January 2002 (sic)]

Had it done so I would have expected that the evidence given in those proceedings by Mr Hotchin might have caused it to raise a query with Transair about aspects of his flying.

I-ron-Bar(tsch)

Maybe a quote from the Trans-Air Ops Manual, CAR, CAO or AIP would be more worthwhile.

My "take" does not include any comment about CASA. If you choose to operate an aeroplane in a reckless and negligent manner it will end badly. Regardless of any amount of CASA supervision.

Get over it numbskull, there is no good to be achieved here.

Frank Arouet.. 

Why would anybody possibly want to quash further comment on this matter?

Why would this tragedy not be a worthwhile example for future pilots and operators to learn from the experiences of others and;

Why would anybody except someone with a vested interest take such a stance. Except of course unless he were a lawyer or a government stooge placed on a committee or board or a tribunal who had an interest in the matter just disappearing?

Why call someone a numbskull and tell him or her to get over it? 

Why?

No good can be achieved here... phooey!

I-ron-Bar(tsch)

Apart form embarrassing dickheads like you, the investigation of this matter has disappeared and no further comment is necessary. 

Why don't you concentrate on chemtrails instead. 

Please lock the thread.

Frank Arouet

Oh! my goodness. Dickheads, numbskulls, chemtrails, and tin hats no doubt.

Did somebody hit a nerve? Perhaps the AAT should be asked to investigate and rule on the matter. Or maybe the Regionals can whip the hat around and give a donation to the "Laborials' to hush it all up?

I'm guessing business is crook in the shyster profession and you are off your medication. I'll make a point in sticking the pin in my AAT doll to help annoy you.

I'll ask again for sensible comment, (not you mate), Why would anybody possibly want to quash further comment on this matter? and now ask for the thread to be shut down. 

---

Last edited by Frank Arouet; 2nd May 2015 at 07:42. Reason: Shyster got mixed up with another word. Sorry.

Oh well done Frank.. 

MTF...P2 

Also for the record here is a couple of links of interest - http://www.avlaw.com.au/team.php

  "...has wide ranging senior management and operational experience in the aviation industry, occupying positions as Head of Safety and Regulatory Compliance at Qantas Airways Limited and Manager of Air Transport Operations with the Australian Civil Aviation Safety Authority (CASA)..."   

& "...Manager Airline Operations

Civil Aviation Safety Authority

March 1996 – June 2007 (11 years 4 months)Sydney Area, Australia

Regulatory and safety oversight of all airline AOCs and MROs based in Sydney including Qantas Airways, Regional Express, QantasLink..."     

Finally a list of suspects specialists for the ID line up..  

http://www.avlaw.com.au/AvLaw_Specialist.pdf

MTF...you bet! - P2  

[P7_TOM]

Barking mad – rat cunning?

Intriguing post P2.   If you can be bothered heeding the Iron Bar barking, and it does have our undivided attention for the moment; you can see a multi-handed stropathon (sorry) 'typothon' taking place.   Any analysis of syntax, sentence structure and the crude variance of invective, derision and attack line, presents either an interesting multiple personality; or small coven of like minded warlocks.  There sure is a whiff of well oiled machinery providing smoke and poisoned gas.  

Perhaps the road from Lockhart river to Rex, Pel-Air and Norfolk Island is not as sharply defined as the paved with gold road to Singapore; but the crumbs can be followed – all the way to the Gingerbread house.  They must feel very sure of their top cover to risk exposing themselves that way.
Anyone have Karma's email or telephone number?.........  

P7_TOM.

[Peetwo]

Barking mad – rat cunning?

Intriguing post P2.   If you can be bothered heeding the Iron Bar barking, and it does have our undivided attention for the moment; you can see a multi-handed stropathon (sorry) 'typothon' taking place.   Any analysis of syntax, sentence structure and the crude variance of invective, derision and attack line, presents either an interesting multiple personality; or small coven of like minded warlocks.  There sure is a whiff of well oiled machinery providing smoke and poisoned gas.  

Perhaps the road from Lockhart river to Rex, Pel-Air and Norfolk Island is not as sharply defined as the paved with gold road to Singapore; but the crumbs can be followed – all the way to the Gingerbread house.  They must feel very sure of their top cover to risk exposing themselves that way.
Anyone have Karma's email or telephone number?.........  

P7_TOM.

 
Old Tom a point of interest in light of the LHR 10th Anniversary is the new DAS Skates view on the historical significance of the Lockhart River tragedy?? The following is a quote from the inestimable Stevie Easton in the Mandarin article - Course correction for air safety co-operation:

The two regulators and their predecessors — whose responsibilities and staff members meet in the emotionally charged field of air crashes — have had formalised arrangements for decades but Skidmore traces the latest one back to the tragic Lockhart River disaster 10 years ago. CASA copped heavy criticism from the families of the 15 victims after the airline’s shonky practices were revealed, and the coronial inquest that followed showed there was little trust between ATSB and CASA.


Queensland coroner Michael Barnes believed CASA had explicitly instructed its lawyers to make a “sustained attack on the integrity of the ATSB’s investigation report” and perceived a “serious, ongoing animosity between the two organisations” that drove him to write:

“In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.”

Barnes recommended the minister consider intervening in the relationship, which led to a review by eminent lawyer Russell Miller, which in turn saw a new three-year MoU signed in 2010.

Skidmore says work on further adjustments had already begun when senators again raised questions about the relationship in 2013 in the context of an inquiry into aviation accident investigations. That inquiry was prompted by criticism of both ATSB and CASA investigations into another crash, the 2009 ditching of a Pel-Air CareFlight plane near Norfolk Island.

“Amongst other things, the committee recommended that the MoU be re-drafted to remove perceived ambiguities in relation to information that should be shared between the agencies in connection with accident investigations,” Skidmore explained. Better information-sharing protocols, he says, is one of the key strengths of the new MoU:

” … it is essential that information be shared between the two agencies, with a view to maintaining as well as improving safety. Insofar as the provision of information by the ATSB to CASA is concerned, this sometimes requires balancing the immediate interests of safety, with the longer-term interests of ensuring that information continues to flow to the ATSB.”

  
Yeah all potentially weasel words but it is refreshing (unlike his predecessor) to see a DAS that doesn't deny the ghost of Lockhart that still haunts the halls of Aviation House.

 MTF..P2

[Gobbledock]

The fallout from Lockhart is ridiculous and unnecessary, much similar to Pelair. Going back to Lockhart, Mr Barnes was correct in his analysis. The ATSB investigation was correct in its entirety. The ATSB basically said CAsA stuffed up with its piss-poor oversight of Transair, and that obviously includes some of CAsA's employees and by default includes I-Ron-bar and his mate the Submarine. Pelair is no different. The ATSB should have pulverised CAsA for its part in the accident for being a contributing factor, but instead the ATSB chose to bend over and allow itself to be anally violated by the Regulator. Naughty naughty.

The autonomy and independence of the ATSB, by it's nature, is and should be maintained. There was no need for post Lockhart 2010 hugs and kisses and reach-arounds between the two alphabet soup agencies. CAsA was a causal factor and the ATSB noted that in its report. Great work ATSB, choccy frogs for you. Unfortunately CAsA cried like a baby and the Mandarins in Government hit the cover-up button, the rest is history and the Dr Voodoo/Pumpkin Head/Chairman Hawke MOPOOH was born.

My advice is if one wishes to examine how the 'relationship' should actually work, look back to 2005. Even better, look at the FAA and the NTSB, you won't see those two organisations dry humping each other or indulging in spit swapping!

"Perhaps I-Ron-bar and L.Ron Hubbard are one and the same"??

[Kharon]

Only two years old - a bargain; considering it remains as valid now as it was at the time.

Restored to active duty by order Aunty Pru.

Noblesse oblige eh!

[Peetwo]

Stuck in a time warp?   - "..It's just a jump to the left.."

The fallout from Lockhart is ridiculous and unnecessary, much similar to Pelair. Going back to Lockhart, Mr Barnes was correct in his analysis. The ATSB investigation was correct in its entirety. The ATSB basically said CAsA stuffed up with its piss-poor oversight of Transair, and that obviously includes some of CAsA's employees and by default includes I-Ron-bar and his mate the Submarine. Pelair is no different. The ATSB should have pulverised CAsA for its part in the accident for being a contributing factor, but instead the ATSB chose to bend over and allow itself to be anally violated by the Regulator. Naughty naughty.

The autonomy and independence of the ATSB, by it's nature, is and should be maintained. There was no need for post Lockhart 2010 hugs and kisses and reach-arounds between the two alphabet soup agencies. CAsA was a causal factor and the ATSB noted that in its report. Great work ATSB, choccy frogs for you. Unfortunately CAsA cried like a baby and the Mandarins in Government hit the cover-up button, the rest is history and the Dr Voodoo/Pumpkin Head/Chairman Hawke MOPOOH was born.

My advice is if one wishes to examine how the 'relationship' should actually work, look back to 2005. Even better, look at the FAA and the NTSB, you won't see those two organisations dry humping each other or indulging in spit swapping!

"Perhaps I-Ron-bar and L.Ron Hubbard are one and the same"??

Excellent re-call to duty Aunty Pru...

Where to begin, how about here via @SimoneFoxKoob from the Oz... :

Air safety bodies spoke ‘more than once’ on pilot’s near-miss
Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images

• Simone Fox Koob
  
• The Australian
  
• 12:00AM February 23, 2017
  

Journalist
Sydney
@SimoneFoxKoob
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/cbd838094c278f870442ad76e8fc0bae/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
The aviation safety regulator spoke “more than once” with investigators from another agency about a 2015 near-miss involving the pilot of a doomed charter flight which crashed into a shopping centre on Tuesday, but insisted the two incidents could not be linked.

The relationship between the Civil Aviation Safety Authority, which licenses pilots, and the Australian Transport Safety Bureau, which investigates crashes and ­incidents, has been strained in the past with a 2013 senate report finding communication from one agency to another was “problematic”.

The ATSB yesterday revealed it had discovered “interesting ­facets” in its early check of the wreckage of the Beechcraft B200 Super King Air, which plunged into a DFO shopping centre on the edge of Essendon Fields airport killing all five on board.

ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.

An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.

“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed.

Mr Hood said it “is not uncommon for (CASA) to take independent action without waiting for an ATSB report”.

The Civil Aviation Safety Authority yesterday refused to say what information was shared between the agencies about Mr Quartermain, with a spokesman telling The Australian the proper safety procedure had been followed.

“The pilot passed the appropriate proficiency tests at Mount Hotham and since then,” he said. “He was properly qualified to fly.”

A 2008 review into the relationship between the ATSB and CASA found the relationship was “sub-optimal”. A further 2013 Senate review into aviation accident investigations found the relationship remained “problematic” and recommended they “remove any ambiguity in relation to shared information”.

Now to begin re-joining the dots and re-making the dashes...


MTF...P2

[Gobbledock]

Of dots, dashes, connections and spit swapping

It is so odd how in one breath the ATsB and CAsA are in bed together, spooning and rooting each other, then they apparently 'don't talk'. Sounds like a husband and wife relationship. So who is the alpha male in this safety conjugal relationship because neither partner has balls?

Then this 'nugget' from Toga boy;

"ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities".

Hmmm, funny that. Wasn't it just within the past few years that the head wobbling bearded buffoon Beaker was constantly moaning and mumbling at Senate Estimates about not having enough manpower and not enough funds? And that is where things get interesting because if we aren't getting to the bottom of accidents in a timely manner then the associated risks or causal factors remain open and until such time that the investigation is finished, root cause is determined and any outstanding risks are mitigated and are closed out, the risk remains. And let's not forget that according to CAsA's holy SMS the CEO, the accountable person, is responsible for providing adequate resources, including manpower and money, to get the job done safely!! Different set of standards for Regulators and Investigators perhaps? Just asking the question..........

Will this accident end up containing causal factors that link back to poor Government oversight of regulations and accident investigations? Don't know. But I'm sure that if there is so much as a whiff of pooh around all of this then the Senators will be on to it.

What do you think NFI Chester? You understanding any of this old mate? Nah, I didn't think so you dopey twat.

TICK TOCK (still)

[Peetwo]

4D - DOT,DOT,DOT-DASH,DASH,DASH-DOT,DOT,DOT -

Latest from Accidents - Domestic:

"Pilots untrained to deal with 'feathering' failure that may have caused DFO crash: experts"

Bollocks – sentence 1.

Failures in both the engine and 'feathering' system, that pilots are not trained to deal with, may be behind Tuesday's fatal plane crash, experts say.

Complete utter rubbish; the first class ‘auto-feather’ and ‘rudder boost’ system are ‘assist’ only. They are categorically not to replace a well trained pilot.  Nor should these systems  ever be totally relied on as the ‘definitive answer’ to an engine failure in the ‘low-slow’ configuration. Even if both systems failed, simultaneously at the most critical moment it would matter little to any pilot who had been ‘trained’ to actually fly the aircraft, rather one only trained to pedal ‘the box’ around the sim exercise garden circuit.

Item one – failed engine – big yaw – big rudder; balance is all. Rudder boost failed – so what, use muscle and trim, but do NOT allow the ‘yaw’ to continue.

Item two – failed engine – balanced aircraft – failed unit identified; feather and fuel off – or Fuel off and feather for fire –no matter – reduce the drag – quickly; after correctly identifying the ‘failed’ power unit.

Item three – Speed – must have – and the ‘right’ one then maintain that speed until clear of obstacles – power available from live engine; performance available from setting up the right ‘asymmetric balance’ take height with speed stabilised; clean up; sort it out then get on the radio and back to earth a.s.a.p.

There are several items which must be considered during this difficult first thirty seconds; e.g. what is there to bang into and how best to avoid it – in terms of given altitude and rate of climb being produced; it is important to remember that the undercarriage will take a longer period of time to retract, (hydraulics question) which will delay accelerating to and achieving the Single engine best rate of climb speed (SEBROC). In fact SEBROC may not be achieved initially; but, a well managed take off takes the aircraft very quickly through the ‘speed gates’. A Be 20 should, on a runway like Essendon be doing 110 -120 knots as the gear comes up before the end of the runway. The old Dash 41 models rotated at 92 (ish) knots and went very quickly through safe single engine speed 104 achieving 115 Kias* (single engine best rate of climb) with the gear retracting SEBROC 121 Kias came within seconds, followed swiftly by Multi engine best rate of climb speed @125 Kias.  In not technical short, from 80 Kias through to 160 Kias (normal climb) happens very swiftly, the only real ‘grey’ period is between 90 and 115 Kias.  ( Sorry P&W- 41 numbers; 42 not to hand). *KIAS – Knots indicated Air Speed.

It is a great mistake to sit back and do nothing while relying on rudder boost, auto feather and the gods to drag you through the very short ‘grey’ period. It is reprehensible for this reliance to become normal; it is completely irresponsible to teach this dependence as a requirement.

I want to know who trained this pilot, I want to know where his ‘retraining’ was done after the Hotham scare. I particularly want to examine the sim print outs and the check list procedures and who’s sim was used to execute these procedures.

FFS someone; get into a Be20 with a camera and a stopwatch; watch the airspeed and altimeter; you will be amazed at the speed which the aircraft achieves safe flight speeds; then do it again for an EFATO with a ‘proper’ King air pilot; use the RFDS, and, be even more amazed as the aircraft, properly handled, breezes through the event; even with the rudder boost and auto-feather disabled.

Lord I am tired to my very bones of bloody ‘experts’ and their empty headed rational.

Aye well – what can you do – except try to explain it to the ‘media’ again and again and again. The up side is they’ll have forgotten it all by next week and we can have a real look at this accident.

Toot toot.

Not wanting to pre-empt any of the good folk on the coal face of this tragic CFIT accident but I see some disturbing similarities to the fatal Darwin Brasilia training accident, that the Dr 'Ghost who walks' Walker took issue with in relation to the PelAir cover-up:  

"There's a hole in the cheese dear Liza, dear Liza??" 

Who'd of thought? The Ferryman doing 'an evening twiddle' just short of the 'witching hour' on a Sunday night? Maybe like the rest of us mere mortals, this bollocks daylight savings has disturbed his evening routine..

Anyway job well done Mr "K"...   (Ps & TY for the edit I was bit rushed with my last - )

Ok onwards & downwards with the dot joining...

Quote from: Opinion :-ATSB since 2003.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they provide further examples of compromised ATSB Final Reports.

In case you need a reminder of the circumstances of the Darwin Brasilia accident, here is a disturbing ATSB simulator animation of that tragic C&T accident: 

From earlier post#33 "K" said:

..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...

And just before the Senate PelAir inquiry, on the 6th August 2012, a certain 'senior' ATSB Transport Safety Investigator (who I believe was actually Dr (BASR) Walker), said this about the Braz tragedy:


{P2 comment - To put this in context this was just prior to the release of the original nearly 3 year, totally shambolic, politically & bureaucratically obfuscated VH-NGA ditching investigation final report}

Now in an effort to track down the 'unflattering comments' that so offended Dr (BASR) Ghost-Who-Walks, I raided the UP archives based on the timing and this is (much to my amusement..) was what I discovered: Air North Brasilia Crash in Darwin (Merged) #446

Without this diverging into a mixture vs closed throttle vs Flight idle vs zero thrust debate has anyone noticed the gradual decay of the quality of investigation reports coming out of the ATSB?

Besides the Hempel Inquest, where the ATSB appears to have abrogated all responsibility to investigate at all, the ATSB report into the Brasilia accident in Darwin is nothing short of totally spare in its conclusions!

There also appears to be no 'Safety Recommendations' generated from a training accident that I think we could have all learnt a lot more from.

Take a look at a couple of extracts from the report:

Quote:
Terminology used in training and checking
The operator’s documentation did not contain any specific terminology for discontinuing a manoeuvre, but did provide clear instruction as to how control of an aircraft was to be changed between crew members.
To take over control from the pilot flying, or for the pilot flying to relinquish control to the other pilot in a multi-crew aircraft, very specific terminology was used. To avoid any confusion as to which pilot was manipulating the controls, the operator’s General Policy and Procedures Manual, section 4.7.2.2 Crew Communication - Handing Over and Taking Over stated:
The process of handing over control of the aircraft shall always be conducted in a positive manner. To minimise confusion or operational risk, the following terminology shall be used.
To assume control, the pilot monitoring shall call "taking over". To relinquish control, the pilot flying shall call "handing over".
Control of the aircraft cannot be handed over until the pilot monitoring has called "taking over"...
The term ‘disengage’ that was used by the PIC during this simulated engine failure was not standard phraseology. Other EMB-120 pilots reported that they had never heard the term ‘disengage’ used for any action other than deselecting the autopilot/yaw damper and had never heard it used to discontinue a manoeuvre.
They also reported that if a training or check pilot decided to discontinue a simulated engine failure procedure, they would expect that check pilot to restore power to the ‘failed’ engine. Alternately, if the training or check pilot wanted to assume control of the aircraft, they would expect to hear the term ‘taking over’.

Which is pretty basic stuff in a multi-crew aircraft....and then in regards to the Yaw Damper....

Quote:
The operator’s flight operations manual for the EMB-120 stated that the yaw damper was not to be used for takeoff or landing, and that the minimum speed for its use during one engine inoperative (OEI) flight was 120 kts indicated airspeed (KIAS).

.....and then more in relation to the apparent Yaw Damper activation...

Quote:
The use of the yaw damper during asymmetric flight was introduced to the simulator testing following consideration of the cockpit voice recording references to the PIC’s command ‘disengage’ and the pilot under check’s response, ‘yeah, disengaging’. It was assumed that the reference was to the yaw damper and not the autopilot because the chime that sounds when the autopilot was disengaged was not heard on the CVR recording. Additionally, the simulator instructor reported having previously observed pilots engage the yaw damper during simulated engine failures in the EMB-120 in response to pilots ‘overcontrolling’ rudder and aileron following a simulated engine failure.

All of the above is all good factual investigative methodology a lot of which points to a number of operational issues (company SOPs etc) and regulator oversight issues....right?? Wrong, take a look at the first paragraph of the ATSB conclusion.

Quote:
No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified as a result of this investigation.

Maybe this conclusion is a result of the regulator putting in place the Mandatory Simulator program and subsequent NPRM leading to the current NFRM, but does it excuse glossing over what was a particularly significant training accident event that, although tragic, we could all have learnt from!

ps ....and what gives with the no 'Safety Recommendations' issued!

http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf

With "K" in tow, the discussion went on down the page:

Now I'm curious

---

I find I am once again forced to read between the lines of an ATSB report. Technically it's spot on; for example, reading the time line analysis, there is a temptation to question the rudder v aileron input, however this is clearly resolved in the computer simulation graphics. Not having operated a Braz – there are a couple of points of interest which perhaps can be explained by someone who has.
Disengage ?? –could this refer to the Flight Director or is it the Yaw Damper ?. I note the AFM mentions –(paraphrased) FD Before take off (SET), expanded to PF select GA and check 7° pitch up; and, that the AP or YD may not be engaged during TOFF and LAND manoeuvres.

Has it been SOP for the PF to engage the YD as part of an EFATO or was this a recent innovation ?.

The V1, Vr and V2, V2 +10, etc. schedule. The AFM seems to be clear about the speed schedule and the acceleration to V2 +, then flaps up then Vfs (paraphrased). There appears to be a deliberate reduction from V2 + 4 (at – 23 seconds) to V2 (at -20.7 seconds). Is this a norm for the type or a new innovation ?.

Is the un monitored management of the OE, the over torque (124%) and the corresponding rudder/aileron excursions normal for the airborne exercise being conducted ?.

It is suggested by the ATSB final analysis that the BASI recommendations made after an investigation into the Flight Idle v Zero thrust (auto feather) scenario have been ignored. There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

P.S. Categorically not having a pot shot at the crew, the company or the simulator. Just seeking a satisfactory explanation of why and how this 'abnormal' chain of events occurred. If this was a new ME instructor and an initial twin conversion, perhaps this event may have occurred, but it wasn't – was it.

   
Which I followed with:

Quote:
It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

A lot of what was covered in the ATSB report touched on the areas of operational concern and hinted to several differences in history where the Check Pilot had started to diverge from his 'norm'. This quote from page 54 of the report is significant:

Quote:
Two of the pilots who were recently assessed by the PIC reported that he selected flight idle (zero torque) to simulate an engine failure after takeoff in their check flights. It was possible that the PIC had decided to deviate from the operator’s approved procedure in order to test the recognition by the candidate of the additional failure of the autofeather, before setting zero thrust.

 
However it isn't clear whether this 'divergence' from his 'norm' started after he had been to the simulator or before. If it was after then one may suggest that he was operating in a 'simulator induced complacency' manner i.e. it was proven that Flight idle (aircraft) or 'Autofeather Failed' engine failure (simulator) could be successfully recovered from while conducting a V1 cut.

This also appears to have been an area of concern for the regulator, as they used this accident as an example in Annex A of the NFRM for Mandatory Simulator, see here:

Quote:
From CASA NFRM Mandatory Simulator training Annex A:

COMMENT 1.2
Some respondents proposed adding wording to allow training and checking to occur in the aircraft provided the exercise had been conducted by all pilots in a simulator in the preceding 12 months.
CASA Response
CASA is firmly of the view that where a qualified STD is available for aircraft of this size, this should be used for all training and checking activities. The ATSB has reported that the training captain of the aircraft involved in an accident in Darwin in March 2010 had undergone training and checking in a flight simulator, however the actions by the training captain in simulating an engine failure in the actual aircraft during the accident flight was not consistent with the training received during the simulator course. This suggests that doing one session of training and one check per year in an STD (with the subsequent session/check in an actual aircraft) does not satisfactorily address the risk of conducting non-normal exercises in an actual aircraft.

If the Check Captain was inducing this scenario (FI V1 cuts) prior to having gone to the simulator, whereas previously he always only induced a Zero Thrust EFATO scenario, then there must have been input from somewhere/someone to change him to suddenly start breaching the company T&C SOPs??

As 'K' suggests there has been many takes, ambiguity and debate..etc..etc..on the regulatory requirements of CAO 40.1.0:

Quote:
There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

Maybe there is an element of rogue FOI's, that lack the necessary industry experience, that insist on adhering to the letter of the law in CAO 40.1.0. Instead of applying practical safeguards and risk management to high risk training and checking scenarios!!

 
So am I offended that 'his nibs' Dr W#*ker believes that I have no idea about what an "..organisational issue actually is, and when it is, or is not important.?"  - Not on your life I luv it... 

In light of the Kharon post and considering it is still way to early to really speculate, but reflect that this is not realistically about some spurious lack of training in a 1 in a million auto fx or rudder boost failure after EFATO. Potentially this is about why two experienced professional aviators - one a senior Training & Check Pilot with years of experience instructing and C&T; the other a 38 year experienced Charter Pilot with presumably much experience on type (B200) that was recently checked (& re-checked) by CASA - would appear to have deviated from what would be regarded as their baseline 'normal' for dealing with (simulated or real) abnormal or emergency twin turbo-prop aircraft operations - just saying...


MTF? - Definitely...P2

[Pixie P]

Delusions of adequacy??

I may be imagining things, but I recall a time when the ATSB produced a half-decent report on aviation accidents and incidents.
The 2001 Toowoomba C90 accident comes to mind. I may be completely wrong of course, and the memory does play tricks.. please correct me if they made a hash of that one too.

It seems things go from bad to worse, but surely the downward spiral of ineptitude can't continue indefinitely?
Actually.. it probably can get worse. If you were writing a performance appraisal on Chester & friends, a likely summary would read: 'He has reached rock bottom and has now started to dig'

It's to be hoped that these entities rediscover the fundamentals: Accurate reporting and relevant recommendations, produced in a timely manner.

Surely that isn't too much to wish for?

[Peetwo]

Delusions of adequacy??

I may be imagining things, but I recall a time when the ATSB produced a half-decent report on aviation accidents and incidents.
The 2001 Toowoomba C90 accident comes to mind. I may be completely wrong of course, and the memory does play tricks.. please correct me if they made a hash of that one too.

It seems things go from bad to worse, but surely the downward spiral of ineptitude can't continue indefinitely?
Actually.. it probably can get worse. If you were writing a performance appraisal on Chester & friends, a likely summary would read: 'He has reached rock bottom and has now started to dig'

It's to be hoped that these entities rediscover the fundamentals: Accurate reporting and relevant recommendations, produced in a timely manner.

Surely that isn't too much to wish for?

Top post Pix and indeed the Toowoomba C90 fatal prang was an exemplary ATSB report... : Beech Aircraft Corporation C90, VH-LQH, Toowoomba, Qld

& supplementary report: 200507077

However the issue with that report was not with the ATSB but with CASA, who effectively O&O'd most of the ATSB safety recommendations and Coroner conclusions that were addressed to them - see page 7 to 10 in PAIN report: Response to Coronial inquiry. Fatal air accidents.   

Coroner Barnes.

http://www.courts.qld.gov.au/__data/asse...070809.pdf

Relevant quote: “It is impossible to say that had CASA been more searching during the audit undertaken in the period 20 – 23 August 2001 that the problems that lead to the fatal crash would have been detected. Nonetheless the failure of CASA to make any further inquiries in relation to these aspects of the operator’s maintenance systems and performance was, in my view, less than the public could reasonably expect of the authority.”

---

Comment – April 2012.

CASA argue throughout the ATSB recommendations and Coroner’s inquest, that their approval, audit and surveillance systems are robust enough to capture non-compliant, rogue elements of AOC or COA holders. However the evidence would seem to indicate otherwise. Therefore, we believe, some of the causal factors in this accident have not been addressed by the regulator and remain ‘high risk’ for a similar accident scenario occurring.

MTF...P2

Ps. Maybe some interesting parallels to rake over between the C90 Toowoomba prang and the tragic B200 Essendon fatal accident - reference pg 7 para 5 & 6:

(5) The ATSB recommends that CASA consider providing formal advisory material for

operators and pilots, based on relevant research and publications, about managing

engine failures and other emergencies during takeoff in multi-engine aircraft below

5,700 kg MTOW. This material should include the factors to be considered by operators

when developing procedures for responding to such emergencies.

(6) The ATSB recommends that CASA consider and evaluate options to improve the

suitability of industry practices for training pilots to make appropriate decisions when

responding to engine failures and other emergencies during critical phases of flight in

multi-engine aircraft below 5,700 kg MTOW. This review should include an assessment of

the suitability of utilising synthetic training devices for the purpose of training pilots to

make decisions regarding emergencies.

& from Kharon Accidents - Domestic thread post:

"..Anyway - since when in this good world, was ‘V1’ ever, ever a consideration in the performance manual or even the approved certification data for the type? Never is the correct answer. Then the ‘expert’ fails to mention that the Auto feather would kick in and that saves valuable seconds at the ‘imaginary’ V1 cut; remember, V1 is but a fleeting second of time – a heartbeat. If you are using a ‘tight’ field length it is prudent to manage the T/Off speed schedule to make damn sure that you can either safely stop or safely go. This means a schedule which gets the aircraft as quickly as possible – to a ‘safe’ speed; preferably above single engine climb speeds. Why? Well if you ‘loose’ one below that speed, it is a sods job to accelerate and gain the additional speed needed for climb; but if you have obtained a better speed than minimum when you ‘loose’ it; even if the aircraft decelerates, then climb is still possible, even probable. There is that wonderful moment when the ‘Speedo’ ticks through to climb speed and the climb indicator shows a positive ‘UP’. Aside, you do realise there is a CASA mutt knocking about who even tries to insist that a reduction from a happy V2+10 to the scheduled V2 is the only ‘right’ way to manage a single engine climb.."

"K" - I did eventually remember to qualify the availability of FAR 25 performance data , with the attached conditions.Toot toot.