[P7_TOM]

I have just realised we do not have a ‘Pel-Air’ thread. I expect, as the years roll by most think it has devolved into ‘history’. This ain’t so.

The endless wait for the revision of the revised report has blunted interest. Seriously, ATSB will probably only release ‘their’ version of the thing when Trump declares war on China  - just to make sure it get lost in the drama – failing that they are holding off until Karen Casey’s judgement is handed down. But, they do have a problem, in fact they have as many problems as CASA does.

Give you a for instance (one of the many).

The Pel Air ‘fuel’ policiy, versions I and II have, somehow, fallen into the hands of those who know about such things –.  Both versions, one on which James was operating, have been branded as either amateurish twaddle or, flying school basics. Neither constitutes a ‘professional’ briefing; or, indeed a reasonable facsimile of ‘policy’; both being fatally flawed, legally and operationally. I will see if I can get the policies on site soon, let the troops have a look-see.

The ATSB claim to be ‘investigating’; I’d like to know if they have investigated who, in CASA, ‘accepted’ as satisfactory, this crock of total bollocks and allowed maximum range operations, internationally, under the IFR to continue on such a basis.

“Ah” says the CASA backroom; “we only accepted it, therefore – all care, no responsibility”. They forget that by issuing an AOC, they offer ‘approval’ for the operations, as writ and accepted. The Pel-Air ‘fuel policies’ V1 and V2 are an absolute travesty. No doubt, they too are all parlayed into being Dom James fault.  The hell they are.

Time for a question or two to the minister of NFI I think; at least that will be entertaining.

[Peetwo]

PelAir cover-up & the 'for instances' -

The inference that the latest O&O on MKII is due to waiting on KC's final judgement is disgusting but typical. How the ATSB can dare to declare themselves an independent, 'no blame' AAI operating, in the spirit & intent of ICAO Annex 13 is risible and proves beyond all doubt why it was PAIN had major disagreement when the ATSB first announce the re-investigation of their VH-NGA cover-up investigation... : O&O #2
 

...“We believe little will gained by utilising scarce resources re-investigating the original ATSB investigative ‘reports’.”

Instead, PAIN points the finger of blame for the original Pel-Air investigation report squarely at the both CASA and the ATSB and hints at deeper issues.

“Our greatest concern is that a deliberate, calculated manipulation of the national aviation safety system was attempted. It is not a ‘one off’ aberration. We firmly believe that the subsequent actions of both the Civil Aviation Safety Authority (CASA) and the ATSB were proven, by the AAI [RRAT inquiry] committee, to grossly pervert the conclusions of the ATSB investigation to suit a clearly predetermined outcome, thus denying industry valuable, safety related knowledge and information.

“It is the process by which these subsequent events occurred which demands an independent investigation conducted  transparently in public. We believe the Senate Committee is the right reporting and oversight platform for that investigation. The committee Senators are well briefed, informed and have a firm, current understanding of what transpired during the events subsequent to the Pel-Air aircraft ditching off Norfolk Island.

“Further, the Estimates committee is very clearly ‘awake’ to the machinations of the various aviation oversight bodies and will not easily be misled or confounded by ‘technical’ issues.

“We submit that any other form of investigation will not withstand the scrutiny of industry experts; as the initial premise is fatally flawed.”...

'Lest we forget'

PelAir & beyond - 'Lest we forget'


The PelAir Norfolk Island ditching came so close to being our first international aviation fatal accident. All on-board miraculously survived and therefore the accident never ended up in the Coroner's Court. However there was still much to be learnt - or there should have been much to be learnt - from one of the rarest survived aviation occurrences, that is a night ditching in open sea conditions of an aircraft. 

However IMO the PelAir cover-up highlights perfectly how our aviation safety system (Annex 19 SSP) is currently so fundamentally & reprehensively broken.

As a reminder of how far we have drifted from the ICAO principles for an effective State SSP, one need not go past the following post from Ziggy...  - The tale of Karen Casey #post65  

---

PelAir - 'Lest we forget' Part II

I note that in the very entertaining Estimate's session on Monday, that there was several references to the PelAir cover-up & indeed the "Chambers Report"...
  

Therefore Ol'Tom good initiative with the thread, if for no other reason than to send the message to these bureaucratic parasites that we haven't forgotten...  

So in order to refresh everyone's collective memory I will endeavour to assist with the many 'for instances' involved in the PelAir cover-up debacle...

On the 'fuel policy', while P7 is endeavouring to track down a copy, it is worth revisiting parts of the Chambers manipulated and obfuscated Special Audit report: http://www.abc.net.au/4corners/documents...t_2009.pdf

---

It is also worth referring to page para 1.18.3 66-69 (pages 22-25 of CAIR 09/3) of attachment 5 of the CASA Senate Inquiry submission. Strangely large parts of para 1.18.3 seem to contradict the Special Audit report...  

Also for reference there is pages 28-32 of the original defective/deficient ATSB final report - see HERE.


MTF...P2  

[Kharon]

As the stomach churns.

Much obliged P2, as time slips away it is important to remember the size, scope and implications of the Pel-Air investigational aberration. The accident itself never really had ‘star status’ and, had the investigation been remotely ‘Kosher’ then it would have served as a grim reminder, the tombstone bearing the legend only dragged out for training purposes.

But that investigation has been proven to not only be flawed, but tainted with the stench of something which, IMO, resembles the outright corruption of all regulatory and investigative tenets. The Senate inquiry committee certainly got a whiff of it; the good Rev Forsyth almost gagged on it; and yet the party continues, unabated to this day.

The Pel-Air ‘fuel policy’ is but one example of a total failure of the safety net system. The failure begins within the company operations manual and ends with the ATSB being satisfied that ‘suitable’ corrections had been made and that it was ‘safe’ for continued operational use. BOLLOCKS.

This 'policy' is typical of normalized deviance, writ by the company, approved by CASA, supported by ATSB. For starters, whoever wrote version one should be pilloried, it is barely compliant with the regulation and of no value whatsoever to an operating aircrew. That this ‘policy was accepted by CASA as part of the approval for the issue of an Air Operators Certificate, stand alone, is grounds for serious examination of the FOI responsible and questions the approval of the chief pilot who either wrote it – or; accepted the policy as being suitable for the proposed operations. Version 1 may, just, have been acceptable as a primer for private pilot navigation training, if supported by extensive briefing; but as a working tool, for long range operations in jet aircraft -. Very few professional airmen would be prepared to work under such a thing.

The second iteration, Version 2 is a simple rehash of V1 and equally dangerous, operationally and legally as the first. This version was deemed, by the CASA, supported by ATSB to be righteous. BOLLOCKS.  

Once you realize that the fatally flawed fuel policy is only a very small, but easily understood part of the whole failure of both CASA and ATSB to ‘do their job’, it follows that any further investigation by either agency will be equally as flawed as the first.

If the ATSB ever get around to releasing the report it will reflect this as fact, in each of what is expected to be a 300 (+/- 50) page epistle, which will do little except dilute and obfuscate the radical problem.  If you take a simple thing like a fuel policy and examine the system which allowed it to effectively become ‘law’ the depth and breadth of the abject failure of the Australian ‘safety net’, one of the world most expensive, becomes abundantly clear. No one; not the chief pilot, the CASA or the ATSB gives a monkey’s about preventing a crew for running short of fuel, for wont of guidance and clarity. No, but the useless policy 'satisfied' regulatory requirements just fine.

MTF is a very safe bet; the tales from the West-wind factory alone will provide a year’s worth of pure entertainment; I know they are still laughing.

Aye well; I’ve just finished knitting my party hat, I used acceptable, suitable and departure alternates as a base, added a little cross checking, some PNR, a dash of operational control and some rather pretty little warning bells – just for show.

For an example of what to expect from the ATSB – see here.

Toot toot.

[Peetwo]

#PelAir cover-up: The 'for instances' continued - 

...why it was PAIN had major disagreement when the ATSB first announce the re-investigation of their VH-NGA cover-up investigation... : O&O #2

PelAir & beyond - 'Lest we forget'

The PelAir Norfolk Island ditching came so close to being our first international aviation fatal accident. All on-board miraculously survived and therefore the accident never ended up in the Coroner's Court. However there was still much to be learnt - or there should have been much to be learnt - from one of the rarest survived aviation occurrences, that is a night ditching in open sea conditions of an aircraft. 

However IMO the PelAir cover-up highlights perfectly how our aviation safety system (Annex 19 SSP) is currently so fundamentally & reprehensively broken.

As a reminder of how far we have drifted from the ICAO principles for an effective State SSP, one need not go past the following post from Ziggy...  - The tale of Karen Casey #post65  

---

PelAir - 'Lest we forget' Part II

I note that in the very entertaining Estimate's session on Monday, that there was several references to the PelAir cover-up & indeed the "Chambers Report"...
  

Before we move onto more 'for instances' that question the veracity, independence and ongoing mendacity of the continued O&O'd ATSB PelAir cover-up (re)-investigation,  it is worth reflecting on the now historical 'we told you so' PAIN supplementary Senate RRAT submission - PA_Review   

Executive summary.

1) The purpose of this report is to draw to the attention of the Aviation Accident

Investigation (AAI) Senate Committee members, who participated in the Pel-Air

inquiry several matters of grave concern raised from within the PAIN network.


2) In short, we are certain that the committee is very aware that the Australian

Transport Safety Bureau (ATSB) has grudgingly condescended to re-open the

investigation into the 'report' of that incident. The following are of concern:-

a) That the ATSB have elected to utilise Dr. Michael Walker of the ATSB to lead the

investigation. We believe that to be effective, any investigation should be

conducted independently and not involve ATSB, the commissioners or staff if only to

preclude any suspicion of 'internal' influence or external bias being raised.

b) The terms of reference cited by Mr. Sangston are narrow and only mention the

'report' itself. Whilst the industry acknowledges that the report was substandard,

there is little doubt that the investigators conducted their work with integrity and

within the prescribed guidelines. Indeed, the early stages of the ATSB report were

exemplary and clearly directed toward serious safety recommendations being made.

We believe little will gained by utilising scarce resources re-investigating the original

ATSB investigative 'reports'.


3) Our greatest concern is that a deliberate, calculated manipulation of the national

aviation safety system was attempted. It is not a 'one off' aberration. We firmly

believe that the subsequent actions of both the Civil Aviation Safety Authority (CASA)

and the ATSB were proven, by the AAI committee, to grossly pervert the conclusions

of the ATSB investigation to suit a clearly predetermined outcome, thus denying

industry valuable, safety related knowledge and information.


4) It is the process by which these subsequent events occurred which demands an

independent investigation conducted transparently in public. We believe the Senate

Committee is the right reporting and oversight platform for that investigation. The

committee Senators are well briefed, informed and have a firm, current understanding

of what transpired during the events subsequent to the Pel-Air aircraft ditching off

Norfolk Island. Further, the Estimates committee is very clearly 'awake' to the

machinations of the various aviation oversight bodies and will not easily be misled or

confounded by 'technical' issues.


5) We submit that any other form of investigation will not withstand the scrutiny of

industry experts; as the initial premise is fatally flawed. The potential for further

disingenuous obfuscation is obvious. This will, ultimately, be detrimental, not only to

the travelling public and industry, but to the government which allowed one authority

to investigate it's own wrong doings, but avoided investigating those agencies and

their officers, which aided and abetted the travesty, which was the Pel-Air accident

investigation became.

Ok back to the 'for instances'...

CASA discombobulating & the PelAir tick-a-box SMS -

With the ATSB now 2 plus year re-investigation, it should be safe to assume that there will more a proactive review of the historical CASA oversight/audit of the significant elements of the pre-ditching CASA approved PelAir AOC.

Therefore for the benefit of readers, the first publicly available document that can be reviewed is a May 2008 PelAir CASA CAR 217/T&C audit report - see HERE - in particular the 'audit summary' pages 3 thru 7.

'Evaluation' extracts... :

 
In terms of aviation safety, by definition such elements as T&C (CAR 217), FRMS and even 'fuel policy', all fall under the CASA approved PelAir Safety Management System (SMS). The  CASA Special Audit report examines the PelAir SMS from page 38 to 42:

    
Keeping the 2008 audit report in mind take note of some of the disturbing findings on page 42.. :

Now compare the findings of both the 2008 & 2009 CASA audits to the findings, causal factors/contributory safety factors & conclusions sections of CAIR 09/3 (pdf pg 77-81) and ATSB VH-NGA original final report (pages 43-44):

Contributing safety factors

• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Other safety factors

• The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert. [Minor safety issue]
• Given the forecast in-flight weather, aircraft performance and regulatory requirements, the flight crew departed Apia with less fuel than required for the flight in case of one engine inoperative or depressurised operations.
• The flight crew’s advice to Norfolk Island Unicom of the intention to ditch did not include the intended location, resulting in the rescue services initially proceeding to an incorrect search datum and potentially delaying the recovery of any survivors.
• The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands. [Minor safety issue]

Other key findings

• At the time of flight planning, there were no weather or other requirements that required the nomination of an alternate aerodrome, or the carriage of additional fuel to reach an alternate.
• The aircraft carried sufficient fuel for the flight in the case of normal operations.
• A number of the flight crew and medical personnel reported that their underwater escape training facilitated their exit from the aircraft following the ditching.
• The use by the flight crew of the aircraft’s radar altimeter to flare at an appropriate height probably contributed to a survivable first contact with the sea.
• The observation of the pilot in command’s torch re-directed the search to the correct area and facilitated the timely arrival of the rescue craft.

Hmm...can anyone else spot the disconnect...


MTF...P2  

[Kharon]

A question for the minister.

P2 – “With the ATSB now 2 plus year re-investigation, it should be safe to assume that there will more a proactive review of the historical CASA oversight/audit of the significant elements of the pre-ditching CASA approved Pel-Air AOC.”

PAIN – “5) We submit that any other form of investigation will not withstand the scrutiny of industry experts; as the initial premise is fatally flawed.  The potential for further disingenuous obfuscation is obvious.  This will, ultimately, be detrimental, not only to the travelling public and industry, but to the government which allowed one authority to investigate it's own wrong doings, but avoided investigating those agencies and their officers, those which aided and abetted the travesty, which is, in reality, exactly what the Pel-Air accident investigation became, internationally, recognized as.”

The incredible amount of time the ATSB have taken to revisit their own report is only a small part of the complaint and protest not only industry, but politicians of all parties should be making on behalf of the tax paying, travelling general population.

PAIN – “3) Our greatest concern is that a deliberate, calculated manipulation of the national aviation safety system was attempted. This, despite contrary, departmental input, is clearly not a 'one off' aberration. We firmly believe that the subsequent actions of both the Civil Aviation Safety Authority (CASA) and the ATSB were proven, by the AAI committee, to grossly pervert the conclusions of the investigation, to suit a clearly predetermined outcome, thus denying industry valuable, safety related knowledge and information.”

Paragraph 3 of the PAIN introduction defines the radical concern. These concerns have not been addressed in any way shape or form. A fact independent research undeniably confirms.  The Senate AAI committee made some 30 recommendations for reform of the regulator; these have, for all practical purposes, been ignored. Those recommendations went to the heart of the matter; the complete lack of trust industry has in the probity of two safety agencies; the breaking of that trust was not of industries’ doing. The ASRR confirmed this as further proof of fact, with an additional 36 recommendations to the Senate deliberations.

One of the more alarming results of the independent study defines, very clearly, not only the very ‘soft ride’ the Pel-Air operating certificate was afforded in terms of operational scrutiny, but in surveillance of the CASA approved operations. Standing alone, this fact is worthy of investigation.  This is not however the most serious concern raised through investigation.

Any comparison between the actions of CASA and it’s officers involved in the closure of Airtex aviation and the almost indecent rapidity with Pel-Air were granted absolution provides a picture which is both stark and clear.

Not only were CASA prepared to overlook the glaring organisational and operational shortcomings at Pel-Air, they were prepared to go to extraordinary lengths to minimise that lack. The treatment of Airtex was diametrically, demonstrably opposite. In depth analysis of the Airtex ‘treatment’ reveals numerous instances of what are alleged to be serious breeches of law, policy and accepted protocol committed by CASA officers during the Airtex audit and subsequent AAAT hearing.

It is not realistic to expect a whole industry to trust or be prepared to ‘co-operate’ in a any form of regulatory reform process until there can be a modicum of trust in the regulator. There is only one way to resolve the situation. The minister must open a judicial inquiry to allow complaints made by industry participants against CASA to be tested. This process is the only option available to ‘clear the air’. There is to be a new DAS; it would be highly desirable to begin the new administration with a ‘clean sheet’ and trust between the regulator and those it regulates re established.

As matters stand now there is little prospect of genuine regulatory reform or, trusting, genuine cooperation. Nor will there be, not until festering resentment is treated with open, fair, impartial rulings made against ‘law’ rather than malleable policy and questionable motives.

This could be achieved without the expense of a Royal commission or the natural delays which encumber the Senate process. A judicial inquiry, in camera would quickly reveal if there was indeed a case for CASA to answer.

A question directed to the minister, asking if he is prepared to resolve the conflicted opinions would reveal whether or not CASA is prepared to stand in a court of law, defend their past actions and be governed by the rule of law. The Pel-Air and Airtex comparison would be a good place to begin the journey.

Selah.

[Peetwo]

Latest PelAir undercover update -

Two days ago on of Planetalking's more observant readers happened to notice that the PelAir cover-up re-investigation had recently been updated... :

ETA for re-done Pel-Air crash report now set for this March

[i]It's now likely that the re-done final investigative report into the Pel-Air crash in 2009 will be published before MH370 is found[/i]

Ben Sandilands


This 3 year old ABC TV graphic is the best done of the moment Pel-Air went down

The much delayed second final investigative report by the ATSB on the Pel-Air medi-vac  flight’s ditching near Norfolk Island in 2009 is now expected to land next month.

The air crash investigator has posted this note on its [b]Pel-Air pages[/b]:

[b][i]During the normal internal investigation review process, the investigation team identified the need to obtain additional information from some organisations in order to clarify various matters. In addition, significant time was allocated to refining analyses of flight recorder data and the aircraft’s fuel status during the accident flight. These activities have delayed the finalisation of the draft report.[/i][/b]
[b][i]It is now expected that the draft report will be provided to the Commission for their consideration and approval in March 2017.[/i][/b]
[b][i]The ATSB’s next update will advise when the draft is released to directly involved parties.[/i][/b]

Thanks to reader Jaeger for picking this up.

 
So in typical ATSB O&O style, this update was released without any fanfare, no media releases, MSM or social media statements, which also conveniently coincided with the media furore of the tragic Essendon crash...


MTF...P2

Ps Chocfrog for Dan Dair for this nail in head comment..

Dan Dair
February 23, 2017 at 7:59 am
I almost laughed out loud when I read this;

“During the normal internal investigation review process,”
Really…?

This is part of a ‘normal’ review process which involved a peer review by the TSB of a completely different country after the ATSB had stood by it’s now discredited report for years.

Only when the Canadian TSB told the ATSB that it’s original report was complete rubbish…. ( I think it actually said significantly flawed.?)

did the ATSB start to re-investigate the Pel-Air crash.
And the ATSB will be over a year late on their original timeline for the new report to be published.

Thank God for Ben, Nick Zenophon & the Canadian TSB.

[Peetwo]

Estimates deferred & VARA ATR accident 3rd Anniversary -

Unfortunately they ran out of time to have Hoody & crew appear at Estimates last night. However I have it on good authority that an additional public hearing date will be announced by the committee, hopefully sooner rather than later...

AAI & the implications of bureaucratic O&O

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

Them holes are aligning

Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering,  aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...



Courtesy the Oz:

Near miss for planes carrying 18 people  

• by: Matthew Denholm
  
• From: The Australian
  
• September 17, 2015 12:00AM
  

Tasmania Correspondent
Hobart




Too close for comfort. Source: TheAustralian

An “unsafe” close encounter ­between two planes near Mount Hotham Airport in Victoria allegedly placed up to 18 lives at risk, fuelling demands for better use of radar at Australia’s regional airports.  

According to an incident ­report obtained by The Australian, two Beechcraft B200 King Air planes on private charters from different companies — one from Essendon in Melbourne and one from Bankstown in Sydney — were vertically within 300ft (90m) of each other on September 3.

It appeared the Essendon-based pilot, struggling with a faulty GPS in heavy morning cloud and poor weather, did not know where he was and reported being in vastly different locations, varying by up to 20 nautical miles, within a short period of time.
Radar traces of this plane, chartered from small Essendon-based operator Seidler Properties, show an apparently erratic path at times, and that the scheduled 38- minute flight took an hour and 27 minutes.

The Essendon plane came within one nautical mile (1.8km) of the other aircraft and eventually landed at Mount Hotham, in the Victorian Alps northeast of Melbourne, but only after what the report by the other pilot ­described as an “unsafe” approach from the “wrong direction”. There were three other aircraft also en route to the airport at the time.

The report, titled “breakdown of separation”, says passengers on the Essendon-based plane were so shaken they refused to return with the same pilot later that day, ­requiring another to be flown to Mount Hotham to pick them up.

In a report being investigated by the Australian Transport ­Safety Bureau, the pilot of the Bankstown-originating aircraft — a senior pilot at a major charter firm — describes the situation as “not safe”.

He suggests he is making the report not to attack the Essendon-based pilot, but rather to highlight an ongoing risk of tragedy in the absence of a safety back-up in cases of pilot error at uncontrolled regional airports.

“If this event did result in a midair collision, two aircraft would have been destroyed and 18 people would have been killed,” says the Bankstown-originating pilot in the report, sent to the ATSB two days ago.

“As a chief pilot, I am significantly concerned with the breakdown of (aircraft) separation caused by this incident. This is not a standard of operation that I would tolerate from my pilots and I do not accept that his event goes without investigation.

“Two high-performance aircraft with 300ft separation (vertic­ally), within one nautical mile of each other (horizontally), in IMC (instrument meteorological conditions), is not safe.”

The incident has further highlighted the lack of radar control of aircraft to low altitudes at ­regional airports in Australia, which The Australian has documented in the series of articles over the past two months.

In uncontrolled airspace, ­pilots must communicate with each other by radio to ensure they remain safely separated, with no support from an air traffic controller monitoring them on radar or providing co-ordination.

At Mount Hotham, radar-based separation of aircraft ends at 18,000ft, below which pilots must self-separate, despite radar being available to a far lower altit­ude.

Veteran aviator Dick Smith told The Australian the latest Mount Hotham incident highlighted the need to make full use of radar coverage at regional airports to improve safety.

“If they were using the existing radar for control at Mount Hotham, neither of these things (the ­alleged mid-air near collision and subsequent alleged dangerous ­approach) would have happened, because the controller would have told the pilot what was happening,” Mr Smith said.

He said it was particularly frustrating the existing radar was not being used to control aircraft to low altitude at Mount Hotham, given the deaths of three people in a crash there in 2005 and of six people in an accident at Benalla, about 150km from Mount Hotham, in 2004. He believed both crashes could have been averted had radar control close to ground level been provided.

“How many more frightening incidents like this before there are more unnecessary deaths?” Mr Smith said.

He said all that was needed to make use of existing radar for separation control to low altitudes at regional airports was for Airservic­es Australia to provide more training to controllers at its Melbourne and Brisbane radar centres.

Airservices insist the air traffic system is safe and that levels of control around the country are appropriate for local traffic volumes and types.

An ATSB spokesman said the latest Mount Hotham incidents were being investigated.
However, an official statement on the bureau’s website refers only to the “unstable approach” to the runway; not the earlier alleged close encounter. Seidler Properties suggested it was unaware of any investigation and declined to comment.

To think this 'serious incident' may have gone unreported 
How many other similarly serious occurrences have gone unreported (I personally know of a couple) because of fear of retribution or incriminating oneself.

Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:

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


...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...

On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13:

Australia requires reporting of ‘transport safety matters’, which, through definitions
and reporting requirements in the Transport Safety Investigation Act 2003 and Transport
Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of  serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.

  
WTD...

Okay what I think the ATSB notified difference to ICAO Annex 13 on the definition of a 'serious incident' means, is that the ATSB can (read will) effectively abrogate all responsibility to investigate all 'serious incidents' under the spirit, intent and compliance of the Annex...

Therefore the ATSB practice of O&O'ing some potentially DIP sensitive 'serious incident' investigations has become a normalised SOP.

In the case of the MT Hotham 'near miss' investigation the delay can be (& probably will be) excused because the regulator CASA has conducted proactive safety risk mitigation by testing, re-testing and overseeing the proficiency checks of the incident pilot. The ATSB only need say that safety risk was being effectively mitigated.

However it is 'passing strange' that nowhere within the AO-2015-108 investigation webpage does the ATSB indicate that they have identified a 'safety issue' (i.e pilot proficiency) that they have subsequently sent to CASA to be proactively addressed. Nor is there any indication of any form of Annex 13 required 'interim report' on the 1st anniversary of the ATSB defined 'serious incident' investigation...

On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE.

(P2 - Eight days now and still no sign of any interim report on the VARA ATR broken elevator accident... )

As this thread, the A&A MH370 forum, the Essendon fatal prang and the above O&O reference post highlight, there are some serious, outstanding and somewhat perplexing questions to be asked of the Hoody led ATSB administration...



MTF...P2

[Peetwo]

ATSB still taking the Mickey Bliss on ICAO Annex 13...

Unfortunately they ran out of time to have Hoody & crew appear at Estimates last night. However I have it on good authority that an additional public hearing date will be announced by the committee, hopefully sooner rather than later...

AAI & the implications of bureaucratic O&O

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:

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


...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...

On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13: 

"..On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE..."


(P2 - Eight days now and still no sign of any interim report on the VARA ATR broken elevator accident... )

Not wanting to flog an obvious dead horse, as far as the Hood led ATSB are concerned; but the following are two ICAO references in regards to 'interim reports' and/or statements:

First to an ICAO newsroom 'fact sheet' on AI & reports:

Accident Investigation

Article 26 of the Convention on International Civil Aviation (Chicago Convention) states that, in the event of an accident to an aircraft of a Contracting State occurring in another Contracting State, and involving either death, serious injury, or serious technical defect in the aircraft or air navigation facilities, the State in which the accident occurs will institute an inquiry into the circumstances of the accident.

Annex 13 (Aircraft Accident and Incident Investigation) to the Convention provides further international requirements for the investigation of aircraft accidents and incidents. It spells out which States may participate in an investigation, such as the States of Occurrence, Registry, Operator, Design and Manufacture. It also defines the rights and responsibilities of such States.

The State of Occurrence may delegate all or part of the investigation to another State or a regional accident and incident investigation organization, and may call on the best technical expertise available from any source to assist with the investigation. States of Registry, Operator, Design and Manufacture who participate in an investigation are entitled to appoint an accredited representative (with or without associated advisers) to take part in the investigation.

A State which has a special interest in an accident, by virtue of fatalities or serious injuries to its citizens for instance, is entitled to appoint an expert entitled to: visit the scene of the accident; have access to the relevant factual information which is approved for public release by the State conducting the investigation, and information on the progress of the investigation; receive a copy of the accident investigation Final Report. ICAO officials only participate in accident investigations upon special request from the State responsible for conducting the investigation.

How are Annex 13 accident investigations reported?

States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

The State conducting the investigation of an accident or incident shall also make the Final Report publicly available as soon as possible and, if possible, within twelve months. 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. For accidents or incidents involving an aircraft of a maximum mass over 5 700 kg, States in charge of an Annex 13 investigation must make the Final Report available to ICAO.

For more information please contact:
communications@icao.int

The statement in bold reflects the general practice of most responsible ICAO signatory countries with an independent aviation accident/incident investigation capacity, as per and in compliance with ICAO Annex 13 Para 6.6:

 ..The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised.

An example of compliance by a signatory state is with the high profile MH370 investigation, which on each anniversary the Malaysian AAIB (so far) have adhered to by issuing either an 'interim factual report' (2015) and last year an interim statement.

However in the Australian case there are numerous examples where the anniversary Annex 13 SARP has been completely ignored without even a press or social media statement.

Perfect examples are in the Hotham incident - AO-2015-108 - and the just past 3rd anniversary VARA ATR accident...


MTF...P2  

Ps And in case you were wondering there is no 'notified difference' (reference page 9) for ICAO Annex 13 Chapter 6 paragraph 6.6...

[Peetwo]

ATSB still taking the Mickey Bliss on ICAO Annex 13...

Unfortunately they ran out of time to have Hoody & crew appear at Estimates last night. However I have it on good authority that an additional public hearing date will be announced by the committee, hopefully sooner rather than later...

AAI & the implications of bureaucratic O&O

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:

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


...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...

On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13: 

"..On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE..."


(P2 - Eight days now and still no sign of any interim report on the VARA ATR broken elevator accident... )

Not wanting to flog an obvious dead horse, as far as the Hood led ATSB are concerned; but the following are two ICAO references in regards to 'interim reports' and/or statements:

First to an ICAO newsroom 'fact sheet' on AI & reports:

Accident Investigation

Article 26 of the Convention on International Civil Aviation (Chicago Convention) states that, in the event of an accident to an aircraft of a Contracting State occurring in another Contracting State, and involving either death, serious injury, or serious technical defect in the aircraft or air navigation facilities, the State in which the accident occurs will institute an inquiry into the circumstances of the accident.

Annex 13 (Aircraft Accident and Incident Investigation) to the Convention provides further international requirements for the investigation of aircraft accidents and incidents. It spells out which States may participate in an investigation, such as the States of Occurrence, Registry, Operator, Design and Manufacture. It also defines the rights and responsibilities of such States.

The State of Occurrence may delegate all or part of the investigation to another State or a regional accident and incident investigation organization, and may call on the best technical expertise available from any source to assist with the investigation. States of Registry, Operator, Design and Manufacture who participate in an investigation are entitled to appoint an accredited representative (with or without associated advisers) to take part in the investigation.

A State which has a special interest in an accident, by virtue of fatalities or serious injuries to its citizens for instance, is entitled to appoint an expert entitled to: visit the scene of the accident; have access to the relevant factual information which is approved for public release by the State conducting the investigation, and information on the progress of the investigation; receive a copy of the accident investigation Final Report. ICAO officials only participate in accident investigations upon special request from the State responsible for conducting the investigation.

How are Annex 13 accident investigations reported?

States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

The State conducting the investigation of an accident or incident shall also make the Final Report publicly available as soon as possible and, if possible, within twelve months. 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. For accidents or incidents involving an aircraft of a maximum mass over 5 700 kg, States in charge of an Annex 13 investigation must make the Final Report available to ICAO.

For more information please contact:
communications@icao.int

The statement in bold reflects the general practice of most responsible ICAO signatory countries with an independent aviation accident/incident investigation capacity, as per and in compliance with ICAO Annex 13 Para 6.6:

 ..The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised.

An example of compliance by a signatory state is with the high profile MH370 investigation, which on each anniversary the Malaysian AAIB (so far) have adhered to by issuing either an 'interim factual report' (2015) and last year an interim statement.

However in the Australian case there are numerous examples where the anniversary Annex 13 SARP has been completely ignored without even a press or social media statement.

Update: 07:30 Report tonight...

Caught by Cap'n Wannabe today...

ATSB starring on 7:30 Report -

Excellent catch Wannabe...  

Also apparently going to be on the 07:30 Report tonight:
Excellent catch Wannabe...  

Also apparently going to be on the 07:30 Report tonight:

Air safety watchdog 'clearly failing': Two-thirds of investigations not completed in required time. #abc730 @L_Day http://ab.co/2mZEEUe pic.twitter.com/zWBikD3klJ

Air safety watchdog 'clearly failing': Two-thirds of investigations not completed in required time
7.30
By Lauren Day
Updated about an hour agoTue 7 Mar 2017, 4:55pm

The body that investigates air safety incidents is struggling with a massive backlog and is only completing one in three investigations inside the targeted 12-month timeframe.

Key points:

• ATSB aims to complete 90 per cent of investigations within 12 months
  
• It is only completing 29 per cent of investigations in that time
  
• Neil Hansford believes the ATSB has been hampered by the search for MH370
  

The Australian Transport Safety Bureau (ATSB) has been in the spotlight since it was revealed the pilot involved in last month's plane crash near Essendon Airport was being investigated over a near collision at Mount Hotham in 2015.

The delay in completing investigations is leaving grieving families in limbo and poses a real risk to aviation safety.

"Until a case is resolved, there can be no remedial action taken by the relevant authorities, CASA (Civil Aviation Safety Authority) or the Department of Transport or even private airport operators," aviation safety expert Neil Hansford told 7.30.

"So it's critical that the ATSB hit their key performance indicators as mandated by the Government.

"If they can't do that we have to look at the whole role of the ATSB."

Do you know more about this story? Email 7.30syd@your.abc.net.au
Has the MH370 search gotten in the way?

Video: Aerial footage shows plane crash site at a shopping centre near Essendon Airport (Courtesy Channel 9) (ABC News)

The ATSB aims to complete 90 per cent of all complex investigations within 12 months. But in 2016 it only managed to complete 29 per cent within the stipulated time, with several investigations still remaining open after years.

"When you are only achieving under 30 per cent of closure in line with your key performance indicators and they've got you at 90 per cent, clearly you're failing," Mr Hansford said.

"If you were in private enterprise, you'd be unemployed, you'd have a new boss and you'd be taken apart because they should have put up their hands and said 'this is going to have an effect on the Australian aviation market and we're not going to be able to deliver our requirements as laid out by the Government'."


Photo: Pilot Max Quartermain was being investigated by the ATSB when his plane crashed near Essendon Airport. (Supplied: Corporate and Leisure Aviation)

Mr Hansford believes the ATSB's failure to meet its investigation targets is linked to its role in the search for downed Malaysian Airlines plane MH370.

"It's had a major effect, because the number of resources, of people. You just take on the investigation regarding Essendon; there are four investigators on the scene almost immediately, now that's for one small aircraft.

"Now, have a look at the effect of an aircraft where we didn't know where it was, as the head of the Air Force said, 'I'm not looking at a needle in a haystack, I haven't even found the haystack.'

"So imagine the labour and the specialist people who were assigned to that.
"They weren't doing the jobs they were mandated and paid for, which is the protection of the Australian aviation industry."

'It's very frustrating, we can't put it behind us'


Photo: John Davis was killed in a helicopter crash in November 2015. His wife is still waiting for answers. (Supplied)

Felicity Davis lost her husband in a helicopter crash in November 2015.

John Davis was flying with friends, Richard and Carolyn Green, shooting aerials for a documentary on coal mining when the chopper crashed.

They were supposed to be gone for only a few hours, but when they failed to arrive at their destination a search was launched.

After an agonising wait, Ms Davis called the police for an update.

"They rang me back five minutes later and said, 'We found the helicopter and unfortunately there were no survivors.' So, that was it.

"I just couldn't believe it, I just couldn't believe it."

Now, 16 months later, Ms Davis is still waiting for the ATSB to tell her what happened in the crash.

All she can do is speculate.

"It's very frustrating because we can't put it behind us, get it over and done with," she said.

One of those unfinished reports related to pilot Max Quartermain, who crashed into a shopping centre at Essendon Airport last month.

After his "near collision" in 2015, a proficiency test found him capable to fly.
That Mt Hotham near miss was nearly 18 months ago, but the completion of the investigation has been delayed three times due to competing priorities and workload of the investigator in charge.

"This is one where the report has not being published and the excuse has been we didn't have the resources," Mr Hansford said.

"So the question has to be, if that had been resolved, would Mr Quartermain still be flying and what other aspects regarding the aircraft types and what happened at Mount Hotham?"


'Safety remains paramount'

Video: Questions raised about safety of suburban airports after plane crash kills five (7.30)

Ben Morgan is the head of the Aircraft Owners and Pilots Association, which also has major concerns about how the ATSB operates.

"One of the most upsetting things that happens after an air accident is the media starts reporting on a wide gamut of historical reports that involve pilots within our industry," he said.

"It does subject the pilot to an unfair assessment by the community.

"We need an ATSB who is far more responsible in getting these reports completed quickly.

"We cannot have scenarios where we're waiting five and seven years to wrap up an investigation.

"The aviation community needs the reports rapidly, the community needs the reports rapidly, so that we can obviously ensure that safety remains paramount."

Mr Morgan points to a lack of resources at the ATSB, saying the organisation has had its staff cut by 25 per cent since 2009.

"The aviation industry for some time has been raising concerns to both the Department of Transport and Minister for Transport, Darren Chester, in that air accident investigations are simply taking too long," he said.

"We have a scenario in which the ATSB would appear now to be vastly understaffed and underfunded and this has been a direct result of the fact that we no longer have a Minister in Government who has a strong interest in aviation."

Both the Transport Minister and the ATSB declined 7.30's request for an interview.
But in a statement, the ATSB acknowledged it faced resourcing challenges.

Its annual report said that would be addressed by being more selective in how it allocates its resources

In contemplating the unacceptable time delays with a large percentage of ATSB investigations it is worth referring to Chapter 3.69 of the Senate Pel-Air cover-up report:

Time taken to produce the ATSB report

3.69      The ATSB's statement of intent, available online, includes an undertaking to conduct investigations in a timely manner and 'aim to issue final reports on investigations within one year from commencement.'[45]

3.70      The aspirational goal certainly did not translate into reality in this instance. Instead, the ATSB's report on the ditching of VH-NGA took nearly three years to complete. The committee is not aware of any suggestions that this was a reasonable, or indeed helpful, timeframe within which to produce a report meant to allow the industry to learn lessons from this accident.

3.71      On the contrary, witnesses called the three year timeframe unreasonable and described it as being 'outside the performance expectations set by the ATSB and other international agencies.'[46]

3.72      ATSB Chief Commissioner Dolan admitted that the time taken to produce the report was unsatisfactory:

I should say up front that there are two areas where we think we could have done better with this investigation and report. The first and obvious one is that it took us far too long by anyone's standards, including our own, to get to a completion of the investigation. There are reasons for that, which I would be happy to discuss, but they do not excuse the three-year time frame for the report.[47]

3.73      Mr Dolan's explanation for the time taken to produce the report essentially revolved around resource allocation and prioritisation:

When, nearly 3½ years ago, I joined the newly independent ATSB as chief commissioner, we had over 100 aviation investigations on hand, including four that we classified as level 2—so substantial investigations requiring major and continuing use of our resources. We were averaging about 18 months for the completion of investigations, with some serious outliers in that. We had more work on hand than we knew how to deal with, and we would normally expect in any given year to get one of those level 2 investigations. So we had a lot more work than we were used to. That led to delays in a range of reports and, as new investigations came in, the shifting of resources to different priorities as they arose. It is clear that, in managing that allocation of resources to always-shifting priorities, we did not give enough attention to getting to an expeditious conclusion of this Norfolk Island report. However, that is the context in which that happened.[48]

3.74      The committee understands that strategic guidance from the minister leads the ATSB to prioritise investigations into what are referred to as 'fare-paying passenger operations'.[49] These generally exclude the type of flight VH‑NGA was undertaking at the time of the accident, which is categorised as aerial work. The Australian and International Pilots Association (AIPA) suggested that the non-fatal nature of this accident suggests that its investigation was not accorded a high level of priority.[50]

3.75      Like AIPA, the committee understands that the ATSB, like most organisations, has to prioritise its workload.

3.76      When the committee asked whether the ATSB had considered outsourcing any of its work, or insourcing extra capacity to expedite the production of reports, Mr Dolan replied in the negative:

Our resources are largely tied up in maintaining our existing investigative capability, who are permanent staff of the organisation. We have a longstanding view that in almost all circumstances it is better to have, if possible, the range of expertise available to us on a permanent basis and therefore immediately available than to rely on potentially risky external outsourcers.[51]

3.77      The committee confirmed with Mr Dolan that this was the case even when the ATSB budget was underspent and its workload was clearly excessive:

Senator FAWCETT:  I am not talking about normal [ATSB] operations. I am talking about a situation where you have a budget underspend and a clear excess of work.

Was it [outsourcing or insourcing] even considered? That is all I am asking.

Mr Dolan:  In that small underspend, no, we did not consider it.[52]

Committee view

3.78      The committee does not believe that an adequate explanation for the delay has been provided.

3.79      Given that the ATSB could not, or certainly should not, have known that it was only going to identify two relatively minor safety issues at the onset of its      three-year investigation, the delay itself had the potential to risk lives by not alerting the industry to the causes of this accident in a timely fashion.

3.80      The committee considers the fact that it took the ATSB close to three years to produce its investigation report following the November 2009 ditching of VH-NGA unreasonable. The committee also believes that the ATSB made a significant oversight by not considering external assistance despite a budget surplus of $0.3 million in 2009-10.[53]

3.81      Furthermore, the quality and complexity of the final report once it was produced—as will be discussed in later chapters of this report—certainly would not appear to readily justify a three-year timeframe. This being the case, the committee is firmly of the view that the stated aim of producing reports within one year of an incident or accident is attainable and should be met in all but the most extraordinary and justifiable of circumstances. During the course of its investigation, if it becomes apparent to the ATSB that it will not meet its one year timeframe, the ATSB should release an interim report, as required by ICAO, which would include a public timing update to ensure that the aviation industry is kept informed of progress and expected timing.

MTF...P2

[Peetwo]

ATSB still taking the Mickey Bliss on ICAO Annex 13...

Air safety watchdog 'clearly failing': Two-thirds of investigations not completed in required time
7.30
By Lauren Day

Updated about an hour agoTue 7 Mar 2017, 4:55pm

The body that investigates air safety incidents is struggling with a massive backlog and is only completing one in three investigations inside the targeted 12-month timeframe.

Key points:

• ATSB aims to complete 90 per cent of investigations within 12 months
  
• It is only completing 29 per cent of investigations in that time
  
• Neil Hansford believes the ATSB has been hampered by the search for MH370
  
  

In contemplating the unacceptable time delays with a large percentage of ATSB investigations it is worth referring to Chapter 3.69 of the Senate Pel-Air cover-up report:

Time taken to produce the ATSB report

3.69      The ATSB's statement of intent, available online, includes an undertaking to conduct investigations in a timely manner and 'aim to issue final reports on investigations within one year from commencement.'[45]

3.70      The aspirational goal certainly did not translate into reality in this instance. Instead, the ATSB's report on the ditching of VH-NGA took nearly three years to complete. The committee is not aware of any suggestions that this was a reasonable, or indeed helpful, timeframe within which to produce a report meant to allow the industry to learn lessons from this accident.

3.71      On the contrary, witnesses called the three year timeframe unreasonable and described it as being 'outside the performance expectations set by the ATSB and other international agencies.'[46]

3.72      ATSB Chief Commissioner Dolan admitted that the time taken to produce the report was unsatisfactory:

I should say up front that there are two areas where we think we could have done better with this investigation and report. The first and obvious one is that it took us far too long by anyone's standards, including our own, to get to a completion of the investigation. There are reasons for that, which I would be happy to discuss, but they do not excuse the three-year time frame for the report.[47]

3.73      Mr Dolan's explanation for the time taken to produce the report essentially revolved around resource allocation and prioritisation:

When, nearly 3½ years ago, I joined the newly independent ATSB as chief commissioner, we had over 100 aviation investigations on hand, including four that we classified as level 2—so substantial investigations requiring major and continuing use of our resources. We were averaging about 18 months for the completion of investigations, with some serious outliers in that. We had more work on hand than we knew how to deal with, and we would normally expect in any given year to get one of those level 2 investigations. So we had a lot more work than we were used to. That led to delays in a range of reports and, as new investigations came in, the shifting of resources to different priorities as they arose. It is clear that, in managing that allocation of resources to always-shifting priorities, we did not give enough attention to getting to an expeditious conclusion of this Norfolk Island report. However, that is the context in which that happened.[48]

3.74      The committee understands that strategic guidance from the minister leads the ATSB to prioritise investigations into what are referred to as 'fare-paying passenger operations'.[49] These generally exclude the type of flight VH‑NGA was undertaking at the time of the accident, which is categorised as aerial work. The Australian and International Pilots Association (AIPA) suggested that the non-fatal nature of this accident suggests that its investigation was not accorded a high level of priority.[50]

3.75      Like AIPA, the committee understands that the ATSB, like most organisations, has to prioritise its workload.

3.76      When the committee asked whether the ATSB had considered outsourcing any of its work, or insourcing extra capacity to expedite the production of reports, Mr Dolan replied in the negative:

Our resources are largely tied up in maintaining our existing investigative capability, who are permanent staff of the organisation. We have a longstanding view that in almost all circumstances it is better to have, if possible, the range of expertise available to us on a permanent basis and therefore immediately available than to rely on potentially risky external outsourcers.[51]

3.77      The committee confirmed with Mr Dolan that this was the case even when the ATSB budget was underspent and its workload was clearly excessive:

Senator FAWCETT:  I am not talking about normal [ATSB] operations. I am talking about a situation where you have a budget underspend and a clear excess of work.

Was it [outsourcing or insourcing] even considered? That is all I am asking.

Mr Dolan:  In that small underspend, no, we did not consider it.[52]

Committee view

3.78      The committee does not believe that an adequate explanation for the delay has been provided.

3.79      Given that the ATSB could not, or certainly should not, have known that it was only going to identify two relatively minor safety issues at the onset of its      three-year investigation, the delay itself had the potential to risk lives by not alerting the industry to the causes of this accident in a timely fashion.

3.80      The committee considers the fact that it took the ATSB close to three years to produce its investigation report following the November 2009 ditching of VH-NGA unreasonable. The committee also believes that the ATSB made a significant oversight by not considering external assistance despite a budget surplus of $0.3 million in 2009-10.[53]

3.81      Furthermore, the quality and complexity of the final report once it was produced—as will be discussed in later chapters of this report—certainly would not appear to readily justify a three-year timeframe. This being the case, the committee is firmly of the view that the stated aim of producing reports within one year of an incident or accident is attainable and should be met in all but the most extraordinary and justifiable of circumstances. During the course of its investigation, if it becomes apparent to the ATSB that it will not meet its one year timeframe, the ATSB should release an interim report, as required by ICAO, which would include a public timing update to ensure that the aviation industry is kept informed of progress and expected timing.

Update 08.03.17: 07:30 Report & Hoody FOI obfuscation.

Via ABC:

Questions raised about the air safety watchdog's ability to investigate plane crashes

The Australian Transport Safety Bureau is only managing to finalise 30 per cent of its air crash investigations within the recommended time, leaving grieving families in limbo and posing a threat to air safety.
Contains: video, image,

Reference link - On FOI requests & word weasel confections - & quote from BITN thread, in particular No 1) on FOIs:

Ps While on matters of aviation safety and the three stooges (ASA, ATSB & CASA) bearing safety risk mitigation gifts and establishing industry trust quotient 'Olive branches':

1) Could we please have the ASA FOI disclosure log updated? - It is fast approaching two years in arrears...

 2) Could we please have the ATSB investigation page updated with interim statements/reports for all O&O'd active investigations? - Such as VARA ATR 'broken tail' investigation (3rd anniversary) and the PelAir cover-up (2+ year) re-investigation... (Reference: ATSB still taking the Mickey Bliss on ICAO Annex 13 ) 

3) Could we please have the CASA 'Enforcement Manual' updated so that the former sociopathic DAS McCormick is no longer the preface signatory and his 'blackletter' embuggerance dispo is also erased from the preface introduction - Download preface.pdf.

On the 3rd Anniversary of the tragic disappearance of MH370 and on the FOI Act, it would appear that Hoody is not adverse to also O&O'ing FOI requests...

Courtesy of 'that man', via the Oz: 

MH370 files ‘could damage ties’

12:00amEAN HIGGINS

Australian officials refuse to release documents on flight MH370 because it ‘could damage international ties’.

...Three years after Malaysia Airlines flight MH370 disappeared, Australian officials refuse to ­release related documents ­because this could damage international ties, apparently with countries including Malaysia.

The Australian Transport Safety Bureau has rejected The Australian’s Freedom of Information request for copies of statements from a panel of international experts that it says supports its interpretation of satellite tracking data. The documents are central to the ATSB’s defence of its failed effort to find the plane.

Colin McNamara, the ATSB’s general manager, strategic capability, said disclosure of the documents “would, or could reason­ably be expected to, cause damage to the international relations of the commonwealth”.

While the ATSB says the documents support its “ghost flight” scenario of “unresponsive” pilots, this theory is increasingly challenged by aviation professionals who think a rogue pilot hijacked the aircraft and flew it to the end. Many commercial pilots and crash investigators say the search was doomed because evidence suggests captain Zaharie Ahmad Shah ditched the plane outside the ATSB’s search zone.

As revealed last year, other FOI documents show the ATSB initially claimed it had “consensus” from the panel for its theory that satellite data showed the plane went down un­piloted in a rapid dive, but deleted that line from its website when its investigators warned not all panel members had at that stage agreed.

ATSB chief commissioner Greg Hood and the head of the search strategy, Peter Foley, refused to answer questions from The Australian ahead of the third anniversary, but a spokesman said “the search for MH370 has always been based on the available evidence at the time”....

Why am I not surprised...  After all Hoody was the decision maker that condemned Dominic James to 'pilot career purgatory' in the PelAir cover-up debacle. All based on largely dodgy, cynically manipulated and slanderous hearsay evidence, compiled by McComic's evil lieutenant Wodger. Therefore he already has a checkered history of self-serving amoral shenanigans in a senior bureaucratic executive role...    

TICK...TOCK - Minister NFI Chester, you now own the sins of the past and the sins of the future from the self-serving toxic personalities that currently inhabit the halls of the aviation safety bureaucracy - TICK..TOCK indeed..


MTF...P2  

[Gobbledock]

Time to call a royal commission

Nice pick up P2, and nice to see 'that man Iggins' picking up an excellent thread and running with it.

Ok, so, read between the lines of this pathetic statement;

"Colin McNamara, the ATSB’s general manager, strategic capability, said disclosure of the documents “would, or could reason­ably be expected to, cause damage to the international relations of the commonwealth”.

Come again? Say what? So, if I have his correct - to save a relationship with a crooked and corrupt country that fosters and breeds terrorism, the Australian GOVERNMENT is happy to shelfware a vital report that may also provide some solace and relief to the affected families and friends of the dead? Pathetic. Turdball, Stick Insect, NFI Chester and Hood should hang their heads in abject shame.

P2;

"Why am I not surprised... After all Hoody was the decision maker that condemned Dominic James to 'pilot career purgatory' in the PelAir cover-up debacle. All based on largely dodgy, cynically manipulated and slanderous hearsay evidence, compiled by McComic's evil lieutenant Wodger. Therefore he already has a checkered history of self-serving amoral shenanigans in a senior bureaucratic executive role"

Spot on P2!! The unconscionable Hood was happy to allow a good man to get rogered over PelAir. And now he has been happy to tow the party line on MH370 and bury whatever he can in the sewers of aviation, at the behest of those who hold his balls. No surprise he was promoted to Chief Commissioner, they knew they had the right man for the job!

I wish the Senate could blow the lid open on our non-transparent, obsfucating deceptive Government and it's bureaucracies. They are a disgrace. BASTARDS. Let's see how long it takes for Turdball to throw Stick Insect on the V.I.P jet for a quick trip to Malaysia to massage the Malaysian PM's shoulders, kiss his puckered arse and whisper in his ear 'it's ok PM, Australia has you covered'!

TICK TOCK

[Kharon]

The whirligig of time.

“Madam, why laugh you at such a barren rascal; an you smile not, he’s gagged?” and thus the whirligig of time brings in his revenges.

Its quite a story though ain’t it; who needs fiction, when reality is so much more twisted and bizarre. Had the FAA and NTSB tried to pull off a stunt like Pel-Air, there would be folk in gaol, heads in baskets and a complete clean out of the rats nest, after a Senate committee inquiry. Not here though.

Do we blame those who allowed the law to be so ineffectual? Do we blame them who blatantly broke not only law, but policy, protocol, trust, good faith and confidence? Dare we ask why they acted as they did? Dare we ask why they were allowed to get away with this gross perversion.

Will they dare do it again? No brainer, of course they will; in fact they already have. But the final insult comes in the form of the delightful, hi-viz Hood.  A man at the very heart of the Pel-Air aberration, decision maker, document signer, he who authorised every perversion possible of an investigation into an accident. No: you’re right, he did not act alone, but do you think Chambers could have manipulated audit and process without a willing accomplice to sign his devious little plots into being? Do you think Hood would have made things happen through his signature had he not had top cover from those above him? IMO, some acts committed during the McConvict era beggar belief; those of Chambers supported by Hood among the worst atrocities ever inflicted, with malice aforethought demand that CASA as part of their rehabilitation address those matters. None of it is ‘secret’, the industry knows what was done, by whom and why. Until these matters are properly addressed, the Senate recommendation enforced and the Forsyth ASRR fully acknowledged and instituted, there can be no hope for industry which knows, deep in it’s very heart, there ain’t any.

That same man, the main cog in a disgusting episode, is now in charge of our accident investigations.  The shambles Dolan left behind as an inheritance includes not only Pel-Air, but a legacy of flawed reports into accidents; a long list of serious incidents all of which may be repeated; and, the scandal which MH370 is likely to become. The denial of legitimate requests under the FoI Act tells the tale very clearly. As head of ATSB Hood could release to the public, information which was gathered at public expense. As a matter of principal. What possibly could be so ‘secret’ or ‘sensitive’ that it cannot be released? It was after all supposed to a ‘Search’ in hope of rescue, with the option of recovery. What could prompt a response such as:-  

“would, or could reasonably be expected to, cause damage to the international relations of the commonwealth”

Pel-Air should have brought about a complete dismantling and restructuring of both CASA and the ATSB; it did not. Why, despite overwhelming evidence did this not happen?

Why Mr. Hood can Australia nor reveal its part in the MH370 search and supply the information requested? Why fuel the roaring flames of speculation of conspiracy to delude the public?  Too hard, then answer this – why is someone so deeply involved in Pel-Air, with a glaring conflict of interest and possibly charges to answer now running the very agency which is investigating its own part in that disgraceful affair?

The international community, particularly those affected by MH370, who cannot obtain the information requested of your department, deserve that question answered at least.

I wonder how this fellah gets to sleep at night or can shave his face in the morning.  One good thing though, he can stop worrying about when Karen Casey’s ruling will be delivered – Thursday Greg, Supreme court, we’ll know by lunch time; then perhaps you will be able to release the often delayed report into your own part in wrongdoings of Pel-Air.

“Conscience is but a word that cowards use,
Devis'd at first to keep the strong in awe:
Our strong arms be our conscience, swords our law.
March on, join bravely, let us to't pell-mell;
If not to heaven, then hand in hand to hell.”

Selah.

[Peetwo]

Hoody sensitive on 07:30 Report -  

My excuse for being five days after the fact...   

Like so much of the ATSB's media/PR releases these days, the latest 'correcting the bollocks' entry was discretely published on 8th of March with absolutely zero fanfare on social media or as an official MR...

Anyway here 'tis, Hoody having a sook, with my OBS alongside... :

Correcting the Record

Inaccurate reporting on the completion of ATSB investigations by the ABC 7.30
8 March 2017

A story on ABC’s 7.30 program (7 March 2017) and an article on the ABC news website, “Air safety watchdog clearly failing”, contains inaccurate and misleading claims that require correction. - err why exactly  

Firstly, the reports quote Mr Neil Hansford as saying:

"Until a case is resolved, there can be no remedial action taken by the relevant authorities, CASA (Civil Aviation Safety Authority) or the Department of Transport or even private airport operators."

In fact, the ATSB does not wait for an investigation to be completed to bring safety matters to the attention of operators and authorities.

When the ATSB discovers critical safety issues during an investigation, it immediately brings them to the attention of relevant authorities and organisations to be addressed. - That maybe true but due to the ATSB 'beyond all reason' (BASR) methodology...

Reference video from PelAir inquiry: 

 ...unless the bureau actually promulgates an official 'safety recommendation' then public or other interested industry stakeholders are left totally unaware of such CSI's and how they are proactively addressed till the Final Report is released. (A classic example is with the 3 year Mildura fog landing incident investigation: AO-2013-100) 

It is also worth noting that because the ATSB subverts it's obligations to adhering to the ICAO (Annex 13 Chapter 6.6) obligations for interim reports/statements, there is no transparency on identified safety issues (critical or otherwise) identified in the course of an investigation:

...If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised...

  
NB: There is one notable exception to the above and that is with the ongoing ATR broken tail investigation.

Examples of where the ATSB has made significant world-wide transport safety improvements before its investigations were completed include the uncontained engine failure of QF32 in November 2010 and Robinson helicopter R44 fuel tank risks in April 2013.

Mr Hansford also claimed that the ATSB's failure to meet its investigation targets was linked to its role in the search for Malaysia Airlines Flight MH370.

The search for MH370 has not affected the ATSB’s core functions. Additional funding was provided by the governments of Malaysia, the People’s Republic of China and Australia to assist the ATSB lead the search for the missing aircraft.

Australian aviation safety has not been compromised by the ATSB’s lead role in the search for MH370. - This is what Mr Hanson actually said:

"It's had a major effect, because the number of resources, of people. You just take on the investigation regarding Essendon; there are four investigators on the scene almost immediately, now that's for one small aircraft.


"Now, have a look at the effect of an aircraft where we didn't know where it was, as the head of the Air Force said, 'I'm not looking at a needle in a haystack, I haven't even found the haystack.'

"So imagine the labour and the specialist people who were assigned to that...

I think Mr Hanson's comment is a fair point, especially when you consider that prior to the MH370 disaster Beaker had made redundant 12 of the ATSB's frontline staff. I also can't remember a recruitment drive solely for the extra specialist staff required for MH370...  
   
The ABC also quotes Mr Ben Morgan as saying “We cannot have scenarios where we're waiting five and seven years to wrap up an investigation”.

In fact, excluding delayed investigations beyond the control of the ATSB, the average time the ATSB takes to complete its reports is 14 months. The ATSB is seeking to improve its efficiency in meeting its self-imposed target of complex investigation reports published in 12 months. - Notice that Hoody doesn't tackle the figures actually quoted:

..ATSB aims to complete 90 per cent of investigations within 12 months....it is only completing 29 per cent of investigations in that time..

Notice also that Hoody generalises 'reports' rather than final reports for a full blown investigation. This means the 'average time' also includes the desktop short investigation reports that feature approximately once a month in the SIBs (short investigation bulletins): http://www.atsb.gov.au/publications/publ...e=Aviation Short Investigation Bulletin
 



Last update 08 March 2017 
 

Verdict: Hoody simply having a sook about the dismal state of affairs at the ATSB...
 
MTF...P2

[Gobbledock]

P2;

Verdict: Hoody simply having a sook about the dismal state of affairs at the ATSB

Couldn't agree more. The hi-vis wearing Chief Ponce needs to get his hormones and pride under control. The ATsB is a joke amongst its contemporaries. A useless political protection racket, nothing more and nothing less.

If Hoody wants to update the media 'for the record' then fine, here is something from me 'for the record' - the ATsB is a pathetic organisation that has been destroyed over the past 6 years and continues to decline under Hood, aka 'Beaker Mk 2'. The PelAir debacle is a good example of an unfinished investigation heading towards 7 years from memory!! Hood, Dolan, Chester, Truss, MrDak = disgrace!!

TICK TOCK

[Kharon]

Poncy or Ponzi ?

1. a form of fraud in which belief in the success of a non-existent enterprise is fostered by the payment of quick returns to the first investors from money invested by later investors.
2. "a classic Ponzi scheme built on treachery and lies"

Item two puts the argument for it being a Ponzi rather neatly, don’t you think.

GD – “A useless political protection racket, nothing more and nothing less.”

For the public and industry, I’d have to agree with GD, “useless”; but for the rest it’s heaven sent and gift wrapped. I wonder what the Feds acting under a search warrant would find, then I wonder what a team of ‘independent’ Accident Investigators would make of the data retrieved. Accident reports seem to go through a ‘mysterious’ process, almost a metamorphism, data going in rock solid comes out as gooey, sticky mess of little structural integrity or practical value.

I can, at a pinch, understand the ‘need’ for a softly-softly approach. I mean it just wouldn’t do for the politicians to be embarrassed by exposing the ASA, ATSB, CASA or any ‘government agency’ as being a part of the causal chain. Can’t have that, can we children; Australia is supposed to be a world leader; ain’t it? The stark truth that the official management of aviation is a complete basket (bastard) case must never be allowed to gain solid form.  

NB> Notice that Hoody doesn't tackle the figures actually quoted:

NB> Notice also that Hoody generalises 'reports' rather than final reports for a full blown investigation. This means the 'average time' also includes the desktop short investigation reports that feature approximately once a month in the SIBs (short investigation bulletins)

Weasel flummery. But I believe there needs to be a line drawn, which none dare cross. Safety recommendations, (if ever issued again) cannot be perverted or diluted, particularly where lives have been lost; or the potential for the loss of life is involved. Coroners and courts must be given the unvarnished facts; industry demands the unvarnished truth; how else are real, effective changes to be made. Every flawed, manipulated report leaves the door to a repeat episode wide open. Accidents happen, that is an undeniable truth. Why that accident occurred can be analysed. The causal chain can be clearly identified.  The industry is mature enough, experienced enough and certainly ‘skilled’ enough to take the lessons gained and make the changes required to reduce the chances of a repeat event;- provided they have unbiased, accurate information to work with. “Sorry Vicar, a band aid wont’ work, stiches are needed”.

To even tinker with the truth of an event, tweak or massage the facts to suit an ‘acceptable’ conclusion, then provide a report with just enough fact to make that conclusion plausible is not only reprehensible, but, IMO criminal.

Farce or facts? Watchdog or kitten? An ATSB which can drive through to conclusion a Safety recommendation; or, a simpering catamite begging to have a carefully worded plea heard and acted on? ATSB needs independence, leadership, teeth and balls, in that order. Otherwise what’s the point – we may as well disband it, save the money and the embarrassment.

The first journalist who picks up a safety report, then has it examined, the implications and ramifications carefully explained by experts, not working for an ‘agency’ will have an award winning story, which no one will believe. Aye, another IOS member in the making.

Toot toot.

[Kharon]

Fetch my drum Minnie; yes, the big one.

ATSB – “Mr Hansford also claimed that the ATSB's failure to meet its investigation targets was linked to its role in the search for Malaysia Airlines Flight MH370.”
 
ATSB - “The search for MH370 has not affected the ATSB’s core functions. Additional funding was provided by the governments of Malaysia, the People’s Republic of China and Australia to assist the ATSB lead the search for the missing aircraft.”
 
P2 - I think Mr Hanson's comment is a fair point, especially when you consider that prior to the MH370 disaster Beaker had made redundant 12 of the ATSB's frontline staff. I also can't remember a recruitment drive solely for the extra specialist staff required for MH370...  
 
Hanson – “"Until a case is resolved, there can be no remedial action taken by the relevant authorities, CASA (Civil Aviation Safety Authority) or the Department of Transport or even private airport operators.”
 
ATSB – “In fact, the ATSB does not wait for an investigation to be completed to bring safety matters to the attention of operators and authorities.”
 
“Safety matters” what a trite, amorphous little expression that is. Is the reader supposed to relax after reading that sentence? The implications are, I believe deliberately, very misleading. You don’t need to be any sort of aviation or accident guru to work out why; any application of common or garden sense will clearly define why this is so.  
 
Accidents; why do they happen? There are some folk who firmly believe that the beating of a butterfly’s wings can create a Tsunami; there are those who believe in the ripples in a pond, Some say ‘fate’ takes an hand; others say coincidence; others say its random chaos. You could probably end up quite mad trying to philosophise whether a camel breaking wind in the Tunis souk started a chain of events which led to a disaster. “All for the want of a nail”.
 
For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail. (Ben Franklin).
 
What the ATSB is trying to peddle is that ‘the kingdom was lost’ ; yes we know that.
What we don’t know – and; by the by, neither do the ATSB is ‘Why’. Until we can determine why the shoe needed a nail, there is no real solution or determination where the radical cause lay. How far do we go back to work that out. Was it the fault of the previous rider who failed to notice; or the groom who failed to call the farrier; or the farrier for supplying dodgy nails: or the maker of dodgy nails? As said; you can go quite mad if you start chasing down the ‘radical’.
 
The notion that the ATSB can, with some certainty, clearly define a ‘safety matter’ accurately and ‘report’ it to “operators and authorities” is a fairly big stretch, - without the entire ‘report’ being available. For example; to tell the “authorities” that ‘twas all the messengers fault will see the messenger prosecuted, new rules for messengers laid, a requirement for a second horse to be available at all times, and the stable master bolloked for not training the messengers properly: etc.
Whereas with the ‘full’ report available, the ‘authorities and operators’ can form a proper picture of the ‘facts and circumstances’. Then real, meaningful changes be made to prevent a repeat event.
 
The ‘loop’ needs to closed; open ended, high speed, knee jerk response to an accident or incident is not only counterproductive; it is irresponsible, in the worst possible way.
 
The ATSB should have been disbanded after Pel-Air and restructured along the lines of the Canadian or American NTSB. Given independent funding, reporting directly to a minister or the Senate; the MoU shredded; competent leadership and a mandate to provide accurate reports in a timely manner, without prevarication, bias or favour. What we have at the moment is a shadow of the fine, world class BASI, living vicariously on that previous reputation. We used to have a watchdog – all we have now is the tick which killed it.
 
Will the minister act? Can the Senate act? Don’t know is the answer; but someone should get off their beam ends and sort this aberration out; before the ATSB slip-shod,  lip service department reports become a radical part of the causal chain in a repeat of a preventable event.
 
Selah.

[Peetwo]

Kharon, the reason the Government doesn't like to compensate its citizens is because they think every single one of us is some kind of crook or criminal. They cannot bare the thought that we may be 'getting ahead' or getting some kind of freebie. Look at the victims of crime, or the Karen Casey's of our country, treated like second rate scum because some vile Government and it's system believe that anybody other than politicans are shonks.

Our country is almost half a trillion in debt, yet Goldman Sachs Turdball is putting us another $60b in debt for submarines to save the ass of a slimeball like Pyne. Not to mention the billions we give to other countries or the billions that Krudd loaded onto us through the BER sham. And check this, what about our involvement in bloody wars that we shouldn't be involved in - The Afghan war involved all elements of the Australian Defence Force (ADF), and thousands of Australian service men and women were deployed to the theatre over the last thirteen years. The shape, size and mission of the Australian contribution to the NATO-led International Security Assistance Force (ISAF) in Afghanistan went through several distinct phases, from initial combat operations against al-Qaeda and Taliban forces, through to reconstruction efforts and security sector reform in Uruzgan Province, to a supporting role. At its height, the ADF had 1,550 personnel serving in Afghanistan and has spent an estimated $7.5 billion on its operations there. Unbelievable!!! They spend money on that shit but then they won't  compensate some poor bastard for poisoning his land and ruining his life and health?? Arsewipes........

Tick Tock

GD – “Look at the victims of crime, or the Karen Casey's of our country, treated like second rate scum; because, some vile Government and it's system believes that anybody, other than politicians, are shonks.”

That GD line, when considered in light of the ‘proven’ evidence, deserves a lot more attention than it will probably get. The Pel-Air debacle encompasses the whole microcosm of what is wrong within the aviation safety net system. FCOL, an entire accident investigation was ‘skewed’ to suit the desired result.

Please, consider the entire picture. The whole mosaic of deceit. You do realise that certain individuals, for various motives, ‘interfered’ with and 'manipulated' an accident investigation; the report of that accident, IMO, sought to pervert an entire ‘system’. Why this was done, i.e. the motive, remains a mystery. But high stakes were on the table. Why? Why all of this risk for one small aircraft, half a dozen lives and a series of preventable ‘mistakes’. It never has made sense to me; at least not in any ‘honest’ way I can see.

Only a judicial inquiry (and; I do know, they are tricky little buggers) into the actions of various CASA and ATSB officers ‘actions’ is the only way to expose the true mendacity of this sorry tale; actions weighed against ‘law’. In fact; there should be an ‘open’ inquiry into the actions of CASA officers during the McComic reign. The results of that inquiry would, no bull-pooh, shock a nation – perhaps, into action.

Well, I can still dream – can’t I?

MTF...P2

[Peetwo]

Hoody sensitive on 07:30 Report -  

My excuse for being five days after the fact...   

Like so much of the ATSB's media/PR releases these days, the latest 'correcting the bollocks' entry was discretely published on 8th of March with absolutely zero fanfare on social media or as an official MR...

Anyway here 'tis, Hoody having a sook, with my OBS alongside... :

Correcting the Record

Inaccurate reporting on the completion of ATSB investigations by the ABC 7.30
8 March 2017

A story on ABC’s 7.30 program (7 March 2017) and an article on the ABC news website, “Air safety watchdog clearly failing”, contains inaccurate and misleading claims that require correction. - err why exactly  

Firstly, the reports quote Mr Neil Hansford as saying:

"Until a case is resolved, there can be no remedial action taken by the relevant authorities, CASA (Civil Aviation Safety Authority) or the Department of Transport or even private airport operators."

In fact, the ATSB does not wait for an investigation to be completed to bring safety matters to the attention of operators and authorities.

When the ATSB discovers critical safety issues during an investigation, it immediately brings them to the attention of relevant authorities and organisations to be addressed. - That maybe true but due to the ATSB 'beyond all reason' (BASR) methodology...

Reference video from PelAir inquiry: 

 ...unless the bureau actually promulgates an official 'safety recommendation' then public or other interested industry stakeholders are left totally unaware of such CSI's and how they are proactively addressed till the Final Report is released. (A classic example is with the 3 year Mildura fog landing incident investigation: AO-2013-100) 

It is also worth noting that because the ATSB subverts it's obligations to adhering to the ICAO (Annex 13 Chapter 6.6) obligations for interim reports/statements, there is no transparency on identified safety issues (critical or otherwise) identified in the course of an investigation:

...If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised...

  
NB: There is one notable exception to the above and that is with the ongoing ATR broken tail investigation.

Examples of where the ATSB has made significant world-wide transport safety improvements before its investigations were completed include the uncontained engine failure of QF32 in November 2010 and Robinson helicopter R44 fuel tank risks in April 2013.

Mr Hansford also claimed that the ATSB's failure to meet its investigation targets was linked to its role in the search for Malaysia Airlines Flight MH370.

The search for MH370 has not affected the ATSB’s core functions. Additional funding was provided by the governments of Malaysia, the People’s Republic of China and Australia to assist the ATSB lead the search for the missing aircraft.

Australian aviation safety has not been compromised by the ATSB’s lead role in the search for MH370. - This is what Mr Hanson actually said:

"It's had a major effect, because the number of resources, of people. You just take on the investigation regarding Essendon; there are four investigators on the scene almost immediately, now that's for one small aircraft.


"Now, have a look at the effect of an aircraft where we didn't know where it was, as the head of the Air Force said, 'I'm not looking at a needle in a haystack, I haven't even found the haystack.'

"So imagine the labour and the specialist people who were assigned to that...

I think Mr Hanson's comment is a fair point, especially when you consider that prior to the MH370 disaster Beaker had made redundant 12 of the ATSB's frontline staff. I also can't remember a recruitment drive solely for the extra specialist staff required for MH370...  
   
The ABC also quotes Mr Ben Morgan as saying “We cannot have scenarios where we're waiting five and seven years to wrap up an investigation”.

In fact, excluding delayed investigations beyond the control of the ATSB, the average time the ATSB takes to complete its reports is 14 months. The ATSB is seeking to improve its efficiency in meeting its self-imposed target of complex investigation reports published in 12 months. - Notice that Hoody doesn't tackle the figures actually quoted:

..ATSB aims to complete 90 per cent of investigations within 12 months....it is only completing 29 per cent of investigations in that time..

Notice also that Hoody generalises 'reports' rather than final reports for a full blown investigation. This means the 'average time' also includes the desktop short investigation reports that feature approximately once a month in the SIBs (short investigation bulletins): http://www.atsb.gov.au/publications/publ...e=Aviation Short Investigation Bulletin
 



Last update 08 March 2017 
 

Verdict: Hoody simply having a sook about the dismal state of affairs at the ATSB...

Update 21/03/2017: Essendon B200 accident investigation - Preliminary report delayed.

Four days ago, via the ATSB accident investigation page - AO-2017-024 :

Updated: 17 March 2017

After spending an extended period on-site, the ATSB investigation team is now preparing a preliminary investigation report into the tragic accident at Essendon Airport. The time on-site has allowed the team to collect a large volume of evidence from a number of closed-circuit television sites and many witness statements.

The team has also extensively examined the aircraft wreckage. Importantly, with assistance from our colleagues at the United States National Transportation Safety Board, the Federal Aviation Administration, and the engine manufacturer, the ATSB was able to disassemble and examine both of the aircraft’s engines.

While the ATSB’s standard practice is to publicly release a preliminary factual report within 30 days of any major accident, the preliminary report release will be slightly delayed due to the extensive on-site activities required for this investigation. It is anticipated that the preliminary report will be released to the public in the week commencing 27 March 2017.

P2 comment - I still find it extraordinary that such a high profile accident investigation is updated (seemingly through stealth),with such an important message as a delay in the preliminary report, merely by a short notation on the investigation webpage. Yet today on what should have been the day the prelim report should be released, the only MR coming out of the ATSB is one where they announce that the NSW Polair have finally found the REX SAAB prop (see HERE)...


MTF...P2

[Peetwo]

Defence contract probity & the PelAir connection.

Recently in the course of BRB debate/discussion, on one of the PAIN email chains, someone re-hashed what IMO was one of the more powerful submissions to the Senate PelAir Inquiry:

22 Mr Dominic James (PDF 38KB) 

Submission- Inquiry into Aviation Accident Investigations (Pel-Air)

Dear Committee members,

As the release of the report draws near, I thought I would share a few things with the Committee that have been worrying me for some time. I have left the details alone and sought to frame the bigger picture, as ultimately this is what really matters.

Section 24 of the Transport Safety Investigation Act was written to prevent any person - regardless of who they are - from interfering with the ATSB's process of investigation. If one was to inhabit the mind of the author of Section 24 and the scenario they wished to prevent, then the events surrounding the investigation of the Norfolk Island accident would almost certainly be what they had in mind. Therefore, in order to respect the purpose of Section 24, it is vital that action be taken when it becomes evident it has been breached. Anything less will make Section 24 abstract and impotent and the integrity of the ATSB will cease to exist.

Consider the following: if it became known that I had taken my training records and other similar documents from Pel-Air and hidden them from the ATSB in fear of criticisms contained within them, then I would have been subject to the provisions of Section 24 and more than likely been charged. The present reality is however far more serious than the hiding of records by one individual. This seriousness stems from the number of persons involved, the self interest driving their actions and most importantly the way their behaviour has diminished aviation safety in Australia. It is therefore only reasonable that this conduct not be overlooked and a fair application of law applied regardless of who is involved.

My other concern is for what may occur if no one is held accountable for the misconduct that has taken place. If this does indeed happen, I fear that employees of CASA and the ATSB would regard those who have been involved in this misconduct as 'rock stars' worthy of admiration and emulation. These employees would then quite rightly regard themselves as above the law and without fear of it, discharging their responsibilities with little care or professionalism. They would take comfort knowing that even if they had to appear in before the Senate that they would emerge almost certainly unscathed. This would have grave consequences for the aviation industry, as it would demonstrate that safety is a secondary imperative after personal reputation. For the sake of the flying public this must never be allowed to occur.

I appreciate the scope of the Senate's powers and I'm not asking for the Senate to reach beyond them. All I ask is that this matter be referred to the appropriate authority so that evidence can be given under oath and the facts be examined in the appropriate forum.

Regards,

Dom James

 
  As history will show the Senate committee referral to the AFP for investigation under S24 of the TSI Act 2004, eventually fizzled into a 'nothing' -

However IMO and in light of the turn of events since that time, the Dom James submission 22 is now more relevant than ever, especially if motivated elected representatives had the mind to ask for a judicial review into the circumstances and suspected illegalities surrounding the still puzzling ATSB VH-NGA cover-up investigation...

Joining dots & making of dashes -  
 
"K" quote from tick & flick thread: 

..However, if he wanted to take a shot at ‘Rex’ top level management, this was not the story to go with; there are other juicy morsels to choose from, which would do the trick. A decent researcher would have questions about ‘defence’ contracts and cover ups and manipulated accident reports; all there, freely and publicly available....

Have just begun looking at this but the timeline "dots" with a little known/publicised 2011 Senate Foreign Affairs, Defence & Trade inquiry; versus the bizarre attempted PelAir cover-up certainly deserves further review.

For the record here is the completed Senate inquiry webpage:

Inquiry into the Department of Defence's request for tender for aviation contracts and associated issues

• Information about the Inquiry
  
• Terms of Reference
  
• Submissions Received
  
• Public Hearings and Transcripts
  
• Interim Report
  
• Report
  
• Government Response tabled 9 February 2012 (PDF 15182KB)
  

For further information, contact:

Department of the Senate
PO Box 6100
Parliament House
Canberra ACT 2600
Australia
Phone:
+61 2 6277 3535
Fax:
+61 2 6277 5818

Email:
fadt.sen@aph.gov.au

Although the context of this inquiry largely focussed on one particular 2010 air services Defence tender, the MEAO tender awarded to Adagold, there was much involvement from related parties (e.g PelAir & CASA) that make this inquiry particularly interesting, while raising suspicions of impropriety in regards to the concurrently ran ATSB VH-NGA accident investigation.

References:

2 Pel-Air Aviation Pty Limited (PDF 153KB) 

&.. former PelAir Chief Operating Officer giving evidence 28/03/11: Hansard reference - 28/03/2011 Sydney, NSW (HTML format) (PDF 57KB) (PDF 208KB) - page 19-26.

---

7 Civil Aviation Safety Authority (PDF 661KB)

&.. Adam Anastasi, Acting Chief Legal Officer, Legal Services Division, Civil Aviation Safety Authority, giving evidence 29/03/2011: Hansard reference - 29/03/2011 Canberra, ACT (HTML format) (PDF 58KB) (PDF 478KB) - page 37-44.

P2 comment - A passing interest in the above interactions that bring to mind shades of Lockhart River and the connection between Aerotropics & Transair: 

Senator JOHNSTON—This is the Adagold case—

Mr Anastasi—Which is Adagold, which is contracted with the Commonwealth. If it were the
case that CASA formed a view that, having regard to all the arrangements, and CASA did review the contract between Adagold and Hi Fly when assessing the application to vary the AOC by Hi Fly; if, for example, there was a view formed that—in fact it looks like—Adagold really has operational control over the aircraft, then we would look at that issue more carefully, make inquiries of Adagold and, in an extreme case, take the view that in reality Adagold is the operator and not Hi Fly. That was not a view that was formed in this case...

---

Senator JOHNSTON—Thank you. On the paragraph that I have taken you to, what
regulatory obligations do Hi Fly have to CASA?

Mr Anastasi—Hi Fly has regulatory obligations to the aviation legislation—that may be a
better way to describe it. The aviation legislation requires any operator to comply with certain rules. Generally, for a foreign registered aircraft the Australia maintenance regulations have no application to such aircraft, but the operational requirements on any aircraft in Australian airspace will generally apply to that aircraft.

Senator JOHNSTON—So operational matters refer to the way they conduct their flying
within Australian airspace?

Mr Anastasi—Yes, and complying with Australian rules when operating in that airspace.

Senator JOHNSTON—But maintenance issues do not relate to that regulation because it is a
foreign aircraft?

Mr Anastasi—That is correct, but CASA will still review the maintenance arrangements for
the aircraft in question. In this case, CASA asks questions of the operator about how the aircraft was going to be maintained and by whom...

---

Senator JOHNSTON—You say that:

Such charter brokers have no regulatory obligation to CASA, and CASA has no authority to regulate the conduct of those charter brokers.

What do you mean by that?

Mr Anastasi—What is meant to be said there is that if a charter broker is not the operator then
obviously the charter broker has no obligations on it as if it were an operator. The only
regulatory—

Senator JOHNSTON—Let me just clarify that: because he is not conducting operations, he
is not bound by the civil aviation legislative framework in Australia? The operator is the one who is bound?

Mr Anastasi—Yes, other than that there is a regulatory provision which states that,
effectively, you cannot hold yourself out as an operator if you are not, in fact, an operator. That applies to anyone...

  
Moving on to the Senate Inquiry Report I note that in chapter 6, much like the PelAir Senate inquiry,  there was another AFP referral for investigation that appears to have fizzled out...

Allegations concerning the 2005 tender and AFP investigation

6.66 As noted earlier, on 2 September 2010, while the external reviews were under
way, an article published in the Age newspaper reported allegations of impropriety in
the 2005 tender process, which resulted in the awarding of the contract to Strategic.93
The allegations concerned the 'leaking' of tender specifications to Strategic prior to the
release of the RFT. The article reported that it had uncovered email correspondence
between Strategic directors which suggested that two members of 1JMOVGP—
identified as Major Charlton and Warrant Officer John Davies—had 'fed' this
information to Strategic.94 This matter was not taken up by the reviews of the 2010
tender process, on the basis that the Phillips Fox (DLA Piper) review of the 2005
tender process did not identify any probity related compliance issues that would
require the process to be set aside.95

6.67 On 10 September 2010, Defence referred the allegations concerning the 2005
tender to the AFP. Defence stated that it had not previously been aware of any
allegations that Strategic had received inside information in 2005. It noted that, 'if
proven, these allegations would give rise to a range of possible criminal offences'.96
At the time of writing, the matter remained under investigation by the AFP.97

So anyone else see why the stink emanating off this inquiry could be causal to the shenanigans surrounding the botched and O&O'd ATSB VH-NGA ditching investigation...


MTF? Yes definitely..P2

[Kharon]

Memo: from the department of funny coincidence.



Good job P2, and timely. The BRB tote odds for the release of the latest Pel-Air ditching report is at very short odds (5/4 on) for a ‘Budget day’ slider, (slipped under the door at 1659 followed by the patter of tiny feet, at speed, out of the building).

There are two very important items on the BRB agenda; to wit. Item 1: the actions of CASA officers during the investigations, audit and rehabilitation of Pel-Air. Item 2: the motivation for the acts and actions of both ATSB and CASA.

Item 1:

DJ_22 – “Section 24 of the Transport Safety Investigation Act was written to prevent any person - regardless of who they are - from interfering with the ATSB's process of investigation.”

DJ_22 –Therefore, in order to respect the purpose of Section 24, it is vital that action be taken when it becomes evident it has been breached. Anything less will make Section 24 abstract and impotent and the integrity of the ATSB will cease to exist.

DJ_22 – It is therefore only reasonable that this conduct not be overlooked and a fair application of law applied, regardless of who is involved.

P2 –“As history will show the Senate committee referral to the AFP for investigation under S24 of the TSI Act 2004, eventually fizzled into a 'nothing' –“

It is not only the Pel-Air matter, but several ‘other’ less publicised cases occurring during the period in question which demand serious scrutiny. Nothing less than an open judicial inquiry into those actions will prevent further ‘embuggerance’ of the spirit and intent of the ‘law’ designed to ensure public safety. We acknowledge the Senate inquiry as a great effort; however, their recommendations have been ignored, contemptuously and summarily dismissed; as was the ASRR. I say the behaviour of individual CASA officers demands the free, fair and impartial scrutiny of JI; if only to establish that they acted properly throughout the period in question. Those questions must be answered if CASA and the ATSB are to have any credibility and public trust; for they have very little of either with which to trade at present. Judicial inquiry into the actions of CASA officers, Sydney region 2009 through to 2012. It will rock and shock you; but will send a very clear message to those within both organisations that they are not above the law, as writ.

Item 2:

I can’t quantify the number of hours spent ‘discussing’ the motivation driving the Pel-Air scandal. Both ATSB and CASA took hellish risks, got caught, went through a Senate inquiry and came out discredited and sanctioned. Then carried on business as usual. There has been absolutely ‘no penalty’ inflicted despite clear evidence that a simple accident report was manipulated. Do you understand what has transpired; a preventable, easily remedied chain of events leading to a life threatening situation was ‘examined’; the report and, more importantly, the results on which the report relied where ‘rearranged’ to suit. Why? What could possibly cause both departments to take such risks? And why have ATSB and CASA been allowed and assisted to escape ‘Scot free’ after foisting their ‘aberration’ onto the public and ignoring almost 70 recommendations. But who arranged to the top cover? That’s a question I’d like answered.  

It is passing strange that the gaining and loosing of ‘military’ contracts time line is interwoven with the Pel-Air debacle. Lots of pennies involved, budgets, friends, rice bowls and reputations to protect there. No matter, if the ‘government’ can’t or won’t get to the root of it all; Aunty Pru will keep trying to ‘answer the riddle’.

Toot toot