[Peetwo]

Wow what a mad week in Oz aviation safety circles, starting with Nick's CASR Part 145 disallowance motion actually getting up & then culminating last night with the 4 Corners story - Ditched . A week perhaps best summed up by Ben in his short article - Pel-Air shock, no trauma damages recourse for victims - yesterday (23 March '15):

...The person at the centre of tonight’s Four Corners report is nurse Karen Casey, who was on board the Pel-Air operated Westwind corporate jet performing an air ambulance flight when it was ditched in the sea near Norfolk Island in November 2009.

Ms Casey suffered serious injuries in the crash, during which she saved the life of her patient Bernie Currall, getting her out of the broken jet before it sank and then keeping her afloat until they and the other four persons aboard the flight were rescued by a Norfolk Island fishing boat.

There were only two and half life rafts  vests onboard for six people,  something our discredited air safety investigator the ATSB brushed aside in its much condemned but now withdrawn final report into the crash.

Ms Currall’s death earlier this month from unknown causes will be investigated by a coronial hearing.

A suppressed internal review by CASA disclosed by a Senate Committee inquiring into the mishandling of the accident investigation by the ATSB found that CASA had failed to properly oversight the operation, owned by REX, and that Pel-Air was in breach of dozens of safety regulations or requirements at the time of the crash.

The ATSB report into the crash was repudiated in its critical elements by a peer review by the Transportation Safety Board of Canada late last year, forcing the discredited Australian investigator to withdraw its report and start again, this time to carry out its full obligations to the truth in examining all contributing factors to the accident rather than simply blaming it all on the pilot.

The Four Corners report also revolves around the suffering Ms Casey has endured since the crash, including physical and psychological traumas that have taken away her livelihood and capacity to live a normal life.

But in 2013 the rights to damages for anything other than bodily injuries were stripped away for domestic air travellers by Australia falling into line with a Montreal Convention exclusion of personal or mental traumas for the survivors of international air crashes. (This wasn’t material for Ms Casey as her flight started in Samoa and WAS considered international. However it was the realisation that Australia’s actions had now put all domestic flyers in the same position as Ms Casey found herself that drove much of tonight’s Four Corners edition.)

“What happened to Karen Casey can happen to anyone, and in fact it can happen to more people now,” Senator Xenophon said.
“The law has been changed in this country to take away people’s rights to claim for psychiatric injury for PTSD which can be as debilitating and crippling as any physical injury.”

Last week Senator Xenophon successfully moved a Senate disallowance of Labor introduced legislation which degraded the standards of aircraft safety certifications in Australia for the apparent purpose of isolating the Licensed Aircraft Engineers Association in this country.

In a somewhat astonishing turn of events Labor senators supported the disallowance of the rule changes championed by former Labor Minister Anthony Albanese while they were strenuously defended unsuccessfully by Coalition Senators.

There are reports on that event and a fierce discussion on Plane Talking here, with a follow-up here.

Once the implications of Karen Casey’s story are more widely recognised, a similar repudiation of an Albanese initiative might just get up...

     
All of which makes a perfectly good setting for me to finally come back to Part II on the Reason model (causal chain) & the search for investigative probity.  IMO (& many expert opinions, including the TSBC) the original PelAir investigation sadly lacked any probity and was devoid of any real analysis & contributory factors of many of the red lettered organisational factors - that were bizarrely bullet pointed in the CASA CAIR 09/3 report (see above post under 1.17 Organisational and management information)??

To begin here is a link for 2 rather long comments that are rehashes of blog posts made by Kharon and myself on another Planetalking article from 20 January '15 - Pel-Air, party donations, and air safety. An inexplicable coincidence? {Warning: They are long but IMO put in context the whole PelAir debacle}

#P9 quote:

...The story of flight nurse Karen Casey will shortly come into the public domain and present an almost unbelievable, but sadly true picture to the world of the depraved practices eschewed by the legal, regulatory and accident investigation systems. The Senate inquiry clearly, unequivocally identified the collusion between the regulator (CASA) and the investigator (ATSB), the cynical disregard for ICAO Annexe 13 reflected in the 1700 registered differences; the open disdain for the condition imposed by an Act of parliament; but worst of all; denied the world the lessons to be learnt from the accident.

The failure of the life vests still remains on the shelf, gathering dust. You do realise that the failed life vests almost caused the deaths of all; had it not been for the unselfish actions of the Norfolk Islanders and a large dollop of luck all could have perished that night. Inconveniently they did not...

  
Then we had a posted comment from Gary Curral - one of the survivors & now sadly the widower of Bernie Curral, the patient on the last flight of VH-NGA -  which absolutely nails where this whole sorry, sordid, true story is at:

currall gary

Posted February 7, 2015 at 9:51 pm | Permalink

I am an enormous fan of the pprune bloggers and of Ben in particular so my aim is simply to project my experience – which may not agree with some of the posted info / opinion.

I, and I suspect others raised the issue of lifejackets with the ATSB during the investigation but from my perspective the issue was not with failure but with the lack of provision, or access or use – I do not know which aspect failed but I am convinced that each of the three lifejackets in use that night inflated as intended and continued to support the lucky three. I have no firm recollection or opinion on the issue of the battery operated light but I thought they operated as they should have.

For me the problem was that 6 people survived with only 3 lifejackets in use – this point was ignored by the ATSB despite my submission highlighting this and for me, was symptomatic of the way in which it appeared that the ATSB conducted their investigation – or at least reported the findings. Blindingly obvious problems – comprehensible even to a layman were ignored – training of pilots, RVSM, never mind the issues later revealed by the 4Corners program.

It was apparent even to me early in the proceedings that the investigation was going awry. I can only imagine the frustration of the regular pprune contributors who exhibit a far more detailed understanding of the issues. So while the problem of lifejackets is only a relatively minor one – unless you happen to find yourself paddling in shark infested waters 6 km off Norfolk Island – it has pointed the way to the ultimate question, posed repeatedly by the pprune contributors – WHY? Karen, through FOI, I think, has found the reason – the reason why the investigation was conducted Beyond Reason – by following the money trail.

The Senate committee -clearly experienced in getting to the bottom of air safety issues now needs to complete their work.
       

This bit...

"...was symptomatic of the way in which it appeared that the ATSB conducted their investigation – or at least reported the findings. Blindingly obvious problems – comprehensible even to a layman were ignored – training of pilots, RVSM, never mind the issues later revealed by the 4Corners program..."

...shows that even Gary - a layman by his own admission - gets the Reason model and its importance in establishing a causal chain - which includes organisational issues - that help to recognise and hopefully mitigate future safety risk issues.
Instead we have a situation where significant safety issues - one that was initially categorised as critical - have been unidentified, or left unaddressed, or with positive safety actions obfuscated for more than 5 years - see here: #Whodunnit & Why : Chapter 3.5 – In the eyes of the investigator & TOE - which IMO is simply unacceptable for a so called independent State AAI..

The following is a quote from Ben's Crikey insider article - Why are victims of Pel-Air crash not entitled to compensation? 

What about the Pel-Air crash anyhow? Where is it at? 

Where to start? A rotten-to-the-core safety regulator, the Civil Aviation Safety Authority, hid the truth about its own culpability in setting up the administrative vacuum in which Pel-Air was able to break dozens of rules or obligations; the safety investigator the Australian Transport Safety Bureau tried to pin it all on the pilot;  and the ATSB’s Canadian peers told them they had screwed up, also revealing in passing that the final report was preceded by turmoil within the ATSB as it wrestled with its direction in the final months before it was released.

That ATSB report is now being redone, unfortunately by the ATSB, possibly adding to the damage this episode has done to Australia’s air safety reputation, and to the lives of all onboard the Pel-Air flight, including Bernie Currall, the patient, who died earlier this month.

Spot on Ben..

MTF...you bet! P2