Quote:P2 - [should] not be again neglected to be reviewed, along with all those other awkward operational/organisational contributory factors, like for example, Err...regulatory oversight.
From the PAIN Lockhart river report:-
Quote:...The Civil Aviation Regulations require that an air operator provide an exposition; usually entitled the Company Operations Manual (or similar) it is required, by strict liability law carrying criminal penalties to provide detailed operational support data. The exercise is designed to produce a 'rock solid' foundation supporting all facets of the proposed Air Operator Certificate (AOC).
....The CASA for the last few years have blurred the distinction as to whether the exposition is "accepted" or "approved". Notwithstanding the fine legal distinctions made, in reality, if the Flight Operations Inspector drafting the approval does not "like" what is presented the manual will neither be accepted or approved. In short, the CASA delegate 'must be satisfied'. etc.
It will be interesting to observe how the ATSB 'manage' the regulators role in the Pel-Air fiasco. Take the RVSM questions as one of the many aberrations the flight crew were forced to deal with. To gain approval for operations in RVSM airspace there is a list of 'requirements' (operational and engineering) a mile long to meet, then the whole endless process of having CASA approve the proposed system; then there are dedicated protocols and procedures for aircrew to learn, be examined in and an approval must be issued. Every step must 'satisfy' CASA. Should the company not have the approval, then aircrew are obliged to flight plan for operations in Non RVSM airspace. This requires clear policy and instruction to be provided in the fuel planning section of the approved/accepted company operations manual. Pel-Air had neither.
Yes, the company Chief pilot (responsible) should have picked up the deficiency, but did not.
CASA as the last link in the safety chain should have picked it up at audit; but did not.
Had the company approached CASA with an amended fuel planning policy for 'acceptance' then perhaps things would have turned out differently.
Had CASA identified a 'gap' in the safety net and brought it to the company attention; then, things may have turned out differently.
Who's to bless and who's to blame? well there's a choice isn't there. But if you put blame aside and focus on 'fixing' the problem; closing the loop: there are at least three recommendations which could be offered by the ATSB to prevent a reoccurrence. The big questions are – will they make those recommendations? – can they make them stick? – will CASA be obliged to 'fix' their wagon? – will the operator be audited to make sure the 'fix' is effective?
Big job for the ATSB and RVSM is just one area. The Norfolk ditching touches nearly every facet of the 'safety net'; from fatigue to flame out. The final question of course is – can the ATSB do the job without external assistance? Not if we are to have a honest, credible answer they can't – who would believe them? They are, after all investigating their own murky part as a major player in a very moody passage of play, some clumsy sleight of hand, being economical with the truth and trying to bluff a Senate full house with two pair.
No matter, we shall see the result of their internal efforts, in another year or two. No rush.
Selah.