[Peetwo]

Aviation safety issues and actions

If you click on the web link above you will see it takes you to the ATSB webpage with links for 849 recorded safety issues and/or recommendations dating back to 1996 when the ICAO Annex 13 State AAI was called the 'Bureau of Air Safety Investigation'.

Example:  

Output No: R19980161

Date issued:18 August 1998

Safety action status:

Background: See report B98/90 -'Systemic investigation into factors underlying air safety occurrences in Sydney Terminal Area airspace'.

Output text

The Bureau of Air Safety Investigation recommends that Airservices Australia review the relationship between the Sydney Safety and Quality Management section and the Sydney Terminal Control Unit with a view to developing procedures to improve the effectiveness of the safety management system, thus contributing to the overall "safety health" of Sydney Terminal Control Unit operations.

Remembering that in 1998 the concept of SMS was still some 14 years away from being enshrined and written into ICAO SARPs in the form of Annex 19.  

Quote from post - Yes: But…. - from the Ferryman gives a bare bones explanation to the average layman on how a properly functioning SMS is supposed to work and how an ATSB identified 'safety issue' leading to a safety recommendation could interact with that company/AOC SMS:

 "..One of the little problems ATSB have is that their ‘recommendations’ have no legal bind on company management. A small shift in ‘thinking’ could remedy that. An ATSB recommendation to the company SMS system would need to be acknowledged and considered through the SMS. Say ATSB recommended that pilots wear Pink socks on Tuesday and Blue on Friday. This is fed into the grass roots level of the SMS; the system is then triggered. This is a legitimate call by the government safety agency and cannot be denied entry. So the ATSB recommendation is duly considered; dealt with and the system decides it’s a crock. This is fine, but should the next incident involve pink socks, not blue, then there is a paper trail leading right to the top mans door. If a middle level decision to deny the recommendation was made it matters not – at the end of the shift the responsibility lays with the top dog. That is how a SMS is structured..."

However the ATSB under Beaker and now Hoody would seem to have lost sight of what the purpose is (other than a CASA auditable tick-a-box routine) for a properly functioning SMS i.e. to identify and risk mitigate 'safety issues' through a company hazard and incident reporting system operating under a 'Just Culture'.

In fact from recent correspondence between DJ and ATSB legal it would appear that the bureau are internally fractured or confused on what exactly their remit is when it comes to proactively addressing identified safety issues.

From the bottom of the ATSB 'Terminology, investigation procedures and deciding whether to investigate' webpage there is a 'safety issue' definition: 

Safety issue: a safety factor that:
a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and

b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

    
However the legal weasel from the ATSB would seem to be arguing the toss on the term and definition of a safety issue within the TSI Act - WTD??

Dear Sirs,

See attached internal CASA email correspondence, which is a clear breach of the TSI Act. I expect there are other similar emails and I will forward them to you as soon as I have them. Further, it would appear that CASA have not controlled the distribution of the draft internally, and that persons not providing or contributing to the CASA’s draft feedback document have copies of the draft report or are privy to the draft report’s contents.

As the ATSB prides itself as a ‘no blame’ organisation, I would hope the ATSB would act on this matter promptly and appropriately.

Regards,

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Dear DJ

Thank you for your email regarding correspondence within CASA concerning the draft report from the reopened investigation into the ‘Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009’.  The ATSB will confirm with CASA its practices for disclosure of the draft report in this matter in the context of section 26 of the Transport Safety Investigation Act 2003.  Please note that section 26 of the Act does permit disclosure and copying of the draft report necessary for:

                  (a)  preparing submissions on the draft report; or
                  (b)  taking steps to remedy safety issues that are identified in the draft report.

Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.  The email you have provided does not establish, prima facie, a breach of the Act with respect to copying or disclosure of the draft report.  The ATSB will make enquiries with CASA.

I note that you have included the ATSB’s Chief Commissioner, Mr Greg Hood, in the recipients list for your email.  As you may be aware, Mr Hood has recused himself from this investigation acknowledging his employment at CASA at the time of the accident.  Mr Hood is not involved in the ATSB’s decision making with respect to this investigation.  You may send any future correspondence on this particular matter to either myself or Colin McNamara, Chief Operating Officer.  Mr McNamara’s email address is colin.mcnamara@atsb.gov.au.

Regards

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Hi ATSB Legal Weasel,

Given that this accident occurred 8 years ago and that the information in the draft is not materially new, how can this be viewed as CASA remedying a safety issue? I’m already back flying and this matter deals with an opportunity for me to be promoted to a captain, so what contemporary safety case or pressing hazard needs to be addressed? To me it appears that a CASA officer is using an ATSB draft to inform their administrative processes, so doesn’t TSI Act 12AA (3)(d) refer?

If this is of no interest to the ATSB, then why would anyone participate candidly in an investigation if the ATSB doesn’t protect those involved from CASA inappropriately using draft reports?

Regards,

P.S. the link below to a Youtube clip of the recent CASA Estimates relates, especially at the 4:00 mark.

https://www.youtube.com/watch?v=tt7DDChxI-Y

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Dear DJ

Thanks you for your follow up email.  I watched CASA's appearance at Senate Estimates on 27 October 2017.  As I advised in my email of 1 November 2017, the ATSB is making enquiries with CASA with respect to this matter

Regards

LW

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Hi LW,

I'm not trying to labour the point, but I sincerely don't understand how no breach is evident in the CASA email extract; maybe I've referenced the wrong part of the Act.

Does 26(1) limit what a draft report can be used for, and in this case, CASA are acting outside of this?

Regards,

DJ

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Dear DJ

Section 26 of the Transport Safety Investigation Act 2003 places limits on copying and disclosing the draft report.  However, there are exceptions to the prohibition on copying and disclosure.  As mentioned, it can be copied and disclosed where it is necessary for the purposes of:

(a) preparing submissions on the draft report; or
(b) taking steps to remedy safety issues that are identified in the draft report.

The content of the draft report can be taken into account to remedy safety issues.  This could include CASA performing its safety related functions  The issue is whether or not the report was disclosed for the purpose of remedying safety issues.  I am following up with CASA.

There is a restriction on use in subsection 26(6) which states that a person who receives a draft report is not entitled to take any disciplinary action against an employee of the person on the basis of information in the report  Further, s.27 prevents the draft report (as well as the final report) from being admissible in evidence in civil or criminal proceedings.

I hope this clarifies the operations of section 26.

Regards

LW

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Hi LW,
 
Thank you - that answers my question.
 
Re CASA’s DIP protocols, I would expect that CASA has:

• carefully identified those persons with history or expertise in this accident whose input is essential to their DIP feedback
  
• formally retained those persons in writing and explained to them how the TSI Act applies to them and the draft’s contents
  
• ensured that those people in the DIP process are aware of who else is a DIP participant and therefore aware of who they cannot discuss the draft report’s contents with  
  

 
Do you know if the above resembles CASA’s present protocol?
 
Regards, DJ

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Dear Mr James
 
The Transport Safety Investigation Act 2003 details that the report should not be copied or disclosed except as provided for by section 26.  We are checking that they follow that practice.
 
Regards
 
LW

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Hi LW,
 
Thank you for that - much appreciated.
 
Re an earlier email where you said that CASA were entitled to use the draft report to respond to 'safety issues', can I draw your attention to the following ATSB document and a section from it:
 
ATSB TRANSPORT SAFETY RESEARCH REPORT
Aviation Research and Analysis Report – AR-2007-053 
2.3 Safety issue

1. 2.3.1  ATSB definition
   

A safety issue is a safety factor that:

1. • can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
     
   • is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. 
     

 
Is this definition consistent with the definition used in the TSI Act? If not, could you please direct me to the definition of ‘safety issue’ that is used in the TSI Act?
 
Regards, DJ

P2 comment: Note that the safety issue definition from AR-2007-053 is the same as the current listed (above) definition off the ATSB webpage. Ironically the person who came up with that definition is none other than the PelAir re-investigation IIC Dr I'm a Psychopath-Ghost-who-walks  

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Dear Mr James

 
The Transport Safety Investigation Act 2003 does not define the term ‘safety issue’.  The Explanatory Memorandum to the Act does not indicate that the term in the Act is limited to identification of organisational safety issues.
 
Regards
 
LW

I can only presume this ATSB legal stance is to support the provision of top-cover for CASA while faciliting the CASA Sydney Regional office continued 8yr embuggerance (anniversary today) of DJ...



MTF?- Definitely...P2