[Peetwo]

PAIN/IOS WTD ATSB QRH -    

Not sure why Hoody's media minion is drawing attention to the fact that 'ICAO Thor' is here auditing the ATSB..   However after a short background check, if the intention is to flatter and therefore placate the dude, nice try but I think the minion may have 'Buckley's or none'...
Excerpt from a Kathryns Report blog post : http://www.kathrynsreport.com/2014/01/ai...-body.html

On November 9, 2012, investigators of the International Civil Aviation Organization (ICAO) completed their probe into the crash which revealed that the incident occurred after the pilot lost control of the aircraft. The ICAO report also termed the CAA investigation report, available on its website, as incomplete and lacking vital information.

The reinvestigation, carried out by ICAO Technical Officer Dr Andre Dekok and Standards and Procedure Officer Thormodur Thormodsson, claimed the SIB was not an independent and impartial organization and could not investigate air crash incidents in a transparent manner. They had recommended that the SIB be turned into an independent entity to avoid misinformation and bureaucratic influences.

“At the ICAO’s headquarters in Montreal a few months back, we advised the ICAO to exert pressure on the Pakistani government to declare the SIB an independent entity,” Hamid said, adding that unless it became an autonomous body, the SIB would not be able to reveal errors of its parent organization (CAA).

 Hmm...shades of PelAir in that lot...  

P7 (snipe) - Not kidding. Should fit right in with the ‘match fit’ crowd; two quick outings with Hoody and Halfwit, he’ll be tho thor he cant pith; anywhere, anytime. Will he enter the ‘wool-pulling’ comp; or, just join in the knitting – Pel one, Kintair two for a nice woolly jumper? Anything but make ATSB ‘independent’ they’d all rather jump off the nearest bloody cliff first.

Yes; yes, two more here barkeep: I know, but I’m in good company when drinking alone. MTF.

Some more helpful references for Herr Thor...

"K" on a WTD ATSB: re Essendon B200 accident investigation...

What’s wrong with these statements?

“Investigators unravel web of companies behind doomed Essendon Airport flight”.

"The question over who was responsible for the flight is still being investigated by the Australian Transport Safety Bureau."

Why FDS are the ATSB investigating legal responsibility, while the priority – determining the radical cause of the accident is still not known? The ‘legal’ ins and outs are CASA’s bailiwick and have sod all to do with the ATSB investigation into cause of accident. There is nothing in the ‘responsibility’ paper trail which will define or explain what occurred during the nine seconds of flight. It is understandable that ATSB would take a great deal of interest in the maintenance aspects, a very keen interest in reported ‘snags’, routine servicing and aircraft general airworthiness. But why waste ‘scarce resources’ investigating who was responsible for, who authorised and who paid for that maintenance; CASA should be able to furnish that information at the click of a mouse button. If they can’t then it is time to investigate CASA (again).

This passion for laying blame and seeking avenues to ‘prosecution’ before we even have a blind clue about the cause always clouds the accident investigation picture; there is always someone ‘in the gun’ before the dust has settled let alone the ‘cause’ is fully known. ATSB need to focus on that, not the intricate details of ‘responsibility’. That is what CASA is for, unless of course they are, once again, part of the causal chain.

Toot toot.

TSBC on a WTD ATSB: Peer review report

Recommendations
The TSB Review is making 14 recommendations to the ATSB in four main areas:

• Ensuring the consistent application of existing methodologies and processes
  
• Improving investigation methodologies and processes where they were found to have deficiencies
  
• Improving the oversight and governance of investigations
  
• Managing communications challenges more effectively.
  

Recommendation #1: Given that the ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, the ATSB should continue efforts to ensure the consistent application and use of its methodology and tools.
Recommendation #2: The ATSB should consider adding mechanisms to its review process to ensure there is a response to each comment made by a reviewer, and that there is a second-level review to verify that the response addresses the comment adequately.
Recommendation #3: The ATSB should augment its DIP process to ensure the Commission is satisfied that each comment has been adequately addressed, and that a response describing actions taken by the ATSB is provided to the person who submitted it.
Recommendation #4: The ATSB should review its risk assessment methodology and the use of risk labels to ensure that risks are appropriately described, and that the use of the labels is not diverting attention away from mitigating the unsafe conditions identified in the investigation.
Recommendation #5: The ATSB should review its investigation schedules for the completion of various levels of investigation to ensure that realistic timelines are communicated to stakeholders.
Recommendation #6: The ATSB should take steps to ensure that a systematic, iterative, team approach to analysis is used in all investigations.
Recommendation #7: The ATSB should provide investigators with a specific tool to assist with the collection and analysis of data in the area of sleep-related fatigue.
Recommendation #8: The ATSB should review the quality assurance measures adopted by the new team leaders and incorporate them in SIQS to ensure that their continued use is not dependent on the initiative of specific individuals.
Recommendation #9: The ATSB should modify the Commission report review process so that the Commission sees the report at a point in the investigation when deficiencies can be addressed, and the Commission's feedback is clearly communicated to staff and systematically addressed.
Recommendation #10: The ATSB should undertake a review of the structure, role, and responsibilities of its Commission with a view to ensuring clearer accountability for timely and effective oversight of the ATSB's investigations and reports.
Recommendation #11: The ATSB should adjust the critical investigation review procedures to ensure that the process for making and documenting decisions about investigation scope and direction is clearly communicated and consistently applied.
Recommendation #12: The ATSB should take steps to ensure closure briefings are conducted for all investigations.
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Recommendation #14: The ATSB should implement a process to ensure that communications staff identify any issues or controversy that might arise when a report is released, and develop a suitable communications plan to address them.

Senate RRAT committee with a WTD ATSB: PelAir cover-up report

List of Recommendations

Recommendation 1

3.68      The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay.

Recommendation 2

4.41      The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification.

Recommendation 3

4.43      The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.

Recommendation 4

4.69      The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.

Recommendation 5

4.78      The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.

Recommendation 6

4.79      The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in training/competence must be advised to the minister and the Parliament.

Recommendation 7

4.87      The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.

Recommendation 8

4.101      The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Recommendation 9

4.103      The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.

Recommendation 10

6.41      The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

Recommendation 11

6.52      The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.

Recommendation 12

6.55      The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.

Recommendation 13

6.58      The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.

Recommendation 14

7.15      The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:
•advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
• provide the ATSB with the relevant review report as soon as it is available.

Recommendation 15

7.16      The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.

Recommendation 16

8.35      The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.

Recommendation 17

9.18      The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18

9.40      The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19

9.42      The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20

9.44      The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21

9.45      The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.

Recommendation 22

9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

Recommendation 23

9.104      The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer.

Recommendation 24

9.106      The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.

Recommendation 25

9.108      The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.

Recommendation 26

10.35      The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

Rev Forsyth with a WTD ATSB: ASRR report

Just getting warmed up but there's a small selection of reading material for Herr Thor that IMO truly qualifies as independent and expert opinion of the ATSB. However if he wants a very informed, pragmatic and qualified take on the real issues with the current version of the ATSB, IMO Thor couldn't go past the inestimable Senator David Fawcett...

 

Of course Thor will not do any of that because he will be required to strictly adhere to some warm & fluffy agreed ToR...

However I wouldn't have thought that would stop certain elected parliamentary representatives from dropping Herr Thor a line to find out what exactly it is he is scoped to look into...


MTF...P2