The Sunday Brunch Gazette.

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Ref: http://www.auntypru.com/forum/thread-30-...ml#pid9629 or https://youtu.be/ilYVNRO0reQ

Setting the odds and playing ‘em.

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A ramble – no excuses. There is a difference: this was taught to me at a very tender age by a wonderful old gentleman; Billy Coils.Esq.  He was a wisp of a man, one of those tough, wiry, terrier types and a great friend of my Grandfather. They met on the cavalry lines during the Boer war, both horsemen. Later, Billy worked and lodged with the family, it was then that I met him. He both knew and understood my interest in the ‘Orses. It was a seriously cold morning with wind driven sleet preventing my usual ‘escape’ plans when I discovered his dark secret. Billy ran a book; not that anyone could place a copper coin bet with Billy; it was his own private delight. Indulge me, there is a point. In short, Billy would take the Bookies odds set for a race and match then against his own version of the forecast odds – and he ‘knew’ horses. He piqued my interest so very easily with a wily question – “I see that Buttercup is running at Epsom at 3.30, think she’ll win?”. Old bugger knew that I knew the animal in question, local and part of my holiday escape perfect day plans. “Course she will” says I. “Dunno” say’s Billy; “they put her out at long odds”. “Long odds” say’s I – puzzled – “Wuzzat?” Suddenly a bleak morning, trapped indoors melted away as I learned to set and play the odds. Billy’s system was shear genius; he never ever placed a bet, but he consistently beat the Bookies. Where the odds set differed between his forecast and those on track; he would note his wager. He both set and played the odds, in his own way, much to our mutual satisfaction.

“What is the fool rambling on about?” asks the mob. Well, I shall tell you. There is a rare aviation success story being told this week. Essendon airport both the star and hero. It is brilliant that one aerodrome has a healthy, good sized fleet of corporate jets. It is wonderful that the maximum allowable weight has been lifted to accommodate the latest residents.


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Ref: Essendon Airport - c.1963 http://www.airwaysmuseum.com/EN%20aerial%20c63.htm

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Ref: https://www.propertyobserver.com.au/find...uxton.html




Essendon has long been a favourite airport of mine and to see it prospering cheers me up. Such things are a matter of course in the USA, but it’s great to see it happening in Australia. How long it will last is anyone’s guess; you see the risks there, at Essendon are much greater than those in the USA – which creates a potential big win for the astute bookmaker, setting the odds.

When Mark Vaile was minister (2007), he rejected, on safety grounds, a DFO development at Sydney airport – ‘too bloody risky” (paraphrased). History shows that the discarded advice (good sense) on the Essendon development was used and the ‘white hats’ won the day, no DFO at Mascot. Finally safety and good sense beat the developers.

I wonder though at folk like Fox and Packer; their Essendon dream could have been so easily destroyed the day the King Air impacted on the DFO roof. These folk are, by nature, gamblers. They take risks, sure they are canny players and often winners, it is the nature of the beast. But consider, just for a moment, the difference 10 feet and a couple of hours would have made to the Essendon tragedy. Had that aircraft been 10 foot lower, departed an hour or two later; there would have been an epic disaster. A five ton bomb slamming into a building, packed full of people. Had that building not been there, the odds of survival increased considerably. A fall of government would be IMO, the loose change of the fall out.



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Ref: https://www.racing.com/news/2018-11-06/w...cup-replay

“The gambling known as business looks with austere disfavour upon the business known as gambling.” ― Ambrose Bierce


Take a moment to see the differences between a very successful American ‘corporate’ airport and Essendon. The picture is worth a thousand words; but the ‘rules’ underpinning that picture, clearly based on sound evidence, categorically prevent anything remotely like a DFO being built in a ‘high risk’ zone. There may have been – in normal circumstances – just enough wriggle room for the King Air pilot to 'fly' the aircraft out of trouble. In fairness we don’t know that; but with two healthy engines and a little more time – who knows. I’d lay odds it was possible.





"..if you look at a safety system holistically—a bit like James Reason and his accident causation model—what we are finding is that each of those pieces of Swiss cheese has been thinned to the absolute minimum that is permissible by law, which maximises the chance of an accident by minimising the options for a pilot who has a malfunction in an aircraft. I guess the request here is that we sit back and look at this holistically, as opposed to saying, 'Yes, they have met this requirement or that requirement,' and look at the aggregation of the loss of margin and, therefore, options for an aircrew member who has an issue with an aircraft. Public safety zones are but one element of that whole system" ― Senator David Fawcett, 23 May 2017.

(ref: https://parlinfo.aph.gov.au/parlInfo/dow...fb/0000%22 )


I would be delighted to see Essendon grow and thrive; but I’m puzzled that those who have so much invested and so much to loose would take what is, IMO an unacceptable risk of a repeat event. “No chance” howls the developer mob. The Billy Coils system disagrees gentlemen; the book is open, the odds attractive.



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“Play interests me very much," said Hermann: "but I am not in the position to sacrifice the necessary in the hope of winning the superfluous." ― Aleksandr Sergeevich Pushkin

Ref: https://bibliophilica.wordpress.com/2014...e-in-2014/


Aye, it could have all been said in one short paragraph “no big buildings in known high risk zones” but where’s the fun in that? Coffee cup empty, smoke gone out, not raining – must be time to go out; I shall confer “wanna go out?” – The Aye’s have it.

Toot - toot.

P2 comment - Can't be long now before the Hooded Canary sings?  Rolleyes


Quote:
"The other point I might add is the ATSB is very much the canary in the mine—and let me tell you, we will sing. But we're not going to sing prematurely, and we're not going to sing without the evidence to sing appropriately. You may be aware, from the other committee, of our report on the ATR aircraft. We have formed a strong view in relation to that aircraft. We published two interim reports and we've got a third one coming. So, we're not afraid to exercise that authority and have our say when we think it's appropriate.  ―  ATSB Chief Commissioner Greg Hood, 29 August 2017."
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Ref: https://www.dailymail.co.uk/news/article...ourne.html

“When the hurlyburly's done, When the battle's lost and won.”

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Ref: https://www.abc.net.au/news/2018-09-24/e...d/10295982

Well, it is well and truly over for 2018. Now as the time approaches the ‘month of the dead’ – (January) and all have sugar plums dancing in their heads; we must decide if the battle is lost, won or has even kicked off. Parliament is buggered; gods alone know what the hell they do down there; but it bears little to no resemblance of ‘good governance’ or Statesmanship.


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"Conservatism discards Prescription, shrinks from Principle, disavows Progress; having rejected all respect for antiquity, it offers no redress for the present, and makes no preparation for the future." - Benjamin Disraeli on Future 


Hell I’ve seen better behaviour in borstals, better manners in brothels, more common sense shown by Brickies labourers and more decency and dignity shown at Mathew Talbot hostels. I’ve no idea which planet the ‘politicians’ live on – but it certainly ain’t one I’ve visited. The elections loom large and scary; which means months to wait for any sort of action on anything, barring self promotion. They, the new government will spend a six month drinking tea and having meetings - so they can ‘get across’ a subject (which is a polite way of saying a stallion is about to mount a mare); then, there will be a further delay until ‘policy’ is formulated and fed through to the minions; then, more delay while the minions work out how best they profit from the ‘decisions’. We are up the proverbial creek, sans paddle for at best a 12 month – if we get lucky. Land of the long weekend – great – unless you run an aviation business, haemorrhaging money, operating in a dying market, crippled by regulation and ruled by the asylum lunatics. But enough of the disintegrating way of Australian life, courtesy of useless politicians; we can, for the moment, at least drink the water.


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A politician thinks of the next election. A statesman, of the next generation. ― James Freeman Clarke



Of course, before the politicians have swanned off to enjoy their hard earned; the top dog bureaucrats have finished their ‘power’ lunches and attended the party rounds – to be seen – to be seen - and to reaffirm old friendships, have departed the fix to enjoy the half million salted away last year; which allows free spending of ‘the bonus’. Critters like the caged, yellow, hi-viz wearing Hooded Canary, for example. Oh, a rare species indeed; no mine shafts for this songster; no Siree. Plenty of Soiree though; at which to be feted as the grand master of Smoke and Mirrors. The accolades and bouquets, all sweet music to the man who has thrown up some of the biggest, bestest, brightest bullshit ever created in the history of the art form. The meaning of “Stop Press” has been redefined by Hood, to the department’s unconstrained glee. I speak of course of the ‘old game’ which involves not only throwing up a super smoke screen to shut the media down, but delaying and prevaricating on an investigation until the facts can be massaged to support the gross defamation - of a dead man.



Of course, Quartermain was a gift from heaven. He had ‘history’. Whatever happened at Mt. Hotham has never been satisfactorily explained– nor is it likely to be explained; it is tailor made to suit the smokescreen and assist in turning the media away to juicer tales. Hood stood and actively defamed a dead man – why? Well children, the answer is as clear as it is 'Murky'. No one department actually had total responsibility for the monstrosity parked, legal to the millimetre, almost in the emergency zone required by aircraft with a directional control problem. In the USA or Europe the DFO at Essendon would never have been built, not where it stands (today). 'Not safe' says the USA scientific evidence. Not on my watch say’s Mark Vaile (Minister) when another concrete lunacy was proposed for Sydney. And yet, with the assistance of Mrdak and our old mate Dolan; liberties were taken at Essendon. As it happened, despite the Hood claim that by the King Air actually hitting the DFO building, lives were saved. Lives were lost - QED.

I say BOLLOCKS.



Hood say’s that the pilot omitted his checks –

I say BOLLOCKS and PROVE IT.

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Hood say’s “I will Sing”.

Sure he will; peach like buggery the moment they try to remove this unqualified Canary from his Golden parachute job. Be a wonderful Christmas present if he did – all the low down on the pigs ear CASA made of Pel-Air and his part (as decision maker) revealed. 


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Quote:"...The main reason being that while HVH was the CASA Executive Officer ultimately overseeing the enforcement actions against both PelAir and Dominic James I also have, on good authority, information that HVH was the designated co-ordinator/liaison officer dealing with the FAA audit team and therefore the consequential cover-up of the actual FAA findings that could have led to the possible Cat II IASA rating..." 

Quote:18 November 2009: Ditching 3 NM south-west of Norfolk Island Aerodrome.

18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. The
ATSB decide to carry out an investigation and CASA decide to run a parallel
investigation, initiated 19 November.


19 November 2009: Pel-Air voluntarily suspend Westwind operation.

20 November 2009: Quote from page 97 of PelAir MKII Final report - "The ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI."

23 November 2009: Richard White MALIU correspondence to ATSB Director Aviation Safety Investigations, Ian Sangston notifying CASA will be conducting a regulatory investigation into the actions of the flightcrew. Note that there is no reference to 'parallel investigations' under either the 2004 or 2010 MOU (ref link - #122 &  #28).

23 November 2009: Richard White receives from Airservices Australia  the complete list of Norfolk Island Terminal Aerodrome Forecasts (TAFs) applicable to the occurrence flight timeframe. This included the Nadi non-relayed 0803 AMD TAF, which appears to be underlined (ref link - #122 & #85 )

25 November 2009: Greg Hood file note email (cc'd Jonathon Aleck, Terry Farquharson, John McCormick.). File note No.4 reference to flight recorder recovery would appear to show, at that point in time, that recovery was inevitable (ref link - #125 )

26 November 2009: CASA initiate a ‘Special Audit’ conducted between the 26/11/2009-
15/12/2009 at the Pel-Air Bases in Sydney, Adelaide and Nowra.

30 November 2009: Richard White email to John Barr (cc Roger Chambers) confirming Airservices passed on weather & received flight plan details from PIC Dominic James by phone in Apia. (ref link - #122 ) 

7 December 2009: Audit team meet with Pel-Air management to discuss a number of
deficiencies within the Westwind Operation. This was backed up by correspondence from
CASA on 9/12/2009.


7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 & FAA Nov 30- Dec 4 2009 Australian audits. (ref links - #53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf

8 December 2009: E-mail from ATSB to CASA raising the possibility of contributing to a
joint fund sharing arrangement to recover the black box and CASA advised they didn’t
have the necessary funds.


11 December: Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (ref link - #122 & PDF 881KB )  


16 December 2009: CASA accept the Pel-Air ‘Management Action Plan’ which consisted
of three phases.

16 December 2009: Dominic James was 'informally' interviewed by CASA  legal and investigative officers. (ref link - #112 )

18 December 2009: Pel-Air successfully completed Phase 1 items and were able to
recommence domestic operations. 

21 December 2009: CASA Special Audit of Pel-Air Fatigue Risk Management System ( ref links - #217 & PDF 5428KB )

23-24 December 2009: CASA overseeing FOI of Pel-Air Eric Demarco issues 14 RCA and
a number of AO. The RCAs needed to be acquitted by 28/01/2010.

24th December 2009: Dominic James notice of suspension of CPL, ATPL, CIR pursuant
to CAR 265(1)(a). Also given notice to undertake examinations under CAR 5.38.

24 December 2009: Pel-Air successfully completed Phase 2 items and were able to
recommence international operations.

References: 
1) The Iron Ring & the Hooded canary - http://www.auntypru.com/forum/showthread...38#pid8238
2) Pel-Air: A coverup: a litany of lies? - Version III - http://www.auntypru.com/forum/showthread...82#pid8182
3) http://www.auntypru.com/forum/thread-143...ml#pid8211


That, boys and girls would make better listening than another round of “Away in a Manger”, Jingle Bells or bloody Rudolph the Red (brown) Nose etc...

Aye well. Time will pass, Christmas pudding and hangovers will dull the memory of Max Quartermain and the disgraceful building he hit. Perhaps not in the minds of his nearest and dearest, facing Christmas without the familiar figure at the table, a man denigrated, defamed, all but forgotten except by those who know a Hood job when they see one. Perhaps, once the Senate has bid a fond fare-thee-well to O’Sofullofit next year; Fawcett and his famous ‘thin slices’ of Swiss cheese will be heard, once again. We can only hope; for there stands a 'Statesman'; an Officer and a Gentleman – in the truest sense of the words. My Christmas wish? You bet it is. Hood would last about one round against Fawcett – I wouldn’t even bother taking your bet. Will sense prevail? Good question that; a very good question indeed.

No matter. Must away; tempus fugit. BRB – BBQ tomorrow; then I’m crewing for Santa Christmas eve; the new gear on the sleigh is remarkable – not CASA approved of course – but who gives a monkeys – not me, not Santa and Rudolph has a new efflux control to test. So:- catch us if you can………..May your gods go with you and see you safe home.

Selah.

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O, that way madness lies; let me shun that;

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https://australiafirstparty.net/essendon...ding-area/


Dear old King Lear was in a pickle; no doubt. No happily ever after for him. Awash in a sea of deceit, treachery and error, burgeoning madness was a direct result of ‘the consequences’. Not that ‘consequences’ (foreseen or otherwise) seem to hold any sway in the modern, dog-eat-dog world of the modern ‘developer’; seems there ain’t any – well, none worth a mention. So many escape clauses and so much cooperation from those who sit in a position to fully ‘understand’ the developers version of ‘logic’. In – Out – fast type; and, the legally arguable (at great costs) finer points of safety may, long after the deed is done; be genteelly argued (at great expense) over a number of years (at great expense) by top dog Barristers (at great expense) to arrive at the conclusion that, maybe, perhaps the development was ‘legal’. The consequences ‘unfortunate’ however…….


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Quote:“Mad Hatter: “Why is a raven like a writing-desk?”
 “Have you guessed the riddle yet?” the Hatter said, turning to Alice again.
 “No, I give it up,” Alice replied: “What’s the answer?”
 “I haven’t the slightest idea,” said the Hatter”


There has existed in this land a document named ‘Making Ends Meet’. It is and remains a critical assessment of matters relating to the development of aerodromes. Not that it made a skerrick of difference. No matter what safety logic is provided the consequences are continually attacked, degraded and belittled until it seems that ‘you’ are the one out of step and better buck your ideas up, get on board and play with the team. All well and good until some chap slams a five ton aircraft with two ton of highly volatile jet fuel into a building, which could have been full of shoppers at the time. It wasn’t; but there were folks there, setting up and preparing for the crowds expected. They must be entitled to some compensation as a direct result of the ‘consequences’ which led to that building getting whalloped, after expert, scientific advice, was blithely ignored. Oh, yes it was – no mistake. The Murky Machiavellian and his side-kick Dolan were granted all manner of latitude to make the sale of airport land (Commonwealth land) to developers as attractive as possible. Hell they even ‘finessed’ some definitions to assist. All in the name of progress aligned with public safety of course.



Ref: https://auntypru.com/forum/thread-30-pos...ml#pid9711


Quote:“Why, sometimes I've believed as many as six impossible things before breakfast.” ― Lewis Carroll, Alice in Wonderland


And yet, despite the warnings, the incidents, the accidents and the potential for future accidents; the Australian government will not contemplate adopting the Californian ‘safety zones’ model. It is, after all only based on impeccable scientific data and developed from the British notion of ‘safety zones’. The Brits being a bit ‘squeezed’ for room and having a serious number of aircraft aloft – took steps I believe in 1958 (P2 will correct) to mitigate the off chance of an aircraft turning a shopping centre into a charnel house. (They tend to do that – when they hit ‘em). The USA developed a code and mitigated the ‘high end’ risk out of the game. Not so for our lacklustre, financially motivated, short term for high remuneration breed of political animal – hell no. 


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"Sooner or later everyone sits down to a banquet of consequences." ― Robert Louis Stevenson


For example; there is a plan to build a large hospital in a regional centre; it is to have all the toys – including a helipad. Bravo. There is even an approach path mapped out for the Choppers which is touted as ‘the best’. For many reasons, that ‘selected’ path suits many people and puts a nice shine on the ‘spin’ delivery. Cool Banana’s; right. Well, answer me one question – just the one, a short one. Do you know what a Flying Fox is?


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Flying-foxes are the largest flying mammals in the world, acting as long-range seed dispersers and pollinators for a large number of native trees.”

“The maps below show the general location of flying-fox roosts in Queensland recorded by the department, and include continuously and periodically (seasonally or irregularly) used roosts. The exact location of roosts may vary within a small localised area.”

Around dusk, grey-headed flying foxes leave the roost and travel up to 50 km a night to feed on pollen,

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Well done class; all correct – now then, for Choc Frog; one last question. How would you like to be a patient flying in a helicopter to hospital, at low level <500' around about tea time or breakfast time through a 1.5 kilometre ‘launch zone for hundreds of flying foxes? For a bonus point, how many Fruit Bats to kill a Chopper?. Give up, can’t guess, well wait a while and the answer will become clear – the route to the emergency ward through the Fruit Bat launch zone is ‘approved’. Consequences? Wuzzat - Never heard of ‘em. The local airport development plan has - but 'what-the -hell'.

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“The future is an ever-shifting maze of possibilities until it becomes the present. The future I have shown you tonight is not yet fixed. But it is more likely to become so with the passing of every day because nothing is being done to turn it aside. If you would change it, do as I have told you.” ― Terry Brooks, The Scions of Shannara

The situation came to critical mass with the DFO accident at Essendon. So deep, ingrained and systematic is the rule of ‘no consequence’ that a dead man must be defamed and denigrated to protect the machinations of those without conscience. The ministerial Catamite vowed and declared that, categorically, absolutely and with certainty the pilot not only failed to do his pre take off checks; but ignored five separate chances to prevent the accident. Utter BULLSHIT. I have, for my sins, completed some ‘re-training’ of pilots who have made a mess of a job – same-same as Quartermain had after the Mt Hotham gig. There are only two pathways for the pilot – get conscientious, or go rogue. Never, not ever have I noted a pilot revert to old slack habits, not once they have seen the error of their ways. I’ve seen them go ‘tuther way – pedantic and more. But Quartermain was psychologically much more likely to make sure that no man could say he was ‘slack’, slip-shod or incompetent. Hood threw up a giant smokescreen to shut the media down. About time they started to ask the right questions – there’d be a Walkley init fur sartain shure.. 

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"How did we get here? Given the age old sin of Adam as a given, I would say it is because we first became a culture of enabling. We found excuse after excuse to mollify behaviours, constantly absolving of fault, and turning everyone into an unappreciated or underappreciated special snow flake. We stroke self-esteem without exhorting towards the things that led to actual self-esteem. What a nasty little narcotic that turned out to be! Real life consequences were to be protected from and ignored lest accountability and responsibility were resurrected like some long dead monster to come and ravage our hollow hyper inflated egos."


Let’s go dogs, grab the tool box; time’s up and we are under extreme pressure. Domestic Tyranny (DT) is making some dire threats, seems the list on the fridge door is long and overdue. Best crack on; TOM is dining with us this evening and peace in the house is always a good way to kick off a New year. (Think’s: If I can lure him here early with the promise of a new keg; maybe my time on the tools can be reduced, now, where’s that phone)….

Selah.

P2 comment - The following is an excerpt video from the same Budget Estimates 23/05/12:


Ref: 1) https://auntypru.com/forum/thread-97.html
2) https://auntypru.com/wp-content/uploads/...alysis.pdf
3) https://www.atsb.gov.au/publications/inv...200304282/

This was the infamous Senator Fawcett 'closing the safety loop' QON. - hmmm...I wonder what the Coroner will make of the Hooded Canary's YMEN DFO accident cover-up final report?  Blush    
Reply

Want the truth Miniscule? - Obviously... Dodgy    



Here's a recap of the dire straits of the total clusterduck Govt has self-created with it's head in the sand (non-)acknowledgement of the deep, dividing issues between the aviation industry and an eternally dysfunctional, 'law unto itself' regulator...

First from IOS Hall of Famer Bruce Rhoades:
 
(01-01-2019, 11:35 AM)Peetwo Wrote:  HAPPY NEW YEAR MINISCULE - L&KS Bruce RHOADES and the IOS... Rolleyes  

Update 01/01/19 : Bruce Roades' - FINAL BATTLE.



FEDERAL ICAC NOW! 

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TICK TOCK MINISCULE - Your days are numbered... Rolleyes

Next a quote from this week's SBG:

Quote:...There has existed in this land a document named ‘Making Ends Meet’. It is and remains a critical assessment of matters relating to the development of aerodromes. Not that it made a skerrick of difference. No matter what safety logic is provided the consequences are continually attacked, degraded and belittled until it seems that ‘you’ are the one out of step and better buck your ideas up, get on board and play with the team. All well and good until some chap slams a five ton aircraft with two ton of highly volatile jet fuel into a building, which could have been full of shoppers at the time....Oh, yes it was – no mistake. The Murky Machiavellian and his side-kick Dolan were granted all manner of latitude to make the sale of airport land (Commonwealth land) to developers as attractive as possible. Hell they even ‘finessed’ some definitions to assist. All in the name of progress aligned with public safety of course...

Revisiting that 2003 H of R Standing Committee on Transport & Regional Services report, you first need to pinch yourself because the feeling of déjà vu is almost overpowering... Confused

To get a sense of what I mean one needs to read Chapter 7 of the final report - https://www.aph.gov.au/Parliamentary_Bus.../chap7.pdf - and the disturbingly familiar recommendations 23 to 28... Dodgy  

Quote:Recommendation 23

7.45 The committee recommends that the Department of Transport and
Regional Services:

- Verify the adequacy of regulation impact statements for
amending aviation safety regulations prepared by the Civil
Aviation Safety Authority; and
- Assess that the cost impacts calculated are reasonable and
justified, taking into account the importance of regional
aviation to regional, rural and remote communities.



Recommendation 24

7.65 The committee recommends that the Civil Aviation Safety Authority
introduce into its service charter mandated response times and fixed and
fair prices for its services.



Recommendation 25

7.80 The committee recommends that the Civil Aviation Safety Authority:
- Review its training processes to ensure consistency of the Civil
Aviation Safety Authority’s interpretation of the law and
regulations;
- Introduce an ongoing program of staff training in regulation
interpretation to ensure improved consistency of the Civil
Aviation Safety Authority’s interpretation of the law and
regulations; and
- Regularly assess and record in its annual report, the levels of
knowledge and competency of its staff in interpretation of the
law and regulations.


Recommendation 26

7.92 The committee recommends that the Department of Transport and
Regional Services:

- Conduct an annual confidential client satisfaction survey to test
industry’s satisfaction with the services that the Civil Aviation
Safety Authority delivers, and assess compliance with its
service charter; and
- Publicly report the results of these surveys, ensuring that
confidentiality is maintained.




Recommendation 27

7.123 The committee recommends that:

- The Civil Aviation Safety Authority provide customer relations
management training to its staff, particularly those in regional
offices;
- The Commonwealth establish an Aviation Ombudsman, and
ensure that this position is filled by an appropriately skilled
person, to consider all aviation industry related complaints;
and
- The duties of the Aviation Ombudsman would include, in
addition to examining operational complaints, conducting
independent surveys of industry, ensuring that the
confidentiality of respondents is maintained. These surveys
would assess the effectiveness of the Civil Aviation Safety
Authority’s measures to improve the consistency of its
interpretation of aviation regulations.




Recommendation 28

7.146 The committee recommends that:

- The Civil Aviation Safety Authority, in addition to enforcing
aviation safety compliance, place greater focus on activities to
assist industry players in complying voluntarily with the
regulations; and
- The Australian National Audit Office periodically audit and
report to Parliament on the Civil Aviation Safety Authority’s:

- compliance with its service charter;
- fulfilment of fostering a culture of safety in the industry;
- policing the regulations to achieve aviation safety outcomes;
and
- provision of information and education services provided
jointly with the industry.

Now let me remind you what the original ToR were for this parliamentary inquiry -  Shy

Quote:Terms of reference

- The adequacy of commercial air services in regional and rural Australia.
- Policies and measures required to assist in the development of regional air services, including:
  • regional hub services;
  • small scale owner-operator services; and
  • the deployment of most suitable aircraft types.
- The adequacy of commercial air services to major populated islands and the adequacy of alternative sea services.
- Interconnectivity between regional air transport systems, major national air services and international services (including on-carriage, through ticketing, freight handling, timetabling and airport slotting).
- The role of all three levels of Government in supporting and assisting the development of regional air services and island transport systems.
- The role of major air transport carriers in providing regional services.
WTF? How did this inquiry get to chapter 7? Did I miss something?  Huh 

Indeed I did, here is a link for the Hansard transcript where CASA first gave evidence to this Parliamentary Inquiry... Dodgy 

Ref: https://parlinfo.aph.gov.au/parlInfo/dow...76/0000%22

As can be read the evidence given by the CASA Executive at the time was typically shambolic and self-serving, example:


Quote:Ms LEY —Sure. I was not talking about the FLOT conference but another NPRM process that an engineer in my area went to. They said that, having made the big effort to travel all day, they just were not listened to. They did not have an opportunity. But they did say that, when the final report came out, they were listed as having been consulted in order to give the impression that they had been, but they were not.

Mr McIntyre —That is probably because they did not see reflected in the rule what they wanted. They were consulted, their view was considered and finally it did not make it into the rule set as being acceptable to CASA as the safety regulator. Can I just say that that maintenance package will be coming before the House soon. It is a huge body of work to rewrite all of that legislation. We have just had four straight days with the industry with CASA in Canberra. This is an industry group. It is the industry coming and commenting to us. They are happy and satisfied with the standards that apply in that package. From my perspective, it is interesting to hear about this one individual, but I do not want to disenfranchise—
Ms LEY —It is never just one individual.
Mr McIntyre —There may be even a group of people. But what I am saying to you is that the majority of people who have been involved in the process and who have looked at what CASA is proposing deem it to be acceptable and reasonable.
Ms LEY —To what extent on that industry group are small operators or, for example, agricultural operators represented? 
Mr McIntyre —We have the AAAA, the Aerial Agricultural Association of Australia; we have the Regional Aviation Association of Australia; we have the Australian Airports Association; and we have Aircraft Owners and Pilots Association—they are all represented. They have all nominated people from within industry who have a good understanding of what is involved.
Ms LEY —They are all happy with the maintenance changes?
Mr McIntyre —Yes.
Ms LEY —Good.
Mr McIntyre —In fact, there is a body now established representing all of the maintenance organisations in Australia. They were strident critics of what we were doing and they are now comfortable with where we have got to. Going back to the point I was trying to make, you have a very silent group of people out there saying nothing. When you open the committee up and make it quite obvious that here is an opportunity to lay your concerns out, you will only hear from those people who have concerns. You will not hear from the large numbers of people in our community who are happy.
Mr SECKER —I think you are actually ignoring the fact that the reason we opened it up is that we were getting complaints. The complaints were coming to us as local members all around Australia about how they felt about CASA. So the fact that we have had the forums and this sort of inquiry is in response to the complaints. We have not just decided that we will have an inquiry for the hell of it; we are having an inquiry into this because we are getting the complaints.
It is all right for one person to say, `They're all not true,' but we are getting different stories all the time. Your first speaker, Mr Gemmell, said you are trying to fix it up, but there must be something wrong if all these complaints are coming through to us in the way things are being handled. It is more on a personal basis where people are saying, `This one has done this,' or `This one has been vindictive to me.' You really need to look at why it is happening and try to fix it up. I am glad to hear that you are trying to do that. But I do not think you can go along this line and say, `None of it is true,' or `Most of it is not true,' or `This has only happened because you have had the inquiry.' I think you have to see where the problem lies and try to fix it, and take that attitude.
CHAIR —For example, while they are not responsible for small vessels to the same degree as you are responsible for small aircraft, we would not get one-tenth of the complaints about AMSA.
Mr Gemmell —I have spent a lot of time with AMSA. I agree with you that we get a lot of complaints and they do not. I said, `How the hell do you do it?' The answer is quite simple: they deal with the commercial end of the market. You have heard from the commercial end of the market. We have a very good relationship there, and they are not saying these things about us. I hope they have not said that to you. I have not read that they have said it to you anyway. I hope they have not said it privately—but I doubt it because we meet with them regularly and we have a good relationship with the commercial end. 
The problem we have as at the private end, for want of a better word, at the lower end of the market. And AMSA does not deal with that at all. They have no responsibility there. Small boats is a state responsibility. In our case, it is that mix of big and small that creates a lot of the problems, both in air space and in activities, and in things we do and how we do them.
Ms LEY —Because you want this `one size fits all' answer. Would you consider a small charter operator at the commercial end of the market?
Mr Gemmell —A small charter operator is a commercial—
Ms LEY —Yes, I know they are commercial operator.
Mr Gemmell —They are carrying passengers.
Ms LEY —But do you treat them like a commercial operator?
Mr Gemmell —Yes, they are a commercial operator; they are carrying passengers. So if I distinguish between a professional passenger carrying operation, which would include charter, and a private pilot flying himself around for the weekend—that sort of distinction.
Ms LEY —With great respect, Mr Gemmell, in your answer there you did sort of indicate that the private people are a problem. There was a somewhat dismissive attitude that these guys are difficult, and I know they probably are in many cases thorns in your side. But I think it is not enough for the big end of town to be happy with you.
Mr Gemmell —I agree. What I was trying to say in the opening statement—I do not mean to be dismissive of them and I am sorry if I was—is that, yes, we have not got things right at that level. We do not have good relations and we have to improve them. To go back to a question Mr Gibbons asked, what we are trying to say is that we do acknowledge there are times when we have not been at all helpful with people trying to do business things; hence the case management approach that we are trying to move forward.
  
Who was it that once said the 'more things change, the more they stay the same'?  Rolleyes

Anyway because the Inquiry was effectively sabotaged by a bunch of pilots (AOPA Oz) and a group of small end of town 'charter operators' and their various issues with the regulator (why does that sound familiar?), there was a follow up hearing featuring the regulator -  Shy 
Hansard link: https://parlinfo.aph.gov.au/parlInfo/dow...86/0000%22

Quote:Mr Gemmell —Thanks for the opportunity to appear before you again. From our previous hearing, there were clearly issues left unresolved. We were also concerned that we had not made our points well enough, leaving the committee to rely on possibly some untested and, at least from our perspective, perhaps sometimes inaccurate evidence. I will recap what we tried to say last time.

Mr Secker, at the last hearing, said in describing the volume of complaints the committee had received about us:
I think you have to see where the problem lies and try to fix it, and take that attitude.
That is exactly what I was trying to say we were doing the last time we were here. We are trying to look at the problems, find out where they are and try to fix them. The only difference between us is that we do not just accept that the complaints are valid. We assess their accuracy and deal with them when they are justified. I think it has to be recognised that on occasions we do things to operators that are not pleasant—suspensions, fines and the like. I cannot say we always get the judgments right, but we seem to get them right more often than not. All I ask of you is that, when you hear complaints against actions taken by CASA, you view them cautiously and perhaps seek our side of the story. You cannot expect a business we have taken action against to thank us or even to agree with us. But parliament requires us, and the travelling public expects us, to take action to protect the safety of air travellers. We know you have received complaints about CASA, so I want to address complaints handling.
There are currently a variety of avenues to pursue if an individual is aggrieved by CASA's actions. First of all, of course, you can appeal to CASA. We have a hotline arrangement. You can apply for an internal review going to the director or chairman, perhaps, or anywhere else. We have an internal ombudsman arrangement. We can direct inquiries to an independent person to assess that case. Indeed, if we think it is sufficiently serious and criminal matters are involved, we can direct things to the AFP, which we have done on occasions. Separately, you can appeal to the Administrative Appeals Tribunal, the Federal Court, the Ombudsman, the minister, the department, local MPs—this committee is an example of that style of thing—the Senate or, indeed if you think there are criminal matters involved, you can go to the AFP direct. We deal with all of these. Some complain they do not get satisfactory responses from these groups of people. In this industry, that generally means that they just did not get what they wanted. 
One thing I am aware of now much more clearly is that you as local members as well as a committee have heard significant complaints and that we are not doing well enough in giving you information to allow you to come to a reasonable, well-balanced assessment of these complaints. I would be very pleased to discuss with the committee ways in which we can do better in this respect. I think that would be of mutual advantage to us both.
The legislation currently before parliament in relation to the reform of CASA should assist in addressing concerns about unfair actions by CASA. I will pick a couple of points in there. In effect, decisions will need to be confirmed by the Administrative Appeals Tribunal before they come into effect and within five days by the Federal Court if an action is taken on the grounds of a serious and imminent risk to air safety—in other words, another body gets to confirm the decisions taken by CASA. While these in fact reduce CASA's current powers, we support them as they help redress the undoubted current perception of unfairness.
Victimisation by CASA is one area that is often alleged but rarely proven. We have sought evidence of it, but again we have rarely been provided with any. Where we have, serious follow-up action has been put in train, including referrals to the Australian Federal Police. But for the supposed high number of claims, there are precious few examples where evidence is actually given to us that enables us to follow through. We remain open to receive such evidence, which is rather more than just making allegations, and are committed to weeding out any examples where we find victimisation is pursued. But I am very uncomfortable with seeing staff vilified based on unfounded rumour and innuendo.
I know you have a particular interest in Brindabella. I just want to remind you what was said last time. I will quote Mr Collins:
I think it is very fair to say that, in this particular instance, CASA did not get it 100 per cent right. However, it is also fair to say that in this particular case the applicant also did not realise the amount of work that he had to do to upgrade his operation from essentially a charter based operation to an RPT operation. There were significant difficulties in understanding on his part and, just as significantly, there were difficulties in CASA imparting the requirements to the operator.
Ms Ley said, in responding to that:
We are not talking about a mickey mouse operation in the middle of nowhere; we are talking about a well-qualified, highly professional outfit in Brindabella that wanted to go that extra step and faced enormous road blocks to doing so.
Brindabella is indeed a safe, professional airline. But since they received their RPT licence, they have experienced three significant incidents. The last, two days after our last hearing, was a wheels-up landing in Canberra airport with four passengers on board. That is getting a bit too close for comfort. Incidents happen. It does not mean the operation is unsafe, but it illustrates what we were trying to portray to you. Perhaps they were not quite as clever as they thought they were in their preparedness for RPT. I should add in fairness that we have been very happy with their responses to these incidents in trying to get to the source of the problem and fix that up. Other than the immediate sacking of the pilot in the wheels-up incident, we do not think an immediate sacking is the best means of promoting an appropriate safety culture. 
In terms of service delivery, as you have heard and as you know, the minister has been similarly approached by operators with complaints about CASA's service performance. Brindabella is one of those. You heard about a meeting that Brindabella had with the minister. As a result, the minister some months ago had an independent analyst review CASA's performance in respect of service delivery. The report was done by KPMG and has recently been finalised. I would like to table it for the committee's information. I think you will find it interesting reading. It puts into context the complaints being made. I will table that particular report.
ACTING CHAIR —Is somebody prepared to move that we accept that report as an exhibit?
Mr MOSSFIELD —So moved.
ACTING CHAIR —Thank you.
Mr Gemmell —My final point is that a suggestion was made at our last hearing that all we are doing is imposing paperwork. The words `bureaucratic requirements' and `paper chases' were used, and it was said that these have little relationship to safety. If that is the view you are forming, I would very strongly encourage you to read closely the report of the Seaview royal commission in 1996, because they directly address this question of paper. I might get Mr Ilyk to give a couple of quotes that came out of that royal commission report.
Mr Ilyk —During the commission, Seaview were saying that all of the things the commission was looking at was simply just aviation trivia, just paper offences, and that they have no safety implications so why bother about them. The commission said:
Inevitably, the commission heard evidence about other operators and maintenance organisations and the approach of the regulatory body towards detecting transgressions and taking appropriate action. The evidence produced to the commission suggests that areas that warrant inquiry and consideration include an attitude that characterises breaches of the Civil Aviation Act, the regulations and the orders as aviation trivia, an attitude about safety and regulation that potentially puts the public at risk, and Seaview in particular sought to characterise the matters that had been the subject of evidence as simply aviation trivia.
But the commission said:
All these matters have a direct bearing on safety. The practices that Seaview engaged in were also breaches of the law. The picture of Seaview Air is a picture of an organisation with which no sensible person would wish to fly if they had been aware of its breaches and attitude to safety.
I think the point Bruce was making was that the breaches that CASA has to regulate are in fact breaches of the Australian law. They are not simply things that CASA imposes; they are breaches of the Australian law. It is the same as the way the Therapeutic Goods Authority looks at the breaches of the legislation for the manufacturing of pharmaceuticals. It is the same as any regulatory authority. These are requirements that have been imposed upon industry not directly by CASA but by parliament indirectly. 
Mr Gemmell —That is it.
ACTING CHAIR —Thanks for that. I would like to make a few remarks before we go to questions. This committee recognises that a strong regulator is essential for aviation safety. We also acknowledge the very difficult task that brings. An effective regulator must be very, very credible. When we started this inquiry, it was not an inquiry into aspects of how CASA does its business; it was an inquiry into the adequacy of regional aviation services in remote and rural locations. However, during the course of that inquiry, we received an overwhelming number of complaints about the way CASA does business, which prompted us to invite you here.
What this committee wants from you today—and I think you have done that in your opening remarks—is to acknowledge that there are a high number of inquiries and that is of concern to you. More importantly, we want to know what strategies you have in place to address it. It is not a witch-hunt. That is what we need to know. As I said, the inquiry is not looking at how CASA does business. If we wanted to do that, we could use the powers we have in this committee to establish our own terms of reference and go off and have a look at the way CASA does business. That is not what the inquiry is about. If we could get from you, first of all, a recognition of the problem and strategies in place to address it, this committee would be reasonably satisfied. With that, I will throw to Ms Ley for some questions.
   
Let me remind you that inquiry was 15 years ago -  Confused



Let's do the time warp again - FDS!  Angry

And the Government response to recommendation 23 thru 28?  Dodgy see pages 33 to 43 here: https://www.aph.gov.au/Parliamentary_Bus...ovresp.pdf


MTF...P2  Cool
Reply

HOT OFF THE PRESS! via the EMAC (Evans Head Memorial Aerodrome Committee) - Wink

Reference:


(12-30-2018, 07:05 AM)Kharon Wrote:  ...The Murky Machiavellian and his side-kick Dolan were granted all manner of latitude to make the sale of airport land (Commonwealth land) to developers as attractive as possible. Hell they even ‘finessed’ some definitions to assist. All in the name of progress aligned with public safety of course....



Ref: https://auntypru.com/forum/thread-30-pos...ml#pid9711

...For example; there is a plan to build a large hospital in a regional centre; it is to have all the toys – including a helipad. Bravo. There is even an approach path mapped out for the Choppers which is touted as ‘the best’. For many reasons, that ‘selected’ path suits many people and puts a nice shine on the ‘spin’ delivery. Cool Banana’s; right. Well, answer me one question – just the one, a short one. Do you know what a Flying Fox is?...


[Image: b88716670z1_20170425222537_000gtrjle3b2-...00x300.jpg]

Flying-foxes are the largest flying mammals in the world, acting as long-range seed dispersers and pollinators for a large number of native trees.”

“The maps below show the general location of flying-fox roosts in Queensland recorded by the department, and include continuously and periodically (seasonally or irregularly) used roosts. The exact location of roosts may vary within a small localised area.”

Around dusk, grey-headed flying foxes leave the roost and travel up to 50 km a night to feed on pollen,


[Image: bats1.JPG]


..Well done class; all correct – now then, for Choc Frog; one last question. How would you like to be a patient flying in a helicopter to hospital, at low level <500' around about tea time or breakfast time through a 1.5 kilometre ‘launch zone for hundreds of flying foxes? For a bonus point, how many Fruit Bats to kill a Chopper?. Give up, can’t guess, well wait a while and the answer will become clear – the route to the emergency ward through the Fruit Bat launch zone is ‘approved’. Consequences? Wuzzat - Never heard of ‘em. The local airport development plan has - but 'what-the -hell'..




Ref: https://auntypru.com/wp-content/uploads/...-2018.docx

Quote:
Media Release
Helicopter Flight Path for Tweed Valley Hospital in Flying Fox Buffer Zone: Why wasn’t this serious risk included in the aviation assessment?


The Evans Head Memorial Aerodrome Committee Incorporated has serious concerns about the adequacy of the Aviation assessment for the proposed Tweed Valley Hospital rooftop Helicopter Landing Site, and the appropriateness of the location because of risk to public safety.  
The Committee has formed the view that the proposed location for the hospital is not appropriate because of significant risk of helicopter collision with flying foxes from a nearby colony.

 “In our view this aviation/flying fox conflict has serious ramifications for the siting of the hospital because of the need for helicopter access for emergencies.  If the hospital is to have a helicopter emergency facility at all then the hospital needs to be relocated to a safer area. 

As the hospital is only in the planning stage this is the ideal opportunity for the State government to relocate the proposal from the current site to one which is safer.    There is not only the risk to the helicopter and its crew and retrieved patient to consider with the current location, but also the community at large should a helicopter be impacted en route to the hospital or on call-out.  Risks to the public must be reduced as much as possible and the State government should discard any use of an “affordable risk” model in its decision-making.  It seems ironic to us that the State should be going to all this trouble to create a health facility to save human life while putting the public at a risk which is clearly avoidable.  This risk cannot be ignored.”

Dr Richard Gates, President of the Committee said today that “the flight path for the helicopter crosses the buffer zone for an identified flying fox colony not far from the hospital[1](see Figure 1).   The helicopter would be flying at low level in this area for more than a kilometre increasing risk of conflict as at airports.  Flying foxes don’t tend to get out of the way.  They are a known risk to aviation.”

Dr Gates said he was surprised when he read the aviation review on the rooftop Helicopter Landing Site (HLS) that there was no mention whatsoever of the flying fox risk for the proposed Tweed Valley Hospital location.  

“The organisation which prepared the report for the government has prepared many such reports for them and we would have thought by now that a risk assessment for birds and bats for northern NSW locations would be considered ‘routine’ given their well-known presence.  Clearly the Health Department Guidelines for HLS, which were recently revised, are not up-to-date and require the addition of such an important consideration and assessment.  Federal National Aviation Safeguards have identified these risks for some time now (see footnote 2)”.
“Birds and flying mammals such as the echo-locating bats and flying foxes are identified in the National Airports Safeguarding Framework Principles and Guidelines (see paragraph 26).  While the HLS is not an airport, well-known risks to aviation MUST be canvassed particularly when there is an established Plan of Management for Flying Fox in the Tweed Valley area and the matter of aviation risk has been canvassed in that Plan for both the existing hospital and the Gold Coast Airport.  The proposed new 



[1]https://www.tweed.nsw.gov.au/Documents/E...t_Plan.pdf (see pages commencing 100)



hospital site is much, much closer to the bat colony.  In our view this is a serious problem requiring urgent attention before any more work is done on the hospital at the current site. 

“Wildlife strikes and / or avoidance can cause major damage to aircraft and / or reduction of safety.  The consequences of wildlife strike can be influenced by the number and size of wildlife involved, phase of flight and the aircraft part hit by the wildlife”.[1]

 “The vast majority of wildlife strikes take place at or close to airports.  Almost all involve birds and flying mammals (such as bats and flying foxes)”[2].  In the case of the proposed Tweed Valley Hospital the flight path to access the hospital is at a low level and well within the heights the bats use to and from their colonies”.  

The NSW North Coast is not without its tragedies relating to bird strike.  “The loss of an F-111 and its personnel to bird strike many years ago at Evans Head is an example close to us[3],” said Dr Gates.   

He went on to say that his committee also has concerns about the independence of the SEARS aviation report prepared for the State government[4]

The consultant referred frequently to the NSW Health Department Guidelines for Helicopter Landing Sites[5]and stated clearly that they were “best practice”, and certainly from our reading implied that they were better than existing pertinent federal government guidelines which had yet to be finalised. 
 
Indeed the consultant made comment on the apparent tardiness of the federal government in this matter:  “..new rules will form Civil Aviation Safety Regulation (CASR) Part 139R, however it is not expected that they will be completed any time soon” [emphasis ours].   

In our view the consultant’s comment is hardly a vote of confidence in the Civil Aviation Safety Authority (CASA) which is charged with aviation safety matters under its Act[6].  And in our view the comment begs questions about CASA and the federal government and delays in matters involving human safety and human life as they have with Public Safety Zones around Australia’s airfields[7]?
 
When we reviewed these State Health Guidelines about Helicopter Landing sites we noted that the consultant who prepared the Aviation Assessment for the proposed Tweed Valley Hospital was also cited very frequently in the Guidelines.  

We formed the view that the consultant to the NSW government should have declared this fact about the use of its material in the Guidelines in their assessment particularly when using them to guide their hospital HLS review.   The consultant may well be the best in the field and that may be why their materials were used by NSW Health, but if this is so why not declare this fact to allay any concern about independence of the assessment process?

We also noted in our review that the consultant has provided a number of reports about HLS for NSW hospitals which also raised questions for us about the tender processes for engagement of consultants specialist in this area.  Is there a tender process and how are consultants selected?  If not, why not?  These are questions which must always be asked in any economy driven by ‘the market place’, a 



https://infrastructure.gov.au/aviation/e...line_C.pdf 
[2]Ibid. 
[3]https://aviation-safety.net/wikibase/wiki.php?id=137482 
[4]https://www.planning.nsw.gov.au/-/media/...15-12.ashx 
[5]NSW Health GL2018_010 Guidelines for NSW Hospital HLS  
[6]http://www7.austlii.edu.au/cgi-bin/viewd...aa1988154/ 
[7]https://www.aph.gov.au/Parliamentary_Bus.../INF/index 


hallmark of the current State and Federal governments, to protect the public interest.  There doesn’t seem to be easily-accessible publicly-available information about this process.  

Dr Gates said that in view of the identified flying fox problem for the proposed hospital site not raised in the Aviation Assessment, the State government needed to review its location, the HLS Guidelines which seemed to be deficient with regard to aviation risk assessment, mechanisms for consultant choice and declaration requirements so that the public has confidence in the planning processes for the new hospital.  The public interest with focus on public safety must always be ‘front-of- mind’.
       
He said his committee also had concern that the solution the government might find for the flying fox problem was a lethal one: The colony to be destroyed ‘in the public interest’ so that there was no longer any risk to the helicopters! “This would be an incredibly dumb solution given the important role flying foxes play in the productive economy of our forests[1][2], something the State government already knows! 
There are better solutions to the current problem such as a new location for the hospital.  Health claims it reviewed 30 potential sites for the hospital[3].  Surely one of these would be better than the current site? The State government needs to make the site evaluation process public so that we can see how the current site was chosen.  Public access to this process is critical to public confidence in our institutions and the political process for this controversial hospital site.  
  
Concluding Remarks

Clearly our evidence suggests that the evaluation process used by NSW Health in selection of the site was deficient.  Where was the due diligence for public risk and why was the flying fox matter missed when it figured prominently in other documentation available to the State government and a report referenced by the consultant?    Certainly Tweed Council raised its concerns publicly with regard to the impact the proposed hospital at its current location would have on the local biology including the flying fox[4].   Surely that query from the local council in whose jurisdiction the hospital is to be built should have set alarm bells ringing about flight risks and proposed location of the hospital?  

 But more than that why was the Civil Aviation Safety Authority, which is charged with aviation safety and related standards for Australia, not involved in this critical process as an independent authority? 

[1]https://environment.des.qld.gov.au/wildl...tance.html 
[2]https://www.aph.gov.au/Parliamentary_Bus...37%2F24314 
[3]https://www.hinfra.health.nsw.gov.au/new...pital-site 
Reply

When you’re in hole- Stop digging.

[Image: digging+holes+.jpg?format=1500w]

We’ve all done it – you’ve said something daft or dopey or even mildly offensive; then you try to talk your way out of the gaff. Too late; you’re too deep in a sandy hole; the sides are caving in, time to stop digging. Metaphorically, this is the place our safety agencies have placed themselves, ASA, ATSB and the CASA all; gotten too deep in the mire and with much to lose, so they just have to keep on shovelling the muck out; or, admit they have completely ducked up the excavation, and admit they have struck a sewer pipe and the filth is getting not only deeper, but highly visible and definitely ‘on-the-nose’.

Perhaps it’s time terminal arrogance combined with gross ignorance was replaced with some cool, calm, sensible logic and a willingness to adapt world best practice. That is all the industry wants. First world aviation grown ups have been quietly working with industry expertise and legal logic to refine their strategies, across all disciplines to provide sensible, balanced, logical working solutions – legal and ‘safety’ related. They may not be perfect, nor suit everyman – but the effort is being made, with the willing assistance of the industry. So why is Australia not following suit? One of the suggested reasons is a lack of expertise; in the field. Another is rotten leadership.  



[Image: 606b9eb4-1aa5-11e8-804d-87987865af94_ima...115841.jpg]

“He knows nothing; and he thinks he knows everything. That points clearly to a political career.” ― George Bernard Shaw, Major Barbara



The following impressive statement was written by someone who not only understands aviation very, very well, but the law and the politics associated. The lady even has the best interests of all topics at heart and; obliquely, offers solutions.

“Thanks Leddie. Ben at AOPA has been very helpful. But I think the real focus is on how they are attempting to bypass proper democratic and legislative processes ( quite apart from lack of consultation with AF and industry). To take away rights or impose restrictions on licence holders, with the stroke of the CEO’s pen, is dictatorial and an abuse of process. Our licences and maintenance requirements are governed by the Regs: any amendment should be by proper Regulatory change . By ambushing us all on the eve of long holidays , and by proposing an administrative direction, ensures no ‘interference’ by our elected representatives in parliament. Parliamentary members can disallow Regs - they cannot disallow a direction, and nor does it have to be presented to either House. The implications of this high-handed and undemocratic action, if allowed to proceed, sets a dangerous precedent which could see all or any of our aviation rights cancelled at the whim of CASA, and not the legislature.

Contacting State and Federal members to alert them to this proposed action would be helpful, particularly the attempt to block them from having a say in this process, which fundamentally alters the rights of licence holders and aircraft owners/operators.  - Marjorie Pagani Chief Executive Officer, Angel Flight Australia.

Ref: https://www.pprune.org/showthread.php?p=10351035

Say’s it all don’t it? By identifying the ‘nub’ of the distrust, dislike and disrespect of both ATSB and the CASA, the solution presents. It would be a simple matter to replace the three stooges at the top of the CASA heap and let the revised top end attitude flow down through the ranks. Despite rumour to the contrary, not all CASA employees are terminally stupid; they may be ‘dumbed down’ to preserve their rice bowls but there is some talent their – not much but some. Although why we have inexperienced flight instructors drafting regulation basis I’ll never understand; but it’s wrong.





“When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years.” ― Mark Twain



I could bang on about the aberrations, cock-up’s; clusters of ducks; pony-pooh; senseless rulings and the evil within the system: even the corruption of purpose and the machinations to achieve the twisted, slightly deranged outcomes we see today. I won’t. I’ll simply say there is a great need of positive change, starting from the top, driven by the minister and the respective boards. We could all walk away from the past, call it back in the dark days and move forward. I know the industry wants to. I’m certain the next minister will want to avoid the adverse publicity further duck-ups will bring, like Essendon for example. To think ATSB have got that little contretemps neatly wrapped up would be a gross, dangerous error of judgement.




Ref: P7 - Not a serious safety concern – Indeed. https://auntypru.com/forum/showthread.ph...33#pid9733

“Ignorance more frequently begets confidence than does knowledge: it is those who know little, not those who know much, who so positively assert that this or that problem will never be solved by science.” ― Charles Darwin, The Descent of Man



On a flight deck, when we see warning lights flashing, we do something about it. There is a full panel of red warning lamps flashing a message; this is no time to hide in the dunny. The warnings are clear and unmistakable.

Come on, you lazy hounds, let’s go. The arrogance of ignorance requires fresh air and a long walk to dispel.

Selah.
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"Let sleeping dogs lie -- who wants to rouse them?"

My old companion Charles Dickens wrote that line in David Copperfield (1850). Most folk are aware of the first part and what it means; but the rest of the sentence poses a bloody good question. A fox coming into your Chook shed would most certainly not wish to wake the dogs; you on the other hand would be fairly disappointed if the dogs slept through the whole event.

There are ‘foxes’ who most definitely do not want the sleeping dogs of Essendon Fields awoken, for they are big, strong well trained animals. The NTSB Rottweiler for example; or, the RRAT Senate Collies for another. Now, up until now the foxes have quietly snuck in, grabbed a couple of tasty morsels and hoped to escape – Scot free. Time to whistle up the hounds methinks. So much for metaphor (whimsy). Time to get down to brass tacks.

Ramble follows - warning:-

Statistically, you have more chance of dying in a burning, aircraft struck building, than you do of winning the lottery – IF that building is in a high risk area, near an active runway. The American development of the UK’s ‘Safety Zone’ notion into a ‘code’ has reduced that risk to a very acceptable level. There is no-way a tall building, which may contain somewhere between a thousand to 4000 people; working, shopping and eating would be allowed, where the Essendon DFO exists; not under the US code. Just wouldn’t happen.

I believe the Federal minister and the Victorian government have a duty of care to warn the shopping fraternity of Melbourne that there is a significant risk factor attached to visiting the Essendon DFO.

In a perfect world, the DFO would be demolished – alas. The vested interests will not allow the ‘right thing’ to be done, despite the fact they know, full well, it is the only right and proper thing to do; not to mention it is only a matter of time before a repeat performance. Such is ‘top end’ money and political obedience. So much for men of good will and conscience.


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“Business!' cried the Ghost, wringing its hands again. "Mankind was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The deals of my trade were but a drop of water in the comprehensive ocean of my business!” ― Charles Dickens, A Christmas Carol.



There was, until the Hi-Viz Canary stuck his beak in, another avenue open, through which both the Federal and Victorian governments could have been made/seen to act responsibly. The ATSB report into the Essendon DFO fatal should have torn the lid off this can of worms. It failed: miserably, to do so. A familiar pattern emerged, same as it has for several other serious events:- ‘pilot error’. The purblind, paranoid media, then, for whatever reason, swallowed it: whole. Once the Hood statement was made, nary an eyebrow was raised; nor, a further question asked. So much for ‘investigative journalism’.


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“By giving us the opinions of the uneducated, journalism keeps us in touch with the ignorance of the community.”


The BRB and the IOS have been digging beneath the surface of this brushed aside ‘non-event’. Seemed ‘passing strange’ that the whole thing was put away, cut, dried without a whimper of censure or even sensible questions on how the wretched building was allowed in the first place (in record time - by the way - Pel Air anyone?) Who approved it? How was it ever sanctioned? Who benefitted? All valid as yet unanswered questions. FDS the ‘politicians’ can’t seem to even differentiate between a ‘Runway End Zone’ and a ‘Public Safety Zone’. But then, as the old folk say, “there’s non so blind” etc. Meanwhile, dazzled by the thought of a discount, the public continue to roll out to the DFO not knowing they have entered the twilight zone. Hell the Vic government are even trying to flog off used road signs now; probably those remaining pointing to the Essendon DFO. So much for public safety as a political priority of the Snake Oil sales force.



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Ref: https://jrbenjamin.com/2014/03/13/mark-t...-an-idiot/

“A few moments from now my resentment will have faded and passed and I shall probably even be praying for you; but while there is yet time I hasten to wish that you may take a dose of your own poison by mistake, and enter swiftly into the damnation which you and all other patent medicine assassins have so remorselessly earned and do so richly deserve.” ― Mark Twain, Letters of Note: An idiot of the 33rd degree



So, who cares? More to the point, who ignored all the warning signs and failed to see the red flags? We have discussed and dismissed the ‘aircraft’ as being the villain in the piece. Clearly the building should never have been built where it stands. Which leaves us with the hapless, dead pilot. Let’s, just for a moment, allow that it was ‘pilot error’. Let us even allow Hood’s statement that there were five opportunities to correct the off-set rudder trim as fact. Then let’s examine the ‘why’ of it.  Why would an experienced, qualified fellah not ‘do’ the required, mandatory checks as a matter of routine?

I ask that you bear in mind that non of the BRB are ‘medical’ men; and are, without exception, wholly unqualified to pass a ‘medical’ opinion. They are however all well qualified and experienced observers of pilot ‘behaviour’. And, it is the behaviour of the pilot which demands further examination. There are ‘operational’ questions to which answers have not been supplied. We must begin with the Mt. Hotham incident; WTD happened that day? Easy answer is to say a ‘cluster duck’ or aberration– but why? What caused this unusual behaviour? Well, to start, It seems the pilot had a diabetes condition.

Quote:“There is strong evidence that diabetes mellitus increases the risk of cognitive impairment and dementia.” 


The quote above comes from an authoritative source. HERE. It is worthy of some consideration, if only to ‘eliminate it’ from our inquiries; so to speak.  Could the debacle at Mt Hotham – I do stress – could; be the result of ‘cognitive impairment’. Was this considered in the initial investigation? NO is the short answer. But there has never been a satisfactory explanation of Quartermain’s behaviour that day. Was it a large red flag? When you consider the next step was – ‘re-training’ without a deeper look at the ‘why’ of it. From this conundrum, another lethal snake pops out of the basket. ‘Cognitive dissonance’ raises it’s ugly head. Now then, I can’t explain it all properly but Wiki can, in another ‘authoritative’ piece. – Dissonance.


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Ref: AAI & the implications of bureaucratic O&O  https://auntypru.com/forum/showthread.ph...55#pid6455

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Ref: Universal MAYDAY call.

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The notion of both cognitive impairment and after a ‘re-training’ session creating ‘conflict’ through dissonance, could lead one to consider seriously the united pair as responsible for the ‘stuck record’ effect of the repeated call of Mayday – made several times, out of ‘phase’ before the ‘normal’ time frame; while no definitive corrective action was being taken. It is a fair question. Happy to be called out for dabbling in area’s out side of expertise; but the questions surrounding this matter far outnumber the answers. 

Not for one minute are we saying that this is correct – it is conjecture; and, has only been given some consideration as a result of the pitiful, bare-bones ATSB investigation into the Essendon Fields accident. There is so much not ruled out as ‘causal’ in the ATSB report that it (of itself) demands Senate committee investigation. The quick condemnation of the pilot and the closure of discussion about public safety and buildings situated close to high risk areas on airports has, IMO, prevented ‘expert’, serious, meaningful safety dialogue and recommendations from being issued. In particular those quick, glib, disingenuous answers supplied - not by ATSB ‘experts’ but those sprouted by the unqualified Hood. Hood ain’t a pilot’s boot strap; he certainly is not a ‘tin-kicker’; in fact he is a glorified clerk, trading on some misbegotten notion that he is qualified and competent to lead our nations ‘accident investigation outfit’. Well -  He ain’t – end of – full stop.



We all believe that the Senate RRAT committee should get off it’s collective beam ends and open an inquiry into this accident. They did it for Pel-Air, an accident without a fatality - (not that it changed anything) Shirley, they can certainly manage another round for an accident which claimed five lives and had, and still has the potential to claim more again. –



Re-investigation and demolition – the only solution? No it bloody well is not. Royal Commission into why Australia trails the world by 60 years (that’s six decades) in properly zoning development around aerodromes, would be a good start. There’s more, but an open inquiry would reveal that ‘more’. Albo as the next incumbent could score a shed load of points just by pushing this through. MTF on that -



Phew! A long ramble indeed; but, I think worth doing. Now I must unload the ‘Ute’. For there rests the lumber for a new garden bench. These are great fun to make, working outdoors under the very shade of the very tree the bench will reside under. The tree is a Fijian Hibiscus, Cape Chestnut* which has just finished flowering; this means the Rosella’s and Fruit bats have stopped their visits. The birds get quite tame and unafraid when you watch them – magic. So, tool bag, saw horses: and; yes, dogs too. All into the Ute and away we go, for a happy day, making something useful, far from matters aeronautical, domestic tyranny, ‘chores’ and suchlike. Toot-toot –toot…………… (if that bloody dog falls off again -- - - - - -).

Selah.

*P7 -  No idea about matters 'agricultural', non whatsoever. We tried ..........

“K” - Right job Pops – just not at the Chestnut tree – but here. The one with the birdies in it. They stayed all day and helped; never a drop of poop on the bench or me. Good eh?

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I sorta copied this one - in Aussie timber..........nice spot for a quiet beer....Or two.?

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The Wichita connection -  Huh


From this "K" post today... Rolleyes  

(01-17-2019, 06:46 AM)Kharon Wrote:  I’m forever blowing bubbles -

P2 - Nah Mate: me bubbles is all in good wurkin’ order, no problems there; the ‘bump of curiosity’ however is working overtime. Shirley is right to be suspicious; this from the SMH rang a few bells and whistles:-

SMH – “It comes as the Australian Transport Safety Bureau is close to completing a major investigation into how Essendon's DFO complex was designed and approved. The probe was launched in the wake of a fatal crash in 2017 when a light aircraft ploughed into the rear of the Centre.”

P7 - "Letters from CASA to the airport released under FOI say it did not have time to check the DFO plans. “Gathering the information required for the authority’s assessment of whether every item in a Draft Master Plan will be compliant with civil aviation safety requirements would be time-consuming and expensive,” one letter says.

Given the ATSB’s piss poor analysis of the accident, the way the Witchita accident was ignored, the rapid, unsupported claim ‘the pilot dun-it’ and the lack-lustre performance of the ATSB management; it leads one to wonder why was the ATSB selected to ‘investigate’. What ‘expertise’ can they offer in the black art of air space design?

You can see why my ‘bubble’ is still floating – the SMH article was good work – corroboration from the AFAP seems, at face value, to be reasonable and it gets the story published; so far so good. The AFAP actually did the ‘right thing’ and Diamond is a ‘white hat’. But bringing the AFAP any deeper into this sorry saga will raise deep seated, long held suspicions. CASA are up their collective Hocks in the approval of this building as are the DoIT. Many rice bowls to protect and ‘alliances’ to maintain; not to mention the big money interests. Not one of these outfits can afford the slightest whisper of culpability in allowing this DFO to be built where it is. Hell I can just about hear the insurance legal Eagles sharpening their talons and beaks from here – as a counterpoint to the tramping of politicians feet as they head for the exits, dragging their safety nets and golden parachutes with ‘em.

Yet responsibility for the investigation rests on the shoulders of the Hood ATSB. Am I worried? – Oh, you bet I am. I doubt I’d trust Hood as far as I could kick him, given the chance. This is a matter of great importance – Australia trails the world best practice by 60 years; the development around airports since privatisation has been uncontrolled. The Essendon DFO accident was a wake-up call; the investigation needs to be independent, unimpeachable, free from any hint government agency involvement. A Royal Commission working with the USA ‘code’ as a guide would reveal the unprecedented ‘risk’ Australians live with in the vicinity of aerodrome ‘high risk’ areas.

We were very, very lucky at Essendon – got off very lightly. The worst case scenario at Essendon would have seen Australia’s very worst ever aviation disaster. Is Hood the right man to entrust with this task?

Aye well; that’s up to you to decide. You’d need four good men, a strong horse and I’d have to be legless before you could get me (or mine) into that airport DFO.

Toot – toot….

Quote: ..Given the ATSB’s piss poor analysis of the accident, the way the Witchita accident was ignored, the rapid, unsupported claim ‘the pilot dun-it’ and the lack-lustre performance of the ATSB management; it leads one to wonder why was the ATSB selected to ‘investigate’. What ‘expertise’ can they offer in the black art of air space design?..

I still don't get that bit ( Huh ) where no comparison was made with the Wichita accident, just take the CCTV footage for example:



Now read this bit from the link provided by "K"... Confused 


Quote:Investigation[edit]

Inspection of the aircraft systems, engines and propellers found no irregularities that could have prevented normal operation. In depth scrutiny of the propellers combined with a sound spectrum analysis led investigators to conclude the left engine was probably generating low to moderate power and the right engine was at a moderate to high power setting at the time of impact. Other evidence, including video taken by cameras around the airport, suggested that considerable left rudder input was applied by the pilot shortly before the crash. Correct reaction to a reduction in power from the left engine would have been right rudder input.[1]

Examination of the CVR reveiled it had survived the crash with usable data intact. On the day of the accident at 9:46:13 a.m. sounds of the pilot performing an engine run up test were recorded along with the words "prop test" in a whispered voice. 35 to 45 seconds later the word "trim" was whispered follow eight seconds later by a two word phrase starting with an expletive and ending in "it".[5]

At 9:47:52 the words "We have 80 knots, feathers armed" were spoken and at 9:48:01 the sound of the propellers operating unsynchronized was recorded. At 9:48:05 a two word phrase starting with the word "the" and ending with an expletive was recorded then at 9:48:16 the pilot radioed the tower saying "and tower just declaring an emergency ah we just lost loss the left engine" followed almost immediately by the sound of the stall warning horn. The horn was recorded twice more than at 9:48:25 the pilot spoke a phrase starting with an expletive and ending "we're going in we're dead".[1][3][5] 

Emergency procedures call for the malfunctioning engines propeller to be feathered and the landing gear to be retracted for an engine failure during takeoff. Inspection of the aircraft revealed that neither propeller was feathered and the landing gear was extended. The aircraft was equipped with an autofeather system and a rudder boost system but their operational condition at the time of the crash is unknown due extensive post crash fire damage. On 1 March 2016 the NTSB released its final report on the accident and states under the heading Probable Cause and Findings that:

Quote:The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.[1]
    
Now I know that the pilot radio transmit is different to the repetitive, broken record MAYDAY x 7 but even Blind Freddy would have to admit the apparent disassociation and complete lack of appropriate emergency actions is very similar. Couple that with the inappropriate rudder inputs, banking and yawing to the left, plus loss of height etc..etc is very, very similar... Rolleyes 

My 2 bobs worth...MTF - P2  Cool
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Reality Check – 101.

Witchita - “The horn was recorded twice more than at 9:48:25 the pilot spoke a phrase starting with an expletive and ending "we're going in we're dead".[1][3][5]

“Duck – we’re going in we’re dead” -  is the only fitting expletive. Whatever ‘cognitive’ functions had failed to work up until then, must have suddenly kicked in. At least long enough for the Witchita pilot to realise that there was indeed a building on his flight path. Not, IMO - that it was the building's fault.

"The pilot, the only person on board, was killed".  "WE" ? Who precisely is (was) "We" ?

I am probably the least likely fellah to say we need more ‘rules’ or ‘complications’ – but – when any medical condition requires the long term use of drugs which can duck about with your ‘cognitive’ abilities; then some basic ground rules must be applied. Particularly if the recipient of the ‘medication’ is not made fully aware of the ‘side-effects’. Especially when the ‘dose' is not specifically tailored to the individual and monitored.

As said – not one for more rules or complications – but we now have two very similar fatal accidents in which ‘drugs’ in one form or another were being used. No quarrel with that – a better life through chemicals is the modern ideal – and a good one: however.

The FAA mandate a ‘cognitive function’ test for those recovering from ‘stroke’ (a much over used, scary term) – I digress. What I am struggling to say is simple enough: if you take a medication which can bugger about with your mind processes; then perhaps the FAA Neuro Psych test for ‘cognitive function should be part of the annual check up. Many pilots on ‘anti-depressants’, many diabetic pilots; all on one form of medication or another.

You seriously need ALL senses fully functional to fly – most importantly your mind functions. Physical inconvenience’s can be overcome – much evidence supporting – CVD as an example – Douglass Bader another; add a hundred to that list and you get the picture. But when the mind, through medication, can deceive the physical and cognitive senses; then that is a whole new world.

I have no ‘right’ quick, simple, easy solution to offer; non at all. But it concerns me that a man may feel ‘good to go’ in his head, but have the med’s have deceived him?  (yes, yes or her). There are tests for cognitive function – if the ‘meds’ can duck with those functions; then ‘we’ need to test that those functions are operating correctly.

No apology – two prangs – both fatal  - the common denominator – by the official reports – mind ducking drugs.  I rest my case M’lud on the question and the jury...............
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(01-17-2019, 09:29 PM)Gobbledock Wrote:  The power of words

“We’re going in, we’re dead”. A solemn statement, a sobering account, my stomach churns knowing this man had less than a breath left in him....... R.I.P

But the mind is a powerful thing. The brain is not yet fully understood. Only dead men know what the final seconds of life are, and they aren’t around to tell us about it. Ok, sure, we have the CVR, it tells us much including vocal pitches, words spoken rapidly or calmly, voices loud or subdued, screaming, and other information. But humans bond with ‘things’. Men bond with planes, motorbikes, cars and their Tiger Woods golf set (women do too, but for this discussion we have two crashes which involve male pilots).

So was Capt. Wichita off his dial due to drugs or some other unexpected  conniption? Or was the Captain simply at one with his aircraft, his trusty machine that always took him from A to B without fail, sometimes with delays, sometimes with a broken part, but they always got there, together. We bond with non-human ‘things’, and planes are one of those non-human items. I owned a Mach One Mustang, 18 years I had her. I knew every rattle, squeak and cough. I knew where her creases in the panels were, where the tiny piece of minute jagged plastic was under the gear shift, where the three brown dots on the roof lining just above the left passenger rear seat were. When I sold her I was devastated. Cried I did, a lot!! I still have the photos, still think of her daily, and still feel a part of her in my heart. Almost 20 years have gone by. She is still my baby. There is a bond that will never be broken.

I’m just saying, throwing it out there. Quite simply the phrase of “we’re going in, we’re dead” could be nothing more complex than a man and his machine working as one, being as one, acting as one. Hence the plural in the Captains final words?
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Strange dissonance in the Hooded Canary's coop?

Top post Gobbles and I must admit I can relate to the man and machine bond etc.. -  Wink  

Quote:...I’m just saying, throwing it out there. Quite simply the phrase of “we’re going in, we’re dead” could be nothing more complex than a man and his machine working as one, being as one, acting as one. Hence the plural in the Captains final words?...

However in the Wichita accident if man and machine had such an affinity why didn't the pilot, in the interests of self-preservation for both man & machine, action the memory items for EFATO - you know...Pitch up...power up...flap up...gear up...identify dead leg..dead engine..etc..etc??

That is the point that I am trying to make the dis-associative behaviour by both pilots in the Wichita vs the Essendon DFO prang is a common element that - along with left bank, left yaw, loss of height and rudder issues - IMO needs some analysis and review to at least ascertain that there is no common element in the causal chain to both these accidents.

List of related occurrences:

Quote:Australian occurrence
Loss of control, 7km west-south-west of Tamworth Airport, New South Wales, on 7 March 2005, VH-FIN (ATSB investigation 200501000)
At about 1326 Eastern Daylight-saving Time on 7 March 2005, the pilot of a Cessna Aircraft Company 310R, registered VH-FIN, took off from runway 30 Right at Tamworth Airport, for Scone, New South Wales. Approximately 1 minute after becoming airborne, the pilot reported flight control difficulties. At about 1329, the aircraft impacted the ground in a cleared paddock about 7 km west-south-west of the airport. The pilot was fatally injured and the aircraft was destroyed by the impact forces and post-impact fire.
Examination of the aircraft's mechanical flight control systems, autopilot and electric trim system did not reveal any evidence of pre-impact malfunction. Those results, however, were inconclusive due to the extensive impact and fire damage.
A periodic maintenance inspection carried out in the days before the flight resulted in the rudder trim tab being set at the full right position and possibly aileron and elevator trim tabs being set at non-neutral positions prior to the flight. There were indications that the pilot was rushed and probably overlooked the rudder and aileron trim tab settings prior to takeoff. The aircraft flight path reported by witnesses was found to be consistent with the effect of abnormal rudder and/or aileron trim tab settings.
United States occurrences
Loss of control in-flight, Hayward, California, 16 September 2009, B200 N726CB(NTSB accident number WPR09LA451)
The aircraft had just undergone routine maintenance and this was planned to be the first flight after the inspection. During the initial climb, the pilot observed that the aircraft was drifting to the left. The pilot attempted to counteract the drift by application of right aileron and right rudder, but the aircraft continued to the left. The pilot reported that, despite having both hands on the control yoke, he could not maintain directional control and the aircraft collided into a building. The aircraft subsequently came to rest on railroad tracks adjacent to the airport perimeter.
A post-accident examination revealed that the elevator trim wheel was located in the 9-degree NOSE-UP position; normal take-off range setting is between 2 and 3 degrees NOSE-UP. The rudder trim control knob was found in the full left position and the right propeller lever was found about one-half inch forward of the FEATHER position; these control inputs both resulted in the airplane yawing to the left.
The pilot did not adequately follow the aircraft manufacturer's checklist during the pre-flight, taxi, and before take-off, which resulted in the aircraft not being configured correctly for take-off. This incorrect configuration led to the loss of directional control immediately after rotation. A post‑accident examination of the airframe, engines, and propellers revealed no anomalies that would have precluded normal operation. The pilot was the only person on-board and he was uninjured.
Runway excursion, Oneida, Tennessee, 25 September 2014, Beech C90, N211PC (NTSB accident number ERA14CA458)
According to the pilot's written statement, he departed runway 05 and the airplane veered ‘sharply’ to the right. The pilot assumed a failure of the right engine and turned to initiate a landing on runway 23. Seconds after the aircraft touched down it began to veer to the left. The pilot applied power to the left engine and right rudder, but the aircraft departed the left side of the runway, the right main and nose landing gear collapsed and the aircraft came to rest resulting in substantial damage to the right wing. The pilot reported that he had failed to configure the rudder trim prior to take-off and that there were no pre-impact mechanical malfunctions or anomalies that would have precluded normal operation. The pilot was the only person on-board and he was uninjured.

There is also the fact that the Wichita accident was not even included as a 'related occurrence'. This apparently was because it did not fit the ATSB hypothesis that the sole cause of the DFO accident was the pilot Max Quartermain's lack of checklist discipline which led to him not identifying that the rudder trim was fully deflected to the left prior to take off - UDB!  Dodgy

Okay, even with the total lack of physical evidence/proof that this was the case, if we take the examples used to paint the commonality in lack of 'checklist discipline' causal to these occurrences, why then is not the classic accident for these type of human factor pilot error and lack of SOP discipline included in the accident report related occurrence list? Of course I am referring to, the much publicised and commonly referred to by a multitude of AAI Human factors experts, the Runway Overrun During Rejected Takeoff of G-IV - https://www.ntsb.gov/investigations/Acci...R1503.aspx - on May 31 2014?

Even the CASA Flying Safety publication did an article on this occurrence: https://www.flightsafetyaustralia.com/20...nto-error/

Quote:THE NTSB SAID, ‘ALTHOUGH ONE OF THE PILOTS COULD HAVE COMPLETED ONE OR MORE OF THESE CHECKLISTS SILENTLY, THE PILOTS DID NOT DISCUSS OR CALL FOR ANY OF THESE CHECKLISTS, EXECUTE ANY OF THE CHECKLIST ITEMS USING STANDARD VERBAL CALLOUTS, OR VERBALLY ACKNOWLEDGE THE COMPLETION OF ANY OF THESE CHECKLISTS.’


Also of interest: .... a few terse words revealed the immediate cause of the crash.


At 21.39.59 the pilot said, ‘Steer lock is on,’ a remark he repeated six more times in the remaining 20 seconds of the flight. Fourteen seconds later he said, ‘I can’t stop it’.

There was no other discussion of the situation and the only other words before the recording stops were one of the flight crew saying, ‘Oh no, no’ as the aircraft sped towards the ravine that would trap it. Fire broke out ‘almost instantaneously’, in the words of a witness...
   
 I can only assume that the ATSB regarded the GIV Massachusetts accident as not relevant because it was a multi-crew jet accident and not a single pilot B200 or equivalent turboprop accident? In other words it did not again fit the Hooded Canary's singular causal slice of Swiss cheese. Which is a pity because there is much to take away from the GIV prang especially under the safety recommendation part of the report: https://www.ntsb.gov/investigations/Acci...c=A-15-034

Quote:...The NTSB determines that the probable cause of this accident was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.

Recommendation: TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.
 
Ah yes, unless it is absolutely positively PC and won't have any blow back for the miniscule, the Hooded Canary's flock, unlike the rest of the 1st world AAI organisations, doesn't do safety recommendations and I guess that includes reading the ones from peer organisations like the NTSB? - FDS!  Angry 
  

MTF? - Yes MUCH...P2  Cool
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Twiddle function – Engaged.


“The aircraft had just undergone routine maintenance and this was planned to be the first flight after the inspection.”

A twiddle - I still remember the day very clearly. Early in one of those pristine Autumn days we get; cool, clear, steady gentle breeze, no traffic – perfect conditions for I fly I thought. As a PPL ‘hanger-rat’ verging on CPL one of my jobs was to open the hanger doors and pull the aircraft out to the ramp. The Chief Engineer was not a man to be messed about with and one whom I held in great respect for he had taught me much (from sweeping the floor to understanding engines and airframes) – “Oi” came a call from the back of the hanger – my call sign – I was wanted. “We’ve just finished with “Delta” and it needs a test fly – you feel like doing it?” (wicked smile). Playing my part I responded “well, if no one else wants to do it – s’pose I could fit it in” - . Quick check for oil, (nothing hanging - nothing dripping) - fuel and water, in I jumped; just about ready to start when the CE materialised in front of the aircraft; shaking his head and making signs that I should turn it all off; which I did. The door opened and he said ”you silly young bugger, I’ve invested a lot of time trying to educate you, not prepared to waste that effort”. I shut up and put my questioning face on. “We have had this aircraft in the shed for a week, trust no one; now lets you and I pre flight this aircraft properly”. And so we did – it took an hour – and it was one of the most beneficial hours I have ever spent, the lessons never forgotten. I did eventually get to go flying, and enjoyed it – but enjoyment was not my focus – I paid a lot of attention to the aircraft and it’s performance. I even got a Tim Tam for morning tea after I had formally presented my post flight notes to the CE. Nothing much was said – but I knew I’d just learned a small part of being a professional. Precious and priceless: thanks Jim….

“Examination of the aircraft's mechanical flight control systems, autopilot and electric trim system did not reveal any evidence of pre-impact malfunction. Those results, however, were inconclusive due to the extensive impact and fire damage.”

Ain’t that the truth though – it’s tough on the ‘tin-kickers’; they do well considering the awful mess a crash and a fire leave behind. It takes time, money and effort to complete an analysis; that and a corporate will to delve as deeply as possible into the why and what-for of the accident. The Essendon crash deserved the ATSB’s very best efforts; it could have been a serious disaster, with manifold ramifications. Yet it was quickly concluded that it was all pilot error, nothing to see and the ATSB would concentrate on whether the building measured up to ‘Black letter’ approval. For starters, ATSB are not in the ‘airspace game’ nor are they forensic legal experts on ‘approval’ to build, particularly in light of the convoluted processes used. So why was the aircraft and pilot quickly dismissed in favour of some half-baked ‘investigation into what Hood claims was a ‘life-saving’ building. It’s bollocks – ATSB’s job is to tell us, as best they can, from the charred remains – why this aircraft crashed and claimed five lives; difficult as that maybe. Here is an example -

“Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.”

That example led to a sane, balanced reasonable recommendation:-

“Recommendation: TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.”

Time our ‘tin-kickers’ united methinks; it’s really not good enough is it? Seriously fellahs, where is your pride, where is your conscience, where is your work ethic? Let the Royal Commission sort out the rats nest surrounding the approval of the building; just tell us your best, considered opinion of why this accident happened; that is your job, it is your only job. But don’t try to treat the aviation community as ignorant, gullible fools. Newsflash – We ain’t.

Twiddle function – Disengaged..

Toot – toot.
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From K’s twiddle;

“The aircraft had just undergone routine maintenance and this was planned to be the first flight after the inspection.”

It sucks to be the first crew to pilot an A320 after it’s been in for a C or D check. They always have little faults, are quick To have MEL’s added. Usually goes on for a few weeks. These things need maintenance but they really don’t like being pulled apart. Bit of a conundrum.
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Mistress Mary, quite contrary…

I’m often quite as ‘confused’ by the results of the 30 year quest for regulatory reform as those at CASA who dream up these pointless ‘reforms’. The changes made seem quite contrary and often contradictory.

For example – take this RAoz outfit – what, of itself is it? What use is it to the national well being? What practical purpose does it serve? There is not too much confusion surrounding an outfit like War-birds or the Glider Federation, both of whom are ‘self administering’. It makes perfectly good sense that a ‘highly specialised’ small  (non commercial) group, should be able to look after themselves – they have done so; successfully, for a long while now and never given the CASA cause to regret cutting them loose from the departmental apron strings. A success story, Bravo. But what is this RAoz thing? It is a to a high degree a quasi commercial association (flight training and aircraft hire), where those who want to potter about in aircraft <600 Kg, in good weather and take the Missus along with on the one hour tour of the local landmarks. All well and good if that is the limit of their aspirations – but the safety case is on very shaky ground.  

The term ‘General Aviation’ (GA) is a misnomer: there are some pretty classy operations lumped into the classification; from long haul, top deck business jets to sophisticated turbine aircraft; from Agricultural applications to the RFDS; from aerial mustering to rescue helicopters. It is a diverse field, providing services and employment, which contributes much to society - and the GDP.

RAoz does non of these things. Compared to ‘commercial’ GA, their training standards well below GA, their airworthiness certification is below the GA bench mark, the maintenance standards are well below GA norm. In short, the average RAoz aircraft and pilot are much more likely to come to grief (on a risk analysis) than a commercial GA aircraft; or even an Australian registered aircraft, privately maintained and operated by a 'private' pilot under the current CASA  rules. And yet, CASA in it’s infernal wisdom is granting more and more latitude to a bunch of amateur Tupperware thrill seekers, while increasing the regulatory burden, exponentially on ‘commercial operations’ which already work under a regulatory impost. Don’t make any sense to me; penalise the ‘real’ operators and pamper the amateur crowd? This passes for ‘reform’? Bollocks it does.

I don’t have a quarrel with ‘home built’ or experimental aircraft; or those as build ‘em. In fact I’d encourage it. BUT, with the two megalomaniacs running the RAoz outfit trying to make it into something other than the original, as intended system, aided and abetted by a purblind CASA – it is time to call halt and bring in some realism. The illych system of divide and conquer, modified by Jonathan (where are my marbles) Aleck is a canker on the industry rump; part 135 is the slow poison seeping from that malefic.

Commercial, professional, top end GA driven into spectre of the past – while the Tupperware crowd revel in their unfettered freedom. Lunacy and arse about face logic. Only in Australia. CASA's current thinking is giving me a serious dose of the screaming Heebeegeebees - truly, loose marble scary........

Done with it – the only hope is for this industry to collectively scream their bloody heads off; get Part 135 and those as wrote it sent back to Hell; where they all rightfully belong.

Aye, I know, more a mini rant than a Gazette: but sometimes it’s better to get things off one’s chest than stew on it. Time the commercial operators joined hands and spoke the one word, with one voice – unacceptable!

Selah……
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Been a’ pondering, have I.

My firstborn has, as usual, skipped through the obvious steps and landed on a conclusion. Furry Muff for those who actually ‘get-it’ and there are plenty who do; but what of the rest of us – we plodders?

Well, loath as I be to but into the Sunday speakeasy; I thought some time would be well spent by looking at ‘essentials’ and they way the Part 135 eliminates those things which are of value and replaces them with ‘desk-top’ audit ease and even easier conviction. We are discussing serious criminal penalties here; without appeal, under strict liability. The devil is in the detail and the translation, only by qualified ‘legal; opinion.

But why don’t we put that aside – just for a nonce and look at ‘practical’ safety enhancement? That is, when all said and done, what CASA are shooting for (despite rumours to the contrary). They believe (firmly) that increased ‘safety-management’ and a lot more office staff will make the commercial, non airline sector ‘safer’. Whatever that may mean.

The CASR Part 135 places a tremendous financial burden on the non airline operators. A sector of industry which has, traditionally, always had a battle with balancing the books. The additional impost of even more compliance cost will send many to the wall. For no – zero – safety gain. The 135 logic is flawed, deeply and cataclysmically.

Funds which could be made available for a ‘better’ rather than bare bones overhaul of an engine are now to be used for the care and feeding of some esoteric ‘safety’ notion person CASA believes will ‘improve’ the ever more nebulous demand for 'safety'. Look deeply and closely into commercial operations, the solutions are crystal clear. The ‘cash’ surplus is being eaten alive by the ‘compliance daemon. Charter operators spend more time, money and effort ensuring ‘compliance’ than they do almost anything else – and go to sleep at night worrying about things which have sweet duck all to do with ‘safe’ operations the next day.

Why does CASA not take it’s big boot of the ‘strict liability’ pedal and ensure that ‘surplus’ funds are directed into the ‘luxury items’?

About now, there is a collective growl from the IOS meeting. ‘Wait” say’s I, “all will explained”. And, verbatim I do quote it:-

How about being able to afford the luxury of sending the Chief Pilot or even a training pilot along on a charter – call it LOFT, call it a ride along, call it a route check – call it whatever floats your boat. A new start, new to the aircraft, new to the company, new to the territory, new to the ‘job’ – needs every single ounce of ‘non punitive’ additional training the company can provide. This costs real money; money now being spent chasing the dragon of ‘compliance’. Senior pilots stuck in the bloody office – ensuring paper compliance, redrafting operations manual – while young ‘Wannabe’ is out there, on his own, with nary a clue of how to ‘get a job done’ - properly (compliantly).

Affordable luxury – the aging, venerable PA 31 is up for overhaul. Three lists -  ‘nice to have list’ a ‘must do list’ and a bloody long ‘wish-list’. All of this cost money, which is in short supply because it is feeding the compliance daemon.

Affordable luxury – new GPS, radio or even instruments - all cost money.

The simple fact is that there is only so much Do-Ray-Me to go around after funding the existing, horrendous ‘compliance’ costs. This precludes any training above the absolute minimum required for 'compliance'; or, spare time for ‘senior pilot’ supervision above and beyond the 'compliance' minimum; or, upgrade and repair/rectification/re-fit is gobbled up by the ever demanding ‘compliance’ daemon leads only to one place – shut down or go tit’s up. But therein, lies real safety. Up to date aircraft operated by carefully nurtured pilot - who know what they are about; courtesy of their employer.

CASA ain’t enhancing ‘real’ safety – they are seriously ‘anal retentive’ in ensuring that ‘safety’ is firmly in the hands of the legal profession, safe conviction and that the reality of ‘operational safety’ is removed from the ambit of the operator. Yes, granted, there are some who will take very penny and not re-invest it their own operation – but they are few and far between.

What say you IOS?   A new GPS or another ‘clerk’ in the office – taking care of administrative safety or another experienced ‘chap’ (or Chapess) taking care of ‘real’ airborne safety?

Where would you spend your safety dollars – operationally; or, on ‘compliance’? Unanimous vote here.

Yes; I’ll shut up now; yes I need a refill and yes – I will walk home with ‘the lad’; it will be my pleasure.

Now, bugger off and let an old man have a quiet Ale (or two?)
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A journey down Compliance Avenue, just around the corner from Pooh Lane and near Bollocks Street

P7 said;

“when all said and done, what CASA are shooting for (despite rumours to the contrary). They believe (firmly) that increased ‘safety-management’ and a lot more office staff will make the commercial, non airline sector ‘safer’. Whatever that may mean”.

Pretty much sums it up perfectly. More compliance under CAsR Part 135 for nil increased safety benefit. Additional burden of hiring a safety manager to meet compliance needs. Ridiculous crap. Later this year -  aerodromes MOS Part 139; changes that will increase airport compliance. More risk assessments, more safety cases, more cost impost on the little airports with a single ARO, a gardener and one RPT flight per week. Bollocks I call, bollocks!!!

Meanwhile, the ever so safety conscious Big R Regulator allows shopping centres to be built within 150m of a runway centreline without so much as a risk assessment because CAsA are too busy and it’s too much work. FFS.

Why do you think the Frogs are firing up in France? The yellow vests are sick of Government mismanagement of taxpayer funds, the over regulation of everything from tax laws, civil laws and legislation, police powers, bankster politicans, speed cameras, CCTV cameras, rules rules rules and more effing rules. The yellow vests, do you know the reason for the vests? No, not Greg Hood. It’s becuase of the fuckwit French Government who has made it law that you carry a yellow vest in every vehicles boot incase the car breaks down. You have to put your vest on. FFS, they made that in to a law!!!!

Enough is enough
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