Times up for Pel_air MkII

Rock a by Skull on the tree top, along comes the clock and it goes tick tick tock....

Well I’m not surprised that the Skull stalled the stick shaker over FRMS. In his Star Chamber world fatigue was a weakness and if you can’t handle it then piss off. Fewer hours flown meant less revenue for his beloved CX. And of course at CAsA, the sheer size of the perceived political fallout from introducing stricter fatigue rules for the poor, worn out and battered pilot fraternity wasn’t palatable to the bonus collectors at the likes of QF, VA and so on. The Screamer did not like the thought of wearing a giant airline CEO sized pineapple up his klacker.

Ironic isn’t it? The Civil Aviation SAFETY Authority, the Regulator who purportedly promulgates, enforces and fosters safety, won’t introduce proper fatigue management rules. These are the same fuckwits that will put you in jail for armour oiling your pilot seat, or patting the engine cowl of your plane as you walk past it, or failing to wear your epaulettes on your pilot shirt as you stroll through a hangar!!!

Unbelievable. And is there any wonder why the industry laughs at CAsA and the political tossers pulling their strings. You would think that the Colgan crash would be the ‘game changer’ in our industry. It was meant to be. After all, it is the accident that forced those other trough swillers at ICAO to start taking a serious look at pilot fatigue matters.

Tick tock ZZZzzzzzz

A younger Skull;


Ben Cook PelAir revisited - Part V (PDF)

Via AA magazine:

Quote:[Image: PA-v-1.jpg]
Part 5

This is our final in a series of five articles where human factors expert Ben Cook has revisited the ditching of the Pel-Air aircraft off Norfolk Island on November 18 2009 – looking at the numerous human factors that influenced the tragedy. In this article, Ben explores the failings of key organisations and the importance of them rebuilding trust within the aviation community and the broader flying public.

Where are we now?

As noted in previous articles, the failure of the Civil Aviation Safety Authority (CASA) – including the impact of personal bias and ego – adversely affected the accident investigation process for the Pel-Air ditching. The CASA special audit conducted after the accident also highlighted inadequate regulatory surveillance.

Now add to this the inability of the Australian Transport Safety Bureau (ATSB) to remain independent of the influence of strong personalities within CASA. It was unable to genuinely consider all the facts available, including the findings from the CASA special audit, and it failed to conduct a timely and thorough first investigation.

The result: devastating consequences for the accident survivors.

Moreover, the total cost to the taxpayer, via Senate enquiries, an independent review of the ATSB by the Transportation Safety Board of Canada, a second accident investigation and more, has been exorbitant – and for what gain? Some suggest, including the survivors, that even today there has been little to no safety improvements as a direct outcome of these processes.

And while you’ve gained further insights into the horrific impact for some of the crew members, namely Dom (the aircraft captain) and Karen (the flight nurse), it is important to remember that the passenger requiring medical assistance was confronted with ongoing post-traumatic stress and a fight for basic medical compensation, which she could not cope with and ultimately lost her will to live. A terribly tragic outcome for her family and friends.

Timeliness and surveillance

Timeliness is a critical factor still impacting on investigative processes.

Even today I am personally aware of several families and organisations still experiencing the same slow response from the ATSB. For instance, I attended a major safety forum where an aviation small business owner, post-accident, openly discussed their case with a presenter as part of the forum. The business owner spoke about how they were repeatedly told by members of the ATSB that the final report would be ready in another month.

Unfortunately, this was the same response received every month for many months.
Eventually, they were told the ATSB investigator had taken stress leave. You could hear the trauma in the voice of this person as they articulated their story to the forum; the tremor in their voice and the visible stress on show due to the uncertainty about insurance and the viability of their family business – all dependent on the timely outcomes of the ATSB investigation to assist with resolution.

Then, there is regulatory relevance.

From my personal experience working for CASA, surveillance remains a challenge. Ensuring you have adequate time to find the real systemic factors impacting an organisation takes time.

Many years ago, CASA employed systems safety specialists to gain a better balance around such issues, including access to adequate data (safety intelligence) to enhance the ability to conduct risk-based surveillance.

The aim was to avoid the ‘old school’ tick-and-flick checklists and a generally shallow audit response (covering too much too quickly) to better focus and spend more time on those areas that genuinely impacted individual and organisational behaviour.

Ultimately, good surveillance helps organisations improve their own standards for continued business success.

It was a good attempt to enhance CASA processes and worked well in some offices and less so in others due to a lack of clarity around the new role. The net outcome was enhancements for CASA but this still has further room for improvement.

What’s your experience with regulators? Are they helping you identify important issues that are making a positive difference? For some the answer is yes, and that’s a great outcome.

For others, you may receive corrective action that leaves you wondering why you should invest resources into something that you don’t believe will enhance your operations, where the costs potentially outweigh the benefits gained.

So where does this leave CASA and the ATSB today?

My view is the Pel-Air ditching had a significant impact on the trust relationship between local aircraft operators and members of the Australian public. It also led to significant questions about the professional standing of the ATSB.

And that impact continues today.

Why is that trust so important and what’s required to rebuild it?

Trust – the one thing that changes everything

From the work of Stephen Covey, the author of The Speed of Trust, society is experiencing a crisis of trust that always affects two outcomes: speed and cost. Covey cites numerous examples of changes within society and organisations, with research from many companies and broader society indicating a sharp decline in trust, which continues today.

If you consider relationships with low trust what are the typical behaviours you might see within an organisation? Let’s consider writing an audit report involving a highly competent and experienced inspector that requires review by a team leader and a regional manager where there is a low trust relationship at all levels.

Some outcomes could include unnecessary questioning, seeking further evidence to substantiate findings and asking for sections to be re-written; initially by the team leader and again by the regional manager. For the inspector it feels like micro‑management and leads to frustration.

Low trust slows down the process – unnecessary additional administration for potentially no gain. Speed goes down and the cost to the organisation and industry (lost time) goes up.

If we consider something critical to aviation operations, such as effective communication and linking this back to trust, Covey says:

“In a high-trust relationship, you can say the wrong thing, and people will still get your meaning. In a low trust relationship, you can be very measured, even precise, and they’ll still misinterpret you.”

It’s a good reminder that trust is hard, real, quantifiable, and can provide significant enhancement to efficiency and cost within any system.

Leaders must address trust as part of a strong culture. As Covey says, “Leadership is getting results in a way that inspires trust”. It also means that leaders must provide opportunities for personnel to learn from their mistakes and to provide a culture that makes it safe for that to happen.

A starting point for CASA and the ATSB is to be more transparent when they get things wrong. They must be upfront, accept all organisations make mistakes, and provide clear evidence that they themselves are making improvements from the lessons learnt. It’s role-modelling the culture expected of operators as part of applied safety management systems for continuous improvement.

As part of my work with organisations to review their ability to achieve and sustain operational and business excellence, I spend time investigating trust through the lens of ability, character and truthfulness.

When considering this from a CASA and ATSB perspective:

>> Are CASA and ATSB personnel technically competent and do they deliver outcomes consistent to an agreed standard?

>> Do you get a consistent response from CASA or ATSB personnel from different geographical regions?

>> Is there a strong customer focus or do members hide behind a veil of bureaucracy?

>> Do staff have the interpersonal skills to deal with difficult issues while upholding a professional relationship with industry clients?

>> Do the words of employees and the broader organisation match the realities of what is delivered?

For every government employee that sits in bureaucratic, semiretirement mode, where they’re not held accountable, they’re letting down those hard-working, passionate employees performing a competent, professional role.

For every service response that demonstrates disrespect to industry customers, it tends to negate the 10‑20 professional and positive services delivered by those other personnel who are respected and trusted by industry.

Empowered accountability for any organisation means you weed out underperformers to protect your brand and industry reputation – and enhance trust.

[Image: PA-v-2.jpg]
Good surveillance helps

organisations improve their
own standards for continued
business success. casa

Now apply these concepts of ability, character and truthfulness to you.

Are you as technically competent as you could be? Do you actively seek feedback to make sure you’re not getting overconfident or complacent?

Do you understand the pros and cons of your character (the mental and moral qualities distinctive to an individual) and seek to modify your attitudes and behaviour to better manage your own personality traits?

Ask yourself and others whether you’re honest, candid, and frank? If you say you’re going to deliver something by a certain time, do you deliver it?

All these elements help to build and instil ongoing trust.

So how does CASA and the ATSB rebuild trust with the industry?

Rebuilding trust – future solutions

The ATSB and other investigatory bodies have a challenge, which was summarised nicely in a statement made by Deborah Hersman, a former chairman of the National Transportation Safety Board (NTSB):

Looking beyond its core mission to investigate accidents, the National Transportation Safety Board also is seeking a major role identifying aviation hazards before they can cause crashes…a departure from the board’s traditional job of dissecting the causes of fatal plane accidents and serious incidents, and then months – or years – later recommending ways to prevent repeats.

In today’s fast-paced society, by the time recommendations are presented, particularly if the timeline is 18-24 months post-accident, an organisation has already moved on. Many of the successful programs I’ve worked with across different industries have only met stakeholder needs if they’ve delivered timely outcomes.

I also propose the premise of proactive hazard identification is a missing link for regulators. They too need to move well beyond traditional surveillance to consider new models for enacting their requirement to regulate industry and to ensure operators have the capacity to deliver the standards necessary to provide safe, effective operations required by the fare-paying public.

Another solution is bright spot thinking. The aim is to avoid focusing on the negatives and to instead look for solutions that could be in plain view, including the opportunity to innovate better ways of doing business. It’s about spending more time identifying, cloning and sharing good industry standards and practices.

I believe it’s time to have an independent group perform a complete review of the existing practices of CASA and the ATSB – with a view to looking at opportunities for innovation.

This could help to identify what’s working well and why; to better understand and consider industry needs from a business perspective. Perhaps it’s about creating enhanced efficiency and effectiveness for business success or the re-alignment of existing resources to deliver enhanced outcomes for the benefit of the whole of industry.

Time and again we’ve heard the same promises: the regulatory reforms will be prioritised, accident investigations will be completed faster, but little has changed.

So isn’t it time for an independent and innovative review of how to get the best we can from both the ATSB and CASA?

Consider this: Some regulators establish relationships with airlines to rotate personnel through inspectorate roles, with clear policy and procedures to avoid conflicts of interest.

The benefit is access to industry personnel with recent, relevant experience for a two to four year placement. Aircrew and engineers gain valuable insights into the role of the regulator, with an ability to transfer those skills back to the airline. This could equally be applied by investigatory bodies. This may not be the correct answer for our industry, but it demonstrates how we can think outside the box.

Some other suggestions for rebuilding trust include:

>> Delivery: Deliver what you say you’re going to deliver and performance manage personnel who cannot demonstrate a genuine contribution to your core business, particularly those lacking trust or respect by industry. They tarnish brands. Meet industry expectations and hold your own personnel accountable.

>> Industry risk profiles: Establish industry risk profiles (work is ongoing in this space) and reconsider the classification of various operations to ensure CASA and ATSB resources are utilised for best effect. With limited resources, they must be utilised across sectors that will genuinely enhance and protect the broader population.

This also allows regulations and acceptable means of compliance to be tailored to match the nature of the industry profile, and for some sectors the outcome might even be enhanced through self-regulation.

>> Regulatory reform: Keep the rules simple and aligned to industry risk profiles. The regulatory requirements considered suitable for high capacity organisations such as Qantas and Virgin Australia need to be much different to those that will support smaller family businesses, such as aerial application and flying training organisations.

>> More safety promotion: Both CASA and the ATSB have delivered outstanding proactive support to industry including the establishment of aviation safety advisors, the delivery of safety promotion products (eg Safety Behaviours Human Factors for Pilots) that have received international praise, and training courses (eg ATSB Human Factors for Transport Safety Investigators) that are recognised and oversubscribed by industry seeking placement. It’s time to take this model to the next level.

>> Collaborative investment: Promote high training standards and outcomes, rather than every operator trying to deliver a minimum standard. Why not establish larger training centres within regions of high training activity (Moorabbin, Parafield, Bankstown, Jandakot etc) focused on delivery of modules such as non-technical skills training, accident investigation, human factors for operators, and applied fatigue management? This could be achieved through use of Aviation Safety Advisors, ATSB investigators, industry experts and aviation universities working in collaboration with a focus on train-the-trainer. Some of our smaller organisations, particularly the flying training industry, require greater assistance to keep their businesses viable. While a one-hour presentation at a local flying club on situational awareness by an Aviation Safety Advisor might be interesting, wouldn’t it be better to deliver longer courses that genuinely upskill future trainers to allow them to deliver enhanced standards and professional practices?

It’s back to bright spots – taking what we’ve already got and delivering better outcomes aligned with industry needs. This will help build a more trustworthy, collaborative and reliable industry.

[Image: PA-v-3.jpg]

Timeliness is a critical factor

still impacting on investigative
processes. atsb

In conclusion

I would like to thank you for taking this journey with me. For those who have read all five articles, we’ve covered much ground including the impact of egos, trust, professionalism, fatigue, inconsistencies with systemic investigation, and the powerful impact of organisational culture.

I hope you’ve gained some practical tips that you can apply within your own aviation operations.

MTF...P2  Cool

How things have changed? NOT! -  Dodgy


(02-27-2019, 09:01 AM)Peetwo Wrote:  
(02-18-2019, 08:38 PM)Peetwo Wrote:  
Update: Via the Oz today.

Quote:Dick Smith urges small airfare levy to fund new MH370 search

[Image: 02efef093bbb67794864e5f8c599c3ed?width=650]

Dick Smith. Picture: Jonathan Ng

12:00AM FEBRUARY 27, 2019
Veteran aviator Dick Smith has used the launch of a new book on the MH370 mystery to call for airlines to introduce a small levy on fares to raise money for another search.

Launching The Hunt for MH370 by The Australian’s Ean Higgins, Mr Smith said it was almost unbelievable that the Boeing 777-200ER remained missing almost five years after it disappeared en route from Kuala Lumpur to Beijing.

There were 239 people on board the Malaysia Airlines flight, including six Australians, but all that has been found of the jet is a dozen or so pieces of debris.

Mr Smith said a levy of just 10c a fare could raise as much as $350 million towards a new ocean search, given 3.5 billion people travelled by air each year.

“I just simply can’t believe that the safety regulators around the world have said nothing about the need to find MH370,” he said.

“I’m not at all convinced we know what happened and because of that, it is imperative we find the aircraft and the black boxes so if it was a design fault (with the aircraft) we can fix it and save lives in the future.”

Mr Smith said if there had not been an extended search for Air France flight 447 in the Atlantic Ocean, information about why the plane crashed would remain unknown.

“They spent the extra money and found the flight data recorder which revealed one of the flight crew held the side stick controller in the stall position,” Mr Smith said.

“No one would’ve guessed that but now every pilot is taught not to do that.”

Higgins said all the families he had spoken to in the course of researching and writing his book were desperate to know what happened to their loved ones and deserved answers.

“I think it’s more a matter of will than money that’s lacking in renewing the search,” he said. “Boeing recently reported $US100 billion in sales and it could, as Airbus did for Air France 447, put up some money to fund a new hunt.

“So could, and so should, China whose nationals accounted for two-thirds of the passengers on the aircraft.”

The International Air Transport Association, which represents 293 airlines worldwide, was unable to support Mr Smith’s call for an airfare levy to fund a new MH370 search.

Assistant director of corporate communications Albert Tjoeng said there was already a well established process for accident investigation, included in Inter­national Civil Aviation Organ­isation’s annex 13.

“There is nothing in the ICAO annexes that would establish a precedent for the kind of funding mechanism being suggested, nor would IATA support such a mechanism,” Mr Tjoeng said.

Mr Smith said that without knowing what happened to MH370 there would always be some doubt about the safety of air travel. “This situation hasn’t occurred before and we have to change that for the confidence of the airline industry,” he said.

“Every passenger who flies now must be concerned.”

And from UP thread:

Quote:The utter dishonesty of the Canberra system – MH370
Many will know that the Deputy Prime Minister Michael McCormack has proposed a legislative change in Parliament which reinforces the unique Civil Aviation Act and the words “CASA must regard the safety of air navigation as the most important consideration.”

Of course, this means that safety is more important than anything else, including cost.

If that is true, can I ask a simple question? Why isn’t the Deputy Prime Minister pushing for the search to be reinstated for MH370?

You got it! Because the powers that be have decided that the extra cost is more important than the extra safety they may gained by finding out what actually happened!

It is clear that not only were eight Australians killed, but Australians are flying all the time on the Boeing 777, which could have an inherent fault. Only yesterday, a Qantas pilot said to me that he does not believe in the murder/suicide theory and believes there is an airworthiness problem with the aircraft – it is tied up with an oxygen cylinder that could blow up.

Of course, we see the utter hypocrisy of Canberra – not one word from Mr Carmody (the Director of Aviation Safety) and not one word from the Deputy Prime Minister or his Chief of Staff, or his head of PR.

I have called for a small levy to be put on air tickets. Ten cents would raise $270 million from the 2.7 billion passengers, so the search could continue and the aircraft to be found. After all, small fortunes were spent in finding the African Airways 747 in the Indian Ocean and the Air France Airbus A330 in the Atlantic.

Once the flight data recorders were found, safety was improved. It is unlikely that form of accident would happen again.

Yes, I know, lots of readers here believe it was a simple (if you could call it that) murder/suicide and nothing will be learnt from finding the aircraft. However, anyone who flies, and anyone who has relatives who fly, should be very wary. There is a chance that the Qantas pilot is correct and there is a problem with the aircraft.

I ask everyone to support me in a campaign to get the search going again (this time probably in the correct area would be a good idea), find the flight data recorders, and show that we are really interested in passenger safety.

No, of course! I have suddenly realised – this won’t be paid for by general aviation. Ten cents on an air ticket could mean ten cents less profit per air ticket by the airlines, so they will completely stop this from happening.

I wonder if the Minister will stand up to the powerful and truely put safety as the most important consideration ?

The international MH370 social media crew were slow to react to the Dick Smith comments but one long time loyal MH370 follower and super sleuth Julie Nihonmama did not miss the irony or opportunity to make a very valid Elephant in the room point -  Rolleyes


[Image: ztUE2EGo_bigger.jpg]


"Why isn’t the Deputy PM pushing for the search to be reinstated for #MH370?

...anyone who flies, and anyone who has relatives who fly, should be very wary. There is a chance that the Qantas pilot is correct and there is a problem with the aircraft."


However what really caught my attention was Julie's next tweet which posthumously referenced a Ben Sandiland's Planetalking blast from the past - RIP BEN!  Angel

Quote:☝️  "CASA clearly considers that cost is clearly more important than the safety improvement that can be made." (2019)

"The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report" (2014) ?


RIP Ben. #MH370


Call for ATSB chief’s removal over Pel-Air report fiasco

Senior mandarins in aviation tried to lock their Minister, Warren Truss, into a position he no longer wants to be in. A very bad career move

DEC 03, 2014

[Image: XenophonSack-Dolan--610x395.jpg]

The scope for major changes in Australia’s air safety investigator, the ATSB,  its aviation regulator, CASA,  and their administrator the department of Infrastructure and Regional Development looms large following the Minister’s abrupt call for a fresh look at the Pel-Air crash inquiry report.

A great deal of political and administrative capital was invested in producing and defending  the vindictive, unfair and inadequate final report that the ATSB issued, and subsequently defended, concerning the Pel-Air crash of a Westwind corporate jet doing a medical charter into the sea near Norfolk Island on 18 November, 2009.

In what might prove a critical development in the public administration of air safety in this country, that report, released after many delays on 30 August 2012, seems set to be undone, or redone.

As might prove to be the case for  Martin Dolan, the discredited ATSB chief commissioner whose testimony before a Senate hearing into the investigator’s botched processes over its Pel-Air findings was rejected by an all party committee.

Independent SA Senator, Nick Xenophon, lost no time in calling for Dolan’s removal  “and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and CASA.”

The human suffering aspect of what at first glance seems like a minor hull loss in the middle of the night is difficult to discuss for legal reasons at present. However it was anything but minor for the six people onboard when it was ditched in the sea because it had reached its intended refueling stop at Norfolk Island, on its way from Apia to Melbourne, when it discovered the weather advice it had received was wrong, it was unable to land, and it no reserves to reach an alternate.

Pel-Air, the operator was a mess. It grounded its surviving Westwinds voluntarily after the crash. Its deputy chairman and former coalition aviation minister John Sharp, even gave a media interview in which he admitted there ‘was no plan B’.  The operator didn’t even have a written oceanic fueling policy.  It was an appalling state of affairs, all seemingly brushed under the carpet by two safety authorities and a federal department.

One of those people on the flight was quite seriously injured, yet more than five years later, she is being appallingly treated, even gloated over by some parties on the basis that Australia’s air regulations in respect of such accidents were so lax/ or non-existent, that anyone using them had no legal protection whatsoever.  (Which may not prove to be the case, of course.)

That regulatory vacuum persists to this day, despite lies from CASA under previous management as to how promptly it was going to fix the situation, and an apparent paralysis of that organization under a recently departed head of safety when it came to actually reforming or performing any of its obligations to aviation stakeholders and the public.

However the testimony of Dolan to the Senate, and the tale of administrative incompetence and lack of clear management on his watch during the bungled Pel-Air inquiry that is set out by the TSBC peer review ought to have him out of the door on skates.

The identification of the secretary for Infrastructure and Regional Development, Mike Mrdak with the Dolan, ATSB and CASA positions on the Pel-Air inquiry places him in a difficult position. Mr Mrdak took his Minister, Mr Truss, to a place where the Minister no longer wants to be, which is always in hindsight, a bad, bad move.

It was Mrdak’s department that told Truss to reject earlier calls, including from the Senate committee inquiring into the ATSB, to recover the flight data recorder from the Pel-Air wreckage and redo the findings, which were essentially a lazy and incomplete scapegoating of the pilot in charge of the Westwind.

The privileged Hansard records of the testimony of Dolan, the then director of air safety for CASA, John McCormick, and Mrdak are substantially incompatible with the findings of the TSBC.

It was Mrdak’s department that wrote the original position taken by Minister Truss that there was no point in retrieving the flight data recorder or correcting the accident report.  It will be interesting to see if Mrdak can perform the necessary U-turn, and repudiate his previous words, while remaining on top in Infrastructure.

When Minister Truss’s Air Safety Regulation Review panel, chaired by David Forsyth, reported at the end of May this year it anticipated that the TSBC report would be both critical and released in the near future.

It was however, repeatedly delayed, to the point where some feared it mightn’t even see the light of day, given reported resistance to its contents within the ATSB.

The report released on Monday was written in a manner likely to put a casual reader into a coma.  But for those who read the full document, it proved highly critical of the ATSB, setting out comprehensive failings in terms of collecting and assessing information.

There was dissent within the investigating team, to the point where a ‘coach’ appointed to assist in the inquiry, sought, eventually successfully, to be relieved of his role.

The TSBC dealt deeply with the disruption caused in the investigation by uncertainty over the appropriate relationship with CASA, which conducted parallel inquiries, including an audit that was withheld from the ATSB, into the Pel-Air Westwind operation subsequent to the crash.

As reported earlier in Plane Talking and examined by a Senate committee into the ATSB’s procedures in relation to Pel-Air, CASA suppressed an audit that found that the crash could have been prevented had the regulator carried out its own duties of oversight over the Westwind operation.

The stench from the ATSB and CASA over the investigative shambles led to a damning Senate committee report, in which the committee took that rare if not unprecedented step of giving a section of their findings to their lack of confidence in the testimony and conduct of the chief commissioner of the ATSB, Martin Dolan.

Today’s decision to have ‘another look’, which to be clear, is a direction not a suggestion, reflects poorly on Truss’s Labor predecessor Anthony Albanese.

Mr Albanese broke several commitments to deal with the adverse Senate findings into the ATSB, and was ineffectual or unwilling in relation to the Pel-Air issues, which first arose on his watch with ample opportunity for ministerial direction or intervention.

Mr Truss has not escaped criticism in this portfolio either, and not just from Plane Talking.  But something has changed, this damaging and disgraceful report will be ‘fixed’ in its procedural or methodological shortcomings, there is already a new Director of Air Safety at CASA, and there may well be further changes for the better in the administration of air safety.
How things have changed? NOT! - MTF...P2  Angry


How things have changed? NOT! - MTF...P2 Angry

One could say that it’s all tautological?

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