Of minds and what matters.
Munro (2004) - “If you were investigating with the intention of finding out what had happened, once you had made a transcript of a recording wouldn’t you send it to ALL those whose voices were on the tape asking them to verify the transcription? But if you were seeking “an ex post facto justification for a conclusion that had already been reached” (to quote Coroner Chivell) then you might well be selective about who got the transcript and who did not.”
Even in the State of Denial (ACT) it must be coming apparent even to the bipartisan house and the Senate RRAT committee that there is a serious credibility problem, which cannot be sketched around much longer. We all must live with glib and the inutile PR ATSB publish for the media. Its not right – but it has become a normalised deviance; largely ignored by professional aviation. Perhaps bipartisan parliament can live with that. Who knows.
But coroners have both a legal and moral duty; their rulings have effect on many elements which impact on peoples lives. Industry professionals have legal, operational and moral duties; and, face criminal charges for even the perception of failing in that duty. How are these obligations to be met without accurate analysis of accident. Tangible, accurate, honest data to assist in improving 'safety' protocols and procedures is an essential element in any 'safety' case. Less than this makes not only a mockery of the expensive 'safety system', but opens the door to a recurrence.
For example: the Essendon DFO event. Almost 6 ton of machinery, carrying a ton of jet fuel slams into a building which, but for chance, was not filled with shoppers. What are the percentage chances of this event reoccurring? If there was no building impinging on the safety zone around the runway, then the chances are remote. In the USA this is an acknowledged risk mitigation fact; there is a widely used code which minimises, within practical limits, building near runways. The ATSB dismissed 'the cause', almost on the day of the Melbourne event (in their time frame) as simple pilot error, based on one element. I would suggest this is a flawed explanation; easily dismissed. Yet the one element in the causal chain is all the coroner will have to work with. It begs the question – 'will there be another similar incident?. The answer is yes; if steps are not taken and enforced to discover exactly what happened to the aircraft, the pilot and how the 'safety system' was breached.
It is all too easy to blame the ATSB standing alone. The problem is they are the 'visible' part of a very ugly, dangerous situation; the face of safety if you will. In reality, they are but a cats-paw, waved at the whim of their masters. Essentially of little more than a team of cub reporters providing 'copy' to their editors and re-write, spin merchants. Oh, it is all very neatly done and no one is truly responsible for the dribble published – a company effort, on behalf of their masters voice.
Poor old Coroner; blinded by science, baffled with bullshit carefully steered to the 'right' conclusion. ATSB turn up at the inquest – having had a good long time to polish the Cue ball and Teflon coat it; CASA's legal weapon turns up to make sure that any and all 'argument is shut down – pronto like; and, all the coroner can do is meekly voice his 'opinion' and bury the case there and then, conscience salved by a good claret over a long lunch; knowing the minister is as happy as Claggy.
PAIN tried to hi light this in an abridged, edited version of a lengthy study of 'coroner inquiry'. Every 'fatal' accident, for over 12 years has been examined, all coroners reports and comments read and discussed. There is also a long, list of 'investigation' and conclusions drawn on almost every accident during that time. To put it mildly, the only folks not reaching for the vomit bucket are the 'official safety agencies' and of course the minister.
The answers you seek Senators may not be found in the current crop of 'officials'. Look to the coroners, seek out those no longer employed by the agencies, invite interested parties to speak. Do this before the charade begins in earnest, get some facts, get a real life picture and FDS get a grip. Boyd Munro penned the article below in 2004. The PAIN short report is – HERE.
KEEP A LITTLE SALT HANDY THIS WEEK, PLEASE …IN CASE ANOTHER ATSB REPORT COMES OUT.
I urge members of the Press Corps to keep a grain or two of salt handy this week. It may be needed when ATSB publishes its report into the Aviation Incident which occurred near Launceston on Christmas Eve.
The Report will probably be released this week, and it may contain the kind of inaccuracy for which the ATSB is rapidly developing a reputation. Before you go to camera, microphone or print on it, please contact us by phone or e-mail so we can – if necessary - tell you what ATSB may have chosen not to reveal.
The Aviation Incident is being beaten up for industrial reasons. Changes were made to Australia’s management of airspace. These changes take us part of the way out of the “quill pen and green eye-shade” era in which our airspace management has been for the past 50 years. Our airspace is now managed like that of the USA, which has an outstanding safety record – and there is far more flying in the USA than in any other country.
Those changes, sadly, are apparently seen by the leaders of the Air Traffic Controllers’ Union as a threat to their members’ jobs rather than the opportunity for professional development that they are,
The relationship between ATSB and the Air Traffic Controllers is a close one – so close that ATSB appointed a former Air Traffic Controller to investigate this incident.
ATSB has been widely criticised for its conduct of investigations. For example –
Mr. Wayne Chivell - Coroner, South Australia, July 2003.
"Mr. Fearon was made available by the ATSB to answer as many questions as he could arising from Mr. Cavenagh's evidence.
"The difficulty I have with Mr. Fearon's evidence on this topic is that he is happy to seize upon data, such as that produced by Mr. Braly, as supporting his theory, but when contradictory data was put to him he reverted to rather facile positions."......Mr Fearon's evidence became unhelpfully speculative.
"I find the ATSB's theory, namely................., as to be so unlikely as to be almost fanciful."In my opinion, the evidence is overwhelmingly against the ATSB theory...........
"As each of these technical issues were put to (The ATSB's) Mr. Cavenagh and Mr. Fearon their explanations and arguments became more abstruse and less credible. I gained the very distinct impression that this constituted an ex post facto justification for a conclusion that had already been reached rather than a genuinely dispassionate scientific analysis of the factors involved.
Ms Lyn McDade - Deputy Northern Territory Coroner, March 2003.
"ATSB apparently acting on the advice of others determined that they would not attend the accident site because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored... ...because Mr. Heitman the ATSB representative who made that determination was not able to give evidence because he could not be located. This has deprived the family of the opportunity to test Mr. Heitman and ascertain why he formed the view about the accident he clearly did, without attending the scene or conducting any other enquiries other than telephone contacts with, it appears, Senior Sergeant B and nobody else. Mr. Alistair Hope - Coroner, Western Australia, September 2002 "I should stress at the outset that any comments in relation to the performance of the ATSB are made in the context where eight people have unnecessarily lost their lives, such a tragic event in my view requires careful analysis of available evidence and where answers are not forthcoming because of a lack of evidence, an examination should take place as to the way in which evidence has been obtained and possible deficiencies in obtaining evidence identified, which should be corrected in future cases if such tragedies are not to be repeated on a continuing basis."
Mr. Kurt Mackiewicz - Father of deceased pilot, on the ABC in July 2003
"The protracted investigation was attributable to the ATSB's questionable culture and also their arrogant and obstructionist conduct at the inquiry."
Mr. Peter Scollard – Pilot involved at Launceston, in the Hobart Mercury on December 29th. 2003 "I was fully aware of the Virgin Blue plane's presence at all times, I was monitoring it on two radio frequencies and I was maintaining separation. It is quite simple for me to diverge one or two degrees. At no stage was there ever going to be a collision or even a near-collision. Peter has good reason for concern. ATSB has not given him a copy of the transcript of the radio transmissions at the time of the incident, even though he took part in the transmissions. If all ATSB was doing was carrying out a “no blame” investigation, why on earth would they not give him a copy so that he could, for example, point out any transcription errors? To make matters worse it seems that a copy of that transcript, or a tape of the transmissions, has been made available to others!
If you were investigating with the intention of finding out what had happened, once you had made a transcript of a recording wouldn’t you send it to ALL those whose voices were on the tape asking them to verify the transcription? But if you were seeking “an ex post facto justification for a conclusion that had already been reached” (to quote Coroner Chivell) then you might well be selective about who got the transcript and who did not.
So keep that salt handy and be sure to give us a call on 08 8276 4600 if you feel an urge to report on whatever character assassination it is that ATSB has in store for Peter.
Boyd Munro
AIR SAFETY AUSTRALIA
Aye well I mind and; believe it or not - it does matter.
Toot – toot........
Munro (2004) - “If you were investigating with the intention of finding out what had happened, once you had made a transcript of a recording wouldn’t you send it to ALL those whose voices were on the tape asking them to verify the transcription? But if you were seeking “an ex post facto justification for a conclusion that had already been reached” (to quote Coroner Chivell) then you might well be selective about who got the transcript and who did not.”
Even in the State of Denial (ACT) it must be coming apparent even to the bipartisan house and the Senate RRAT committee that there is a serious credibility problem, which cannot be sketched around much longer. We all must live with glib and the inutile PR ATSB publish for the media. Its not right – but it has become a normalised deviance; largely ignored by professional aviation. Perhaps bipartisan parliament can live with that. Who knows.
But coroners have both a legal and moral duty; their rulings have effect on many elements which impact on peoples lives. Industry professionals have legal, operational and moral duties; and, face criminal charges for even the perception of failing in that duty. How are these obligations to be met without accurate analysis of accident. Tangible, accurate, honest data to assist in improving 'safety' protocols and procedures is an essential element in any 'safety' case. Less than this makes not only a mockery of the expensive 'safety system', but opens the door to a recurrence.
For example: the Essendon DFO event. Almost 6 ton of machinery, carrying a ton of jet fuel slams into a building which, but for chance, was not filled with shoppers. What are the percentage chances of this event reoccurring? If there was no building impinging on the safety zone around the runway, then the chances are remote. In the USA this is an acknowledged risk mitigation fact; there is a widely used code which minimises, within practical limits, building near runways. The ATSB dismissed 'the cause', almost on the day of the Melbourne event (in their time frame) as simple pilot error, based on one element. I would suggest this is a flawed explanation; easily dismissed. Yet the one element in the causal chain is all the coroner will have to work with. It begs the question – 'will there be another similar incident?. The answer is yes; if steps are not taken and enforced to discover exactly what happened to the aircraft, the pilot and how the 'safety system' was breached.
It is all too easy to blame the ATSB standing alone. The problem is they are the 'visible' part of a very ugly, dangerous situation; the face of safety if you will. In reality, they are but a cats-paw, waved at the whim of their masters. Essentially of little more than a team of cub reporters providing 'copy' to their editors and re-write, spin merchants. Oh, it is all very neatly done and no one is truly responsible for the dribble published – a company effort, on behalf of their masters voice.
Poor old Coroner; blinded by science, baffled with bullshit carefully steered to the 'right' conclusion. ATSB turn up at the inquest – having had a good long time to polish the Cue ball and Teflon coat it; CASA's legal weapon turns up to make sure that any and all 'argument is shut down – pronto like; and, all the coroner can do is meekly voice his 'opinion' and bury the case there and then, conscience salved by a good claret over a long lunch; knowing the minister is as happy as Claggy.
PAIN tried to hi light this in an abridged, edited version of a lengthy study of 'coroner inquiry'. Every 'fatal' accident, for over 12 years has been examined, all coroners reports and comments read and discussed. There is also a long, list of 'investigation' and conclusions drawn on almost every accident during that time. To put it mildly, the only folks not reaching for the vomit bucket are the 'official safety agencies' and of course the minister.
The answers you seek Senators may not be found in the current crop of 'officials'. Look to the coroners, seek out those no longer employed by the agencies, invite interested parties to speak. Do this before the charade begins in earnest, get some facts, get a real life picture and FDS get a grip. Boyd Munro penned the article below in 2004. The PAIN short report is – HERE.
KEEP A LITTLE SALT HANDY THIS WEEK, PLEASE …IN CASE ANOTHER ATSB REPORT COMES OUT.
I urge members of the Press Corps to keep a grain or two of salt handy this week. It may be needed when ATSB publishes its report into the Aviation Incident which occurred near Launceston on Christmas Eve.
The Report will probably be released this week, and it may contain the kind of inaccuracy for which the ATSB is rapidly developing a reputation. Before you go to camera, microphone or print on it, please contact us by phone or e-mail so we can – if necessary - tell you what ATSB may have chosen not to reveal.
The Aviation Incident is being beaten up for industrial reasons. Changes were made to Australia’s management of airspace. These changes take us part of the way out of the “quill pen and green eye-shade” era in which our airspace management has been for the past 50 years. Our airspace is now managed like that of the USA, which has an outstanding safety record – and there is far more flying in the USA than in any other country.
Those changes, sadly, are apparently seen by the leaders of the Air Traffic Controllers’ Union as a threat to their members’ jobs rather than the opportunity for professional development that they are,
The relationship between ATSB and the Air Traffic Controllers is a close one – so close that ATSB appointed a former Air Traffic Controller to investigate this incident.
ATSB has been widely criticised for its conduct of investigations. For example –
Mr. Wayne Chivell - Coroner, South Australia, July 2003.
"Mr. Fearon was made available by the ATSB to answer as many questions as he could arising from Mr. Cavenagh's evidence.
"The difficulty I have with Mr. Fearon's evidence on this topic is that he is happy to seize upon data, such as that produced by Mr. Braly, as supporting his theory, but when contradictory data was put to him he reverted to rather facile positions."......Mr Fearon's evidence became unhelpfully speculative.
"I find the ATSB's theory, namely................., as to be so unlikely as to be almost fanciful."In my opinion, the evidence is overwhelmingly against the ATSB theory...........
"As each of these technical issues were put to (The ATSB's) Mr. Cavenagh and Mr. Fearon their explanations and arguments became more abstruse and less credible. I gained the very distinct impression that this constituted an ex post facto justification for a conclusion that had already been reached rather than a genuinely dispassionate scientific analysis of the factors involved.
Ms Lyn McDade - Deputy Northern Territory Coroner, March 2003.
"ATSB apparently acting on the advice of others determined that they would not attend the accident site because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored... ...because Mr. Heitman the ATSB representative who made that determination was not able to give evidence because he could not be located. This has deprived the family of the opportunity to test Mr. Heitman and ascertain why he formed the view about the accident he clearly did, without attending the scene or conducting any other enquiries other than telephone contacts with, it appears, Senior Sergeant B and nobody else. Mr. Alistair Hope - Coroner, Western Australia, September 2002 "I should stress at the outset that any comments in relation to the performance of the ATSB are made in the context where eight people have unnecessarily lost their lives, such a tragic event in my view requires careful analysis of available evidence and where answers are not forthcoming because of a lack of evidence, an examination should take place as to the way in which evidence has been obtained and possible deficiencies in obtaining evidence identified, which should be corrected in future cases if such tragedies are not to be repeated on a continuing basis."
Mr. Kurt Mackiewicz - Father of deceased pilot, on the ABC in July 2003
"The protracted investigation was attributable to the ATSB's questionable culture and also their arrogant and obstructionist conduct at the inquiry."
Mr. Peter Scollard – Pilot involved at Launceston, in the Hobart Mercury on December 29th. 2003 "I was fully aware of the Virgin Blue plane's presence at all times, I was monitoring it on two radio frequencies and I was maintaining separation. It is quite simple for me to diverge one or two degrees. At no stage was there ever going to be a collision or even a near-collision. Peter has good reason for concern. ATSB has not given him a copy of the transcript of the radio transmissions at the time of the incident, even though he took part in the transmissions. If all ATSB was doing was carrying out a “no blame” investigation, why on earth would they not give him a copy so that he could, for example, point out any transcription errors? To make matters worse it seems that a copy of that transcript, or a tape of the transmissions, has been made available to others!
If you were investigating with the intention of finding out what had happened, once you had made a transcript of a recording wouldn’t you send it to ALL those whose voices were on the tape asking them to verify the transcription? But if you were seeking “an ex post facto justification for a conclusion that had already been reached” (to quote Coroner Chivell) then you might well be selective about who got the transcript and who did not.
So keep that salt handy and be sure to give us a call on 08 8276 4600 if you feel an urge to report on whatever character assassination it is that ATSB has in store for Peter.
Boyd Munro
AIR SAFETY AUSTRALIA
Aye well I mind and; believe it or not - it does matter.
Toot – toot........