20/20 Hindsight.

1, 2, 3, and 4 the order doesn’t matter but just some action that will demonstrate to our beleaguered General Aviation (GA) industry that the Government is serious about rational policies that will grow GA jobs, businesses and services.
5. Minimum starting move for our infamous Aviation Medical branch of CASA would be car driver medical standard for Private Licence holders. Thirty something years proven in our light weight category and the success of the USA model leaves no doubt that this reform is viable.
6. Recommend the removal of the Aviation Security Identification Card, a most useless and multi $million impost on an ailing GA industry.
7. Recommend a halt to the alienation of irreplaceable airport land, noting that GA businesses can only operate from airports just as other businesses operate with roadways. Pip Spence and Mark Binskin can put to government that its not safe or efficient to cover these airports with shops and factories. They might point to the ludicrous situation where adjacent golf courses for the recreational benefit of a few golfers are protected from commercial developments.
8. As in the USA allow independent instructors who could then start to repopulate flying schools in numerous country centres replacing the hundreds that have disappeared by the impossibility of the ever worsening CASASTROPHE of the last thirty three years.
9. Structure all aircraft operating rules and administration together with a stepped approach as in the USA.
We are just getting started.

So, what's to become of us?

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way – in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.

“It was the best of times,” - and so it is in many ways. There has never been a better time to tear down the mountain of cumbersome, legally dangerous, operationally inutile, internationally embarrassing regulation and associated restrictions. While the wretched virus holds sway, aviation activity is in a holding pattern and running low on fuel. Money always helps to refuel – but, to expect a rapid recovery under the current regulations and regime, is simply wishful thinking. Adoption of 'world class' rules and a change of regulatory attitude would be a perfect stimulus and allow industry to flourish, on its own initiative; as it has for decades despite lousy regulation and administration.

“It was the worst of times”: not only has industry had a pasting through the virus outbreak; it was in dire straits before that. There is a long list of reasons for this – development of airports; increased administrative costs for operations; an almost insane bunch of regulation; manic regulators, an administration system which, at best could only be described as 'unhelpful' and etc. To add to the existing woes, there is the appointment of a new director of aviation. If Ms Spence is fully backed by heavy duty mandarins and serious changes are to come, then 'hope' may be rekindled. If not then doubt and uncertainty will quickly blossom and all hope of recovery will vanish as fast as investors can find the keys to the Range Rover.

“in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only."

The muted response to the announcement of a new director and chair reflects that. For there is no tangible evidence that anything will change. We have had a series of hamstrung ministers who happily take shelter behind 'the authority'. We have an 'authority which has taken full advantage of never being checked or questioned. The most risible rule set on the planet, ever increasing in size, dominating an industry which dare not call bollocks for fear of decimation through the outlandish legal chicanery those rules allow. This not new – there is a thirty year history of 'fact' to support concern that nothing material will change.

“...but everything in our intercourse did give me pain. Whatever her tone with me happened to be, I could put no trust in it, and build no hope on it; and yet I went on against trust and against hope. Why repeat it a thousand times? So it always was.”

Now, we must all, once again, sit and wait to see which way the coin will land. More time wasted waiting to see which way the hammer will fall. This industry desperately needs positive reassurance that 'change' for the better is not some mythical thing for some time in the future. The need is now and it is urgent.

McDonald could get her finger out – there is a mountain of damning evidence before her, why the delay in taking direct positive, reassuring action? Spence has the job; why is her jacket not hanging on the DAS door, sleeves rolled up swinging the metaphorical axe of real change, in real time? All well and good being cocooned within the bubble, safe salary and protection, remote from the real world – but those in aviation have no such luxuries.

Aye well; back in my box I go; but as we know the wheels of the gods are supposed to grind slow; but I wonder if the gods knocked off and shut down the mill; slow ain't even close, moribund perhaps would be a better descriptor of the Canberra output. There, patience exhausted – Click.............

“So new to him," she muttered, "so old to me; so strange to him, so familiar to me; so melancholy to both of us!...”

Submission 54 - Name Withheld. 

Via GA Inquiry submissions page, there is a new submission that IMO should be essential reading for all the Committee members, the new DAS and indeed the mandarins from the Department. Inside of 4 pages, this submission cuts to the chase and highlights very clearly all that is wrong inside of the Flight Operations division of the regulator - Well done that girl... Wink :

We are making this submission to the enquiry because we have personal experience with
regards to the failings of the Civil Aviation Safety Authority. We are the family of one of the
pilots killed in the tragic accident at Renmark in 2017 which occurred during a training flight
which should never have taken place. We would like to point out that we are not making this
submission simply from the perspective of bereaved lay-people with no knowledge of the
workings of the aviation industry. We have combined backgrounds which include, among
other things, a CPL(H), a law degree and an engineering degree. The following submission
will focus specifically on the operation and effectiveness of CASA, with particular reference
to CASA’s aviation safety frameworks, in the context of the accident investigation report
issued by the ATSB (AO-2017-057 - 30 April 2020).

1. CASA approval of incorrect procedures

Following their very lengthy investigation, ATSB finally produced a draft report in late
December 2019. This was presented to Directly Involved Parties (DIP’s) for comment and
clarification prior to the final report which was expected 30 days later.

The draft report made reference to the fact that the operator’s procedure for simulating
engine failure after take-off was different to the procedure outlined in the Pilot's Operating
Handbook and the Civil Aviation Advisory Publication (5.23-1(2).

The draft report further states:

ATSB has sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Analysis of CASA’s response will
be outlined in the final investigation report.

The final accident report published on the 30 April 2020 states the following:

The ATSB sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Despite this request, no
information was provided by CASA. Consequently, the ATSB was unable to determine
whether the approval of incorrect information was an isolated human error or symptomatic of
a systemic deficiency with the approval process.

Despite there being four months instead of the expected 30 days in between the draft and
final reports, it would appear that CASA did not respond to the request for information from
the ATSB. It would also appear that ATSB did not bother to exercise their rights under
section 32 of the Transport Safety Investigation Act 2003 to compel them to do so.

In recent correspondence in respect of the above the DAS/CEO CASA stated:

CASA provided all information we understood to be required or that was formally requested
by ATSB and we have since confirmed that ATSB is of the same view. We acknowledge that

there was an absence of clarity here and that it should have been resolved prior to the
finalisation of the report.

This statement merely confirms that CASA and ATSB have had communications with each
other, however this information was not in the final report and has never been made
available publicly or to DIP’s. Despite this, ATSB claimed that the information was sought in
a manner that was transparent to all Directly Involved Parties. There is no transparency with
regards to the fact that we still do not know whether this was an isolated human error or
symptomatic of a systemic deficiency with the CASA approval process.

2. Issues surrounding auditing

It would be hoped that such a fundamental, yet very serious error made by CASA in
approving the incorrect operations manual would be detected and rectified during a routine
CASA formal audit. The following extract from the ATSB report explains why this did not

In the 5 years leading up to the accident, the Civil Aviation Safety Authority had not
conducted a systemic or detailed audit during that period, and its focus on a largely informal
and often undocumented approach to oversight increased the risk that organisational or
systemic issues associated with the operator would not be effectively identified and

In their investigation report ATSB published a flight operations surveillance table which
showed the recommended frequency for audits at Rossair as one per year. Unbelievably, the
last recorded audit was undertaken in 2012, and even this audit was performed on Air South
prior to their merger with Rossair.

ATSB go on further to state:

Rossair personnel reported that the lack of formal oversight placed them in a position where
they did not always have the required support for safety related initiatives and, as a result,
addressing commercial matters became a higher priority (emphasis added). The risks of
informal surveillance have been shown in previous accident investigations.

The 2009 Pelair Westwind ditching highlighted CASA’s process for obtaining information with
regard to the nature and extent of an operator’s procedures as limited and informal, yet
incredibly the same mistakes were still being made in 2017 and are likely to be continuing to
be made today.

Despite CASA personnel advising that the recommended frequency of surveillance was not
achievable with their current resources, the DAS/CEO CASA has attempted to justify CASA’s
failure to adhere to their own surveillance schedule in the following statement:

CASA’s approach to the safety oversight of air service providers is risk-based, having regard
to a range of relevant factors. This does not always translate into a fixed schedule or
mandatory frequency of audit and surveillance uniformly applicable to all operators, or even
all operators within the same sector.

This statement was made despite the knowledge by CASA, albeit informally, that a formal
audit was urgently required in order to address serious concerns raised with regards to high
levels of work-related stress and financial pressures placed upon staff. Had such an audit
occurred, it would have identified the serious cultural flaws and apparent lack of resources
affecting the company.

3. Lack of simple risk assessment

On the accident flight was a pilot undergoing a check flight for induction into the company.

The Chief Pilot was performing this check, however he was also undergoing a check by the
CASA flying operations inspector (FOI) to assess his competence for this role. With both the
flying pilots undergoing supervision, the FOI was the most experienced Cessna 441 pilot on
board and a valuable available resource. Despite this, the only avenue of communication
between the FOI and the pilots was a tap on the shoulder, yet still the flight was authorised
to proceed.

In 2015 CASA produced an advisory publication (CAAP 5.23-1(2)) in which they state that
the use of simulators has reduced the perils of simulating engine failures after take-off,
however where simulators are not available, instructors should not simulate engine failures
below 400ft AGL to provide a reasonable safety margin.

In June 2017 CASA issued a Temporary Management Instruction, part of which mandated
that simulated engine failures not be attempted below 1000ft AGL, however this has now
expired and there is no evidence to suggest that this will become part of the regulations. Is it
unreasonable to assume that older aircraft are less likely to have simulators available and
are more likely to sustain maintenance issues due to their age? Is it also unreasonable to
assume that extra altitude during highly risky training manoeuvres allows more time for
issues to be rectified?

According to DAS/CEO CASA there have been subsequent improvements to internal
procedures and guidance for staff conducting in-flight aircraft activities as a means of further
supporting future activities, however this is of little consequence to the three pilots who lost
their lives due to lack of a simple risk assessment.

4. CASA regulations re on-board recording devices

Under current regulations there is no requirement for any on-board recording devices in
aircraft of this weight, however in 2008 ATSB made a recommendation (R2006004)
regarding the fitment of lightweight recorders:

The Australian Transport Safety Bureau (ATSB) recommends that the Civil Aviation Safety
Authority (CASA) review the requirements for the carriage of on-board devices in Australian
registered aircraft as a consequence of technical developments.

It is now 13 years since that recommendation, and technology is even further advanced yet
still the Safety Authority is procrastinating over the use of this basic simplistic device. If
CASA had made a conscious safety decision, in respect of ATSB’s recommendation, in all
probability we would know the cause of this accident rather than being guided by some
outlandish hypothesis proposed by an investigation report which took three years to produce
at huge expense to the tax-paying public.

The point has been made in many other submissions to this inquiry that the production of
reams of new regulations has taken almost thirty years and enormous amounts of money
and man hours. Surely it would make more sense for a safety regulator to move away from
such onerous, prescriptive rules and focus their attention on monitoring to ensure aviation
companies are financially stable and running safe and competent operations. Accidents are
generally extremely detrimental to the viability of most aviation operations and therefore it
would be presumed that safety would be paramount to ensuring business continuity.

Regular, thorough and competent safety audits would identify and rectify those operators
who are not running their business in such an ethical manner. The travelling public surely
has a right to expect that this is how their tax-payer funded money is being spent?

In 2018 and 2019, during presentations to a number of aviation bodies, the DAS/CEO of the
CASA made references to the apparent dark days in safety standards prior to the formation
of CASA in 1995. He went on to emphasise just how good CASA currently is in exercising its
responsibility in respect of aviation safety.

In one of his speeches from 25 May 2018 he states "Aviation Safety and the safety of the
travelling public is CASA’s number one priority. We are the Safety Regulator and our
principle mandate is aviation safety. Our operations are based on the Civil Aviation Act 1988.
One of the most formative amendments of the Act was in 1995 when we became the Civil
Aviation Safety Authority, and a conscious decision was made that our focus would be first
and foremost of Safety".

It would appear the principle mandate of CASA failed abysmally on 30 May 2017.

Hmm...wouldn't this submission be a worthy contribution to the ANAO Audit??  Rolleyes

MTF...P2  Tongue

Submission #54.

Is indeed a good submission. Once again the highlighting the end result of what is a seriously flawed system.

However, whilst we can see 'result'; the path taken, which allowed that result is IMO not clearly defined, nor does it illuminate the radical elements which allow the great liberties taken in 'operational management' of a flying operation.

A simple, yet clearly defined administrative interference with an operational control safety system may be found in any company library – the 'Operations Manual'.

When the administration seeks to control every aspect of an operation, rather than defining the 'sector risk' matrix and allowing the industry experts to manage those risk elements, the administration involves itself in the minutiae – down to insisting spelling errors be corrected before any form of approval is granted. The purpose of the humble operations manual is to define how compliance and risk management is to be achieved. It is not a document writ specifically for the benefit of the prosecution, And yet it often is turned into such – the dictates of the administrator must be satisfied before approval or acceptance is granted.

There are countless examples where the administration has actively interfered with or influenced company operational tenets; which would be acceptable – provided that should there be a breach or accident, all those, including the administrator were held to account; and, corrections were put put in place to prevent recurrence. A better, safer result is much more desirable than fines, loss of operational approval, or even goal for the operator. Micro management, without responsibility and the endless cycle of 'satisfying' the demands of the administration provide nothing of value to anything other than the safe conviction of those alleged to have committed an offence.

Stand alone 'Sector Risk' analysis removes many of the administrative 'traps'. Allowing the 'experts' in any sector to 'manage' their own risks, without administrative interference would mop up many of the grey areas surrounding operational control and risk assessment. In short, the administration should set the boundaries and leave operational matters to those who know and understand the risk factors. As it stands – CASA have total control of operations but accept no responsibility for their part in demanding a 'preferred method of compliance' – their procedure or process incorporated into a manual which then is cited as part of an accident or incident event. See Ross Air or Pel-Air for ready reference.

“He can switch from one view to another with frightening ease. I think it is a sign of being accustomed to such power that the truth does not matter because you cannot be contradicted.”

Toot – toot.


I agree wholeheartedly with what you are trying to get at K but the devil is in the making.

How many times in the regulations does the statement "CASA must be satisfied" appear. The question is just who in CASA does the satisfying? what is their level of competence, experience and background? CASA is not a singular entity. It is a conglomerate of opinions and egos, all based on personal perceived experiences and notions of how or what something should be accomplished or carried out, or achieved. Unfortunately the level of experience and competence is so often lacking within the regulator, for sure there are some very fine people within it, but they alone cannot "Be satisfied" for every interaction CASA has with industry.
There are many within industry who believe based on bitter experience that CASA regulates and enforces based on their desire to above all else avoid liability, rather than an objective aim of improving safety.The Glen Buckley imbroglio is a classic example IMO, where well meaning people "got" what Glen was about, saw the safety benefits, and encouraged him to pursue his business plan. Others higher up the food chain perceived a threat, not to safety, but to liability, so poor Glen had to go. Its so hypocritical because within the regulations there is oft repeated "Acceptable means of compliance" recognising perhaps, that there are different ways of doing things to achieve what CASA continually throws in the industries face "Safety" that word that nobody seems able to definitively define, which CASA use as a blunt instrument to bludgeon industry participant's into complying with their opinions and egos and directions, where liability is born by the participant's for any flaws that may subsequently become apparent.

Because of the varying opinions residing within the regulator in Australia there can be multiple operators of the same aircraft all operating with different procedures, something you don't see with larger transport category aircraft, other than minor differences in call outs and workflow, operational protocols are remarkably similar throughout the world.

As much as CASA is violently risk averse when it comes to liability so are aircraft manufacturers, especially in the GA arena. A very large portion of an aircraft's cost is for product liability insurance. GA manufacturers therefore produce operating instructions and procedures which endeavour to cover every eventuality, with the cloud of litigation hanging over their heads for aircraft that have long passed their life cycle but continue in service, nobody could blame them, but that provokes another problem. With large RPT aircraft is can be assumed they will be operated by well trained and experienced professional pilots therefore procedures are developed to cater for practical commercial operations.
Most GA aircraft are produced for the "private" operator, approximately 80% of light jets produced by Cessna are flown by private operators. I'm not attempting to cast dispersion on private pilots, many if not most are highly competent safe operators.
The operational material manufacturers provide attempts to cover the lowest common denominator and therefore is sometimes impractical when used in a commercial sense. Technically, modern GA aircraft are now matching and sometimes surpassing large RPT aircraft in terms of technical sophistication making them a much safer vehicle than in the past. In some cases the Flight Manual operating procedures have caught up with modern thinking, but still impose impediments from a commercial sense and can be safely streamlined for commercial operation with practical solutions which reduce workload and still achieve desired safety standards.
The unfortunate problem in Australia endeavouring to do this ends up a buggers muddle of competing egos within the regulator which is why complication rather than simplicity rules the day, sometimes to the detriment of safety.

One thing high performance aircraft drivers are wary about.

Being low, being slow, being dirty (configured).

Reported by a high performance aircraft driver out of BK a week or so ago. Just airborne with a strong south easter blowing, encountered very strong mechanical turbulence, the sheer was such that it was very difficult not to bust flap limit speeds and keep the shiny side up.....Hmmm, asked if it was reported, response no, being already up to the neck in alligators the last thing wanted was to poke them.

I wonder what caused that? firstly the turbulence secondly the reluctance to report? Hmmmm.

A safety hat trick.

Good catch Thorny – a hat trick.

Catch 1 – 'strong mechanical turbulence'. When you consider that Bankstown has been operational since WW2 and the landscape has changed very little (apart from 'modernised' flood plains) you must wonder why – suddenly 'turbulence' has become so aggressive that it can kick seven bells out of a 'performance' air craft. Could the minister provide the 'vortex' and wind shear' analysis portion of the 'safety analysis for Bankstown – the one that was part of the 'master plan'? Just so can be sure all possible 'risks' to air safety from this very real and present danger was taken into account before runways were closed and large buildings close to the operational surfaces appeared and that data was properly assessed. If HP Jet traffic is being belted around what chance the mutt in the Tupperware?

Catch 2 – No doubt the crew obtained and studied the BoM forecast before departure. There may have even been a one line warning – turbulence below XXX feet – fair warning – but BoM rely heavily on 'models'. Now it takes time and data to construct a 'model' – so have the BoM been feeding the effect of additional construction data into their model as fast as they can? Have they set reference points and monitoring equipment to measure the effect of 'new' topography? I feel sure the minister has this information at his finger tips; perhaps the McDonald inquiry could ask him to provide it, fare for us all to contemplate.

Catch 3 – Alligators, wolves and crocodiles aside – I believe there exists – in law – a requirement to report such speed excursions and 'keeping the shiny side up'. Not filing a report is a double crime (IMO) : but such is the fear of CASA taking the thing to some extreme length for 'safety' reasons that both industry and BoM are deprived of valuable data which may, just in time, help avoid another 'shear' induced accident.

There are good reasons for the almost universal adoption of the 'California Code' – insurance being just one of the many. There is also some pretty solid reasoning in the ICAO 'advice' pertaining to safety zones not only on take-off and landing paths, but on the alongside a runway clearances. Our minister, his department and those responsible for 'safety' seem to have found ways around what is, essentially, common sense, to dance to a developers tune – its the same one snake charmers use by the way.

Hellish din - and, until now, I thought bagpipes were 'beyond' -


Thomas, mate, the snakes have their fangs pulled, not so the development sharks.

One of the most dangerous things you can do is stand between a development shark and a dollar.

If they cannot get it by Hook they will get it by Crook.

There is a reason why they are prevented from political donations in NSW, doesn't apply federally,

Ever wonder why?

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