On joining the dots and making of dashes.

The Iron Ring & the Hooded canary - Confused  

Quote from this week's SBG: Speak softly; yonder, as I think, he walks.

 "...The opening gambit is readily seen in the media – see: there’s Hood, doing a Geoffrey Thomas (he of Sunrise fame). This is not a top quality act, but ‘twill suffice. Firstly, we must examine the ‘props’ used, the title for a start will impress – ‘top dog in the Australian Transport Safety Bureau (ATSB) and a natural performer. Always seen looking ‘windswept’ and interesting, dressed in his canary yellow vest, wearing his ‘courage’ wrist band. The ‘shrinks’ would have a field day with that little lot, no matter. The long suffering public will not know the lack of qualification, or the association with some of the most disgusting ‘Acts of bastardy’ which hover about the ‘windswept’ visage. They will have no concept of conflicted interest or even ‘departmental’  manipulations. No; they just see the ‘fluff’ and hear the soothing words, reassured; they happily hop on the cheapest flight and toddle off to booze in Bali..."

 &.. from SBG post #95:

"...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..." 

So with interest piqued the BRB have tasked me to re-examine the HVH crumb trail with the intent to join some further chronological dots & dashes on the PelAir cover-up timeline (i.e Pel-Air: A coverup: a litany of lies?)... Huh

To begin let's revisit the HVH CV up till the time he started with CASA:

[Image: AAEAAQAAAAAAAAayAAAAJDdjOWQ2MTc5LWE4ZDUt...ZTY1Zg.png]Air Traffic Controller

Company Name
Royal Australian Air Force  

Dates Employed
1980 – 1990  

Employment Duration
•10 yrs  

East Sale, Sinai Desert, Darwin, Townsville


Air Traffic Controller

Company Name
Airservices Australia  

Dates Employed
Jan 1990 – Apr 1993  

Employment Duration
•3 yrs 4 mos  

Melbourne Adelaide Alice Springs


Instructor - Centre for Air Traffic Services - University of Tasmania (Launceston)

Company Name
Airservices Australia  

Dates Employed
Apr 1993 – Dec 1994  

Employment Duration
•1 yr 9 mos  



Team Leader, Group Leader, FIR Manager

Company Name
Airservices Australia  

Dates Employed
Jan 1995 – Mar 2002  

Employment Duration
•7 yrs 3 mos  

Brisbane ATC Centre


Manager Melbourne Centre

Company Name
Airservices Australia  

Dates Employed
Apr 2002 – Dec 2005  

Employment Duration
•3 yrs 9 mos  

Manager National Towers and Regional Services

Company Name
Airservices Australia  

Dates Employed
2006 – 2008  

Employment Duration
•2 yrs  

Canberra, Australia

As can be seen HVH had all the right pedigree and Quals to continue a long career with progression up the gravy train at ASA. However inexplicably HVH leaves ASA to take up a lesser/nothing position at CASA Huh :

[Image: 3705424.png]

Group General Manager Personnel Licensing Education and Training

Company Name
Civil Aviation Safety Authority  

Dates Employed
2008 – 2009  

Employment Duration
•1 yr  

Canberra, Australia

However with the arrival of McComic in 2009, it would seem HVH's obvious talents (??) were noted by the new DAS and once again Hoody's star was on the rise.

Extract from CASA Corporate Governance webpage 2013: https://www.casa.gov.au/standard-page/co...vernance-4
Quote:Operations Regulations Implementation
[Image: greg_hood.png]
Greg Hood
Executive Manager (Program Director)
Phone: 02 6217 1118
Email: greg.hood@casa.gov.au

Mr Greg Hood is a glider and fixed-wing private pilot. He commenced his career as an air traffic controller in the Royal Australian Air Force. His nine years in the military included postings across Australia, and he served with the Australian contingent to the Multinational Force and Observers in the Sinai Desert.

From 1990, Mr Hood spent 17 years with Airservices Australia, in roles including Manager of the Melbourne Air Traffic Control Centre, Manager National Towers and Manager Regional Services.

In 2007, Mr Hood joined CASA as Group General Manager for Personnel Licensing Education and Training, prior to moving to Brisbane to lead the General Aviation Group. In 2009, he was appointed Executive Manager of the Operations Division. In April 2012, he took on the role of Program Director for the newly established Operations Regulations Implementation Division.

Operations Regulations Implementation is responsible for the development, planning and oversight of the regulatory implementation program.

Now remembering that HVH was both the ultimate executioner in the DJ embuggerance case while at the same time the designated liaison officer schmoozing the FAA IASA audit team (till their return in April 2010), the following Oz Flying article on McComic's 1st deckchair shuffle in April 2010 provides some intriguing dots begging to be joined:

Quote:...The restructure stems from organisational improvements the regulator commenced in 2009.

At the top of the list, Terry Farquharson has been appointed acting Deputy Director of Aviation Safety, where he’ll support Director of Aviation Safety, John McCormick, in a range of strategic and executive functions. Farquharson will also be directly responsible for a number of areas including accident investigation liaison, the CASA safety management system and Australia’s state safety program.

As part of the restructure, CASA has created the new position of Associate Director of Aviation Safety, which has been given to CASA’s former executive manager, legal services, Jonathan Aleck. Aleck will work with Deputy Director Farquharson to oversee the further development of regulatory and governance policies and practices.

The final changes see Greg Hood appointed as executive manager, operations; Peter Fereday as executive manager, industry permissions; and Gary Harbor as executive manager, corporate services.

McCormick said the changes will form the basis for the further enhancement of safety and regulatory capabilities into the future.

“We now have a strong and focussed leadership team in place which is committed to the goals and priorities which have been established for CASA and its workforce,” said the CASA boss.  “Senior managers and staff alike understand the need to deliver on CASA’s core activity of regulating aviation safety, while strengthening safety oversight and surveillance and completing regulatory reform.  

“At the same time we are continuing to work on developing more robust governance procedures and practices.”

On another note, CASA has released its latest corporate plan, setting out priorities and initiatives for the next three years.

Goals established in the plan include:
* An enhanced focus on regulating aviation safety;
* Enhanced governance and operational efficiency; and
* Enhanced relationships with key aviation participants.

In realising these goals the regulator says it will strengthen its specialist surveillance staff, determine key safety risks through analysis of data, actively manage delegates and authorised persons to ensure ongoing competence and compliance, take a proactive approach to the shortage of skilled aviation staff, review new regulations and develop and refine appropriate enforcement strategies. Other initiatives cover continuing airspace reform and safer management of flight approaches to aerodromes.

Say what you will about McCormick, but he's clearly keeping busy in the job.

Read the full CASA corporate plan here

Read more at http://www.australianflying.com.au/news/...6wK8Q0d.99
Now fast forward to April 2012 where apparently HVH's job description changed and he became the.. 

..Program Director for the newly established Operations Regulations Implementation Division..

At the same time he mysteriously departed the scene (MIA) as the ultimate executioner/decision-maker in the DJ embuggerance case:

Quote:[Image: DJ-11.jpg]
[Image: DJ-12.jpg]
Less than 12 months later (again seemingly inexplicably) HVH leaves CASA to return to ASA... Huh

Via Oz Flying:

Quote:[Image: greghood_web.jpg]
Greg Hood has left CASA for a position at Airservices Australia, (CASA)

Greg Hood Resigns from CASA
31 January 2013

A key member of the CASA executive team, Executive Manager Greg Hood, is to leave CASA and return to Airservices Australia.

No date has been set for Hood's departure, but CASA has described it as "imminent". His new position at AsA will be as General Manager, Demand and Capacity Management.

In announcing the move, CASA Director of Aviation Safety John McCormick said: "Greg has been an integral part of CASA’s Executive Team over the last six years and I have personally valued his contribution, energy and enthusiasm and I know his management and leadership capabilities have significantly benefited CASA."

Greg Hood is highly thought-of within the general aviation community as a champion for GA, and it is expected his expertise will be missed at the regulator.

Read more at http://www.australianflying.com.au/news/...7IhhbIh.99

MTF...P2 Cool

Three-peat: The Empire (CASA Iron Ring) strikes back.

To follow on from my last with a few more breadcrumbs of intrigue and wonderment.. Rolleyes

Referring to the PDF link & excerpt pic from this week's SBG: Lost – perhaps in translation.

Quote:...Rather than ramble on, for the serious student I shall provide just one, solitary link. Fair warning, there are some 37 pages to digest – however; the first dozen or so may be skipped past as they are the written Questions on Notice (QoN) and are repeated as part of the intriguing answers. The questions, standing alone, are incisive; IMO the answers are incredibly revealing...

[Image: DUlyLVhUQAIcgog.jpg]

From two posts above, you may recall that another significant event also occurred on 7 December 2009:

Quote:7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 Australian audit. (ref links - #53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf
And prior to that date and also in relation to the FAA audit, the Iron Ring (et.al powers to be) successfully managed to muzzle the minister of the Crown responsible for the oversight of aviation safety. The effective muzzling of Albo was only revealed when WikiLeaks leaked the following US Embassy cable nearly 2 years after the event:


Quote:¶2.  (SBU) Terry Farquharson, head of the host delegation from
the Australian Civil Aviation Safety Authority (CASA),
alerted Econoff November 25 that the office of Minister
Albanese (Minister for Infrastructure, Transport, Regional
Development and Local Government, which oversees CASA) had
decided, against CASA's recommendation, to carry out a press
release regarding the upcoming FAA assessment.  In the coming
day, CASA will post the statement (a draft of which
Farquharson read to Econoff) on its website and will conduct
an interview with a reporter, with a strong possibility that
an article may appear in the aviation section of "The
Australian" newspaper's Friday edition.  It should be noted
that the draft release did not contain anything controversial
and points out that the assessment visit is being conducted
at the request of CASA.

¶3.  (SBU) CASA's view is that the press exposure may
unnecessarily complicate the conduct of the assessment, given
that at its core, the assessment is an attempt to clear the
record from a previous audit in which several shortcoming
were identified (see reftel).  The Ministry's office
preferred to carry out the release for the sake of
transparency and in order to preempt after-the-fact
questioning of what the Minister knew or did not know prior
to the FAA teams arrival.

¶4.  (SBU) Comment:  We are in close contact with both FAA and
CASA and are facilitating final coordination of the visit.
We do not anticipate this media release will become a
problem, but do expect questions from the press.  We would
appreciate press guidance from the Department and/or FAA.
Therefore IMO it would be safe to expect that, as a topic of conversation at least, the very troubling revelation that Australia was (at that point in time) 3 steps away from possibly losing it's Category 1 IASA rating should have figured somewhere in the meeting agenda:

Quote:1. (C/NF) Summary: The FAA team concluded their audit (reftels) and gave a brief assessment of preliminary findings. While the team recognized improvements on previous shortcomings and commended many areas, a few problems remain. Australian officials seem committed to overcoming the shortcomings before a second and final FAA visit within the next three months, but the possibility of a category downgrade does exist and is being taken seriously. The team outlined the sequence of events going forward and agreed to work closely with Embassy Canberra. End Summary.
Now apparently the whole purpose of the CASA Board is to provide independent, effective governance of CASA (the agency) and therefore provide oversight of the administration of aviation safety regulation in Australia. With that in mind you would have thought with the seriousness of the situation, the Board might just have made a press statement in regards to the FAA findings?

Passing Strange - However to this point in time I have not been able to find any evidence that the CASA Board was even aware that the FAA had conducted and completed an audit of CASA 3 days before the 7 December 2009 Board meeting... Huh

And despite mentions in dispatches by former DAS McCormick in his 2009-2010 AR review...

(ref: Pg 10-14)
Quote:Technical training was identified as an issue by the International Civil Aviation
Organization (ICAO) in its 2008 audit and in the US Federal Aviation Administration’s International Aviation Safety Assessment (IASA) audit. We have responded by developing a comprehensive technical training and professional development program to enhance staff capability in areas such as leadership, regulatory skills and technical expertise.


An audit of Australia’s air safety system by the US Federal Aviation Administration’s IASA program confirmed that Australia has retained its Category 1 IASA rating. The FAA was invited by Australia last year to conduct the audit of aviation safety regulation and oversight. Australia’s overall system of aviation safety oversight was found to meet applicable international standards.

...it was not once touched on in the 'message from the Chair', by then Chair Allan Hawke.

Although he did mention the extra funding facilitated by government in the 2010-11 Budget by gouging an extra 4 cent per litre fuel levy from industry, supposedly provided to fix the FAA issues. 

Extract from Hawke's message (note the 'cop out' Bureaucratese weasel words - Dodgy ) :

Quote:..The Board of CASA has now been in operation for the full year covered by this report. Appointed by the Minister and charged with the principal responsibility of ensuring that CASA conducts its business in a proper, effective and efficient manner, I believe that the Board has partnered and supported the CASA executive team and staff to deliver the
demanding agenda set for the Board by the government.

While CASA’s functions are specified in the Civil Aviation Act 1988, its direction has been set by the 2009 National Aviation Policy Statement (the White Paper) and the 2010
Australian Airspace Policy Statement. The White Paper makes the explicit statement that: ‘…the government is committed to ensuring that it [aviation] remains as safe as it can be. Safety remains the number one priority of the government in aviation’. The Board has therefore approached its tasks mindful not only that safety is the paramount aviation priority of the government, but that the industry must also have this priority as the foundation of their sustainability and future growth.

The Minister has made it clear that CASA needs to be a firm, fair and effective regulator. The announcement of additional funding in the May 2010 Budget was welcome and will be used to strengthen oversight of the industry. CASA’s organisation is now settled and aligned more closely with the Civil Aviation Act and the Board is satisfied that resources are appropriately directed toward CASA’s core functions. The Board has also noted that through the leadership of the Director of Aviation Safety and his executive team, there are now improved governance arrangements designed to provide the foundation for more consistent action and advice to industry concerning the
interpretation and application of legislation...

A subject that I wish to highlight this year is CASA’s achievement in regulatory development. Australia already has exacting aviation regulations, but these must be
continually reviewed, refined and enhanced. This year the Board has reported substantial progress to government in a number of regulatory areas, including the requirement for safety management systems, human factors training for regular public transport operations, drug and alcohol management plans, and the preparation of a new suite of maintenance regulations. We are pleased with these achievements but also aware that the task of ensuring that Australia’s aviation regulations are relevant, effective and aligned with international best practice is an enduring and challenging responsibility. What we consider to be the optimum means of achieving the best possible safety outcomes today will no doubt be succeeded by better approaches in the future...

And an extract from Albo's speech:  http://anthonyalbanese.com.au/category/m...hes/page/9

...CASA, the nation’s independent aviation safety watchdog, will recruit almost 100 additional frontline staff with the $89.9 million in new funding provided by the Budget. This extra investment in safer skies will be funded via a small increase in the aviation fuel excise, from 2.8 cents per litre to 3.5 cents per litre. The Government considers this to be a reasonable and responsible step considering the industry’s continued growth depends on the public’s ongoing confidence in its safety standards. Following the ICAO and FAA audits this investment in CASA’s staff and training is critical, and will strengthen the organisation’s oversight of the industry. Aviation safety should be bi-partisan, and the Government puts the safety of passengers ahead of other interests...

Reading that load of old codswallop and keeping in mind this extraordinary 'power shot' statement from McCormick in the (above) No.27 AQON...

"...Consistent with the functions of the Board and it's relationship with the Director of Aviation Safety, who has statutory responsibility for all regulatory decision-making, at subsequent Board meetings the Director has continued to keep the Board informed of the high-level changes and internal reforms he had initiated, or intended to initiate, to address operational and organisational improvements, including those cited in the answer to question 25..."  

...you begin to get an impression of the untrammelled power that both the Board and the Minister had gifted McCormick, all apparently in the pursuit of achieving the government policy of 'all care but no responsibility' for aviation safety... Dodgy

Now fast forward to 'here & now' with a different government, a new minister and a professional bureaucrat for a CASA CEO.

Q/ Then ask the question what has changed? Answer: Not much - Confused

Q/ Now ask what happened to the money ($89.9 million back then) that was gouged and continues to be gouged (reportedly +$120 million & climbing) from industry, supposedly to fix the deficiencies discovered in the FAA IASA 2009 audit?

Hmm...sounds like a question for Senate Estimates... Rolleyes

MTF...P2 Cool

Barnaby’s little conundrum.

P2 – “Q/ Now ask what happened to the money ($89.9 million back then) that was gouged and continues to be gouged (reportedly +$120 million & climbing) from industry, supposedly to fix the deficiencies discovered in the FAA IASA 2009 audit?”

Amazing is it not; when you think about it. CASA make a total pig’s ear of running ‘aviation’ and the grown ups want it fixed; or else. Yet it is the industry they are buggering up which has to pay for them to fix the major problems. I wonder did CASA contribute to the ‘fix’ by reduced salary and entitlement cuts; or, did the same sad, sloppy, ignorant, arrogant crew just keep doing what they do best (same old) and even manage a salary increase?

Even more amazing is that the Board, still, to this day have no control. In the corporate world a CEO running an organization which had received a shocking audit report would be on the carpet, with the board of directors kicking seven bells out of him. But not in CASA; the grandiosely named DAS can, with impunity, tell the board to sit down, shut up and mind their own damn business. The board must have either have ‘proper’ power and control or; be disbanded, which is favourite - save us all a few bucks. The board is nugatory and therefore redundant. The 'director' has unlimited power - without any tenable checks and tangible balances, it is time that changed.

The whole P2 post above simply demonstrates the depths to which CASA will stoop, their skills in misdirection and subterfuge amply demonstrated and their inflexible reluctance to change. Total power etc. The barn door is wide open, horse has bolted, it’s time to shut the paddock gate.

Can Barnaby reach the gate before it’s all too little, too late. Has Barnaby got the sand to call a Commission of Inquiry; a one where those being looked at do not write the terms of reference; or, will we have another period of Darren6D do nothing?

Toot- toot.

From the CASA website:-

“Our Board

The Minister appoints the Board and provides the Board with a statement of expectations. The Board is responsible for deciding the objectives, strategies and policies to be followed by CASA and for making sure that CASA performs its functions in a proper, efficient and effective manner.”

Obviously the Board has been incapable of causing CASA to “perform....in a proper, efficient and effective manner.” That is, neither the present Board nor in years past.

If nothing else, CASA’s inability to rewrite the rules after 30 years and counting, would be sufficient for a responsible government to at least question whether there is a structural or systemic problem in the regulation of aviation in Australia. But add to this extraordinary fact the possibility of our aviation world being downgraded by the FAA then surely a new Minister would have reason to make changes. NZ seems to manage it’s international aviation standing pretty well on a fraction of the money we spend on CASA, upwards of $150million pa.

The call for an independent inquiry I understand but do not support. Years ago perhaps, but the Can’tberra dynamic is so incestuous, its become an inquiry factory that generates far more heat than light. The Government appointed “independent umpire” concept, much loved in Australia as a sure fire method of fixing anything is a myth, a comfort blanket approach which diverts responsibility to those who legally cannot exercise it.

Another inquiry would be welcomed by Can’tberra all and sundry with heaps of overtime in the offering, lots of meetings to decide who will represent whom and how. By the time The Inquiry has finished spending and enriching itself and government mulls over the results, forwarding to Directly Involved Persons, the routine, etc., where are we then? Just about where we were one year after the ASRR Forsyth report.

The shocking malaise that infects aviation in this country can only be cured by politicians. There is no substitute for political action, this is the hard yards. Going to meetings, writing, ringing newspapers and MPs. Talkback radio, magazine and article comment. Anything that will give publicity to educate the public and give reason for MPs to want change.

[Image: AMROBA-GA-Meeting.jpg]

Dear Sandy - Wink

I agree about the Parliamentary inquiries and government reviews. The effectiveness of such inquisitions is completely undone by bureaucratic obfuscation and procrastination, all designed of course to wait out and wear down the significance and urgency of the current inquiries/reviews latest findings and recommendations.

[Image: Untitled_Clipping_013118_093436_AM.jpg]

However I believe if the minister/government had the political will to cauterise the CASA Iron Ring and it's malevolent loyal lieutenants, then I think some kind of Judicial inquiry will be required to build a legal case for prosecution of what amounts to decades of ingrained bureaucratic malfeasance that has cost 100s of millions of dollars for no discernible safety benefit to either industry or the air traveling public.

Of course such an inquiry would still take time and money but it is probably a necessary evil if you are to ensure the cancer within has been fully cauterised. After all isn't that exactly what the Kiwis did? 

From P7 on the AMROBA thread: post #95

Quote:ATSB and CASA must be disbanded; the Kiwi’s did it very neatly and have never looked back. They reformed the regulator; then the regulations and have set an enviable bench mark for sanity, economy and a way forward ever since. Can anyone see CASA agreeing to that?


Quote:But at the end of the shift – you still have to convince a basically uninterested politician to tangle with CASA and make some radical changes. That politician must be persuaded that ‘the Act’ as it stands is unconstitutional; that CASA is an escaped lunatic and that the blood is not on his hands.

And from your post in response Sandy:

Quote:Secondly it behoves all of us to share and refine our thoughts on what is wrong and to reach some consensus on the method of reform. To this end it is clear that only by a change to the Act can reform occur. In the variety of diverse opinions about specifics, one would be hard pressed to obtain clause by clause complete agreement. Therefore the focus must be on the necessity for legislative change by demonstrating that the current trajectory is one of failure.

Because such an inquiry is being conducted does not mean that the legislative solution (that most believe is required) could not be acted on by the government and parliament, as such legislative changes are a parliamentary process and not subject to Judicial review or the ultimate findings of such an inquiry.

MTF...P2 Cool

The beginning of the end for the ATSB - Undecided

Recently an associated PAIN member with considerable expertise in such matters as Human Factors in Aviation Accident Investigation (in particular FRMS) was tasked by the BRB with reviewing the bollocks PelAir MKII final report. Still a work in progress but the following quote from this associate's DRAFT summary report caught my attention  Confused :  

Quote:   Communication-misunderstandings: 

- The responsibilities of CASA and the ATSB were never resolved, even though the ATSB had become a separate statutory agency in July 2009. As a result the ATSB did not collect sufficient information from Pel Air.
Personally I had never even contemplated joining the dots on the real implications of the ATSB becoming a 'statutory agency' in July 2009... Huh

Here is a link for the amendment changes to the TSI Act which came into force in July 2009: TRANSPORT SAFETY INVESTIGATION AMENDMENT REGULATIONS 2009 (NO. 1) (SLI NO 149 OF 2009)  

However it wasn't till I stumbled across the former Minister for Non-aviation Albo's explanatory speech, for the introduction of the amendment, that the penny dropped that this was nothing more than Albo creating further 'degrees of separation' between himself, the government and anything remotely resembling responsibility and oversight of aviation safety - read it and weep... Dodgy  

Feb 12, 2009

Transport Safety Investigation Amendment Bill 2009

The second Bill I introduce to the Parliament is the Transport Safety Investigation Amendment Bill 2009. As I stated when I introduced the Civil Aviation Amendment Bill, the Transport Safety Investigation Amendment Bill fulfils undertakings in the Government’s National Aviation Policy Green Paper. The Bill will amend the Transport Safety Investigation Act 2003 and enhance the independence of the Australian Transport Safety Bureau (ATSB) by establishing it as a statutory agency within my portfolio. The ATSB will have a Commission structure and the new body will come into being on 1 July 2009.

Australia has an impressive safety record and the ATSB’s accident investigation role is a fundamental part of Australia’s transport safety framework. Under the Transport Safety Investigation Act 2003, the Executive Director of the ATSB already conducts systemic ‘no-blame’ investigations into aviation, marine and rail accidents and incidents with the objective of identifying contributing safety factors. The lessons arising from those investigations are used to prevent future accidents and incidents through the implementation of safety action by the industry and the Government. By making the ATSB a separate statutory agency, public confidence can be strengthened in Australia’s commitment to advance transport safety.

While I am confident that the ATSB has operated successfully as a Division of the Department of Infrastructure, Transport, Regional Development and Local Government, I believe that the future safety of Australian transport will be enhanced by this measure. In 2007 Mr Russell Miller AM was tasked by the then Government to review the relationship between the Civil Aviation Safety Authority (CASA) and the ATSB. In finding there was room for improvement in the way the agencies interact, Mr Miller addressed the ATSB’s governance structure and recommended that the Government move to clarify the ATSB’s independence as the national safety investigation agency. The Government accepted this key recommendation, which received strong support from industry.

Investigations that are independent of transport regulators, government policy makers, and the parties involved in an accident, are better positioned to avoid conflicts of interest and external interference. Consistent with international standards, this Bill leaves no doubt that investigations will be conducted without fear or favour and findings will be transparent and objective. Standard 5.4 of Annex 13 to the International Convention on Civil Aviation (the Chicago Convention) states:

The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct.

Enhanced independence will result from a combination of factors. The ATSB will alone be responsible for administering the functions of the Transport Safety Investigation Act 2003 and exercising its investigation powers. There will be the capacity for the Minister to provide notice of his or her views on the strategic direction for the ATSB, to which the ATSB must have regard. However, other than the ability for the Minister to require the ATSB to investigate a particular matter, the ATSB will not be subject to a direction from anyone with respect to the exercise of its powers and functions.

The creation of a statutory agency will also give the ATSB discretion and responsibilities in its own right under the Public Service Act 1999 and Financial Management and Accountability Act 1997 with respect to the management of its staff and resources. The ATSB will, therefore, have operational independence with respect to the exercise of its investigation powers and functional independence with respect to the administration of its resources.

The ATSB will consist of a full-time Chief Commissioner who will also be the Chief Executive Officer of the agency, and two part-time Commissioners. Commissioners will be appointed by the Minister and they will have an appropriate mix of skills and expertise. Additional Commissioners can be appointed as necessary for major investigations or where a particular skill or expertise is required. The powers in the Act will be vested in the ATSB for overarching responsibilities such as determining which transport safety matters to investigate and publishing reports. Powers relating to day to day investigation activities such as entry to an accident site premises will be vested in the Chief Commissioner. Both the Chief Commissioner and the ATSB will have the ability to delegate powers, as appropriate, for the purpose of carrying out investigations.

A new power that the ATSB will have to assist with its function of improving transport safety is the power to require responses within 90 days to any formal recommendations that it makes. This requirement will provide confidence that the ATSB’s safety recommendations are being properly considered and addressed.

In addition to the function of improving transport safety through investigations and communicating the results of those investigations, the ATSB will have a function involving cooperation. The ATSB will be required to cooperate with similar agencies around the world to ensure there is coordination when investigating a transport accident or incident in cases where another country is in some way connected. Domestically, the ATSB will be required to cooperate with Commonwealth and State and Territory agencies having functions concerning transport safety, or who are affected by the ATSB’s function of improving transport safety. Other agencies, such as the police or a transport safety regulator, are likely to have an interest in conducting investigations into some accidents or incidents that the ATSB is investigating. It is intended that those agencies should continue to be able to conduct their own separate investigations and that there be cooperation to allow this to occur. However, the ATSB will need to preserve the ‘no-blame’ nature of its investigations.

The Transport Safety Investigation Act 2003 already states that it is not an object of the Act to apportion blame or provide the means to determine liability in relation to a transport accident or incident. With the translation of the objects of the current Act into the functions for the ATSB, the Act will state that apportioning blame and determining liability is not a function of the ATSB. Investigations that may result in punitive action will not necessarily have safety information freely flowing to them because there is an apprehension of a penalty by the persons subject to the investigation. This is recognised internationally by Annex 13 to the Chicago Convention and similar International Maritime Organisation instruments.

If the ATSB is to conduct systemic investigations, in the overriding interest of improving future safety, it must have access to all the available information. To preserve the free-flow of information to its investigations, the ATSB will need to maintain an appropriate degree of separation from processes that could result in a punitive outcome, an award of damages to one party against another or an adverse inference being made about a person subject to an investigation. The existing provisions in the Act for the protection of safety information, such as aviation cockpit voice recorders and witness statements, provide part of the framework for the ATSB to prevent itself being involved in the apportionment of blame or the determination of liability. Commissioners, ATSB staff members and consultants will be subject to the requirement to protect this type of information.

The Bill provides for transitional provisions so that investigations commenced under legislation existing before the new laws come into effect on 1 July 2009, can be continued by the ATSB. For investigations already completed, the ATSB or the Chief Commissioner, as required, will be able to exercise powers in relation to such things as the disclosure of information. The Bill also provides for the ATSB to perform the functions of the Executive Director under other legislation such as the Inspector of Transport Security Act 2006 and regulations made under the Navigation Act 1912 and the Air Navigation Act 1920 establishing confidential reporting schemes. With respect to the confidential reporting schemes, the Bill provides for a regulation making power to consolidate those schemes under the Transport Safety Investigation Act 2003 in the future.

The introduction of the Transport Safety Investigation Amendment Bill 2009 will serve to maintain and improve the already excellent safety record of the Australian aviation, marine and rail transport industries by establishing the ATSB as a separate statutory agency. Strengthening the independence of the ATSB in this way will facilitate better interaction with the transport industry and other agencies and demonstrate the Government’s strong commitment to ongoing and important improvements in Australia’s transport safety framework.

Now contemplate that with those ministerial weasel words and then the 'inconvenient ditching' of VH-NGA, how the exact opposite has occurred with the establishment of the ATSB as a 'statutory agency' - Undecided  

Is it any wonder that Albo went scampering away from all responsibility for addressing the damning findings of the Senate PelAir inquiry prior to the 2013 Federal election.

Here is a reminder from the late Ben Sandilands of Albo's gutless obfuscation tactics in responding to the PelAir cover-up Senate report:

Aug 28, 2013

Pel-Air on prime time TV snares Minister’s false statement

Ben Sandilands — Editor of Plane Talking     

The Minister for Transport Anthony Albanese was caught out on 7 News tonight in a report by Chris Reason on the festering sore that is the proven hush up by CASA and the ATSB of all of the circumstances that were relevant to the crash of a Pel-Air operated air ambulance flight near Norfolk Island in 2009.

Albanese said he was unable to take action over a damning Senate committee report on lies and deceits of Australia’s two air safety authorities because parliament went into caretaker mode.

Minister, this is total unmitigated rubbish. Caretaker mode began on 5 August.

On 29 May after consultation with your department Plane Talking published this story as to the urgency with which you and your departmental head Mike Mrdak were claimed to be responding to the unanimous report of the Senate Committee inquiry into aviation safety investigations with particular reference to the performance of the ATSB (the safety investigator) and CASA (the safety regulator).

At that inquiry the Director of Safety at CASA, John McCormick, admitted to withholding an internal audit by CASA that found that the accident was preventable if CASA had actually carried out its duties and obligations in law in relation to the oversight of Pel-Air.

Mr McCormick also apologised for his actions, which the committee has referred to the Australian Federal Police to resolve whether or not it was action that constituted an offence under the Transport Safety Investigations Act of 2003.  (If the words in the act mean what they say, McCormick broke the law.)

The committee went on to devote an entire chapter of its report into its lack of confidence in the testimony given by the chief commissioner for the ATSB, Martin Dolan.  The committee’s findings, made by a panel drawn from Labor, the Coalition and the Greens, was unanimous in its findings.

It also recommended, among other things, that the ATSB reconsider its final accident report and in the process retrieve the data recorder from the wreckage of the jet, which lies at a recoverable depth on the sea floor near Norfolk Island where it came to rest after being ditched immediately before it ran out of fuel. (All six persons on board were subsequently rescued by a fishing boat in the middle of the night).

The ATSB has deliberately chosen not to recover the data, which carries the distinct possibility of proving that the pilot did not receive correct meteorological information before flying the jet to a position where it could no longer divert to an alternative airport in Noumea or Fiji should it be unable to land at Norfolk Island for a refueling stop.

The ATSB failed to honor its international obligations to make safety recommendations in relation to the failure on board the ditched jet of all of the safety equipment to perform as intended.  It regarded the eventual discovery that CASA had found Pel-Air to be in breach of dozens of safety requirements at the time of the crash as ‘immaterial’, and it framed its final report to visit the entire blame for the accident on the captain Dominic James, who was central to the 7 News report, which should be readily found by a search query on the internet later tonight.

As Mick Quinn, the former deputy chief executive officer of CASA told Chris Reason on 7 News tonight, this corrupted and untruthful circus performance by the safety bodies in relation to the Pel-Air investigation has destroyed Australia’s reputation as a first class nation when it comes to the administration of air safety.

Minister, you are personally responsible for this. You allowed commitments to be made on your behalf, which were not honoured, and you have demonstrated contempt for the Senate of Australia by not responding to the committee’s recommendations within 90 days.

This means you have not acted in a timely manner to correct or restore the integrity of the aviation safety authorities, and that means the safety of Australian air travellers, and those of foreign airlines and their passengers using our air space and airports, is no longer a given.

On 30 May Plane Talking reported on the intention of the department of Infrastructure and Transport to ‘ride out’ the controversy over the disgraceful report issed by the ATSB into this accident.

Minister, surely you are not a party to ‘riding out’ critically important air safety issues? The world is unlikely to let Australia get away with such a poor attitude, as explained in this more recent report.

If the Minister can say so during caretaker mode, what was he thinking when he gave his misleading answer about his inability to repond to these matters in the Chris Reason interview?

Was it amnesia? Or did he think no one would notice that what was broadcast tonight was in conflict with his position at the end of May? & Ref - CH7 Chis Reason link: https://au.news.yahoo.com/a/18694051/pilots-scathing-attack-on-air-safety-agencies/

Fast forwarding to today's incarnation of the ATSB and we can see why it is that Greg Hood feels so emboldened to threaten singing like a canary if anyone dares to threaten his 6D Chester gifted fiefdom -  Dodgy

MTF...P2  Cool

P2 – “However it wasn't till I stumbled across the former Minister for Non-aviation Albo's explanatory speech, for the introduction of the amendment, that the penny dropped that this was nothing more than Albo creating further 'degrees of separation' between himself, the government and anything remotely resembling responsibility and oversight of aviation safety.”

The following – combined with the ICAO and FAA audit; the cosy ATSB – CASA convenient MoU, the ‘lacklustre’ primary report on Pel-Air spell out only one simple solution to P2’s cryptic crossword puzzle.

"- The responsibilities of CASA and the ATSB were never resolved, even though the ATSB had become a separate statutory agency in July 2009. As a result the ATSB did not collect sufficient information from Pel Air."

Abrogation of ministerial responsibility and a perfect system for both ATSB and CASA to be responsible to no man. The CASA board may be seen an being completely inutile, ATSB answer to no man. Both may, with legally approved, ministerial sanction tell the world and it’s wife to go and ‘boil their bottoms’. And they do, repeatedly and often. O'Sullivan's next for the pot, if he don't get a shift on and catch up.

When you add the ‘Act’ to the untrammelled power bestowed on the incumbent ‘Boss’ of either department there is a clear picture of total separation from question, inquiry, responsibility and governmental control. A free hand with a lovely big circuit breaker between them, the DoIT, the minister, the Senate or even the gods themselves.

It is no wonder the Estimates committee, despite some pretty good efforts, cannot lay a glove on these free of constraint or accountability government sanctioned, publically (one way or the other) funded, completely autonomous, self regulating agencies.

What a pity it is that ‘government’ focus on BJ’s little contretemps far outweighs any attempt to rein in a satellite arm of government – to protect an industry – and by default the safety (physical and financial) of the travelling public. Maybe they just don't care, provided they are 'screened' from responsibility.

Albo – arrogant, callous, deviant and beneath contempt; safe as houses from any and all responsibility – and yet he still holds out his hand and takes, without qualm, the money paid to him for accepting that very responsibility to the Australian public.

Where do I sign up?

P2 - "Is it any wonder that Albo went scampering away from all responsibility for addressing the damning findings of the Senate PelAir inquiry prior to the 2013 Federal election?"

“No, and  Oi – this glass is empty.”

[Image: Untitled%2B2.jpg]

Dear Lachie - Rolleyes

Correspondence from the Department of Infrastructure etc..etc:

Dear P2,
In responding to this chain of correspondence I have tried to summarise some questions for ease of reading.
For questions on the provision of accident reports, the ATSB remains committed to meeting its international obligations in providing reports to ICAO, noting it has already acknowledged the circumstances relating to previous delays.  The ATSB requested a full audit from ICAO in relation to their implementation of Annex 13 which was conducted in April 2017.  This resulted in no findings relating to its reporting processes.  ICAO is not currently awaiting any further reports from the ATSB.
In relation to the recruitment of Australia’s nominee to the Air Navigation Commission, this was advertised publicly.  As per Departmental policy this was advertised on the APS Jobs website as well as the Seek website from 16th May to 2nd June.  The nominee to the ANC is a non-ongoing employee with the Department.  There is no conflict of interest in the role, as they are providing Australian expertise to an international aviation body which focuses on defining global standards to facilitate safe and efficient international air services.
For comments on filing of differences, as per Article 38 of the Convention on International Civil Aviation (the Chicago Convention), of which Australia is a signatory, we file a range of differences with ICAO. Airservices Australia regularly publish these in the Aeronautical Information Publication available on their website.  Australia takes a proactive and conservative approach, updating its differences often and reporting any point of difference to allow operators the information they need to conduct safe operations.
Due the subjective nature of filing differences, the comparison of numbers of differences is not regularly used as a measure.  State’s safety oversight arrangements at ICAO are benchmarked through an assessment process leading to an effective implementation score.  Australia was assessed in October 2017 by ICAO auditors and while the results are yet to be made public it places Australia in the top 10 States for safety oversight compliance. 
An earlier email refers to a trigger of 20 aviation fatalities for an audit, however this is not the case.  ICAO maintain their own risk profile for conducting audits and accident rates are compared, particularly relative to air traffic volumes.  This is one factor along with outcomes from recent assessments, State’s level of updating differences, responding to ICAO correspondence, aviation growth, political stability and maturity of safety systems amongst others.
Lachlan Phillips
Director International Standards
Aviation Environment Branch | Airports & Aviation Division
Department of Infrastructure, Regional Development and Cities
T: +61 2 6274 6869 | M: +61 432 756 844 

& my reply...  Shy

Dear Lachlan,

Thank you for responding to my questions which were originally addressed to our permanent representative to ICAO Sam Lucas to be forwarded to the ICAO Secretariat. For your ease of reading, and in order to properly summarise what we (PAIN) require from the department, I have attempted to address each of your ‘summary points’ in an abbreviated Q&A paragraph format. 

To begin you said: 

“..For questions on the provision of accident reports, the ATSB remains committed to meeting its international obligations in providing reports to ICAO, noting it has already acknowledged the circumstances relating to previous delays…The ATSB requested a full audit from ICAO in relation to their implementation of Annex 13 which was conducted in April 2017.  This resulted in no findings relating to its reporting processes.  ICAO is not currently awaiting any further reports from the ATSB…” 

Q/ When you said - ‘circumstances relating to previous delays’ - did you mean the ATSB response to Karen Casey in the DIP process to the VH-NGA re-investigation final report? (See attached at ATSB response to K3)

Your response and the ATSB DIP reply comment fails to address the identified safety concern that was relayed to Sam Lucas in PAIN’s supportive report for and on behalf of Karen Casey (see attached).

 Due to the Norfolk inquires, serious investigations began in 2015. This revealed that a ‘modified’ PDF copy of the preliminary Pel-Air ditching report did exist on the ICAO data base. Tracking of the document shows no changes were made. It appears that the document was ‘on-file’ within the Australian Transport Safety Bureau (ATSB) from ‘created’ date - 15 January 2010; but, was not provided to the ICAO before 10 November, 2015.
Further investigation of preliminary and final reports between 2009 to 2015 revealed that almost every report entered between 2009 and 2011 was uploaded by an ATSB officer during the same week the ‘modification’ of the Pel-Air ditching took place.
There exist four (4) examples of the 2009/2010 reports which were, apparently, submitted to ICAO ADREP in the first week of November 2015, presumably by an ATSB data input officer.
These are attached as PDF copies. To allow a determination of when the PDF copy of the [i]occurrence report was actually created, click on FILE, go to 'Properties' in the drop down box and click. Then view date 'created' date.[/i]
Research indicates a ‘selective’ approach to reporting and categorising of incident and accident.
The PAIN data base reflects the manipulation of categorisation and subsequent lack of reporting clarity – even where an investigation as actually been carried out. ICAO reporting aside, the significant, progressive reduction in SR made since the fatal accident at Lockhart River, 2005 is of grave concern to the industry.     
For your information PAIN has access to both the ICAO iSTARS ADREP and ECCAIRS databases, to which there is considerable evidence that these reports are not being properly disseminated to industry.
Now it could be, as you say and have obviously been led to believe, that these ICAO reporting aberrations have been addressed from the ATSB/Australian end. This would then suggest that the disconnection of Australian AAI reports being made publicly available could be somewhere in the downstream communication with ICAO. Therefore the ATSB excel file (see attached), containing 108 ATSB completed investigations between November 2015 till November last year, could provide a valuable reference for both Australia and ICAO to cross reference to check the integrity of the ADREP system and the downstream dissemination of these valuable air safety reports.
You said:
“..In relation to the recruitment of Australia’s nominee to the Air Navigation Commission, this was advertised publicly.  As per Departmental policy this was advertised on the APS Jobs website as well as the Seek website from 16th May to 2nd June.  The nominee to the ANC is a non-ongoing employee with the Department.  There is no conflict of interest in the role, as they are providing Australian expertise to an international aviation body which focuses on defining global standards to facilitate safe and efficient international air services…”
Comment: Thank you for that, I guess I didn’t go back far enough inside of the Seek website to which I regularly refer. On the comments on COI I guess I’ll have to agree to disagree but PAIN will be actively monitoring the performance of Mr Tiede in both his roles. Especially in light of the ongoing ATSB/Coroner investigation(s) into YMEN B200 DFO accident and it’s tie in with the Senate Inquiry into the Airport Amendment Act 2016 and the 41 pages of Australian notified differences to ICAO Annex 14 Vol 1 (see attached pic).
You said:
 “…For comments on filing of differences, as per Article 38 of the Convention on International Civil Aviation (the Chicago Convention), of which Australia is a signatory, we file a range of differences with ICAO. Airservices Australia regularly publish these in the Aeronautical Information Publication available on their website.  Australia takes a proactive and conservative approach, updating its differences often and reporting any point of difference to allow operators the information they need to conduct safe operations. 

Due the subjective nature of filing differences, the comparison of numbers of differences is not regularly used as a measure.  State’s safety oversight arrangements at ICAO are benchmarked through an assessment process leading to an effective implementation score.  Australia was assessed in October 2017 by ICAO auditors and while the results are yet to be made public it places Australia in the top 10 States for safety oversight compliance…”  

Comment: I am fully cognisant of the Airservices AIRAC publication but disagree with some of the premises and assumptions that you make in the above paragraphs.
To begin here is the link for the latest ASA notified differences AIRAC: http://www.airservicesaustralia.com/aip/...7-h136.pdf
I guess it could be argued that the AIP SUP does allow operators the information they need to conduct safe operations ?? However whether that information can be easily disseminated when you consider the many 100s of pages and thousands of notified differences that AIP SUP links to is an entirely different matter.
In comparison please refer to the five pages of GEN 1.7 of the Singaporean CAAS AIP:  https://www.caas.gov.sg/docs/default-sou...1feb18.pdf
The following is a quote from the KC_ICAO_1 PDF (see above or attached) which we believe summarises why it is that we have such a huge number of notified differences to ICAO and why we think this is a significant safety issue concern:
“.. In general, it must be stated that the Australian Civil Aviation Safety Authority (CASA) has an unique approach to ICAO compliance, with record number of ‘notified differences’. Many of the notifications may, at face value, seem insignificant. It is our opinion that the noted differences are structured to support the complex, contradictory, flawed rule set in place. Reform of this rule set has been in train for thirty years, with successive government ministers and directors of civil aviation promising to complete the task ‘within the next three years’. This is an important consideration as it reflects on the operational approach taken to both open reporting of ‘incident’ or event; and, the tangible fear of prosecution. Australia’s Civil Aviation Regulation (CAR) are founded on the ‘criminal code’ and ‘strict liability’; this, standing alone, provides a strong disincentive to openly reporting safety related matters. This attitude is reflected in the government safety bodies approach to ICAO compliance and reporting…”
PAIN understands that the department policy is to place very little importance on notified differences being a ‘measure’ on aviation safety standards of ICAO signatory States.
Reference: 1.2 Supplementary to submission 1 (PDF 60 KB) 
Did the Department of Infrastructure and Regional Development collate and analyse the differences lodged with the ICAO by Serbia and Vanuatu when their respective Memoranda of Understanding and proposed Air Services Agreements were being negotiated?
No. Air services arrangements provide an economic framework in which airlines can consider serving a market. Differences lodged by States, among other more pertinent kinds of safety-related information, may be taken into account by the Civil Aviation Safety Authority in the assessment of applications for the operation of foreign aircraft into and out of Australia.
Gilon Smith
Director (a/g), Air Services Negotiations
Department of Infrastructure and Regional Development
gilon.smith@infrastructure.gov.au Ph: 02 6274 6634

However the above departmental answer to the QON would seem to have been contradicted in the other supplemental submission:  1.1 Supplementary to submission 1 (PDF 78 KB) 
“..The process of notification of differences provides a structured way for each State to communicate its aviation rules by measuring itself against the neutral framework of the ICAO standards…”
Q/ Given this conflict in interpretation of notified differences as a ‘measuring’ stick of aviation standards and the fact that the department was obviously responsible for creating the Serbia/Vanuatu/Australia 10696 notified differences table, for the benefit of the Senate RRAT committee and industry stakeholders, would it not be possible for the department to collate a similar table for say the top 50 ICAO signatory States?
Q/ For the benefit of the committee would it be possible (in camera if required) for the department to forward the:
a/ 2017 ICAO audit report of the ATSB;
b/ The 2009 FAA IASA audit report of the CASA;
c/ The 7 December 2009 CASA Board minutes;

Finally, considering the positive feedback the department has received from ICAO’s October 2017 audit, would it be possible for the committee to view that report prior to it’s public release? Would it also be possible for the department to suggest that CASA invite the FAA IASA auditors back to audit and compare whether all the 2009 FAA IASA audit findings have been properly and proactively addressed? 

PAIN and associates look forward to your response and welcome the dialogue the department has opened up with industry.
Kind regards,

P2 Tongue


Wagga Summit - Let's not do the 'timewarp again'.

Extract from this week's SBG... Wink : A rustling – in the bushes? 

Quote:...I ramble: – point is there needs to be a healthy tension between parties in the lower house. No problem at ‘committee’ or inquiry level, where they seem to be able to focus on a narrow ‘band’ in the true spirit and intent of a bi-partisan ideal; but elsewhere, it is not too good a thing methinks. But, the silence of those reading the wind and sniffing the breeze was more than concern for politics – they sense a danger lurking in the bushes, the stealthy approach of something unwholesome. They are right to be apprehensive; no matter what comes into reality at Wagga. The creatures of the deep swamps and denizens of the Sleepy Hollow dark lagoons will not willingly embrace change which they have not generated – not  if it don’t suit ‘em. Some call this the grip of Iron Ring; which many believe will never be broken. It is not in the nature of the beast to simply roll over and say OK minister; we’ll do just as you ask. Gods know, history is loaded with fact that proves categorically that ministers, senators, even top dog mandarins have been bully-ragged into submission by this element.... 
In the lead up to the Wagga Summit the underlined statement from "K" should be firmly branded on the psyche of all industry stakeholders that truly give a fig about arresting the decline of the GA sector of the Aussie aviation industry... Rolleyes

However if industry participants of the Wagga Summit feel they need historical point(s) of reference, to remind them how the aviation safety bureaucracy has been taking the 'Mickey Bliss' out of Federal government from both sides of the political spectrum, the following decade look at the expensive, self-serving, ATP funded, obfuscation of political aviation policy of both Labor and LNP governments is (IMO) a disturbing eye opener... Dodgy 

Quote from the 2007-2008 Dept annual report

Quote:...This year saw the commencement of a major review of the policy settings for Australian aviation and its regulation. The Department assisted in the development of a wide-ranging issues paper, published in April 2008, seeking comments from the industry and general public by the end of June. The Australian Government intends to release a reen paper (discussion paper) later in 2008, as a basis for further consultation, and to release a final policy statement in 2009.

The broad policy review will build upon two reviews of specific aspects of the regulatory framework that were conducted in 2007-08 with support from the Department.
  • A joint industry-government review of reform to the civil aviation regulations examined ways to expedite progress towards an updated and outcome-based set of regulations which are effective in protecting safety standards without imposing unwarranted requirements on operators.

  • An expert review of the working arrangements between the Civil Aviation Safety Authority, as regulator, and the Australian Transport Safety Bureau, as independent investigator of accidents and incidents, examined options for legislative or operational changes to improve interaction between the agencies in the interests of the best overall outcomes for aviation safety.

Reports of both reviews were published in the first half of 2008. Some of the practical measures identified have been implemented; others will be addressed in conjunction with the broader range of issues raised in the current review process.

The Department also coordinated the response by agencies to a comprehensive audit of Australia's regulatory arrangements by the International Civil Aviation Organization as part of the Universal Safety Oversight Audit Program (USOAP). The final report of the audit is yet to be received. While the results are expected to recognise that the arrangements in Australia are among the most advanced, the cyclical audit process provides an opportunity to identify areas for further improvement...
Now fast forward to May 2014 when the Abbott LNP Govt was just starting to get into it's stride. The following is a copy of a letter from the former DPM/miniscule Warren Truss to the now DPM/miniscule McNobody... Confused :

Quote:[Image: Dear-MickMac.jpg]
Now fast forward to today, a decade after the 2007-8 Dept AR was published, the obvious questions are - What has actually changed? What has been reformed and how has this actually improved the aviation safety standards of Australia? Finally how much has this 'bollocks' bureaucratic charade cost the industry and the ATP? 

So at the Wagga Summit - go in 'eyes wide open'; get a firm commitment from both sides of the political spectrum; and let's not do the 'time warp' again... Undecided 

MTF...P2  Cool

Dots, dashes and holes in the garden…

5 Am, kettle boiling, house quiet and not a canine face in sight – strange; normally a queue at the kitchen door, a ritual – morning pack greetings and things to do outdoors. Softly, I call for ‘big dog’, soft, slow footfalls and a head pokes around the door frame, looking very sheepish – “Wuzup” says I. The amber eyes flick towards the garden, which tell me all I need to know. Jack has been at his midnight excavation work – again. It happens, ‘tis but his nature, out of the stable into the wilds – a hunting he will go. “S’OK” says I, which has the immediate effect of relaxation as the crew turn up, tails wagging for first coffee. Peace will now reign until DT discovers the destruction - unless; I can get out there first and make the necessary repairs. Right then, coffee, boots, shovel = Pax Vobiscum.

I only mention this to describe a similar, occasional event in the AP archives; P2’s gone ‘a – digging and we don’t know where he are. (Nod to Banjo). No damage this time, only a decade of data has been rummaged, dug through and dragged home. The post above provides a sketch of ‘the great black hole’ of aviation reform.

A black hole is a region of space-time exhibiting such strong gravitational effects that nothing—not even particles and electromagnetic radiation such as light—can escape from inside it.

The sketch provides a timely warning to those on pilgrimage to the Wagga Reform Plate. Millions of dollars, countless man hours, a mountain of paper work and uncountable words have been invested and lost in the great departmental Black Hole. A cautionary tale of how history repeats. We do not have a ‘strong’ minister, we do not have a reform DAS, the Wagga gabfest threatens the Empire and the power of those who dwell in Sleepy Hollow.

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.” (Sun Zu).

But make no mistake – history does not show the reformers as winning many battles. It would be a cardinal sin to imagine that after Wagga all will be rosy in the garden.

For those looking for security, be forewarned that there’s nothing more insecure than a political promise. (Harry Browne).

At best, at the very best, it is the start of a long uphill battle to force the demanded changes through to conclusion.

“First they ignore you, then they ridicule you, then they fight you, and then you win.” (Ghandi).

Nothing less than a written, signed, legally binding statement of intent to make real reform happen in real time will do; and even then, that may not be enough.

Toot – toot…..

Warning – A ramble follows:-

Quandary - Night VMC – Unresolved.

The accident report – HERE – (page 9 on) and the Safety Recommendation – HERE – clearly identify the horns of a dilemma onto which any honest safety authority would hate to be tossed. The operation of aircraft at Night in Visual Meteorological Conditions (NVMC), is a not only curly, dangerous area, fraught with legal peril – for the authority but for aircraft operators as well. Several serious attempts have been made to iron out the kinks, without impinging on the latitude the notion provides; it presents a problem with which one could find some sympathy for the authority dealing.  You can, very quickly find much comment related to the subject and many a good argument for both sides.

What you cannot find (I cannot find) is an analysis – by operational class of the fatal accidents which occurred after dark. The ATSB have provided a graph which aligns ‘private’ operations against fatal accident by hours operated, which is fine – if a little dramatic. The ‘private ‘kill ratio’ is compared to Airline operations and Charter operations. This – IMO – provides a slightly skewed picture, not by any means deceptive when carefully read, but IMO (again) it fails to isolate and define a true picture of the seemingly high death rate in ‘private’ operations. This I believe is unhelpful when trying to establish a true picture and a safety case.

There are two basic tenets which demand that legislatively there must be a facility which allows visual flight at night; pilot training being one; the freedom to make a visual approach to landing after dark being another; which saves vast sums of money for commercial operations, and the ability for a Visual Flight Rules (VFR) operator to complete a task after daylight ends. All of which, in principal is a fine idea which could be fully supported, without a worrying aftertaste. It is a safe, practical and very valuable allowance. So where does the wheel come off?

“On a Gin clear night” after a while in the cockpit, you can actually see the features on the ground quite clearly, towns normally unseen can be identified by their loom, lakes and rivers seem to glow in the dark; with just a little moonlight the picture becomes almost perfect. The other side of the coin ain’t such an idyll. There is an expression ‘black-hole approach’, the RFDS probably know more about this than any operator on the planet. A dark night, middle of nowhere, rudimentary runway lights and no guidance other than the compass and your watch. It is bloody tricky stuff, not taken lightly by those who are regularly confronted by such conditions, it takes training and practice (lots of) to become proficient – if not comfortable.

And it is the ‘comfort level’ I am rambling towards. At very best there must be compromise which increases the risk level for government, operators and aircrew. The simple solution is to ban the concept, make any flight after dark subject to the Instrument Flight Rules (IFR) while keeping ‘visual approach’ in the mix. Then one could consider providing clearly defined rules which prohibited night flight under certain conditions; which is fine provided those conditions can be measured and met and argued about, later in court.    

I confess to not having bothered to read the Part 61 rule set relating to the matter; (a) it is impossible (b) I have no need to – mea culpa. (Bite me). But a separate rating system could be developed, based against operational requirements could be hammered out, not that it would please all – but there is a need to find a level of comfort for all. For instance; the amount of ‘instrument flying training’ required could be matched to the stated operational requirement – say return to a town base within 60 minutes after the End of Daylight (EoD); or departing a bush strip after EoD with more than a 90 minute flight to destination etc. The details are endless, but a systematic approach could/should be evolved. We do loose aircraft and lives in the dark skies when the weather is being unhelpful, that is a stark undeniable fact. Another fact is that pilots will push on without having a key to the backdoor on their shirt pocket – that is human nature and cannot be controlled by regulation. This is particularly true of the modern age where ‘navigation’ is done by GPS and auto pilots work. The problem with this fine innovative technology is those aids cannot think, but they do lend a false sense of security.

End of ramble I think – for mine, I’d like to see the NVMC rating ‘beefed up’ and at least an annual check ride, without auto pilot or GPS. I know ‘old school’ methodology but a vast improvement is ‘situational awareness’ – IMO. As said, a puzzle for the regulator to solve, but solve it they must. Shutting down Angel Flight will not achieve this goal.

Phew, a long winded ramble, but I do feel the very real, chronic  'problem’ is worthy of serious discussion and positive action. Perhaps AOPA or AF could present a proposed solution to start the ball rolling?  All above my pay grade – handing over.

Toot - toot

Joining the dots on Fort Fumble's 18 year obfuscation of ATSB identified Night VFR safety issue -  Dodgy

To begin I would like first to refer to what is IMO two of the better and (unfortunately these days) rare examples of a truly systemic, (based on the Reason model) AAI investigations: 
1) https://www.atsb.gov.au/media/4462266/ao..._final.pdf
2) https://www.atsb.gov.au/media/5668844/AO...0Final.pdf

No1. was of course the first AF fatal accident in 2011, involving Piper Cherokee VH-POJ and No2 was the high profile ATSB AAI into the fatal crash of an ABC squirrel helicopter at Lake Eyre that occurred 3 day after the VH-POJ crash.  

To set the scene, before joining the dots in with what is now IMO clearly a joint CASA/ATSB smokescreen, the following is extracts from page 15 and 16 of the No1. report:

Quote:[Image: NTSB-1.jpg]

[Image: NTSB-2.jpg]

IMO the above extract is a clear example of how the ICAO Annex 13 AAI system is supposed to work -  Wink  Perhaps in the real world of international Annex 13 aviation safety investigation the ATSB would issue a similar safety recommendation to Angel Flight in conjunction with the soon to be released Final Report into the tragic crash of VH-YTM near Mount Gambier?  

However the odds of that happening are IMO extremely remote given the continued attempted embuggerance of AF by St Carmody and his Iron Ring minions -  Dodgy

Back to joining the dots... Rolleyes

On the same page of the No1. report there was also attention brought to another NTSB SR:

Quote:United States occurrences

Safety Alert

In March 2013 the United States (US) National Transportation Safety Board (NTSB) issued Safety Alert SA-020 Reduced Visual References Require Vigilance. This alert highlighted that about two thirds of US general aviation accidents in reduced visibility weather conditions are fatal, and typically involve pilot disorientation or controlled flight into terrain. The NTSB observed that even in visual conditions, the combination of flight at night with limited ground lighting and therefore ground references could be problematic.

A number of common accident scenarios in conditions with limited ground reference were provided in the alert and strategies for pilots to manage that risk were suggested. Of note in the context of the accident near Horsham on 15 August 2011, the NTSB highlighted that:

Remote areas with limited ground lighting provide limited visual references [sic] cues for pilots, which can be disorienting…
and that pilots should:

Consider following instrument procedures if you are rated or avoiding areas with limited ground lighting (such as remote or mountainous areas) if you are not.

And from the 'safety analysis' section of the report, this was the ATSB's comments in relation to the NTSB Safety Alert:

Quote:Other efforts to reduce the risk of night operations

The United States National Transportation Safety Board (NTSB) recently issued Safety Alert SA-020 Reduced Visual References Require Vigilance. The alert included the following guidance:

Remember that, when flying at night, even visual weather conditions can be challenging. Remote areas with limited ground lighting provide limited visual references cues for pilots, which can be disorienting or render rising terrain visually imperceptible. When planning a night flight, use topographical references to familiarize yourself with surrounding terrain. Consider following instrument procedures if you are rated or avoiding areas with limited ground lighting (such as remote or mountainous areas) if you are not.

The ATSB strongly supports such guidance, and advises all operators and pilots considering night flights under the VFR to systematically assess the potential for the flight to encounter dark night conditions by considering weather conditions, celestial illumination and available terrain lighting. If there is a likelihood of dark night conditions, the flight should only be conducted by a pilot having a high degree of instrument flying proficiency in an aircraft that is equipped to a similar standard.

Consequently, with the NTSB SA in mind, backed by the findings gathered in the VH-POJ investigation, it is highly probable that this was what led the ATSB to follow up with a rare but important safety recommendation, that was titled Requirements for visual flight rules flights in dark night conditions: ref - https://www.atsb.gov.au/publications/inv...100/si-01/

Ironically this is where the two reports (No1. & No2.) intrinsically come together - quote from the si-01 link above:

Quote:ATSB response:

This safety issue and report of safety action by CASA in response reflects that reported in ATSB safety investigation report AO-2011-102. The ATSB welcomes the intent of this proposed action by CASA in response to this safety issue. In particular, the ATSB agrees that expanding what is meant by the term ‘visibility’ at night to include the requirement for a visual horizon will help ensure that pilots operating under the night VFR will have sufficient visual cues. However, as discussed in investigation report AO-2011-102, given the importance of the safety issue, the ATSB is concerned about the indefinite nature of the proposed evaluation and other exploratory activities proposed by CASA.

As a result of this concern, the ATSB issued safety recommendation AO-2011-102-SR-059 to CASA on 8 November 2013. Although specifically referring to investigation AO-2011-102, this safety recommendation will, when adequately addressed, also address safety issue AO‑2011‑100-SI-01 in respect of the accident involving VH-POJ, 31 km north of Horsham Airport, Victoria on 15 August 2011. The safety recommendation is therefore repeated below for ease of reference.

This is the link for AO-2011-102-SR-059: https://www.atsb.gov.au/publications/inv...102-si-02/


Action organisation: Civil Aviation Safety Authority
Action number: AO-2011-102-SR-059
Date: 08 November 2013
Action status: Monitor

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority prioritise its efforts to address the safety risk associated with aerial work and private flights as permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.

Date received: 07 February 2014
Response from: Civil Aviation Safety Authority
Action status: Monitor

Response text:

CASA partially accepts the recommendation in as much as regulation 61.970 of the Civil Aviation Safety Regulations 1998 (CASR) requires pilots to demonstrate competency during biennial night visual flight rules assessments. The regulation was made in February 2013 and commences in September 2014.

In addition, CASA also commenced a project on 16 December 2013, OS 14/01 Night Visual Flight Rules. This will consider whether to require a discernible external horizon during flights under Night Visual Flight Rules (NVFR). CASA proposes to clarify the definition of visibility in regulation 2 of the Civil Aviation Regulations 1988 (CAR) to ensure the primary coincident safety issue above is dealt with. CAR 2 defines visibility as the "ability, as determined by atmospheric conditions and expressed in units of distance, to see and identify prominent unlighted objects by day and prominent lighted objects by night". Project OS 14/01 CASA will consider whether to seek an amendment to this definition by adding to it the requirement that for NVFR, the determination of visibility must also include the ability to see a defined natural horizon. This will in effect address the root cause of the matters outlined in the safety issue as pilots will need to have a discernible horizon throughout their flight. If a discernable horizon is not present then the flight should be conducted under the Instrument Flight Rules (IFR) and all associated regulations for IFR flight will apply.

The project will also review the current NVFR regulatory requirements and CASR definitions to ensure it limits the visual environment to that in which a defined external horizon is available for aircraft attitude control. The project will examine the night VMC requirements for both rotorcraft and aeroplanes. However the outcome of the project may limit the change to the night VMC requirements to rotorcraft only in recognition of the difference in certification requirements between the categories. The project will also amend the guidance provided in CAAP 5.13-2 to emphasise the importance of maintaining a discernible external horizon at night particularly in light of the certification basis for NVFR rotorcraft.

ATSB response:

The ATSB recognises CASA’s ongoing efforts to address this safety issue.

Date received: 24 October 2016
Response from: CASA
Action status: Monitor
Response text:

CASA partially accepted the recommendation and advised the ATSB in February 2014 that regulation 61.970 of the Civil Aviation Safety Regulations 1998 (CASR) requires pilots to demonstrate competency during biennial night visual flight rules assessments. The regulation was made in February 2013 and commenced in September 2014.

In addition, on 16 December 2013, CASA advised the ATSB that we had commenced project OS 14/01 Night Visual Flight Rules. This considered whether to require a discernible external horizon during flights under Night Visual Flight Rules (NVFR) and whether to amend the definition of visibility in regulation 2 of the Civil Aviation Regulations 1988 (CAR).

The project also reviewed the current NVFR regulatory requirements including CASR definitions and examined the NVMC requirements for both rotorcraft and aeroplanes. The project also proposed to amend the guidance provided in Civil Aviation Advisory Publication (CAAP) 5.13-2 to emphasise the importance of maintaining a discernible external horizon at night particularly in light of the certification basis for NVFR rotorcraft.

The outcomes of the project were limited to rotorcraft only in recognition of the difference in certification requirements between rotorcraft and aeroplanes.

As a result of this project I would like to advise that CASA has taken the following actions:

CAAP 5.13-2 was withdrawn and Advisory Circular (AC) 61-05 Night VFR Rating was published in April 2016 to provide information on the certification criteria for helicopters under the NVFR and the importance of maintaining sufficient visual cues for aircraft attitude control in light of the certification requirements (at section 6.5), and
On 27 April 2015, Civil Aviation Order 20.18 Amendment Instrument 2015 (No. 2) was made and commenced on 1 January 2016. The amendment instrument inserted a new paragraph 3.2A into CAO 201.18, to clarify that a helicopter may only be operated under V.F.R. at night if equipped with: the instruments specified in Appendix VIII of the CAO; and any other instruments and indicators specified in the helicopter's flight manual. It also required that if the helicopter's attitude cannot be maintained by visual external surface cues, the helicopter must be equipped in accordance with subparagraph 4.2 (d) of CAO 20.18 regarding an automatic pilot or automatic stabilisation system, or be operated by a qualified 2-pilot crew.
CASA considers this safety recommendation has been addressed and requests that this advice be published on the ATSB website

ATSB response:

On 24 October 2016, CASA advised the ATSB that it considers Safety recommendation AO- 2011-102-SR-059 had been fully addressed. While acknowledging the safety actions undertaken by CASA, the ATSB remains concerned about instrument proficiency, and visibility requirements for fixed-wing operations at night.

The ATSB welcomes the introduction of a biennial flight review for the night VFR rating, however does not consider that it fully supports the safety recommendation as there is no formal ongoing requirement to maintain instrument flying proficiency and currency.

CASA has addressed night visibility flight requirements for helicopter flights by amending AC 61-05 (section and CAO 20.18 (section 3.2A ©) however the ATSB is concerned the same standards do not apply to fixed-wing operational equipment. This relates directly to the safety issue raised as a result of another VFR flight into dark night accident investigated by the ATSB (AO-2011-100).

Based on CASA's actions to date, the ATSB intends to publish CASA's response on its website and retain the current status of safety recommendation AO-2011-102-SR-059 as 'Monitor'.

Current issue status: Safety action pending

Status justification:

The ATSB recognises CASA’s ongoing efforts to address this safety issue.

Note that both of the SR's are still open and the status is listed as 'safety action pending' -  Undecided

Okay let's go back to the No1. report and on page 13 under 'Related Occurrences' is listed...

Collision with terrain 3 km east of Newman Airport, Western Australia on 26 January 2001 – ATSB investigation BO/200100348

Quote:ATSB investigation BO/200100348 examined the circumstances of the collision with terrain that occurred 3 km east of Newman Airport, Western Australia on 26 January 2001 and involved a Cessna 310R aircraft, registered VH-HCP. The flight was conducted at night under the VFR, with one pilot and three passengers on board. All were fatally injured and the aircraft destroyed.

During its investigation the ATSB identified a safety issue in respect of the requirements for pilots to maintain currency, recency and proficiency for night VFR flight under dark night conditions. In consequence, on 23 October 2002, the ATSB issued safety recommendation R20020193 that stated:

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority (CASA) review the general operational requirements, training requirements, flight planning requirements and guidance material provided to pilots conducting VFR operations in dark night conditions.

In response to this recommendation, on 13 December 2002, CASA advised that:

CASA acknowledges the intent of this Recommendation. As part of the proposed CASR Part 61, CASA is developing the requirements for night VFR ratings which will be based on the existing Civil Aviation Order CAO 40.2.2. In addition, a draft competency standard for night visual flight operations has been developed for inclusion in the proposed CASR Part 61 Manual of Standards. CASA plans to publish a Notice of Proposed Rule Making in relation to this matter in March 2003.

Collision with water off Cape Hillsborough, Queensland on 17 October 2003 – ATSB investigation 200304282

Quote:At about 2132 on 17 October 2003, a Bell 407 helicopter, registered VH-HTD departed Mackay Airport for Hamilton Island, Queensland (Qld) with the pilot, a crewman and a paramedic on board. The pilot transmitted a departure report for the night VFR flight and submitted an estimated time of arrival for Hamilton Island. No additional communication was received from the pilot and a subsequent search identified aircraft wreckage floating in the sea off Cape Hillsborough. The aircraft occupants were fatally injured and the helicopter destroyed on impact.

As part of its investigation into this accident, on 6 November 2003, the ATSB issued safety recommendation R20030213 to CASA recommending:

…that the Civil Aviation Safety Authority review the night visual flight requirements and promulgate information to pilots emphasising the importance, during flight planning, of considering whether:

• environmental conditions allow for aircraft orientation by visual reference alone,
• there is likely to be sufficient ground or natural lighting and flight visibility along the proposed route to provide visual reference to the ground and/or water during the flight, and
• they are capable of safely operating the aircraft should non-visual conditions be encountered.

CASA responded to R20030213 on 10 December 2003 and stated, in part that:

CASA supports the issues raised in the Air Safety Recommendation and advises that the Authority is currently reviewing the night visual flight requirements with a view to emphasising to pilots, through its safety promotion activities, the importance of considering the above factors.

On 21 December 2004, CASA further responded to the recommendation and advised:

CASA does not agree that a review of night VFR requirements is necessary. Firstly, regulations specify that weather conditions of night VFR must be such that a planned flight can be conducted at a safe height clear of cloud. With respect to pilot competency, Civil Aviation Order (CAO) 40.2.2 specifies that the night VFR rating requires pilot be trained to control an aircraft solely by reference to instruments. Any notion that celestial lighting and/or an apparent visible horizon are appropriate references for the control of an aircraft by night is misleading and dangerous and increases the probability of pilot disorientation.

On 27 January 2005, after being asked for clarification on the issue, CASA responded:

Reliance on ambient lighting at night rather than instruments for attitude reference is potentially hazardous due to the high risk of pilot disorientation. CASA strongly believes that the requirements specified in Civil Aviation Order (CAO) 40.2.2 are adequate for night VFR operations. It is the responsibility of the operators to ensure that pilots meet the requirements specified for rating issue, especially those related to instrument flying. Therefore, CASA does not believe that a review of these requirements is necessary given that Australia already has the most comprehensive night VFR pilot qualification.

And that my Dear Watson IMO are some pretty big and damning DOTS... Dodgy

MTF? - Yes much!...P2  Cool

Scrambled dots, for breakfast.

I know the post  P2   post above is a long, long one – but P2’s dots are well worth joining, take some time and consider why AF is the convenient whipping boy; the noise of the beating masking the sounds of the chook shed being plundered

Willyleaks – Memo: don’t worry about the mirrors Jon, the smoke machine will do nicely.”

Thanks P2, I believe we are almost there; at the sticking point. AF in the USA responded quickly and, quite correctly to the NTSB concerns. Real changes, in real time were made by folk with a ‘can-do’ attitude. The FAA were never involved. NTSB spoke, AF responded and, quite correctly the warnings and remedies were not only heeded, but collaboratively acted upon. Much kudos to the USA and the system they use to ‘prevent’ accident, rather than prosecute those unfortunate enough to have one. Cost effective, safety based solutions to an acknowledged killer. Bravo the USA.

Did the Australian AF team follow their lead? You bet they did.

The only outfit that failed to respond in a positive manner seems to be CASA.

P2 – “IMO the above extract is a clear example of how the ICAO Annex 13 AAI system is supposed to work. Perhaps in the real world of international Annex 13 aviation safety investigation the ATSB would issue a similar safety recommendation to Angel Flight.”

Once again we see the NTSB saying to the operation “hey guys, there’s a problem here”. Seems AF has said “you’re right”. Then a solution was knocked out, applied and then everyone got on with job”. Safety management working as it is meant to – fantastic.

P2 – “However the odds of that happening are IMO extremely remote given the continued attempted embuggerance of AF by St Carmody and his Iron Ring minions”.

True dat. The ATSB (pre Hood) did issue a Safety Recommendation (SR) after a fatal in 2013. A second fatal accident triggered a second SR. This is a rare occurrence and ATSB used their most powerful tool in an attempt to get CASA to respond appropriately. Both SR are still, to this day, pending ‘Safety Action’.

This ongoing, unresolved saga can be traced back 16 years, to 2003.

When you join P2’s dots and spend a minute or two wondering why, once again, the lead of the NTSB was not followed; it was neatly and properly addressed, by all involved, great result. In Australia we have two SR outstanding and a sixteen year period of CASA telling ATSB “thanks for your opinion, don’t call us, we’ll call you”.

Classic example of a gutless regulator; terrified to engage directly in the SR – just in case any shadow of blame falls on them. Classic example of a cowardly regulator, preferring to hammer AF out of existence rather than acknowledge their chronic lack of positive operational safety action relying on ‘the law’ rather than operational common sense. A classic example of an ignorant regulator refusing to believe that anyone else could possibly know anything about positive operational safety enhancement. All of which paints a pretty grim picture; we could live with ineptitude; but foisting lies, damn and statistics on a Senate Committee is a chancy strategy. Mind you, stepping around Senate recommendations is considered a relaxation therapy session following the stress of morning tea.

Toot - toot.

Scrambled dots & Angel Flight smokescreens - cont/-


(04-10-2019, 07:52 PM)P7_TOM Wrote:  Hood – Should, Could and did not. Why?????????

O’Sofullofit; fails, utterly (as usual) by stepping around the glaring, basic issues. Perhaps he should take a slightly broader view, in particular, the complete disregard CASA have continually demonstrated in relation the ‘safety recommendations’ offered by ATSB. It is quite a history and those who are not totally across the subject matter should spend a little time getting familiar. I know P2 is delving deeply into various matters in an attempt to discern why CASA have thrown up a huge smoke screen, using AF as their whipping boy to excuse their past dismissal of ATSB (pre Hood) and Coroner recommendations as suggestions only. Despite O’Sofullofit’ continual, fatuous, repetitive claims to ‘understanding’ , experience and being full bottle on ‘investigations’ I say he needs to STDU and do his homework, rather than keep telling us what a whizz-bang safety guru he is. He ain’t – he’s either a very naughty boy; or, we need to question his ‘motivation’...(sic)...

...The AF debacle is a smoke screen; Essendon was an important event; Ross Air was an important event; the Braz was an important event; the Coal Loader event at Newcastle was an important event; the Virgin / Qantas episode was an important event; the ATR was an important event; the Swan river crash was an important event – must I go on? WTD are we wasting time, money and effort on here; Angel Flight deaths? It’s a total Bollocks. Safety as ‘we’ (the industry) have understood it – operationally – is going to Hell in a hand cart – CASA is driving – Hood is pushing and the Devil is working the whip. Will someone , anyone please put the brakes on this lunacy.

Something in Denmark stinks to the high heavens... 

Referencing pages 3 to 4 and 13 to 15 of the P7 SR document link above:

Quote:1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003. Report - R20050002. Issue date 14 March 2005. http://www.atsb.gov.au/media/24411/aair2...82_001.pdf

As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS operations.

ATSB Safety Recommendation. The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2) operational procedures and (3) minimum equipment for conduct of such operations at night.  

Quote:Ref: https://www.atsb.gov.au/publications/rec...r20030213/

Further correspondence

Date issued: 27 January 2005
Response from: Civil Aviation Safety Authority
Response status: Closed - Not Accepted

Response text:
CASA expressed concern that the report appeared to attribute the cause of the accident to night VFR regulations rather than the shortcomings in recruitment, induction and training.

Moreover, CASA was troubled by the emphasis placed by ATSB on the need for specifying minimum ambient lighting requirements for night VFR operations. Reliance on ambient lighting at night rather than instruments for attitude reference is potentially hazardous due to the high risk of pilot disorientation.

CASA strongly believes that the requirements specified in Civil Aviation Order (CAO) 40.2.2 are adequate for night VFR operations. It is the responsibility of the operators to ensure that pilots meet the requirements specified for rating issue, especially those related to instrument flying. Therefore, CASA does not believe that a review of these requirements is necessary given that Australia already has the most comprehensive night VFR pilot qualification.


5) En-route Engine(s) Failure (Fuel starvation): Newman Airport, WA; Cessna 310R, VH- HCP; 26 January 2001.
Safety Recommendations – (1) R20020205,(2) R20020193, (3) R20020194, (4)R20010195. Issue Date: (1)(2)(3) 23 October 2002, (4) 07 September 2001.

http://www.atsb.gov.au/publications/reco...20205.aspx http://www.atsb.gov.au/publications/reco...20193.aspx http://www.atsb.gov.au/publications/reco...10195.aspx

NB. This SR was originally promulgated by the ATSB in response to:


As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority:

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the provisions for planning a fixed fuel reserve and determine if this fuel should be contained in the fuel tanks that are to be used during the approach and landing.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the general operational requirements, training requirements, flight planning requirements and guidance material provided to pilots conducting VFR operations in dark night conditions

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the required qualifications and/or competencies for chief pilots, with particular reference to management and system safety issues.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider proposing an increase in the operations' classification, and/or the minimum safety standards required, for organisations that transport their own employees and similar personnel (for example contractors, personnel from related organisations, or prisoners, but not fare-paying passengers) on a regular basis. This recommendation applies to all such operations, regardless of the take-off weight of the aircraft involved. 

Quote:Further correspondence

Date issued: 13 December 2002
Response from: Civil Aviation Safety Authority
Response status: Monitor

Response text:
CASA acknowledges the intent of this Recommendation. As part of the proposed CASR Part 61, CASA is developing the requirements for night VFR ratings which will be based on the existing Civil Aviation Order CAO 40.2.2. In addition, a draft competency standard for night visual flight operations has been developed for inclusion in the proposed CASR Part 61 Manual of Standards. CASA plans to publish a Notice of Proposed Rule Making in relation to this matter in March 2003.
"K" said: "..All of which paints a pretty grim picture; we could live with ineptitude; but foisting lies, damn and statistics on a Senate Committee is a chancy strategy. Mind you, stepping around Senate recommendations is considered a relaxation therapy session following the stress of morning tea..."

For instance in regards to the now infamous but shelfwared Senate Inquiry into Aviation Accidents and Investigations, the matter of addressing ATSB SR in a proactive, transparent and timely manner was the subject of recommendations 17 to 21 of the PelAir cover-up report... Undecided

Quote:Links for PelAir cover-up Senate Inquiry:

Recommendation 17

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

Recommendation 18
9.40      The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42      The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44      The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45      The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.

The (Coalition) Government response to R21, IMO adequately highlights why it is that Carmody and the Iron Ring cadre feel totally secure in thumbing their noses at any recommendations issued by Govt (Forsyth report), Senate (too numerous to mention) and indeed the ATSB:

Quote:[Image: D31PapjUYAAoNhZ.jpg]
No further comment required except to draw your attention from (about) this post off the 'Closing the safety loop' thread: Beyond Reason - & the pale?? 

&/or this Google image search link: see HERE.

Quote:Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?
Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.
Senator FAWCETTYou do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?
Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.
Senator FAWCETTThank you.

MTF...P2  Tongue

my dear fellow, joining the dots leads me in a slightly different direction and a different question.

Why do around 80% of US private pilots hold an instrument rating, and almost 100% of commercial pilots?

The answer my friend is blowing in the wind, because hardly any private pilots in Australia hold that qualification.


Could it be that in the USA it is very affordable? Clear, concise standards, laid out in clear concise regulations
make operating an aircraft there considerably less than in Australia, therefore gaining an instrument rating is not the expensive, convoluted odious exercise it is here.


When "Safety" is supposed to be CAsA's core function.

Just one of life’s great deceptions.

For far too many years now, I’ve been fascinated by ‘magic’. Not a rare disease, indeed, quite a commonplace fascination. However (and thankfully) ) I’ve never been moved to indulge; it has always been more a question of how did they do that? “K” is not the only one with a ‘curiosity bump’. This ‘curiosity’ does extend to some of the masterful tricks and illusions CASA have provided over the decades; magical? Miraculous? Or just plain old ordinary deception?

Professional entertainers using illusion to mystify a crowd of punters usually do not have the well being or the safety of the travelling public and the industry which supports that within their remit. CASA do.

One of the most famous illusions is the Indian Rope Trick.  Not even the great Houdini mastered that one, in fact it almost deceived him. I say almost because he never, ever tried to use the deception or emulate the performance. It is an intriguing subject about which argument has raged for many a long year now: still, to this day - unresolved.

“To the point old fool” bellows the IOS crew.

Well, CASA seem to have mastered the trick. Up to their hocks in Alligators when, suddenly, the magic rope appears, they escape and the body parts fall to earth; just like the in original Chinese version of the illusion.

It leaves me wondering – how FDS do they do that: every time? The do-do hits the windmill – out comes the basket – up goes the rope, and – POOF – nobody is there - except the fools paying good money to watch the performance.

What a performance it is – forget the Proms. Watch Estimates.

For almost 20 years, the spectre of death under NVMC has haunted CASA. Proper, evidence based Safety Recommendations (SR) have been issued; Coroners have written volumes only to be matched by industry provided solutions, even Senators call for remediation  – all ignored.

NVMC is relied upon by Aerial Agriculture, flight training, airline operations, helicopter (police, emergency and charter operators), it is a safe, viable asset to many operations. BUT – there are problems – not so much with professional outfits, but at a ‘private level, the potential for accident and injury is increased. Not by much, the majority are sensible, safety conscious folk.

I reckon that the current open antagonism directed at AF is nothing more than CASA knowing; full well, for over 16 years, that they must ‘deal’ with the operational short falls and have not. Cowardice on their part?

Well, yes. I rather think it is. It is however a problem which can only be solved by ‘operational’ safety logic, not more rules and certainly not by using AF as the ‘reason’ CASA have gone nuts and written up a storm of new regulation which excuse ‘em from doing their designated job, properly – in the first instance. Angel Flight ain’t the radical cause – the proposed new regulatory placebo is a piss-poor apology for real, operationally sensible rules which should have been drafted a decade ago – but were not. Why: ‘cos CASA are terrified of drafting sensible operational requirements, but really good at off setting the blame and ducking the radical causes.

Gutless bloody parasites; arrogantly ignoring and ridiculing ATSB SR: – Cuss the lot of ‘em.

Now, let’s see -  48 to win, need a triple: so – treble six + double top – and a spare dart – easiology. Get ‘em in boy – thirst rules – OK.

Timeline of bureaucratic O&O, embuggerance & sheer bloody bastardryDodgy

This AM "K" has written this post on the Closed loop thread: Safety Loop or Hangman’s noose?

Quote:Cheers P2; this has been coming for a while now and is well over due. Sen. Fawcett tried to get the ball rolling in the right direction way back in 2012, yet seven years later the core subject matter has not been properly addressed in a positive or even a satisfactory fashion.

We did do an abridged version of the analysis we ran – HERE – but – as I recall we left it on the shelf after while when the promised legislation and amendments failed to materialise (as per usual). There is a long list of them; and all that seems to have surfaced is more ways to allocate blame, but little in the way of ‘preventing’ a reoccurrence. The same ‘accident’ has been claiming lives for quite a while, clearly demonstrating that ‘rules’, no matter how complex, simply are not preventing repeat accidents. 

16/10/2012 - Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Fawcett, with a flick of his wrist has unveiled the Elephant in the room. It is a simple concept which, IMO the departments involved have been at some pains to avoid acknowledging. The construct is a simple one:- (a) there has been a fatal; (b) ATSB have, best they may defined the nature of it; © there is a Coroners court; (d) the Coroner makes recommendations and hands down his findings; (e) nothing further happens – in real terms.

For some reason that thread post title sounded very familiar?? So with a quick AP forum search, to my amazement I was to discover there was a "K" thread post with the same title from almost exactly three years ago, which ironically and disturbingly highlights the issues that "K" is banging on about -  Undecided  

(04-15-2016, 07:22 AM)Kharon Wrote:  Safety loop or hangman’s noose?

Quote:Ventus 45.

The final paragraph of:-
Investigation number: AO-2014-032 Updated: 10 June 2014
( https://www.atsb.gov.au/publications/inv...FI.twitter )

“The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser.”

For a “supposedly” benign and “routine” encounter with so called “moderate” turbulence, that should not have caused “any” damage or flight upset at all, the nature of this structural damage is alarming.

What we do know, is the aircraft was partially repaired and flown back to the manufacturer by the manufacturer’s test pilots, where it was “repaired” – presumably with the entire vertical tail and tail-plane removed and replaced – and was then subsequently flown back to Australia, to Virgin, and placed back in service.

Presumably, the “removed vertical tail and tail-plane” have been “examined” and or further “tested” by the manufacturer, and possibly (presumably) the “Design Certifying Authority”.
Presumably, the results of those investigations have identified the “reasons(s) for failure”, and have been dealt with in an “appropriate” manner, and the ATSB have been fully advised – of course. Frankly, I doubt it.

It is also interesting to note, that presumably, both the ATSB “AND” CASA were “quite happy” to grant a “permission to fly” for a “damaged” (partially repaired) aircraft over Australian Territory (and by inference – all other countries involved) for the “ferry flight” back to the manufacturer. Interesting point that, interesting indeed M’lud.

Why did they do so ? Why was the “physical evidence” (the tail and tail-plane) “allowed to leave the jurisdiction of the investigation”?

Why indeed ?

Two years on, and no definitive “structural report” ?

As the copper says at the crime scene: “Nothing to see here folks, move right along “thank you”, (and be bloody-quick-smart about it too).

I lifted the entire Ventus 45 post from Ben’s blog as it steps us through to what should have provided definitive answers to at least the ‘engineering’ parts of this puzzle.  It is remarkable that a manufacturer investigation of an event of this magnitude has not been fully documented.  It is not from idle curiosity or vicarious thrill seeking that answers are sought.  There are, clearly demonstrable areas of real concern which need to addressed: for example:-

Flight crew training and response to an uncertainty situation; there are many areas which have not been even cursorily examined.  The PIC ‘interference’ with the FO actions begs questions; why not call ‘taking over’; or, why not monitor and advise; or, why was there such confusion that the elevator channels were split. Etc.  There’s many more related to crew actions and reporting to engineering.

Then we examine what were the engineers told against what was committed to the tech log. This may give some insight into the initial maintenance actions.

The subsequent flights and tech logs preceding to eventual ‘discovery’ at Albury need to be examined in detail and crew questioned in relation to the in-flight performance of the aircraft.

No one is on a witch hunt here; not looking for a scapegoat in the form of an engineer or pilot.  However, this incident, like several others raises several red flags over ‘system’.  Hiding facts and delaying reports, then producing a ‘thing’ like the latest ATSB rubbish simply assists to hide potential problem areas, which, if not addressed could, when luck runs out end in an avoidable, preventable accident.

ATSB can do better than this – we know they can; so why are they not performing design function.  Perhaps when the minister gets done with taking selfies and studying phallic symbols, he could ask that question; maybe even do something about the shameful, deceitful way an expensive investigative body does it’s job.  He could even consider doing something to resurrect the inutile and transform it back to at least being honest, if not effective.  

Yes GD, I know there’s an election in the wind; so much more important than bodies and aircraft parts blowing in the same breeze.  Aye well; tempus fugit and tempers fray; I hope the inevitable never happens on some another day.

Toot toot.

Now keep in mind that today's "K" post was written 1 week short of 6 years from when the very damning findings and recommendations of the Senate Inquiry into Aviation Accident Investigations - see HERE & HERE - was made public; plus approaching a decade after the VH-NGA ditching and just over a decade since the ignored wake up call immersed inside of the significant findings and recommendations of the 2008 ICAO Audit report of Australia - see from page 30 HERE.

[Image: 71dc5aa7d66548b7ad6131235e775dc6]         

Hmm...see what I mean? - MTF...P2  Cool

Diarrhea theory -  Rolleyes 

(WARNING: Long post with a number of dots & dashes to follow -  Big Grin )

Reference from Mick Mack's thread:

(12-09-2019, 05:42 PM)Peetwo Wrote:  Via the SMH:

Aviation safety inspectors claim staff shortage amid CASA restructure

[Image: 1113e378aaa73452e3c5ce608df57110d474f64f]
By Patrick Hatch
December 9, 2019 — 12.00am

Federal transport minister Michael McCormack has declared "full confidence" in the nation's cash strapped aviation safety regulator amid claims a restructuring of the agency has led to a dangerous shortage in frontline inspection staff.

The Civil Aviation and Safety Authority is facing a $3.4 million budget shortfall this financial year, amid uncertainty around domestic aviation fuel excise revenue. Revenue from the 3.5¢-a-litre excise tax has been flat because major airlines Qantas and Virgin Australia have been limiting the number of domestic flights they offer in a bid to ensure stable profits.

[Image: 9c7946bbee538c94a099ce20fb2b3983facbf5d8]

CASA also faces a growing workload from international flights, which do not pay the excise tax.

Professionals Australia claimed there are 41 unfilled technical air safety positions at CASA, representing a 25 per cent reduction in airworthiness, pilot and safety systems inspectors over the past three years.

CASA said its inspector numbers have only fallen by eight, from 151 to 143. But the union claimed a further 33 positions are vacant due to inspectors being taken off front-line duty through secondments, special projects and acting roles.

"CASA has refused to fill these positions and has informed staff it has no intention of filling them until an anticipated restructure has taken place," said the union's Australian government group director Dale Beasley.

CASA inspector Wrote:History has shown repeatedly what happens when standards slip. We are on a slippery slope towards degraded safety standards.

Mr McCormack, who is also deputy prime minister,  said in a statement he had "full confidence in CASA’s ability to perform its industry oversight obligations and ensure aviation safety.”

A CASA spokeswoman said the agency was in the process of "transforming the way we operate to provide more consistent and standardised safety oversight", and was developing a new "oversight model" that would identify staff roles and capabilities.

One CASA inspector, who spoke on the condition of anonymity because he was not permitted to talk about the organisation publicly, said the staff shortage was forcing inspectors to cut corners and adopt “box ticking” approach to safety checks.

“We’ve got a huge number of people in CASA who have zero faith in management and genuinely believe that we’re setting ourselves up for a catastrophic event,” he said.

[Image: fcb00fb181ab5a4eaa2611c31ebaa1f450b3aa0f]

“We set a high standard, but that’s what first world aviation safety requires.

“History has shown repeatedly what happens when standards slip. We are on a slippery slope towards degraded safety standards.”

The resourcing gaps meant CASA has been unable to carry out inspections of overseas maintenance facilities, and unacceptable delays , Mr Beasley said.

CASA's latest corporate plan said it expected to run at a $3.4 million deficit in this financial year, and that it would try to balance its budget during "challenging" forward years.

CASA was to present a "detailed review" of its activities and funding requirements ahead of the government's Mid-Year Economic and Fiscal Outlook, in a fortnight. CASA's spokeswoman said this review was likely to be considered in the next federal budget.

Labor's federal transport minister Catherine King said the union's claims were "extremely concerning", and Mr McCormack "must explain how he thinks this level of resourcing is sufficient to keep Australians safe.”

The government earlier this year amended the Civil Aviation Act so that CASA must now "consider the economic and cost impact on individuals, businesses and the community" of its safety regulation. This followed an outcry from smaller aviation operations who claimed they were being strangled by red tape.


Aussie lives at risk from understaffed air safety workforce

A couple of takeaways from that article: It is unprecedented in recent history to have; a) someone breaking ranks internally with comments like this..

“We’ve got a huge number of people in CASA who have zero faith in management and genuinely believe that we’re setting ourselves up for a catastrophic event,”

and for b) the unions to combine to back up those comments so stridently :

According to Professionals Australia – ACT Branch and Australian Government Group director Dale Beasley:“Right now, these technical air safety staff are struggling to cover 41 vacant positions and have been doing so for 18 months. It’s an unacceptable risk for air travellers and is unsustainable for air safety staff,”


Australian Federation of Air Pilots industrial and legal officer Paul Ferguson said CASA was not giving flying operations inspectors sufficient support, with flying training falling short of maintaining pilot qualifications...

...“Stalled recruitment has resulted in significant staff shortages, which is now compromising the effectiveness of CASA.”

Even if the unions are just typically playing the 'safety card', the unity of these high powered unions would suggest that this is not the case of one or two disgruntled technical/inspectorate staff and that there is a high probability of underlying systemic issues here that any real over-sighting Minister should be concerned about given the abysmal track record of this regulator in the last thirty odd years (think Monarch, Seaview, Lockhart, ICAO/FAA audits, PelAir etc..etc).

This got me thinking about where you might possibly find recent evidence of poor, possibly duplicitous, regulatory oversight (ie 'tick-a-box' audits etc.) possibly masking/covering up, real systemic safety issues? Then I thought of confidential reporting ie ASRS or REPCON. ASRS reports are not generally published but some REPCON are, so I then referred to the ATSB Aviation REPCON webpage: https://www.atsb.gov.au/repcon_reports/?mode=Aviation

The last two were dated and effectively closed off back in July:

1) https://www.atsb.gov.au/repcon/2018/ar201800096/

2) https://www.atsb.gov.au/repcon/2019/ar201900052/

I will come back to number 1) because there are IMO some real conflicting issues and parallels which are worthy of further exploration - Huh .

Number 2) however particularly perked my interest because it was dealing with Airservices Australia and the reporter was obviously a Senior and current serving ATCO that had some real concerns about the changed management structure and oversight/supervision of the live 24 hr, 7 day a week air traffic control system. Also this is one area, based on past experience and evidence where CASA leave it to the ASA SMS to handle, could possibly show CASA oversight as being merely a tick-a-box routine:

Quote:Reporter's concern

The reporter has advised that Airservices has recently replaced Air Traffic Control Line Managers with Operations Line Managers (OLMs) in some locations. The OLMs were initially responsible for oversight and decision making regarding non-operational matters. However, in at least one location, OLMs are now involved in reviewing ATC incidents, delegating operational tasks to controllers and overseeing remedial management processes.

The reporter is concerned that the lack of any ATC experience will result in OLMs assigning operational duties to a controller not best placed to complete the task, due to the OLM not having the understanding of the complexities or procedural requirements of a particular task.

In addition, the reporter queries how OLMs are able to determine the appropriate remedial action for controllers, or ascertain which controller requires the remedial action in case of handover issues, when the OLM has no experience operating as a controller in a complex operational environment.
Now the response from AirServices management was fairly atypical but the CASA response IMO was not so atypical and was more akin to making sure that in hindsight that the CASA technical crew had covered the potential liability of CASA if this matter was ever to turn to custard:

Quote:Regulator's response (Regulator 1)

CASA is satisfied that the change in management of “operational matters” is not generating any additional safety concerns.

CASA conducts regular risk-based surveillance and auditing of Airservices to ensure compliance with CASR 172. CASA has not identified any compliance issues or safety concerns related to the changes in management structure or manager responsibilities.

CASA notes that an ATS provider must, at all times, maintain an appropriate organisation with a sound and effective management structure to enable it to provide, in accordance with the standards set out in the Manual of Standards and the standards set out or referred to in Annex 11, the air traffic services covered by its approval. This is an area subject to surveillance and auditing by CASA but there have been no findings or indications that recent management changes are impacting the level of ATC service provision, compliance or safety.

CASA notes that an ATS provider must have, at all times, enough suitably qualified and trained personnel who are able to supervise the provision of any air traffic service that it provides. CASA considers safety and compliance for provision of ATC services from a systemic perspective which includes assessment of management capability. CASA has not identified any issues in relation to manager roles.

CASA notes that MOS requires the Airservices Operations Manual to contain a description of the chain of command.  OPSMAN172 mentions the position of Operations Line Manager and there is reference to ATC Line Managers. CASA is satisfied that there is no evidence that would justify a safety finding regarding OLMs.

CASA inspectors recently determined that the OLMs they interviewed were highly qualified and experienced in staff management. The OLM was responsible for the training portfolio but was not involved in determining what training a controller may need. The OLM was only responsible for organising the training and keeping adequate records.

CASA notes the need to ensure unqualified and untrained managers are not assigned responsibilities based only on experience or familiarity. These positions should be adequately trained as managers in those areas relevant to their accountabilities.

CASA does not have evidence that supports the issues identified in the REPCON. Whether the use of a manager without an ATC licence is compliant with the regulations is a matter of judgement. The regulations do not rule out such a manager, but they do require them to be suitably qualified and trained

Hmm...do I get a hint of some Dr A influence in that response?

However for ASA and CASA the matter would appear to have been effectively closed and dropped into the infamous bottomless cyber-pit of obscurity... Dodgy

That was until I got to the bottom of the page and read this...

 Last update 11 December 2019 

...keeping in mind this trolling of mine through the ATSB website was conducted yesterday at approximately 9 am EDST??

Now I am not big on conspiracy theories but the probability of it just being a coincidence that some ATSB numpty was effectively reviewing the same cyber-binned REPCON as myself at pretty much the same time would have to be virtually zero?

It is worth noting that in light of the SMH and Yahoo Finance articles on Monday, that the ATSB now has skin in the game because if we are now to have (God forbid) another Seaview, Lockhart type accident where lack of proper regulatory oversight was an issue then the ATSB would potentially be in the gun for not picking up the warning signs?? 

Which will eventually bring me back to REPCON 1) but first read this: NTSB: Fatal FlyNYON flight was exploiting ‘loophole’ in regs

Quote:...The board also identified several contributing factors to the accident, including Liberty and NYONair’s “deficient safety management, which did not adequately mitigate foreseeable risks associated with the harness/tether system.” The NTSB’s investigation confirmed that, as previously reported by Vertical, Liberty pilots were aware of and repeatedly voiced concerns about hazards including the passenger harness and tether system. However, Liberty’s upper-level managers, notably director of operations Patrick Day, Sr. — the father of NYONair CEO Patrick Day, Jr. — “were disengaged from day-to-day operations and did not advocate for the pilots’ concerns.”

The NTSB found that Liberty improperly allowed NYONair to influence the operational control of Liberty’s FlyNYON flights, and that Patrick Day, Jr. “chastised the pilots and deprioritized their concerns.” Homendy highlighted several such exchanges, including one in which Day declared that FlyNYON’s motto is “rubbin’ is racing” — a reference to the Days of Thunder adage about playing rough — and said that pilots “just can’t get their snowflake feelings hurt.”

The board also had harsh words for the FAA’s “inadequate oversight” of commercial passenger-carrying operations conducted under Federal Aviation Regulations part 91. At the time of the accident, Liberty and NYONair were conducting their doors-off flights as “aerial photography” flights, exempting them from the stricter regulations that normally apply to air tour operations. Despite concerns raised by other FAA inspectors, the principal operations inspectors for Liberty and NYONair decided they didn’t need to evaluate these doors-off operations.

Consulting with the FAA’s legal department, the NTSB found that the agency intended “aerial photography” to include “only business-like, work-related aerial operations” — such as those conducted by trained professional photographers, not tourists wanting to take cell phone photos of their feet. NTSB investigator David Lawrence noted that FAA inspectors should have conducted the same due diligence: “Had they done that, they would have gotten the same legal interpretation that we received, [which] said this is not aerial photography, it was an air tour.”

The board highlighted how NYONair deliberately exploited the aerial photography loophole, advising its personnel to avoid the words “tour,” “route,” and “sightseeing,” and to instead use the words “custom,” “photo flight,” and “photography.”

“These companies were knowingly exploiting a loophole to avoid stronger regulation and oversight and people died because of it,” Sumwalt emphasized. The NTSB wants the FAA to establish clear definitions for the terms “aerial work” and “aerial photography” that specify only business-like, work-related aerial operations, as originally intended.

The FAA is currently allowing FlyNYON to conduct its tour operations under part 91 and part 136 with a letter of authorization (LOA. Liberty is no longer performing the doors-off flights). While part 136 imposes some additional requirements on the company, those fall far short of the part 135 safety rules that most passenger-carrying operations must comply with.

The NTSB revived a recommendation it initially made to the FAA in 1995 that all air tour operations be conducted under part 135. In 2007, when the FAA instead introduced part 136 — allowing small operators to conduct local tour flights without part 135 regulatory burdens — the NTSB marked its recommendation “closed – unacceptable action.”

“In this particular accident, [Liberty and NYONair] were operating under an egregious interpretation of current regulations — there’s no doubt about that,” said board member Homendy. “However, now NYON is operating under part 91 and 136 and an LOA, which is exactly what the NTSB opposed in [2007] when we closed this recommendation. Unacceptable.”

Sumwalt echoed, “Why is the FAA not requiring that higher level, that higher standard of care? . . . I think we need to take a hard line and say that by George if you’re going to charge people to go up for an air tour, it will be conducted on your part 135.”

Note that the NTSB do not in anyway hold back from chastising the regulator for not properly oversighting this operator and allowing the operator to exploit a loophole in the regs.    

MTF? - Definitely  Tongue

RossAir Cover-up: An insight of CASA's toxic culture within? -  Dodgy   

Quote from Tony Kern's - Cultural Threat Detection: Business Intelligence for the 21st Century:

Quote:Whatever wars are being waged in your organization between your strategic objectives and your actual outcomes, your culture tips the scales for the winning side

A McKinsey survey of some 3,000 executives found that two out of three organizational change efforts fail—the majority due to cultural resistance. Recognizing this threat, some organizations seek to first move the culture into alignment with the planned organizational change strategy. These fare somewhat better, but still fail more than 50% of the time. This isn’t because something else trumped culture in these situations. Rather, it’s likely due to the organization being unable to successfully change the culture to align with their new objectives—so they quit trying.

Have now reading (several times) the bollocks PC'd ATSB final report into the tragic Renmark C441 RossAir accident (plus other less publicly available documentation) and in the context of the Senate RRAT committee GA/CASA inquiry, IMHO the good Senators would do well to forensically examine all available documentation and request witness presentation before the committee of all key personnel and directly interested parties to this latest aviation safety bureaucratic cover-up. The reason being that like the Tony Kern quoted extract above highlights, there is much evidence to suggest that despite the efforts of David Forsyth and his fellow ASRR panel members to put forward proactive recommendations to address the toxic culture within CASA, that culture is alive and well, at least in the CASA flight operations inspectorate -  Dodgy      
Ref: #SBG 24/05/20: Liar, liar, hair on fire. 

Quote:AAAA - “CASA officer interpretations – an issue that was at the core of the ASRR Report findings and recommendations - individual officers within CASA continue to make interpretations that are not bound by regulatory heads of power, consistency, experience, sector knowledge or specific safety risks. It is opinion parading as policy – and frequently ill-informed opinion. CASA continues to lack a coherent, centralised policy interpretation and expertise centre to standardise regulation. Different offices have different interpretations, and generally CASA is not troubled by using subject matter experts that it may have on staff – as there is no centralised policy development system. In a modern regulator that had this pointed out to them in an independent review (the ASRR), serious questions must be raised about why this situation is perpetuated by senior management.” 

Indeed serious questions do need to be asked and perhaps the RossAir cover-up properly examined could be the catalyst to finally force serious reform within the Halls of Aviation House?

Could I also suggest to a certain South Australian Senator, that before this matter is shuffled from the SA Coroner's 'still pending' in tray to the 'no further action' out tray, that he should be making representations and FOI requests on behalf of the victims families, friends and directly effected constituents of SA.  Rolleyes 

Enough said back to the dots and dashes -  Wink 

Previous reference from Accidents -Domestic:    

(05-09-2020, 06:53 PM)Peetwo Wrote:  P2 OBS: Dots, dashes and passing strange disconnections??? -  Undecided  

While the BRB continue to mull over the IMO obvious (for whatever reason??) top-cover edited version of the final report, I intend to go off on a slightly different toot... Rolleyes

Ref: https://www.atsb.gov.au/media/5777738/ao..._final.pdf

Throughout the report there are several references to a pratice flight conducted a week before the accident flight - initial  reference from page 21:

Quote:...In preparation for the occurrence check flight, a practice flight covering similar sequences was conducted in XMJ the week before with the chief pilot and inductee pilot. That flight also had an observer on board with extensive Cessna 441 check pilot experience. The practice flight was not conducted as a training flight, but rather a private flight with two licenced and experienced pilots on board, preparing for their respective roles during the CASA check flight.

The observer advised that during the practice flight, the engine failure was simulated by the chief pilot reducing the power lever but not all the way to the flight idle stop. He further recalled that once the inductee pilot completed the initial response actions, the chief pilot partially advanced the power lever. The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation...

Page 26:

In assessing personal competency under this regulation, CASA recommended that ‘pilots should seek advice and consider refresher training or practice before commencing an operation they haven’t carried out for a while’. Although the pilot is already licenced and current on the class of aircraft, training for general competency can only be given by a pilot who holds an instructor rating and appropriate training endorsements.

The check flight briefing (see the section titled Check flight sequences) prepared for the flight had a series of questions at the end of the briefing for the inductee pilot to answer, consistent with the areas of competency identified above. Additionally, the practice flight conducted by the two pilots the week prior was an opportunity to practice the handling skills in this aircraft rather than other aircraft flown by each of the pilots...

Page 34:

...The chief pilot completed two flights as a check pilot in the year since being judged ready for assessment (Cessna 441 fleet manager’s OPC and a line check) and the practice test flight the week prior...

Page 35:

...Other than during the practice flight the week prior, the inductee pilot had not managed an engine failure in the Cessna 441 in over two and a half years, and the chief pilot had not had the opportunity to set an engine failure in almost a year. It is unclear from the chief pilot’s training records if he had ever been required to demonstrate a recovery from a mishandled engine failure after take-off in a Cessna 441.

The Cessna 441 check pilot observer who was present on the practice flight the week before described that flight as ‘messy’, with the inductee pilot appearing to be ‘rusty’. Specifically he recalled that the inductee:

•had to make reference to the checklist as he was unfamiliar with the memory items and wastherefore ‘well behind’ the aircraft
•adopted a steep pitch attitude that resulted in a lower than normal climb airspeed.

The observer further advised that there were also omissions by the chief pilot during the flight including that the:

•pre-flight briefing did not cover the procedure for transferring control of the aircraft between the two pilots
•incorrect use of the engine anti-ice system was not identified.

He also stated that the practice engine failure simulation after take-off from Renmark was ‘quite safe’ and that he debriefed both pilots on his observations...

..The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise...

P2 questions? 

1) To begin I wonder if there is a Flight Radar 24 &/or GPS record of the 'practice flight' from the week before? If so it would be interesting to see if the flight profile did indeed mimic the accident flight profile?
2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a pax and; b) the Chief Pilot didn't yet have CASA approval to conduct an OPC as a 'Check Pilot' on the C441, wouldn't that necessarily deem any simulated/practice asymmetric (OEI) as illegal, despite the fact the observer had extensive Cessna 441 check pilot experience? 
Quote: "..The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation..."

Now note the following from page 7:

Quote:Part 1 of the aircraft’s Log Book Statement specified that the aircraft was to be maintained in accordance with the AE Charter Services system of maintenance and all applicable airworthiness directives. The following summarises the maintenance activities conducted on XMJ leading up to the accident.

• On 31 August 2016 a number of parts, including both the left and right engines were removed for use on other company aircraft. These engines were reinstalled on 24 November 2016 and had operated for 385.2 hours on XMJ since this time.
• On 30 April 2017, the installed fuel control unit (FCU) from the aircraft’s left engine was replaced by an FCU borrowed from a third party maintenance organisation.
On 4 May 2017, the aircraft was erroneously released to service prior to in-flight FCU set-ups having occurred, with an endorsement in the deferred defect list that the left engine had to be operated in manual mode until the FCU set-up had been completed but could continue in service until no later than 14 May 2017 without the set-up being completed.
The Rossair chief pilot raised a concern on 8 May 2017 about the aircraft being released into service without the in-flight set-ups being completed, as the aircraft was more difficult than normal to operate with one engine in manual mode. Further maintenance work was performed on the aircraft, and, on 10 May, the aircraft was released into service, with both engines operating in normal (automatic) mode.
• The aircraft subsequently flew 28 flights, totalling 32.6 hours with no reported issues.
• On 26 May 2017, the original FCU that was removed on the 30 April 2017 was reinstalled onto the left engine of XMJ following removal, cleaning and reinstallation of the FCU’s manual mode control valve.
• A certification regarding a wing de-icing system unserviceability was made on 26 May 2017. It stated ‘No action was carried out at this time. Aircraft unavailable due to flying requirements. Customer notified.’ There was no entry in the defect field of the current maintenance release Part 3.
• Between 26 May and 30 May, the aircraft flew 6.9 hours without reported issue, including 4.5 hours across five sectors on the morning of the accident.

So the observer had prior experience conducting simulated/practice OEI in the accident aircraft to the extent that he/she could remember to the ft/lb what was required to be set in order to achieve zero thrust.  
3) Was the observer's experience with the accident aircraft before or after any of the listed maintenance to the engines (and in particular the LH engine)?

In relation to the above, I note the following from page 49 of the report:

Quote: The self-recommendation made by the chief pilot on his training records was for CASA to assess him in checking other check pilots, that is, just the Cessna 441 fleet manager, rather than checking all line pilots. Following that recommendation, a CASA FOI (who was on the accident flight) observed the Cessna 441 check pilot’s OPC, which was conducted by the chief pilot in the right-hand seat.

The OPC of the Fleet Manager, conducted by the CP and observed by the accident flight FOI, occurred in May 2016:
4) Did the FOI have de-brief notes on that flight? If so did he make mention of the procedure and possibly the setting of zero thrust of the Chief Pilot? I also wonder if there was a Flight Radar 24 record for that flight?

5) I wonder if it would be worth requesting through FOI (or Senate order) a copy of the ATSB interview transcript of the practice flight observer who had extensive check pilot experience on the C441?

P2 - Q&A.

I'll have two bobs worth of that please.

To that I'll add a link to this document: CASA RSR - VH-XMJ - REDACTED (28.10.19)

Keeping in mind the above extracts from the ATSB topcover edited report and then read and absorb the following from page 3 of the CASA RSR -  Shy

[Image: RSR-1-639x1024.jpg]

[Image: RSR-2-646x1024.jpg]

[Image: RSR3-651x1024.jpg]

[Image: RSR-4-647x1024.jpg]

"Once investigations are finalised..etc..etc.." - Hmm...wonder what the hold up is -  Huh

MTF? - Definitely...P2  Tongue

By the book:

Followed by bell, candle and requiem.

“In June 2017, CASA published TMI – etc.

“4 km west of Renmark Airport, South Australia on 30 May 2017.”

Perhaps the Ross Air fatal crash was not inevitable; but as a sporting man, you'd have to place it at short odds. Much now depends on how wide the scope of the Coroners inquest reaches and how deep the investigation is allowed to go. On the surface, supported by the ATSB report and backed by CASA – it seems pretty well cut and dried. But is it?

When you strip all the words back to basics, you are left with some fundamental flaws, which I believe must be addressed. In primus the flight was scheduled to test the ability of one pilot to asses the competency of another. This exercise to be conducted under the CASA approved system for the checking and training of pilots. Part of this was assessment of the pilot flying to manage emergency procedures, such as an engine failure.

What is a check pilot looking for during this exercise? The first and probably the most important is 'control' – the aircraft is bound, by nature and design, to behave in a certain, predictable manner. The corrections are well known and, essentially the same for all multi engine aircraft. Next comes 'recognition' -  what's gone wrong and what's to to be done. For this there are 'drills' which a pilot must know and execute from memory. What to do next? Once again we meet 'routine' behaviour; for most situations there is a basic 'escape' plan which must be executed. So, engine fails after take off; control, execute drill, and follow escape path, gain a safe height and decide what to do next. The candidate manages all of this, check pilot signs off and its all over for a while. Straight forward, routine day at the office. Provided it is all done by the book. But was the Ross-Air event done strictly 'by the book'?

It depends on which book you read. Certainly the check flight was not conducted by the Aircraft Flight Manual (AFM), which legally supports a much higher minimum height for the exercise. At the end of every argument, if the AFM states X and you do Y then the operation is technically illegal. The flight was operated outside of the Ross Air, CASA approved system, which mandated a height lower than the AFM required but much higher than that at which the event occurred at. To prove what?

There are several, safe scenario which can be used to establish that the pilot under check can perform the required drills. There is no need, in this class of aircraft (FAR 23) for a demonstration of an engine out continued take off. Once that notion is dismissed , it becomes a matter of executing the drill at a safe height at a safe speed.

I couldn't begin to count the number of EFATO and OEI drills done on a daily basis across the country – but it is a substantial number. All quite safely managed by junior pilots, in low performance aircraft obtaining their first multi engine rating. Countless pilots routinely demonstrating their ability to manage both airframe and drill during simulated failures, under instrument conditions. It is part and parcel of everyday flight operations. Provided the flight manual 'script' and basic safety precautions are followed there is only a slightly elevated risk, for a very short period of time.

The Ross Air – CASA approved – manual stated a height which was considered 'safe' for the demonstration of the EFATO drill. The aim to establish that at a critical speed and configuration the pilot could manage the aircraft with defined parameters.

So why was the exercise conducted outside of both the AFM and CASA approved systems?
And why did CASA feel the need to draft the TMI?

I'm with P2 on this one – too many parallels with Pel-Air; too many cosy chats and far too many outside influences being brought to bear. The “Make it Happen” philosophy espoused and force fed certainly did it's job. Aye, it happened all right...........

Toot – toot.

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