[Peetwo]

TICK TOCK goes the ATSB and CASA topcover clock -

Drifting slightly "K" I want to firstly focus on this post from Lead Balloon off the UP thread dealing with RossAir cover-up report:

https://www.pprune.org/10772770-post127.html

What is that power for, if not to compel the provision of information and the answering of questions for the purposes of an investigation? You don’t “request”, you “require”. And you then prosecute those who fail to comply with the requirement to produce material and answer questions.


The ATSB was “unable” to make a determination about the circumstances under which the incorrect procedure was approved for use by the operator, because the ATSB failed to exercise powers that it has to obtain information about those circumstances.

There will some sophistry around words like “approval” and “acceptance” - a matter touched on in the report - but the bottom line is that the incorrect procedure got there ‘somehow’ and there should be records in CASA and knowledge in CASA about that ‘how’.

Astonishing.

And that is not the only aberration/disconnection contained within the ATSB topcover report but first, also off the UP, an extremely relevant quote from OA:   

Old Akro once again nails it on the UP -   

OA via the UP: https://www.pprune.org/pacific-general-a...st10795136

Old Akro

But it can be reduced. That's why pilots participate in cyclic check and training, flight reviews etc. It's why we have developed checklists and crosschecking etc. All these came through studies and and research leading to redesigning of systems based around human factors. It's the basis for why T.E.M is now a mandatory competency for pilots. 

Tell that to the Renmark pilots operating a periodic review under supervision of a CASA FOI.

James Reason himself details the limits of process based safety in his books. In many ways Tony Kerns work takes over from James Reason. But personal responsibility doesn't fit well with a regulators mind set.

This forum is good at being unforgiving of pilots. But this accident had 4 very well qualified pilots with very good recency flying well equipped aircraft. Both had active IFR flight plans. Both were flying consistent with their flight plans. Personally, I cannot point to anything that would give me any comfort that the same thing would not have happened to me.

The ATSB report acknowledges that both aircraft were identified via ADS-B returns received by the AsA system (as opposed for F24 etc). The ATSB preliminary report acknowledges that the AsA system had the information that indicated a traffic conflict (note that I say system, not controller. Its unknown what the controller was presented). ATSB have departed from typical practice by not making any comment on the recorded radio transmissions in its preliminary report, nor presenting any transcripts. Which is curious.

This is going to be a complex report and I'll put money on the ATSB not publishing a final report for 3 years after the accident. But I'm pretty sure that airspace design (ie class E, CTAF and control step location), radio frequency boundaries, radio procedures and the concept of aircraft self separating in IMC are all likely to feature in the final report. These are all systems based issues.

Although technically not totally correct ie 'pilots operating a periodic review..' the point that OA makes does go to some of the other 'organisational factor' aberrations/disconnections that appear to have been glossed over inside of the bollocks O&O'd ATSB report. - 

Let me begin...

Extract from page 49 of the report:

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 Cessna 441 fleet manager believed that this check gave the chief pilot approval to conduct the fleet manager’s OPCs from then on, in line with the recommendation made on the chief pilot’s training form. Although the chief pilot submitted his training records to CASA following successful completion of his check pilot training in May 2016, no formal application form for check pilot approval was submitted to CASA at that time, and no regulatory services task was raised by CASA. The June 2016 flight was processed as a regulatory services task as a check pilot OPC, with no CASA documentation to support the chief pilot’s approval as a check pilot in this capacity. Following the accident, CASA verified the chief pilot did not hold any formal check pilot approvals.


In January 2017, a regulatory services task was raised for the chief pilot to be assessed as an EMB 120 check pilot. As noted in the section titled CASA awareness of Rossair workload, another CASA FOI observed the chief pilot undergoing an OPC (as captain/in the left seat), and made comments about his performance and CASA needing to observe his personal proficiency again before considering any check pilot privileges. Some of the operator’s personnel and staff within CASA interviewed by the ATSB recalled that CASA had observed the chief pilot again in the EMB 120 simulator, and they were under the impression that the chief pilot’s check pilot approval for the EMB 120 had progressed. However, CASA advised that no further observations of the chief pilot’s flying performance had been undertaken prior to the day of the accident and as of May 2017 the assessment for the EMB 120 check pilot approval had not been completed.



On 2 May 2017, the chief pilot sent an email to CASA noting that the Cessna 441 fleet manager’s loss of a medical certificate presented an ongoing challenge. He noted that the contractor Cessna 441 check pilot, who had recently conducted two checks on two of operator’s Cessna 441 pilots with CASA approval, would be conducting checks on behalf of the operator in the future. However, the chief pilot requested that he would like to conduct an OPC and line check on the contractor check pilot to induct him into the operator. Alternatively, he requested approval to conduct OPCs on another experienced Cessna 441 pilot. The chief pilot noted that he had been undergoing training as a backup to the fleet manager, and had conducted the fleet manager’s OPC in June 2016 under CASA observation. He also noted that he had since gained further experience on the Cessna 441 and had observed the fleet manager conduct other checks on the operator’s pilots.



On 4 May 2017, CASA responded to the chief pilot, and advised that it could arrange for an FOI to observe him conducting another OPC which, if successful, meant that it could issue him with an approval to conduct OPCs and line checks. CASA subsequently varied the EMB 120 check pilot task to become a Cessna 441 check pilot task. No formal application form was received (as requested by CASA), and therefore the normal pre-flight assessment verification process, as per the CASA AOC handbook, was not recorded as having been conducted.


In subsequent correspondence, the inductee pilot was nominated by the chief pilot as the person he would conduct the OPC on. The flight was to be observed by the CASA FOI who was a Cessna 441 specialist and had previously observed the chief pilot during the June 2016 flight. CASA personnel advised the ATSB that, following the chief pilot’s request on 2 May 2017, they had discussed the request among themselves (including the CMT manager) in the Adelaide office. They believe they had considered all the risk factors involved with the proposed flight, and had sufficient mitigators in place. However, there was no written record of these considerations.

Now note the following from the CASA RSR - VH-XMJ - REDACTED (28.10.19):
(Note that where a | is indicated in the timeline(s) denotes a redaction of the identity of the CASA FOI)

A review of the Check Pilot training records(5) for Martin Scott indicates he completed the training
in Part C of the operations manual, by completing the activities listed below:

• 4 April 2016 C441 2.8 Hrs by |
• 8 April 2016 C441 2.5 Hrs by|
• 20 April 2016 observing only
• 21 April 2016 observing only
• 22 April 2016 observing only
• 30 May 2016 C441 2.6 Hrs by |

Martin Scott provided the below documentation (which was forwarded to CASA) as certification
of completing the specified Check Pilot training:

• 15 April 2016 C441 OPC (LHS) 1.9 Hrs by|
• 30 May 2016 C441 OPC (RHS) 1.4 Hrs by |
• 30 May 2016 C441 Line Check Assessment 2.6 Hrs by|
• 30 May 2016 C441 Training syllabus check form recommendation

The Check Pilot training described in the manual was concluded 12 months prior to the
assessment by CASA (accident flight). Evidence was gained that a single refamiliarization
flight took place the week prior to the assessment. The practical functions that would have
been authorised by the CAO 82.0 Check Pilot approval are reasonably comparable to those of
a CASR Part 61 Flight Examiner Rating holder and the holder of a CASR Part 61 multi-engine
class (aeroplane) training endorsement. 

The timeline(s) above were from a CASA internal document (ie the RSR). Therefore one must assume that this was the official recollection/version of events from the applicable FOIs from the SA CASA regional office. Personally I would like to see the log book entries from all three accident pilots and also the former C441 Fleet manager. Especially when you consider the Fleet manager's interpretation (underlined above) and the fact that there would appear to be a 12 month disconnection between the Chief Pilot completing the required CASA outlined C441 training syllabus and then completing his check pilot approval assessment flight?        

MTF...P2