A kingdom, on the toss of a coin.
The LB ‘list’ of fundamental flaws is particularly useful up to the point of impact. The holes in the safety net are exposed and, IMO, form a great part of the causal chain. Had those areas of interest been the subject of the Senate inquiry, we may have seen some ‘reform’ of the system to mend the net. The short list of ‘system’ flaws, properly addressed, is a good place to start reform – from an air safety perspective. There would be a gold star from an external auditor if these matters were ‘sorted’, particularly if the agencies concerned could say ‘hand on heart’ that they identified and corrected these deficiencies without prompting or ministerial involvement; part of a developing improving safety culture. Alas. Up went the drawbridge, out came the defenders armed with denial and obfuscation. This is bad enough and typifies the Hedgehog like defence mechanisms automatically deployed when a ‘threat’ is nearby.
It reminds me of the old WWII tale, told by an Uncle who flew during that dreadful conflict. When aircraft returned from a mission – shot full of holes, the ‘engineers’ not only repaired the damage but added additional armour plating to the damaged area. Nothing changed; the aircraft which returned still had holes shot in them, in roughly the same places. This went on until some bright spark said “it’s the ones which are not returning we need to examine; that will tell us where to reinforce”. Well, seems they had a look at a few lost aircraft and began putting the ‘armour’ in the vulnerable places, the places which cost lives and machinery. Immediate improvement – lesson learnt. No one got blamed or denigrated; they were all too busy and pleased to be able to reduce losses. Seems to me like a bloody good place to start an overhaul of ‘service’ to industry.
If you continue along LB’s line (as you must) then the next step involves the handling of the Norfolk debacle by ATSB and CASA. The extraordinary behaviour of the ‘Bankstown’ crew and management; after the event, does little in the way of begging for answers – it stridently demands those answers. The aircrew are being used as a focus point, bait for the ‘looky-loo’s’. This distracts attention away from the almost incredible behaviour of upper, middle and low level management. The Pel-Air operation was almost a basket case, sliding along mostly on luck, benign weather and ‘derring-do’. A protected species, there is no audit trail showing where CASA brought deficiencies to the attention of ‘management’. There is no record of extensive, progressive amendments to the company operations manual supporting the changes in operational dynamics. There is no record of ‘international’ operations being a recognised risk area nor of a progressive maturing of both system and guidance, let alone education. Hells bells, Pel-Air could not even address the demands of the French authority; choosing instead to let it be known to ‘avoid’ Noumea whenever possible – even if not possible…..
If and it is a big IF, the Senate committee ever decide to take another look at the Pel-Air debacle it should focus on the behaviour of ‘the regulator’ throughout not only this disgraceful episode, but of several ‘other’ bizarre events which, IMO demand answers. There are many strange tales told from across the wide, brown land of CASA behaviour; some are likely to be true – but non so strange as the tale of Wodger and his merry band of misfits.
Not that any of this matters anymore than a Tinkers curse. The minister will return to his man-scaping activities; St Carmody will pour oil on troubled waters, Aleck will continue to confound and confuse; the rest will simply sit back, do as they are directed, count their super and wait for the opportunity to extract pay-back, from those who dare to mention how severely ducked up CASA is, in reality. So don’t say word children – lest the bogey –man turn up at your next audit. “Is he really real?” asks one of innocent faces “Yes child, I’m afraid he is”.
“I am not even prepared to meet Professor Einstein or Bertrand Russell; why should I vaingloriously assume that God would find me interesting? (Robertson Davies).
Toot (sigh) toot…
Quote:The coin having fallen the other way on 18 November 2009, the PIC of NGA exposed fundamental flaws in:
- Australia’s Pacific neighbours’ flight services
- BOM
- Australia’s ANSP
- the governance of an external Australian territory
- the operations of a politically-connected air operator, and
- the regulator’s oversight of the air operator.
The LB ‘list’ of fundamental flaws is particularly useful up to the point of impact. The holes in the safety net are exposed and, IMO, form a great part of the causal chain. Had those areas of interest been the subject of the Senate inquiry, we may have seen some ‘reform’ of the system to mend the net. The short list of ‘system’ flaws, properly addressed, is a good place to start reform – from an air safety perspective. There would be a gold star from an external auditor if these matters were ‘sorted’, particularly if the agencies concerned could say ‘hand on heart’ that they identified and corrected these deficiencies without prompting or ministerial involvement; part of a developing improving safety culture. Alas. Up went the drawbridge, out came the defenders armed with denial and obfuscation. This is bad enough and typifies the Hedgehog like defence mechanisms automatically deployed when a ‘threat’ is nearby.
It reminds me of the old WWII tale, told by an Uncle who flew during that dreadful conflict. When aircraft returned from a mission – shot full of holes, the ‘engineers’ not only repaired the damage but added additional armour plating to the damaged area. Nothing changed; the aircraft which returned still had holes shot in them, in roughly the same places. This went on until some bright spark said “it’s the ones which are not returning we need to examine; that will tell us where to reinforce”. Well, seems they had a look at a few lost aircraft and began putting the ‘armour’ in the vulnerable places, the places which cost lives and machinery. Immediate improvement – lesson learnt. No one got blamed or denigrated; they were all too busy and pleased to be able to reduce losses. Seems to me like a bloody good place to start an overhaul of ‘service’ to industry.
If you continue along LB’s line (as you must) then the next step involves the handling of the Norfolk debacle by ATSB and CASA. The extraordinary behaviour of the ‘Bankstown’ crew and management; after the event, does little in the way of begging for answers – it stridently demands those answers. The aircrew are being used as a focus point, bait for the ‘looky-loo’s’. This distracts attention away from the almost incredible behaviour of upper, middle and low level management. The Pel-Air operation was almost a basket case, sliding along mostly on luck, benign weather and ‘derring-do’. A protected species, there is no audit trail showing where CASA brought deficiencies to the attention of ‘management’. There is no record of extensive, progressive amendments to the company operations manual supporting the changes in operational dynamics. There is no record of ‘international’ operations being a recognised risk area nor of a progressive maturing of both system and guidance, let alone education. Hells bells, Pel-Air could not even address the demands of the French authority; choosing instead to let it be known to ‘avoid’ Noumea whenever possible – even if not possible…..
If and it is a big IF, the Senate committee ever decide to take another look at the Pel-Air debacle it should focus on the behaviour of ‘the regulator’ throughout not only this disgraceful episode, but of several ‘other’ bizarre events which, IMO demand answers. There are many strange tales told from across the wide, brown land of CASA behaviour; some are likely to be true – but non so strange as the tale of Wodger and his merry band of misfits.
Not that any of this matters anymore than a Tinkers curse. The minister will return to his man-scaping activities; St Carmody will pour oil on troubled waters, Aleck will continue to confound and confuse; the rest will simply sit back, do as they are directed, count their super and wait for the opportunity to extract pay-back, from those who dare to mention how severely ducked up CASA is, in reality. So don’t say word children – lest the bogey –man turn up at your next audit. “Is he really real?” asks one of innocent faces “Yes child, I’m afraid he is”.
“I am not even prepared to meet Professor Einstein or Bertrand Russell; why should I vaingloriously assume that God would find me interesting? (Robertson Davies).
Toot (sigh) toot…