[Peetwo]

Sense & Credibility??- Norfolk Island ditching six years on.

Couple more key moments from that infamous hearing, first from Doc JA - who perhaps has also studied the silver tongue methodology of economic delivery:

Then ffwd to the McComic response on questioning by Nx on the Chambers report at Budget Estimates 3 months later: 

And that is where I believe the whole NX 'Motion of Privilege' first started:

 161st Report

Pel-Air air safety issues spelt out by pilot and Senator, David Fawcett:

..In 2010 a review was done into the operations of those two agencies.

Of the eight desired outcomes of that review, the committee found that actions by ATSB and CASA failed to deliver against six of the main areas.

I will list them and then talk in more detail about them.

They failed to maximise the beneficial aviation safety outcomes that could have been derived from the investigation into this incident.

They failed to enhance public confidence in aviation safety.

I think we saw that in the controversy in the aviation industry and the media around the report when it was finally released.

They failed to support the adoption of a systemic approach to aviation safety.

They failed to promote and conduct ATSB independent no-blame safety investigations and CASA regulatory activities in a manner that assured a clear and publicly perceived distinction between each agency’s complementary safety related objectives, as well as CASA’s specialised enforcement related obligations; they also failed to avoid to the extent practicable any impediments in the performance of each other’s functions.

They also failed to acknowledge errors and to be committed in practice to seeking constant improvement.

The committee made 26 recommendations to address a number of systemic deficiencies that were identified in both the investigative and regulatory processes but also in funding and reporting.

Safety outcomes is one area that I would like to touch on.

Accident investigations are an opportunity for an informed and expert body to sit back and take a considered look at why an incident occurred.

That body may be expert but they are not necessarily the best judges of how the lessons from that incident may be applied to other sectors of the aviation industry.

The committee found that for various reasons and over time the ATSB processes have got to the point where much evidence can be excluded if it does not fall into the categories that they consider will impact on high-risk future operations. So we have a situation where they are making an arbitrary decision to exclude evidence, and without evidence they are not then investigating or reporting on what actually occurred.

That means that other aviation operations are not the beneficiaries of an explanation of occurrences and failures in a system safety approach and what defences failed such that the accident occurred. It has been the traditional approach to identify each of those factors and let the stakeholders make their own assessment. But the safety outcomes are no longer optimised because of this approach of trying to make that arbitrary decision at the front.

That is a significant flaw in the current approach which the committee has recommended be revisited.

The report and CASA’s statements in name supported the concept of a systemic approach to aviation safety.

But what we found very clearly was that the investigation focused very quickly on the pilot in command on the night, as opposed to looking at the raft of other factors.

Looking at the James Reason model of system safety, one sees that there are a number of defences which are in place, which include the operating company, the regulator and a raft of things—training et cetera—as well as the pilot. But many of those factors were given, at best, lip-service. They were mentioned in the report so a box could be ticked to say that they were considered, without a detailed consideration of them.

For that reason, the report was quite flawed...


ventus45 - Joining the dots to MH370..

Much like the ASAM blog piece from Feb 2013 (Blast from the past), the following post from ventus45 nails down the bureaucratic bollocks that we were expected to swallow as acceptable behaviour by Chief Commissioner Dolan, in his attempt to obfuscate the complicity of the ATSB in the CASA Pel-Air cover-up. 

As a background the ventus45 post relates to the following video segment from the 28th February 2013 AAI, Senate inquiry public hearing:

Also relevant to the Ventus post is this video segment to that same public hearing:

  

ventus45

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Aussie my dear girl, the "modern" Annex-13 IS the PROBLEM, not the answer.

A clasic example is our own ATSB.  

Dolan's masterpiece on the ditching at Norfolk Island is up there as a prime example of the problem.
Years, to produce what ?
Rubbish.
May I remind you of the little matter of the spat between Chief Commissioner Dolan (ATSB) and Senator Fawcett, the Senate Estimates ?
Remember that ?

A recap.
They were arguing over which "amendment" to Annex-13 was applicable to the "ditching".
It was all about whether or not the cvr/fdr could, should, would, or must, be recovered.
Dolan used a later amendment than both the date of the accident and the date of the initial decision and report, to post-facto justify his prior decision not to recover them.
He wiggled and squirmend, but he got away, effectively, scott free.
We (the people) lost - yet again.

Sir Humphry Appleby on the other hand, probably smiled.......

The ATSB did not even do any significant investigation of the evacuation or the life jackets etc.  
They are "significant" requirements in Annex-13 are they not ?  
APPARENTLY NOT.

Last I heard, the life jackets were still in the Police Station on Norfolk Island.
It makes you wonder why we have a Senate anyway, when such "incompetence and deriliction of duty" is "allowed" to pass for "world's best practice".
Way beyond reasun me-lud, way beyond reason.

If you have been around as long as I have, grey hair, thick glasses, etc, you can look back at older, earlier reports, and older editions of Annex-13.  
It becomes clear, that over the years, the industry has very skillfully, and very deliberately, progressively amended Annex-13, to water down it's fundamental original purpose, "enhance safety", and have managed to morph it, into a document, seeming designed only to "protect the industry".

With each passing amendment, required time frames get longer, investigative requirements get diluted, and reporting requirements get diluted almost to the point of "why bother at all".  Modern investigations thus take longer, and they produce less substance at the end.  
If you read reports of 20 years ago, and compare them to those of recent years, the trend is clear, as is the obvious intent.

In short, Annex-13's reporting "milestones" have become the "millstone of the truth", in this, and many other investigations.
In days of old, "genuine" investigations were updated more or less "on the fly" so to speak.
Interim reports were issued, and recommendatiions produced, issued, published, and acted upon, also, "on the fly", in public, with full disclosure. The "final report" effectively "consolidated" the lot.

What we have today, is, unfortunately, entirely different.

Annex-13 gives the industry the luxury of playing the time game, to protect itself, it's own interests, not the public interest.
The best way to do that, is to release as little as possible, as late as possible.
People eventually forget, time goes on, it drops of their radar, especially so with the media.

In the case of MH-370, they are not just "letting the money run out", more importantly, more significantly, and more specifically, they are deliberately "running out the clock".

I listened to an address on ABC Radio by Angus Houston in Adelaide recently.
He spent almpost the entire speech on MH-17.  
What little he said about MH-370 (at the very end) was all about "damping down expectations" - "it took us 75 years to find HMAS Sydney" ... etc.
What does that tell you ?
Cast your mind back.
When did Angus come on scene with the JACC ?
When did he leave the JACC ?
The JACC still exists, and does what, of substance ?

The Chinese have walked away from the sham of this investigation already.
How long before it is shut down entirely ?

Hoorah for ventus45 & a packet of TimTams...P2