[Peetwo]

Leopard & Spots - time for an RC 

Made a most disturbing discovery yesterday, first for some background read the first 8 posts from AP thread: Closing the safety loop - Coroners, ATSB & CASA

From the AAP news feed etc. many of the DIPs & witnesses to the Canley Vale tragic accident were under the impression that the Andrew Wilson coroners inquest was, for some reason, to be held separately at sometime in the future. 

Contrary to recommendation 2 from the Kathy Sheppard inquest Coroners findings, there was also several key witnesses that were quite prepared to give evidence and were awaiting to be called prior to the (presumed) Andrew Wilson inquest.

However yesterday I was reviewing the ATSB Canley Vale Final Report - AO-2010-043 - where I saw there was an additional bookmark, labelled 'Inquest', that I had not noticed before:

"..The Coroner made two recommendations, the first of which reflects a minor safety issue identified by the ATSB in its report:

Coroner’s Recommendation

That the Civil Aviation Safety Authority (CASA) finalise the guidance material for Civil Aviation Advisory Publication (CAAP) 5.23 Multi-engine Aeroplane Operations and Training such that the guidance material is completed and released as soon as possible. The coroner noted that the guidance material provides for multi‑engine aeroplane operations and training to support the flight standard in Appendix A of s.1.2 of the CAAP. This relates to engine failure in the cruise.

Safety message

This accident reinforces the importance when flying twin-engine aircraft with one engine shutdown that the optimal speed be selected, along with maximum continuous power on the operative engine, and that the aircraft’s performance should be verified prior to conducting a descent. Pilots should also use the appropriate PAN or MAYDAY phraseology when advising air traffic control of non-normal or emergency situations.

What has been done as a result

CASA has started a project to amend advisory material relating to multi-engine aircraft training and operations to include guidance information about engine problems encountered during the climb and cruise phases of flight. This amended guidance material will include information about aircraft handling, engine management, and decision making during these phases of flight. Updates on this work by CASA are available on the ATSB website

Inquests are separate to ATSB investigations
Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident involving VH-PGW.

The ATSB's report can be downloaded by clicking on the link: Final report
The Coroner's report can be obtained from the Coroner's Court of NSW. Contact details are available at: [/url][url=http://www.coroners.justice.nsw.gov.au/]www.coroners.justice.nsw.gov.au. Queries regarding the Coroner's findings should be directed to the NSW Coroner’s Court..

This sub-page summary of the coroners findings vs the ATSB findings, sounded too final & conclusive. Which led me to the NSW Coroners Findings & Recommendations page, which is where I discovered this: 

Inquest into the death of Kathryn Anne SHEPPARD

Decision of Deputy State Coroner MacMahon on 14 August 2015

Catchwords: CORONIAL LAW, death following aircraft engine failure, section 81(1) findings, engagement of families of deceased with regulator, Recommendations made in accordance with section 82. 

Inquest into the death of Andrew Alan Thomas WILSON

Decision of Deputy State Coroner MacMahon on 14 August 2015

Which leads me to Kharon's post: A quiet, valuable achievement.

A quiet, valuable achievement.

K Sheppard   A Wilson.    At the Coroners inquest.

I don’t expect a head of steam would achieve very much; fury after the fact is  of little value.  But I am curious about the selection of witnesses to appear in this below the radar coroner’s inquiry.  I am also curious that the only published article we could find was a very crafty piece published in the AAP loop which reads as though young Wilson ‘killed’ Sheppard and that the inquest was all about one death, not two.  Considering the amount of press Hempel and others got, you could reasonably expect a little more coverage.  The only reason I can fathom is that very few people even knew the inquest was on.  Certainly several who had been advised that they were to be witness did not.  Gutted, gobsmacked and angry are some of the comments.  

No doubt it was all done legal and nice, the coroner really only to do his job and determine the cause of death, not too many facts needed for that – two killed in a crash: full stop.  CASA lift up the carpet, ATSB sweep the mess underneath; everyone off to lunch.  Nothing to see move along.

There was even a trite, mealy mouthed recommendation from the coroner:-

2. That CASA undertake public consultations in order to assist CASA in the development of a legislative proposal enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that; a. a significant safety risk exists or existed in an aviation operation; and

b. evidence of a witness or witnesses likely to have knowledge of an aviation safety risk cannot be obtained in any other way.

Read that half a dozen times, carefully

"enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that; a. a significant safety risk exists or existed in an aviation operation; etc."

Pure fiction. Had we been invited or even informed of the scheduled date, I and others would have very much liked to be there, if only just to listen to the ATSB/CASA discourse which prompted such a recommendation; I really would.  Must have been a work of art and with no dissention offered, a very easy piece to sell.

“to compel the attendance of persons at compulsory sworn interviews”

Does this imply that people did not turn up for interview; or, perhaps many witnesses were not summoned to interview; or, CASA did not bother to interview anyone?   Many had ATSB interviews, several provided empirical evidence, we can’t find any one witness (yet) who was informed of the inquest, let alone attended.

As I say, all neat and tidy, dry as dust and no skin off the watchdog’s arse.  If you thought the handling of Pel-Air was a clever bit of legerdemain, Canley Vale will blow your socks off: the ATSB report is a good place to start.  ATSB may well have written the ‘technical’ analysis, for what that’s worth, but the back end was pure malice aforethought and had little to do with the accident; just the politics of yet another predetermined result.

As the members of the Senate standing committee have been advised on several occasions; you think Pel-Air was a rum do? Brothers, you ain’t seen nothing yet.  Just take a peep under that plush, expensive carpet, then tell me what you see.  We cannot stop this from happening, perhaps you can.  But after the nett result on Pel-Air, we wonder.

It is a tale Told by an idiot, full of sound and fury, Signifying nothing.

This ain’t good enough, not by a bloody long shot.

Selah.

UFB! Nope - TFB (Truly Duckin' Believable)



MTF..P2