[Peetwo]

Canley Vale & the Senate PelAir Inquiry - Joining dots, dashes & calling for resurrection of R10 & R11 NOW!   

Reference from - The noble Art - Embuggerance thread:

Embuggerance & investigative probity - In the Sleepy Hollow shelf-wared tales of embuggerance, there is one case, that of Airtex, that keeps on rearing its ugly, festering head.  Like the long trail of industry exemptions, the Airtex ET provides many puerile examples of CASA double standards in regulatory enforcement. How this - vindictive, hypocritical trail of nonsensical, big "R" embuggerance - all began is hard to define but it escalated not long after the fatal accident into Botany Bay of Metro VH-OZA and culminated with the tragic accident on 15 June 2010 of Skymaster (sister company) VH-PGW Mojave at Canley Vale.

Either way the Airtex case now sits as a benchmark of the extreme lengths of enforcement persecution that CASA deployed throughout the McCormick years.   
 
Another Airtex 'point of comparison'.

Conduct of training not in accordance with operator
and regulatory requirements.

Significant safety issue

The pilot’s Metro III endorsement training was not conducted in accordance with
the operator’s operations manual and Civil Aviation Safety Authority regulationsgoverning training and checking requirements, with the result that the pilot’scompetence and ultimately, safety of the operation cannot be assured.

Action by the Civil Aviation Safety Authority

On 10 July 2008, Civil Aviation Safety Authority (CASA) officers met with the aircraft operator to discuss the results of the June 2008 risk-based audit. As a result of those meetings, on 11 July 2008 CASA imposed the following conditions on the air operator’s certificate:

• no passenger carrying charter or aerial work operations were to be conducted whilst the then chief pilot held that position, with such operations only to resume upon CASA approval of a new chief pilot.

• the operator was required to develop multi-crew procedures in order to crew Metro aircraft with two qualified pilots when carrying passengers, with those procedures to be in place prior to such operations.

• by 18 July 2008, the operator was required to implement a system that printed pilot flight and duty time records to ensure a permanent record is kept.

• by 25 July 2008, the operator was to implement a confidential reporting system to provide the chief executive officer (CEO) with information relating to poor operational standards or hazards and risks within their operations.

• by 31 July 2008, the operator duplicate, via a secure back-up process, all computerised operator records and keeps these back-ups in a secure place

• by 31 August 2008, the operator was to employ an appropriately-qualified independent auditor that was acceptable to CASA. The auditor was required to conduct comprehensive quality and aviation safety systems audits on a 6-monthly schedule, and provide CASA with a copy of each audit report within 3 weeks of the completion of the audit

• by 30 September 2008, the operator was required to develop a comprehensive, company-wide safety management system that was fully supported by the CEO

• by 30 September 2008, the operator was to review and where required, amended the operations manual, any amendments were to be submitted to CASA for acceptance.

Action by the aircraft operator

In response to the issues that were identified in CASA’s risk-based audit of June 2008, on 30 July 2008 the operator advised CASA of the following actions to rectify those issues:

• the operations manual was being rewritten to:

– bring the operator’s training and checking into line with the regulations and address multi-crew operations

– ensure that base and line checks accurately reflected the operator’s procedures and testing requirements by reference to specific test-content forms

– include the requirement for all inducted pilots to complete ‘wet drill’ training on the use of life jackets and life rafts. The results of that training would be recorded and renewed annually

– ensure the review of ground course theory examinations and that they were corrected to 100% knowledge of the subject

– ensure the completion of formal ground courses and that the training and syllabuses were documented

– ensure that pilots undertook pressurisation endorsement with a minimum training criteria

• several pilots were being retrained as required to meet the operator’s endorsement training requirements

• the operator’s computer-based flight and duty time records were password protected and a monthly copy of each crew member’s record would be printed out and placed on the individual’s file

• flight crews had been informed about the importance of accurately completing paperwork

• the head of training and checking had resigned and a new individual had been approved by CASA

• one pilot who had been identified as not having sufficient in command under supervision hours had been recertified.

Subsequently, on 17 September 2008, the operator provided an amended operations manual to CASA for review. That included amendments to Part C of the manual.

On 16 December 2008, CASA issued a new Air Operators Certificate to the operator.

ATSB assessment of CASA and operator action

The ATSB is satisfied that in combination, the action taken by CASA, and response to the CASA action by the aircraft operator, adequately addresses the safety issue.

Now again I am not being critical of the outcome, on the contrary it is a perfect example of how the system is supposed to work, the ATSB identifies significant safety issues with the AOC holders operations, which implicate CASA through some lack of oversight issues.

CASA (much like with PelAir) puts in place requirements they feel need to be addressed before granting the company an AOC renewal.

The company embraces & proactively addresses these requirements and even further to the CASA expectations puts in place a SMS to help identify & mitigate any future safety issues.

The trouble for Airtex was that Wodger (backed by McComic) then came on the scene and finally they were done by association with Skymaster & the Canley Vale tragedy. 

A passage from the Senate PelAir Inquiry report (Chapter 6) that is very relevant to the ATSB whitewashed Canley Vale accident report and subsequent 'nothing to see here' Coroners Inquest:

Comparison with another ATSB report


6.32      Although it was drawn to the attention of the committee very late in the inquiry, the committee notes some similarities regarding the treatment of organisational and regulatory issues with the ATSB's report on 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010' or the ‘Canley Vale report’.


6.33      Also a medical flight, VH-PGW crashed while the pilot was trying to make an emergency landing after an engine failure. Tragically, both the pilot and the nurse on board lost their lives.


6.34      The ATSB report discusses significant issues within the operator (Skymaster, owned by Avtex), some of which were recognised by CASA prior to the accident. The report also acknowledges that CASA did not detect that the pilot in question, and a number of other pilots, did not receive appropriate training from Avtex.


6.35      However, the ATSB then excuses this lack of oversight by stating that this non-detection by CASA was ‘probably due to the two companies having separate Air Operator’s Certificates, with different CASA inspectors being assigned to the surveillance of each company’[44]

6.36      The Special Audit conducted by CASA of Skymaster following the accident in June 2010 revealed a large number of safety deficiencies in the systems and work practices in place, including issues with training and checking. The committee notes that in August 2010 CASA cancelled Skymaster’s AOC, based on a serious and imminent risk to air safety if operations continued. This decision was upheld by the Administrative Appeals Tribunal (AAT).[45] The committee also notes that CASA had issued Avtex with a show cause notice on 28 May 2010, just over a fortnight prior to the accident.


6.37      While the committee acknowledges it has not had the opportunity consider this report, or the transcript of the AAT hearing, in detail, it would like to express concern about the following matters, given what the committee now knows about the Pel-Air incident:

• while the incident occurred in June 2010, the ATSB only issued its final report on 20 December 2012, some two and a half years later. This is a similar timeframe to the Pel-Air report, which is discussed in Chapter 3;
  
  
  
• the ATSB concluded that ‘it was unlikely that any deficiencies in the pilot’s PA-31 endorsement training contributed to the accident’,[46] despite acknowledging in its report that the pilot had not received training in mid-flight engine failure. The committee notes that the ATSB reports engine surging led to the pilot’s actions, which resulted in the crash[47];
  
  
  
• the ATSB also concluded that ‘no organisational or systemic issue was identified in respect of CASA’s surveillance that might adversely affect the future safety of aviation operations’[48]. This is despite the fact that a post-incident Special Audit by CASA led to a suspension of Skymaster’s AOC because of a ‘serious and imminent risk to air safety’ [AATA 61, point 5]; and
  
  
  
• the ATSB excused CASA’s lack of oversight on the basis that the companies had two separate AOCs and therefore CASA investigators may not have been aware that Avtex owned Skymaster[49]. However, during the AAT review, CASA justified the cancellation of Avtex’s AOC due to CASA’s opinion that ‘because of the close relationship between Avtex and Skymaster, and the joint resources shared by those companies, if Avtex continued its operations under its AOC, that would also result in a serious and imminent risk to air safety’ [AATA 61, point 5].
  
  
  

6.38      The committee considers that this report, and the associated evidence from the AAT review, could point to a disturbing trend where the ATSB disregards or excuses CASA failures. It appears, from the publicly available material, that there are significant similarities between this and the Pel-Air report. The committee is of the view that the establishment of the independent panel (recommendation 8) should play a vital role in ensuring no such reporting trend continues...



Recommendation 10


6.41      The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.


6.42      The committee is concerned that the ATSB report ATSB's report on 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010' could demonstrate a trend where organisational and regulatory factors are not considered appropriately or in sufficient detail by the ATSB, despite post-accident investigations by CASA indicating there were significant deficiencies with the operator and appearing to indicate insufficient oversight by CASA. As highlighted in Chapter 5, the committee is also concerned about ATSB attempts to predict future risk for operators. The ATSB should analyse why the accident happened but operators are best placed to assess how the lessons may affect their current and future operations.

 
This was the Murky Mandarin (& his minions - including the former miniscule ) non-committal response to R10:  



Fortunately the former miniscule (to his credit), after the TSBC peer review, had an epiphany a put pressure on the ATSB to re-open the PelAir investigation.

However after the whitewash/obfuscation (as identified by the Senate Committee above, & which apparently included both the TSBC & the NSW Coroners Court) by the bureau providing, yet again, top cover for CASA with the Canley Vale tragedy; we suggest that R10 should be invoked for the re-opening of the ATSB VH-PGW investigation.

6.50      The Chambers Report highlighted surveillance deficiencies which concern the committee.


6.51      The committee believes that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to:

• non-RPT [regular public transport] passenger carrying operations;
  
• approach to audits (eg. the need to evaluate line aircrew for effectiveness of Safety Management System (SMS) not just elements of SMS itself); and
  
• training and standardisation of FOI [Flying Operations Inspector] across regional offices.
  
  

Recommendation 11
6.52      The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.

This was Murky's, again spin-n-bulldust, response to R11:



Bizarrely M&M seems to be comfortable with the idea of allowing ICAO, through the USAP-CMP audit process, to rule on whether CASA meets NAA best practice in regulatory oversight & enforcement. Therefore, in light of the Canley Vale whitewash, we call on the Senators to pressure the government to invite the FAA to audit CASA & the Australian SSP - ASAP


MTF..P2