[Peetwo]

A decade of obfuscating an open safety loop??

Via the embuggerance thread:

Also GlenB replies to Luce on the UP -  :

Luce

Dear Luce and others,

Please be assured that I value your comments.

I understand your sentiment. My matter is unique, in that it has no safety element to it all. There has never been any allegation of any safety concern with my operation at all. It was simply an allegation of a breach of the Civil Aviation Act that states “An Air Operator Certificate cannot be transferred. It is that fact that makes my matter unique, and I do run the risk of “muddying “my own case.

I have taken your advice on board, and it will be in my “considerations” going forward. Cheers.

As a final thought about the Bruce Rhoades matter. Drawing on 25 years’ experience in the flight training industry, I am fully satisfied that the young back packer in that incident would still be alive if:

The CASA Flight Operations Inspector (FOI) adopted this approach.

He/she was allocated 20 businesses by CASA, and committed to popping into each of those businesses once a month, for morning or afternoon tea, on a mutually convenient date.

They sat together for an hour and discussed matters with good intent. They built a relationship of confidence and then trust. A natural part of that conversation could have been as simple as “Run me through how you conduct adventure flights Bruce?” or “can I come along on one of your adventure flights Bruce”, or "how would you handle XXXXX Bruce?"

Any CASA concerns or questions could be resolved right back at that stage. The accident and fatality would most likely never have occurred.

Its hard to digest, but it really is that simple.

If the FOI turned up for morning or afternoon tea, and was told to bugger off, that would be a justifiable CASA concern.

The Operator that invites them in, as almost all would, with welcome arms is the Operator that will work collaboratively with CASA to improve safety and quality outcomes.

Its all well and good to have thousands of pages of documentation, laws, rules, advisories, regulatory philosophies, statements of expectation, exemptions, etc etc, but if the good intent and professional approach isn’t there, then it just won’t work. It really all starts with intent. Intent from the operator and intent from CASA.

The intent exists with the vast majority of operators, and CASA will know, because they will be invited in.

Sadly, and tragically, and most especially at the GA level, there would be less accidents if CASA choose to act with good intent. No amount of legislation can solve this very real problem that is so critical to flight safety in GA

That is what will improve safety outcomes. Good intent. CASA just doesn’t have the intent. Its not in the Organizational culture, and that stems from leadership..

In my own matter, and far closer to home. I operated only a few hundred meters from SOAR aviation. The truth is that industry, including other Government Departments raised safety concerns about that organization on multiple occasions, and repeatedly so over a protracted period. The Company had more accidents, incidents, than most, and even a fatality. That business went on right under CASAs nose and they knew about it. They ignored it. It wasn’t CASA that shut SOAR down. It was the students going to the Australian Skills and Qualifications Authority (ASQA), Its mind boggling.

ASQA was taking action against SOAR, while CASA was shutting me down. Its simply inexplicable at least.

By the way Luce, an industry colleague gave me a copy of “the art of war”, when this matter started. A very informative read, and after your post, I have located it for a re-read.

Cheers. Glen.

Also from the UP:

Checkboard

What's going on between about 0.37 to 0,45 (when '... something goes wrong' flashes up)? Doesn't exactly look like a reasonable thing to be doing with paying pax on board now, does it?

The operation was to land on the beach. A precautionary search and landing involves a low pass over the uncontrolled landing area to check for obstacles, like drift wood, and the suitability of the surface, which depends on the tide and weather. As part of the landing process, it is a permitted operation below 500 feet.

The prec search and landing is part of the PPL syllabus (or was when I was teaching 30 years ago), so every pilot should be aware of it.

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Arm out the window

Hi Checkboard, fair enough to do a precautionary search, but why would you do it downwind at low level offset from the beach with very limited options in a power loss (as per what ended up happening?)

High recce followed by a pass along the strip into wind, offset enough to see but also able to get to it, would be how you would have taught it, or something along the lines of that, wouldn't it? It doesn't make any sense to be blasting along at low level with nowhere to go, which is why I don't think a strip assessment was the primary reason for having the aircraft in that position, although that's of course only my opinion.

The thing is, as Luce is I think getting at, Glen's arguments seem compelling and legitimate, and muddying the waters by drawing supposed parallels with others just because they too are in a stoush with CASA isn't likely to be particularly helpful to his cause. Everything I've seen of Glen's situation from what he's put up here and said on the record sounds fair dinkum. Some others making a lot of noise about being victimised do not appear to have the same credibility. Again, opinion only of course.

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Squawk7700

Much quicker to do a downwind prec search, a quick u-bolt at the end to turn around, then land. Something you’d expect more from a crop duster.

Having much interaction with Bruce Rhoades (for about a year and a half before his passing), I found some of the above discourse insulting and ill-informed, for I know full well (with hand on heart) that Bruce was a well-intentioned operator that was not seeking to flagrantly break rules or to be in any way non-compliant with his obligations under the terms of his CASA issued AOC.

However the thread discourse did get me to going back over the ATSB Final report (AO-2017-005 - which IMO was cynically released a month after Bruce's passing). So in regards to the Arm out the window and Sqwawk7700 comments on the 'prec search' procedures for Wyndham Aviation I note the following from pg 38 of the FR: 

CASA advised that many flying training organisations have adopted the guidance provided by the Aviation Theory Centre, a publisher of commonly-used flight training manuals in Australia. This guidance included the following for carrying out a safe approach and landing at an unfamiliar field with engine power available:

• conduct a first inspection at 500 ft AGL circuit height, slightly to the right of the landing area (to check for obstacles on approach and departure and general condition of the landing surface)
• conduct a second inspection at 200 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (for a closer examination of the landing surface and other hazards)
• a third inspection at 50 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (if required for a closer inspection of the landing surface)
• conduct the inspections with some flap extended (to provide a slower speed and other advantages, such as a smaller turn radius and better view from the cockpit due to a higher nose attitude).

     
Hmm...so was this accepted procedure for a prec search by FTO's throughout Australia disseminated by the CASA FOI oversighting Wyndham Aviation and then perhaps suggested that Wyndham Aviation should adopt as an SOP? This despite the fact that a 'prec search' procedure is in no way applicable to an operation that uses a beach landing area (ie a company defined ALA) on a regular basis and the definition of the procedure is a 'airborne inspection of a beach landing area' (quote from pg 39): 

The operator’s normal practice was to conduct an airborne inspection of the Middle Island ALA on the first fight of the day to the ALA and at other times when deemed by the pilot as necessary to inspect the beach landing surface. The chief pilot and pilot of the accident flight stated that between them they normally conducted one inspection each day that flights were conducted.

The chief pilot reported that, following a high tide, the beach conditions could change. The airborne inspection was therefore necessary in order to detect if there were any hazards such as ruts, pot holes, washaways, debris or areas of soft sand. He advised a good indicator of hard sand was the sand balls made by crabs.

The operator’s Operations Manual contained no guidance as to what height or configuration to use when conducting an airborne inspection, or how many passes to conduct. The manual required a pilot to look for the sand balls, and the chief pilot stated that in order to conduct an appropriate inspection (including looking for the sand balls) a pilot had to be at a low level.

       
Plus:

The pilot of the accident flight stated that such guidance applied to situations where a pilot was dealing with an unknown landing area, whereas their operations to Middle Island ALA involved a known landing area with conditions that could have changed.

The Operations Manual contained no guidance on what to do in the event of an engine failure at low level during an airborne inspection. The chief pilot stated that he had not considered the possibility of an engine failure during a low-level inspection. He also noted that pilots received training for engine failures at low level as well as precautionary search and landing during their basic training, and therefore he had not considered it necessary to require any further training or guidance in these areas.

Both the chief pilot and pilot of the accident flight noted that, at almost all stages of their flights to the beach ALAs, they had more than sufficient height to glide to and safely land on a beach in the event of an engine failure. They stated that the only exception, identified following the accident, was when doing an airborne inspection at the Middle Island ALA to the north (such as during the accident flight) (although see also Review of take-offs from Middle Island ALA and Operations over water and ditching procedures).

I could continue on down that rabbit hole but the point to note here is the part in bold: 

"..The Operations Manual contained no guidance on what to do in the event of an engine failure at low level during an airborne inspection..."

This brings me to page 43 of the FR under the heading "Airborne inspection procedures of another operator":

...The ATSB obtained the operations manual of another operator that routinely conducted passenger charter flights that involved landings at a beach ALA in small aeroplanes. The manual, last revised in 2015, included specific procedures that stated that beach landing area inspections had to be conducted no lower than 300 ft AGL.

The landing area inspections were generally conducted while flying downwind. However, the operations manual stated that inspections would typically be conducted ‘at an indicated airspeed no greater than 100 knots and it is preferable that a stage of flap is used for this procedure’.

This other operator’s beach ALA had significant areas of beach available at each end, and therefore a pilot could always land straight ahead in the event of an engine power loss during an inspection.

The other operator’s procedures also required that each pilot undergo a proficiency check every 90 days with a check pilot, and that such a check involved conducting a beach inspection...

Presumably the Ops Manual entries for the above operator were all CASA approved SOP additions. So why wasn't these 'safety risk' mitigation procedures generally disseminated (across industry) for operators conducting operations to approved (ALA) beach landing areas? 

This brings me to the safety issues section of the FR and in particular under the heading of 'Regulatory surveillance – scoping of surveillance events'- link: https://www.atsb.gov.au/publications/inv...005-si-08/

Safety issue description

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Which then brought me to the following disgusting, puerile response from CASA, one month before Bruce passed away..

Response by the Civil Aviation Safety Authority:

In August 2019, in response to the draft ATSB report, the Civil Aviation Safety Authority (CASA) stated:

CASA, as a regulator, has the ability to help ensure that an operator complies with aviation safety regulations and operations manual procedures through ongoing surveillance. Both CASA’s records and the draft [ATSB] report indicate that CASA had identified issues with the operator which were addressed (at least in terms of operations manual procedures).

However, the effectiveness of CASA’s system of regulatory surveillance and auditing in ensuring safety is based on the assumption that operators are genuinely interested in, and meaningfully committed to, compliance. What appears to have occurred in this case is that Wyndham Aviation had developed a culture of wilful, or at least habitual, non-compliance with both the safety regulations and the requirements of the Wyndham Aviation operations manual.

CASA has a robust entry control and oversight system which is continually under review and in this case additional or different oversight is unlikely to have significantly impacted the attitudes and behaviours of the operator.

- 

I then noted the ATSB response:

ATSB comment:

The ATSB notes that CASA has advised that it continually reviews its entry control and oversight system. However, the ATSB is concerned that CASA has not outlined any specific safety action to address this safety issue, nor has it undertaken any apparent safety action to effectively address a similar safety issue released in November 2017 (AO-2014-190-SI-14). Accordingly, the ATSB issues the following recommendation.

Curious I then went to the reference: AO-2014-190-SI-14

Where I discovered this 'safety issue' addressed to CASA was in reference to investigation report AO-2009-072 ie. the 1st PelAir Final Report??

Safety issue description

The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

According to the ATSB this safety issue was 'adequately addressed' - 

This was despite the ATSB final comment stating:

ATSB comment:

The ATSB notes the surveillance planning and scoping form provided by CASA to its inspectors is still the same as the form used from 2004–2009, and this form does not refer to the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Nevertheless, the ATSB acknowledges CASA’s surveillance processes have undergone significant evolution since 2009, and that it is continuing to review and develop its surveillance processes. It should also be noted that the ATSB will review CASA’s oversight processes since the introduction of the CSM in 2012 during the course of other investigations, including investigation AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion).

Hmm...to anyone with half a brain, does that sound like the 'safety issue' was 'adequately addressed'?

Again curious (as the reference rang a bell??) I went to this:  AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion)

Overview of the investigation

As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems.

The ATSB collected a significant amount of evidence and conducted an in‑depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

As part of its investigation, the ATSB:

interviewed current and former staff members of the operator, regulator and other associated bodies
examined reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
reviewed other investigations and references where similar themes have been explored.

Ahh...yes the ATSB/CASA cover-up/cock-up of the VARA accident: In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014

That saw a VARA ATR (post accident) fly around for a further 5 days and 13 sectors with a bent tail:


However. for an incident/accident that had the potential to result in the worst Australian air crash disaster (ie. a catastrophic airframe failure leading to multiple fatalities onboard, or worse if the aircraft was to crash into a highly populated suburb of Sydney) this was the outcome of the nearly 3 year 'systemic' investigation: 'Discontinued' -   

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation. The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations.

Much...much MTF...P2