[Peetwo]

Beyond Reason - & the pale??

Very much related to 'closing the safety loop' is some recent posts on the O&O thread here: 

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason model is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning...

That was followed up by this excellent post from the Ferryman that highlights the various holes in the Norfolk Island ditching Swiss Cheese:

A journey, through the Swiss cheese.

Do you remember – one of the first things ever taught – apart from Up, Down, Left, Right and ‘it nuffin was – escape.  This was lest you required your ‘superior’ skills to extricate your arse from a situation in which your superior talent should never had placed you.  The lesson is a simple one – paddock – paddock – paddock; why?  Well if the single fan up front quits – over the tiger country – where can you park the beast.  It’s a habit, deep ingrained; same-same with weather, engine out in fact, the whole gamut of caution and back door theory, so that when things turn unpleasant – there is a viable alternative...

cont/- ..So the answer to the question, why paper over the cracks instead of plugging the holes becomes crystal clear – ASA, BoM, CASA, Pel-Air were all ‘slices’ with holes and most definitely, IMO, own a large share of the event, as does James.

1) - The conclusion is stark – James acknowledged the errors made and apologised, then set about correcting his part to ensure  that a repeat performance was not going happen.

2) - ASA ducked the issue, threw both Nadi and Auckland under bus, and joined in the cover up of systematic failure. Which fooled no one, least of all the Senate committee.

3) - BoM so secure in their latitude to be wrong in forecast and their wriggle room cast in law need make no reparation or apology – their system secure, their hands legally clean.  It has always been so, even being asleep at the wheel is forgivable – legally.  

4) - CASA realising that they had been partly to blame by not only ‘accepting’ flawed procedure, failing to realise the fuel policy was ‘incomplete’, failing to realise there were serious holes in the check training procedure; and, IMO worst of all, allowing the operation to continue with almost 20 potentially serious ‘events’ on record.  Many operations have been closed down for much less.  To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence.  No apology, no corrections.  Just another pilot crucified...

 So I've decided to start by examining the Ferryman's - "IMO worst of all"- in his identified Swiss cheese hole 4; because I believe it is pivotal to Senator Fawcett's original question - to Murky Mandarin & his Department - on how best to close the safety loop. 

 A journey, through the Swiss cheese - Part II

To continue P6 in the above post said:

...allowing the operation to continue with almost 20 potentially serious ‘events’ on record.  Many operations have been closed down for much less.  To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence.  No apology, no corrections.  Just another pilot crucified...

   
The 'almost 20' incidents to which he refers were on the record in the ASA answer to QON for PelAir inquiry public hearing on the 19 Nov 2012 - Answers to questions taken on notice on 19 November 2012, in Canberra; (PDF 9401KB):

8. HANSARD, PG 9

Senator FAWCETT: Could you take on notice whether you passed on to Pel-Air the
concerns about their Westwind aircraft.

Mr Harfield: Yes.

Answer:

In the period five years before the Norfolk Island accident (2004 to 2009) Airservices

reported to both CASA and the ATSB, 19 safety incidents that were known to Airservices involving VH-NGA.

In July 2005, VH-NGA was involved in a safety incident during a flight from Nowra to
Darwin whereby the aircraft was unable to maintain it’s assigned level in RVSM airspace
and another aircraft was therefore required to change its altitude in order to maintain
the separation standard. Pel-Air was informed about this incident under a standing
Letter of Agreement.

Also in the period, VH-NGA was involved in 18 other safety incidents – 16 were pilot or
aircraft attributable (2 engine failure, 2 fuel dumps, 1 Loss of Separation, 3 incorrect
time and position reporting, 8 pilot errors) and two were air traffic control attributable
information display errors. Pel-Air was also informed about the details of these
incidents under the Letter of Agreement.

 
 And that was just for one aircraft??- UFB!
But what is probably worse is that not one of these incidents - that were captured by ASA & forwarded to the ATSB & CASA - was featured, further investigated or even remotely mentioned in either; the CASA Special Audit Report or their infamous CAIR09/3; nor does it appear that such records were requested from CASA or the ATSB in the course of their original investigations .  I guess they were too busy shovelling yet more shit on top of the DJ mound - again UFB!    
MTF..P2