Who’s to bless and who’s to blame? – AP Forum version.
At the end of every accident; every single one of ’em – that question gets asked, and; it is an important one. Blame implies failed responsibility and the attendant liability, a lawyers payday and misery to those roasting ‘on the spit’. So the scramble for ‘blessing’ (exoneration) begins in earnest.
Of course, a ‘signed confession’ is the pinnacle for the prosecution; but even then the winkling out of ‘compensation’ is a not a task for the feint of heart. Tackling the big boys like CASA or your friendly prudential insurance company in court, even with a ‘signed confession is a seriously difficult, expensive, mind bending, life changing passage of play. Should you find this difficult to believe, track down and talk to someone who has been through that particular mill; the tale will beggar belief.
“We make guilty of our disasters the sun, the moon, and the stars: as if we were villains by necessity; fools by heavenly compulsion. ― William Shakespeare, King Lear
Which, for the last time I hope, takes my ramble back to the Ross Air fatal accident. There are IMO two questions which, stand alone deserve answers.
So why was the exercise conducted outside of both the AFM and CASA approved systems?
And why did CASA feel the need to draft the TMI?
Enter what is I believe a signed confession from CASA. To clarify, I must (once again) quote the AAAA submission to the next Senate Inquiry.
AAAA – “CASA officer interpretations – an issue that was at the core of the ASRR Report findings and recommendations – individual officers within CASA continue to make interpretations that are not bound by regulatory heads of power, consistency, experience, sector knowledge or specific safety risks. It is opinion parading as policy – and frequently ill-informed opinion. CASA continues to lack a coherent, centralised policy interpretation and expertise centre to standardise regulation. Different offices have different interpretations, and generally CASA is not troubled by using subject matter experts that it may have on staff – as there is no centralised policy development system. In a modern regulator that had this pointed out to them in an independent review (the ASRR), serious questions must be raised about why this situation is perpetuated by senior management.”
The paragraph above clearly spells out a serious industry wide concern. Those who write or are responsible for ‘operations’ management will completely understand the statement above. How much needless, mindless, unnecessary twaddle has been ‘drafted in’ as an amendment to satisfy a particular FOI’s notion of how things should be done. How many of those FOI have ever actually been in a position of company operational management and understand the complexities involved: and, can supply experience based input? How much personal opinion and preference has been grafted onto a sound, simple operating edict? – Far too bloody much. But I digress. Back to the TMI
You can find the ‘TMI’ document at the end of a long P2 post – HERE -. It follows a CASA RSR of the Ross Air operation, which of itself is worth careful consideration. The accident occurred in May 2017. The ‘Temporary Management Instruction’ (TMI) was produced a month later in June 2017. A reasonable man could be pardoned for reading this trite little document as a ‘signed confession’. Also, be forgiven for thinking ‘Bollocks’. The give away is “should consider” – after the event. “Should” don’t enter into it; they should be instructed to bloody well allow the expert, experienced folk doing the job set the test and manage the operation safely. The Aircraft Flight Manual (AFM), from the manufacturer, which is mostly based on test flight and certification data legally holds all the trumps. To dictate anything which contravenes the AFM is fraught with peril. Not only will the legal eagles have you by the short and curly, but to ignore what has been demonstrated as acceptable risk, by qualified, peer, experienced, responsible check pilots and insist on ‘alternative’ procedure for ‘testing proficiency’ is tantamount to a dangerous situation developing, resulting in tragedy. The Air North Brazillia a classic. Engine failure at a critical speed combined with an Auto Feather failure is borderline premeditated murder; a mathematical improbability and plain bloody stupid – yet there stands yet another fatal accident – during a test flight – over sighted by another bloody CASA expert. Don’t get me started; I’ll be at it all night.
So – to the TMI which wants CASA to ‘consider’ the stuff of potential liability in the case of death. I say this; if an experienced check pilot says how a check is to be conducted, unless the CASA FOI can trump his Ace, then it is best to let the experienced man dictate the odds. Should the CASA man consider that his way is best – simply cancel the flight and take it all to a higher level. At least then those you leave behind will have the benefit of a clearly defined line of blame. \
Para 1. CASA should consider reviewing CASA and industry practices for conducting assessments of Check pilots and etc. – simulated engine failure…….
Para 1. CASA should consider reviewing relevant operations manuals to ensure procedures relating to the simulation of engine failure in turbo prop aircraft consistent with either the aircraft flight manual etc.
Para 2. CASA should consider – risk assessment etc.
AAAA – “CASA still does not understand the difference between safety and compliance and continually considers itself to be the creator of safety, when in fact it is a well informed, safety motivated and guided industry – flying, maintaining and organising aviation operations – that creates safety. CASA clearly has an industry-accepted role in rule-setting, surveillance and enforcement – but it is industry that delivers safety. The dimension of the daunting task facing anyone in GA in simply absorbing, recalling and using the vast amount of written regulation of the industry, is now a safety impediment in its own right.”
The ASRR has been almost shuffled off into the shredder; nothing of significance has changed since then. Is the Australian Senate so piss weak that it will allow another a multi million dollar Senate Inquiry to be obfuscated into a shadow of what should have been? Are we to watch another expensive pantomime achieve nothing but a couple of hundred pages of Hansard. How many more avoidable accidents will be allowed to happen while CASA enjoys Bi-Part-Insane support from every brainless politician?
It’s nowhere near good enough and a very poor investment of faith and tax payer monies; is it.
Oh, I miss the Pub, the BRB/ IOS and darts. Email and ‘the net’ are OK but not the same as a ‘robust’ discussion and venom on the dartboard. Must hope things return to some semblance of normality soon, home is a great place but………
Aye well, P7 is up for darts tonight, the keg is working, stable clean, logs split and dry next to the stove, which only leaves my two best mates waiting a word to be away. Through the orchid gate and off into the moonlight.
FAR from my dearest Friend, ’tis mine to rove
Through bare grey dell, high wood, and pastoral cove;
Where Derwent rests, and listens to the roar
That stuns the tremulous cliffs of high Lodore;
Where peace to Grasmere’s lonely island leads,
To willowy hedge-rows, and to emerald meads; ― William Wordsworth
Selah….Oh: and avoid Bunnings on Saturday – seriously…
Ps P2 addendum:
So where is your stakeholder advisory panel, or your subject matter expert list or your sectoral working groups or annual consultative forum or ….???
Communications and stakeholder engagement are the primary tools we use to influence improvements in transport safety.
Please help us by completing a short 10-question survey on the effectiveness of our engagement and communications channels: https://www.surveymonkey.com/r/ATSB_2020…ly60lWs_3D
And the “K” reply: ‘Roll Up, roll up: