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The best laid plans of mice and men.

by | Aug 5, 2017 | Accidents and Inquiry, ASA, ATSB, CASA, Minister for Transport, Senate Estimates - Unplugged

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 The best laid plans of mice and men. via Aunty Pru Forum.

There I was, muddling and bumbling my way through another week, I’d even found some snippets which made me smile for the SBG. Grr8 thought I, a light hearted, quick post on Sunday; off the hook and the day’s my own – alas.

I believe ‘we’ are all aware that the aviation safety agencies are in a hell of a state; that condition being exacerbated by probably most useless minister for transport ever inflicted on a long suffering industry. It seemed reasonable to me that a little fun was in order, break the monotony and tedium of trying to ‘get it sorted’. All was going along well until P2 called – the dreaded words “You seen this”? Well, I had, ages ago when we did our own digging on the Pel-Air scandal; “Yup” says I (dodging the bullet) with enough venom to end the conversation. “Ah: yeah, but what about this” – he posed a question, the curiosity bump kicked in; and, just like that, there I was, back in the toils of deep research; week end shot to blazes.

So, we did the work. Then we tore it all down and tried to arrive at a different conclusion, from another perspective; then we did it all again. Every time, from every direction we could imagine, it was impossible to shake the foundations. Remember, we don’t go at this stuff with the intention of finding a line and building a case in fresh air; quite the reverse. We do try to ‘justify’ through the law, the Act, departmental policy and the constraints imposed on our ‘safety agencies’ the actions taken. It is the only way to reach a fair and reasoned conclusion; in fact we have been able to exonerate ATSB and CASA from some pretty nasty accusations ; believe it or not, we do try to play fair; if not always nice.

P2 – “From that extraordinary public hearing of revelations, obfuscating admissions, spin, bull-dust and denials, it would now appear that some of those involved individuals must have been telling the committee porky pies. This is because the existence of the Chambers Report was known at least 12 days before the first public hearing and is listed as a tabled document from CASA (i.e. 01 CASA_Doc 3_Web – PDF)”.

We sent our conclusions to the BRB, IOS and PAIN. There was not one dissenting response. In short, the Pel-Air Senate Inquiry; not the accident, but the evidence presented to the Senate Inquiry must be forensically examined, by the AFP. It is our considered opinion that an enormous blanket has been pulled over the eyes of the Senate in Parliament, the industry and the Australian public. There is also untested, but persuasive ‘research’ to support the notion that ICAO has been ‘hoodwinked’ particularly in relation to Australia’s much touted ‘safety record’.

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“Everyone admits how praiseworthy it is in a prince to keep his word, and to behave with integrity rather than cunning. Nevertheless our experience has been that those princes who have done great things have considered keeping their word of little account, and have known how to beguile men’s minds by shrewdness and cunning. In the end these princes have overcome those who have relied on keeping their word.”

So, it’s not just my Sunday buggered. Full team, all stops out, report to the RRAT required. You’re probably wondering what the fool is rambling on about; the answer lays within the following AP posts, start here:-

Dots and Dashes

Times up for Pel-Air.

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If you have a mind to, spend a half hour, do some digging and see where you finish up. I’ll even give you a hint – check the dates against the rhetoric; follow the time line breadcrumbs and pay particular attention to who was left standing. The Chambers report is of particular interest. You may, with some certainty, forget about the PA MkII report shedding any light on the Senate inquiry; that is the safest bet on my tote board; well, that and the fact that the accident re-investigation has SDA to do with the Senate findings. Those have all been very neatly despatched to history, classed as ‘opinion’ and not legally binding.

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The stable door is closed, I can see it from my desk, bathed in the early sunshine, quietly waiting to be opened, racks of timber idle, the smell of sawdust and shavings to greet you, a keg of fine ale in the fridge not far from the fire place. Aye, ‘tis incentive enough to finish this ugly work as soon as possible; but, AP has priority and needs must, when the devil drives.

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P2 on received vs tabled Blush

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You maybe wondering why our EAL (editor at large) P9 appears to have totally lost his marbles and in the process sabotaged our normally sedate, hopefully IOS topical, SBG? Well unfortunately I must admit that I am largely to blame…  Rolleyes

Yesterday I had an impromptu BRB sub-committee teleconference with “K” about my embarrassing (for me) extra findings in the process of scratching a 5 year itch – see: Dots and Dashes.

It was embarrassing because I had several penny drop moments… Blush

To begin here is a link for the PelAir (COVER-UP) Inquiry submissions page: http://www.aph.gov.au/Parliamentary_Busi…ubmissions

And here are the offending tabled ‘Additional Information Received‘ documents in the order in which they are listed:

Quote:11 Internal CASA report titled “Oversight Deficiencies- Pel-Air and Beyond” also known as the Chambers report (dated 1 August 2010), received 10 October 2012;(PDF 6210KB)

12 Internal ATSB email regarding the ATSB and CASA’s approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)

13 Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report (dated 18 August 2010), received 10 October 2012;(PDF 1193KB)

14 Internal CASA email (dated 4 February 2010) ATSB identification of a ‘critical safety issue’ may have ramification for CASA actions in relation to Mr James, received 10 October 2012;(PDF 913KB)

15 Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (dated 11 December 2009), received 10 October 2012;(PDF 881KB)

16 Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB)

17 Internal ATSB email- reviewer indicating they can’t deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB)

18 Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)

19 CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

Note that the date they were all received by the Committee Secretariat was on the 10 October 2012. However the date that all the offending documents were copied/tabled, therefore made available for the Senator Committee members & public consumption, was on the 14 February 2013. This fits with the extraordinary revelations in the Senate inquiry public hearing the following day:  15 February 2013 Canberra, ACT
(HTML format) (PDF 104KB) (HTML & PDF)

First QON & OBS (so far):

Q/ What was the delay in processing those documents?

Q/ In the context of this inquiry, how is it possible that such critical information and documentation effectively have been sat on (obfuscated), when the inquiry was still some 12 days from it’s first public hearing?

Now besides the fact that I was slow to pick up (nearly 5 years – Blush ) on the date that the 9 documents were received by the Secretariat, I was also deceived by the PDF titling for the individual files, which also led me to be deceived by the significance of the order in which those documents were listed.

Here is the PDF titles as listed (above):

  1. 01 CASA_Doc 3_Web (Chambers Report)
  2. 02 ATSB_Doc 5_Web
  3. 03 CASA_Doc 4_Web
  4. 04 CASA_Doc 2_Web
  5. 05 CASA_Doc 1_Web
  6. 06 ATSB_Doc 7_Web
  7. 07 ATSB_Doc 6_Web
  8. 08 ATSB_Doc 9_Web
  9. 09 CASA_Doc 10_Web

(P2 note: The ‘Doc’ numbers fit a chronological order for the individual agencies)

What this appears to indicate is that the documents were sent collectively by an individual/entity/group, independent (officially) of either the ATSB or CASA. This IMO strongly suggests that this was a whistleblower(s) initiative.

This opinion/suspicion is reinforced by the fact that the documents were received prior to the 1st public hearing and around the date the submissions from both the ATSB and CASA were received and/or copied/tabled.

If the ATSB and CASA had of wanted the information contained within those documents (with the obvious ‘dirty linen’ implications) made public, they had the perfect opportunity to send as part of their submissions… Dodgy

At this point I’ll let those who are interested join the rest of these very disturbing dots and form their own conclusions – my bet is the picture that emerges from underneath the smoke and mirrors won’t be too far off the ugly portrait that now sits before P9 and myself… Undecided

MTF…P2 Cool

Ps Excerpts of interest from Hansard AAI Inquiry 15 February 2013… Wink :

Quote:Senator FAWCETT: Could I start off by clarifying: were ATSB aware of the existence of the Chambers report or the fact that CASA had conducted an internal inquiry specifically into the efficacy of its oversight of Pel-Air and like operations? Were ATSB aware of the existence of the special audit into the FRMS at Pel-Air. Until the lawyers of the captain raised it, were you aware of the special audit that was conducted into Pel-Air?

Mr Sangston : I had no knowledge until I heard this morning, of the Chambers report. The second part of the question was about the special audit report. We had an awareness of the special audit report.

Senator FAWCETT: When did you have an awareness of that?

Mr Sangston : Via the draft report, the safety action that was reported by the operator Pel-Air was in response to the special audit report. So we had that awareness and it was included in the draft report and the safety action by Pel-Air. I am sorry, I have forgotten the third element of your question.

Senator FAWCETT: There were two special audits. The second one was on the FRMS of Pel-Air. Were you aware of that one?

Mr Sangston : I do not have an awareness of that one; no.

Senator FAWCETT: I accept that as well. Have you had a chance to read the chambers report?

Mr Dolan : I received it at most half an hour ago, so I have only had a chance to look at the broad headings in it.

Senator FAWCETT: I accept that. I also accept that so far you have not had a look at the fatigue special audit, because that is still being redacted prior to being distributed. Perhaps you could take this on notice: the committee would appreciate getting your feedback as to the content of those two reports and whether that would have changed some of your decision points in terms of the scope of the investigation.

I take you to emails of 9 and 10 February, between one of your officers and yourself, with a CC to Mr Sangston, where the officer talks about the fact that, from the systemic investigation perspective, there are three separate slices of the James Reason defences—that being the flight crew, the operator and the rule maker—and that it is important to look at all of those.

As I follow through the email traffic, it becomes clear to me that the scope of the operator and the rule maker appears to be reduced as a function of a lack of evidence. There is some discussion around evidence tables and what is hearsay versus what is clear evidence, and so those things are, essentially, scoped out of the report.

Mr Dolan : On the basis that we can only work on facts and evidence, Senator, and not on speculation, yes.

Senator FAWCETT: I understand that. If you had hard evidence that there were, in fact, issues with both the operator and the rule maker, is it therefore a logical conclusion for the committee to reach that you would have considered in more detail each of those elements of the factors leading to this accident?