ATSB - Gulfstream 695A: Fatal.
Pilot incapacitation, loss of control and collision with terrain involving Gulfstream 695A,-VH-HPY. - REPORT.
Of long habit ATSB reports have been 'filed' in categories; the one above has joined a now considerable pile which mentions CASA 'surveillance' operations within the history time line leading to the event. There is IMO a clearly defined, significant 'clearly identifiable. trend' which may be described as one of the holes in the cheese slices. The ATSB remarks below, in one form or another can be found in many of their reports.:-
ATSB - “This issue had been reported to CASA in 2019 and a surveillance event was conducted in response. The scope of the surveillance event did not include a crosscheck of maintenance releases against the aircraft logbooks, limiting the ability to determine whether any non-reporting and improper deferral of defects had been taking place at that time.”
and again:-
ATSB - “However, the ATSB found multiple instances where these requirements were not met. AGAIR has not addressed how the organisation intends to assure future legislative and procedural compliance by line pilots and management personnel. As such, the ATSB has issued a formal safety recommendation to AGAIR to initiate an independent review of their organisational structure and oversight of operational activities to assure ongoing effective operational control by management.”
There is no way, not legally, morally or through 'threat' of job loss that any pilot should be operating at F280 with any sort of pressurisation problem. Non whatsoever !
There is no way, not legally, morally or through 'threat' of lost revenue that a certified operator should task an aircraft to operate at FL's with a known defect in the pressurisation system. Non whatsoever !
And yet, there it is – again.
ATSB - “As such, the ATSB has issued a formal safety recommendation to AGAIR to initiate an independent review of their organisational structure and oversight of operational activities to assure ongoing effective operational control by management.”
Now CASA is supposed to be the almighty keeper of aviation safety; it is an expensive operation to run; and supposed to be crewed by 'expert' aviation professionals. There is little to excuse the on paper, 'tick a box' surveillance reports presented which support on going operations which end up with a 'fatal' (or even close call) on the books. Non whatsoever!
Across the history of 'fatal' events there is a theme; recent events clearly define this. Where the event could have been prevented had the CASA process been conducted by someone with sensible 'operational expertise' and a clear understanding of what happens once they have left the building. Boxes ticked, now back to the old ways. I could, if there was a Senate inquiry provide a dozen recent examples of where CASA ticked the boxes, fiddled around the edges and walked away, job done – the event following the departure.
I could present a dozen cases where CASA have sided with the operator, against the pilot who dared to say 'No' or even 'No way' to operating illegally or even dangerously. There is a long list. Conversely there is a reverse case; where the 'operator' has been ruthlessly pursued and prosecuted after the fact, despite CASA 'audit' and surveillance signed off.
But, the most fatal flaw, IMO, the immoral, inexcusable fault lays within the industry itself, often supported by the CASA. Pilot A says 'no-way- I'll fly that aircraft with a busted 'whatchamacallit' – sacked, with a reputation following everywhere; grim future outlook. Then, there is the other side of the coin; Buckley a classic example; Middle beach event another; long list of similar cases.
Could the 'safety watch dog have prevented the 695 A event? Probably, the clues where all there. But better still, could CASA change the culture, where it is Macho to operate an un-serviceable aircraft, in a commercial operation? A couple of beers with the pilots would have told the tale.
Fix the ducking aircraft or ground it. This was a known defect, a certified killer, innocent observers on board. RIP..
Not good enough Minister King; not good enough Ms Spence, not by a long, bloody mile it ain't anywhere near good enough. (see preceding posts for an inkling)..
Selah...
Pilot incapacitation, loss of control and collision with terrain involving Gulfstream 695A,-VH-HPY. - REPORT.
Of long habit ATSB reports have been 'filed' in categories; the one above has joined a now considerable pile which mentions CASA 'surveillance' operations within the history time line leading to the event. There is IMO a clearly defined, significant 'clearly identifiable. trend' which may be described as one of the holes in the cheese slices. The ATSB remarks below, in one form or another can be found in many of their reports.:-
ATSB - “This issue had been reported to CASA in 2019 and a surveillance event was conducted in response. The scope of the surveillance event did not include a crosscheck of maintenance releases against the aircraft logbooks, limiting the ability to determine whether any non-reporting and improper deferral of defects had been taking place at that time.”
and again:-
ATSB - “However, the ATSB found multiple instances where these requirements were not met. AGAIR has not addressed how the organisation intends to assure future legislative and procedural compliance by line pilots and management personnel. As such, the ATSB has issued a formal safety recommendation to AGAIR to initiate an independent review of their organisational structure and oversight of operational activities to assure ongoing effective operational control by management.”
There is no way, not legally, morally or through 'threat' of job loss that any pilot should be operating at F280 with any sort of pressurisation problem. Non whatsoever !
There is no way, not legally, morally or through 'threat' of lost revenue that a certified operator should task an aircraft to operate at FL's with a known defect in the pressurisation system. Non whatsoever !
And yet, there it is – again.
ATSB - “As such, the ATSB has issued a formal safety recommendation to AGAIR to initiate an independent review of their organisational structure and oversight of operational activities to assure ongoing effective operational control by management.”
Now CASA is supposed to be the almighty keeper of aviation safety; it is an expensive operation to run; and supposed to be crewed by 'expert' aviation professionals. There is little to excuse the on paper, 'tick a box' surveillance reports presented which support on going operations which end up with a 'fatal' (or even close call) on the books. Non whatsoever!
Across the history of 'fatal' events there is a theme; recent events clearly define this. Where the event could have been prevented had the CASA process been conducted by someone with sensible 'operational expertise' and a clear understanding of what happens once they have left the building. Boxes ticked, now back to the old ways. I could, if there was a Senate inquiry provide a dozen recent examples of where CASA ticked the boxes, fiddled around the edges and walked away, job done – the event following the departure.
I could present a dozen cases where CASA have sided with the operator, against the pilot who dared to say 'No' or even 'No way' to operating illegally or even dangerously. There is a long list. Conversely there is a reverse case; where the 'operator' has been ruthlessly pursued and prosecuted after the fact, despite CASA 'audit' and surveillance signed off.
But, the most fatal flaw, IMO, the immoral, inexcusable fault lays within the industry itself, often supported by the CASA. Pilot A says 'no-way- I'll fly that aircraft with a busted 'whatchamacallit' – sacked, with a reputation following everywhere; grim future outlook. Then, there is the other side of the coin; Buckley a classic example; Middle beach event another; long list of similar cases.
Could the 'safety watch dog have prevented the 695 A event? Probably, the clues where all there. But better still, could CASA change the culture, where it is Macho to operate an un-serviceable aircraft, in a commercial operation? A couple of beers with the pilots would have told the tale.
Fix the ducking aircraft or ground it. This was a known defect, a certified killer, innocent observers on board. RIP..
Not good enough Minister King; not good enough Ms Spence, not by a long, bloody mile it ain't anywhere near good enough. (see preceding posts for an inkling)..
Selah...