On joining the dots and making of dashes.
#40

(01-13-2018, 10:53 AM)Peetwo Wrote:  FAA IASA audit, FRMS & an 'inconvenient ditching'? Dodgy

From a search 4 IP post #222:

"..Then came the ditching off Norfolk Island. Any serious investigation into systematic flaws would reveal and confirm the worst fears of the ICAO and FAA audits. Although the mystery of two resignations and the decision to discard some fairly important reports is yet to be solved, there remains one curiously intriguing element yet to be satisfactorily resolved. I will leave providing the ‘dots’ up to P2 (patience, patience). I will make a dash toward a conclusion, the reader may make of it what they will..."

This is a long and ongoing tale, so let us begin by setting the scene Wink :

Quote:A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.
[Image: cockpit.jpg?w=300&h=200]

To see the ABC 7:30 report: http://www.abc.net.au/reslib/200912/r487807_2516710.asx

How would react, if you opened the cockpit door and saw both pilots fast asleep!  It really happened on a commercial flight.

Such incidents are not the norm, but even these rare occasions need to be managed, as in the aviation industry there is little room for error.

The Australian Transport Safety Bureau concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!

Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

Prof Drew Dawson and Dr Matthew Thomas of the Sleep Research Unit at the University of South Australia conducted an in depth study involving 260 pilots.  They wanted to find out how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance.   They found that even though pilots are compliant with the rules, there are a small number of occasions when they aren’t actually getting sufficient sleep to be safe.  Pilots who had less than five hours’ sleep were twice as likely to make safety errors.

The incident of this happen is relatively small.  “The broader studies which show us that it’s a small percentage, but every day there would be some. It’s in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots”. That is still 10 to 20 pilots too many in my book!

Prof Dawson: “The aviation industry in Australia is surprisingly slow to react to the studies report’s recommendations.  I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don’t wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way“.

Better check on your pilots, when you go on holidays…

Source: http://www.abc.net.au/7.30/content/2009/s2773888.htm#[/url]

To put that quite disturbing 7:30 report segment in context, it is worth remembering that it was released 9 days after the FAA IASA audit findings were discussed with CASA:

7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 Australian audit. (ref links - [url=http://www.auntypru.com/forum/showthread.php?tid=149&pid=7350#pid7350]#53
& WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf


Reflect on this: "...concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!.." 

& this from McCormick: "..If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority..."

Now fast forward to August 2012, via ABC 4 Corners 'Crash landing':  

Quote:GEOFF THOMPSON: ..It was hours before the flight crew got access to hotel rooms to get some - interrupted - sleep.

By now they'd been awake for more than 24 hours.

GEOFF THOMPSON: And how much sleep did you get?

DOMINIC JAMES: Not much. Couple of hours.

GEOFF THOMPSON: Were you tired?

DOMINIC JAMES: I didn't feel tired, no.

BRYAN AHERNE: It sounded like to me that he was fatigued. When you do the timelines, it's, it would be impossible for anyone to suggest otherwise.

HOUSEMAID (Reconstruction): (Knocking on door) House-keeping.

MICK QUINN: He misses two nights' sleep, basically. The accident happened on the second night of him missing sleep.

GEOFF THOMSON: CASA's special audit found that Pel-Air failed to comply with approved fatigue management systems. It concludes that:

(Reads audit report): "Pel-Air have not managed fatigue risk to a standard considered appropriate, particularly for an operator conducting ad hoc 24 hour medivac operations"

MARTIN DOLAN: There was an indication there fatigue may have had a role to play. But the evidence available to us wasn't such that we'd come to the definitive view that there was a major fatigue related element.


JOHN MCCORMICK: In the end it's only the pilot who can decide whether he is fatigued or he or she is fatigued and unable to conduct a flight.


&..

...But there's a document which the Australian public was never meant to see.

It's CASA's special audit of Pel-Air, completed just after the ditching in 2009.

It identifies significant deficiencies within the company's Westwind operations in Pel-Air.

What it describes sounds like an accident waiting to happen.

It lists numerous breaches of aviation regulations and legislation covering fuel policy, flight planning and pilot training.

JOHN MCCORMICK: None of those, 31 I think it is, requests for corrective action that we found when we did the in-depth audit of Pel-Air would've affected that accident or prevented that accident.

GEOFF THOMPSON: But given that the operator was failing in areas of fuel planning, fatigue, check and training, lack of support for pilots, and these were regulatory breaches, isn't that something the Australian public has the right to know about, given that that's what the operator was doing when this ditching occurred?

JOHN MCCORMICK: Well as I say, none of those particular incidents or events that we looked at within that audit would've prevented that accident. The accident was caused by poor fuel planning, poor decision making.

Now rewind and this is what former AIPA President Captain Woodward said approximately one month after the ditching:

Quote:RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

Five days later Ben Cook and Mal Christie presented their comprehensive scientifically based findings on the CASA approved Pelair FRMS. Extract example from that report (note that the email to Wodger, the 'audit coordinator', was sent the day after the FAA IASA findings were handed down):




Now again let's rewind to exactly a week after the 'inconvenient ditching' to this inconvenient US embassy cable that WikiLeaks also released in August 2011: http://cables.mrkva.eu/cable.php?id=236548

Quote:SUBJECT: FAA'S UPCOMING ASSESSMENT OF AUSTRALIAN CIVIL
AVIATION

REF: STATE 119313

1.  (SBU) SUMMARY:  Australian aviation authorities will
release a statement on the FAA's upcoming assessment of
Australia's civil aviation, which is scheduled for November
30 - December 4 (reftel).  The government release will be out
in the next day and could be in the press as early as Friday,
November 27.  Post would appreciate press guidance in case
this becomes an issue.  End Summary.

2.  (SBU) Terry Farquharson, head of the host delegation from
the Australian Civil Aviation Safety Authority (CASA),
alerted Econoff November 25 that the office of Minister
Albanese (Minister for Infrastructure, Transport, Regional
Development and Local Government, which oversees CASA) had
decided, against CASA's recommendation, to carry out a press
release regarding the upcoming FAA assessment.  In the coming
day, CASA will post the statement (a draft of which
Farquharson read to Econoff) on its website and will conduct
an interview with a reporter, with a strong possibility that
an article may appear in the aviation section of "The
Australian" newspaper's Friday edition.  It should be noted
that the draft release did not contain anything controversial
and points out that the assessment visit is being conducted
at the request of CASA.

3.  (SBU)
CASA's view is that the press exposure may
unnecessarily complicate the conduct of the assessment, given
that at its core, the assessment is an attempt to clear the
record from a previous audit in which several shortcoming
were identified (see reftel).  The Ministry's office
preferred to carry out the release for the sake of
transparency and in order to preempt after-the-fact
questioning of what the Minister knew or did not know prior
to the FAA teams arrival.

4.  (SBU) Comment:  We are in close contact with both FAA and
CASA and are facilitating final coordination of the visit.
We do not anticipate this media release will become a
problem, but do expect questions from the press.  We would
appreciate press guidance from the Department and/or FAA.


BLEICH
   
On review of former Minister Albo, CASA, Department and the Australian media archives it would appear that by November 27th the 'powers to be' (Iron Ring) eventually got a rope on Albo as there was no formal MR announcing the imminent arrival of the FAA audit team... Huh

In fact it wasn't till around 8 months later that I can find a passing 'off the cuff' comment by the former Minister for Non-Aviation on the FAA IASA audit: http://anthonyalbanese.com.au/category/m...hes/page/9


...CASA, the nation’s independent aviation safety watchdog, will recruit almost 100 additional frontline staff with the $89.9 million in new funding provided by the Budget. This extra investment in safer skies will be funded via a small increase in the aviation fuel excise, from 2.8 cents per litre to 3.5 cents per litre. The Government considers this to be a reasonable and responsible step considering the industry’s continued growth depends on the public’s ongoing confidence in its safety standards. Following the ICAO and FAA audits this investment in CASA’s staff and training is critical, and will strengthen the organisation’s oversight of the industry. Aviation safety should be bi-partisan, and the Government puts the safety of passengers ahead of other interests...

And from the former DAS McCormick there was no mention, that I can find, of the FAA audit findings till nearly a year later in his 'review' contained in the 2009-2010 Annual Report (note there is no mention of the fact that the FAA were three steps away from consigning Australia to CAT II):


...A comprehensive training and professional development
program has been put in place to ensure that our
staff have ongoing training. Technical training was
identified as an issue by the International Civil Aviation
Organization (ICAO) in its 2008 audit and in the US
Federal Aviation Administration’s International Aviation
Safety Assessment (IASA) audit. We have responded
by developing a comprehensive technical training and
professional development program to enhance staff
capability in areas such as leadership, regulatory skills
and technical expertise...



(P2 comment: Hmm...kind of ironic that in the same year CASA was to lose two of the foremost experts in Australia on aviation Human factors and FRMS/SMS)

Quote from 7:30 report segment: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.


G'Day Aunty, long time reader. Bloody good stuff.

So P2, let me check if a boofhead like me has got a grip on this Pel-Air/FRMS situation mate.

The ïnconvenient ditching" happened bang smack at a time when a new DAS was appointed, the FAA & ICAO were sniffing around and a new airline academy, owned by the "ditched jet"company was goin' on.

FRMS was on the FAA & ICAOs radar from a previous visit. A possible downgrade was on the horizon...then that bloody ditching put a big fat fly in their (CASA) chardonnay!

Experts like Ben Cook (ex-CASA) showed clear evidence that FRMS was an issue within Pel-Air and Aviation in general. 

That's when the öh shit" happened within the agencies and the snowball of collusion, corruption & witch hunting started.

Then the bloody first report had no FRMS issues in it & wasn't reported to ICAO. Struth mate, this is serious enough, but it seems to get worse.

The Senate documents (those 9 emails) of more evidence showing what the turds were up to was hidden for 4 months. So the Senators were not able to read them before the inquiry & ask questions. Shit mate, they were only put back on the Senate website less than 24 hours of starting the inquiry. I dunno about you lot reading this stuff, but that is an obstruction of justice. Someone took a big dump on those good Senators. Gotta be a mole from inside. 

Albo did nothing, right? His Aviation White paper became Aviation's Invisible paper. I think I saw  a picture of him not long after with John Sharp. He's the CEO of Pel-Air. Fancy that, bloody grubs. Albo & John opened the Airline Academy 5 months after the ditching.

Well that makes no bloody sense now, does it. Have a massive screw up then teach the world how to fly. You've gotta be joking!

REX/Pel- Air have a serious incident. So many flaws in their operations. Audit issues coming out of their ears, government investments into the Academy...no wonder the pricks ignored the FRMS problems...would've been the friggin nail in their coffin mate.

REX even donated 300k around the same time the Senate was going on. Albo got a chunk, 100k I think. I mean shit, blind Freddy could figure out what's happening here.

How much money over the eights years has been spent off Tax Payers coin. Gotta be in the millions? 

That wingnut Carmody better put his big girl pants on if he is going try & deal with this Snowball of Corruption. They've got no chance of skipping away from this.

The other bloke, Hood...what a tool. He needs to grow a set too. These guys have a shitload of explaining to do. Hopefully in front of the Senators real soon. 

Can't see the Senators being impressed with the second report either. Just have to wait & see hey?

Yeah, nah, yeah, nah, yeah, nah, yeah mate. I can see where you're coming from now.

Awesome bloody reading. Keep digging mate, you're surfing on the edge of a frothy revolution in Aviation Safety.

Good onya Aunty.

WTFIncorporated salutes your fact finding! 


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P2 comment - For a 1st post, & from a layman's POV, bloody good dot joining WTFI - chocfrog is in the mail... Wink   

Ps Luv the meme too!
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Messages In This Thread
On joining the dots and making of dashes. - by Kharon - 02-24-2015, 06:27 AM
RE: On joining the dots and making of dashes. - by Peetwo - 02-24-2015, 10:59 AM
RE: On joining the dots and making of dashes. - by Peetwo - 04-05-2015, 01:01 PM
RE: On joining the dots and making of dashes. - by Kharon - 04-07-2015, 07:26 AM
Which MoU?? - Eeny meeny miney MoU - by Peetwo - 04-07-2015, 08:40 PM
RE: On joining the dots and making of dashes. - by Kharon - 04-08-2015, 07:11 AM
RE: On joining the dots and making of dashes. - by Peetwo - 04-08-2015, 08:41 PM
RE: On joining the dots and making of dashes. - by Kharon - 04-09-2015, 08:56 AM
RE: On joining the dots and making of dashes. - by Kharon - 05-03-2015, 07:37 AM
RE: On joining the dots and making of dashes. - by Peetwo - 05-03-2015, 11:02 AM
RE: On joining the dots and making of dashes. - by P7_TOM - 05-03-2015, 11:51 AM
RE: On joining the dots and making of dashes. - by Peetwo - 05-03-2015, 01:38 PM
Is it really so difficult? - by Gobbledock - 05-03-2015, 06:44 PM
RE: Is it really so difficult? - by Peetwo - 02-23-2017, 07:23 AM
RE: On joining the dots and making of dashes. - by Kharon - 02-22-2017, 05:40 PM
RE: On joining the dots and making of dashes. - by Gobbledock - 02-23-2017, 12:33 PM
RE: On joining the dots and making of dashes. - by Peetwo - 02-23-2017, 10:36 PM
RE: On joining the dots and making of dashes. - by Pixie P - 02-23-2017, 11:02 PM
RE: On joining the dots and making of dashes. - by Peetwo - 02-24-2017, 11:34 AM
RE: On joining the dots and making of dashes. - by Kharon - 02-25-2017, 08:26 AM
RE: On joining the dots and making of dashes. - by Peetwo - 07-27-2017, 01:09 PM
RE: On joining the dots and making of dashes. - by Peetwo - 08-04-2017, 10:24 AM
RE: On joining the dots and making of dashes. - by Peetwo - 08-07-2017, 07:00 PM
RE: On joining the dots and making of dashes. - by Peetwo - 08-11-2017, 12:57 PM
RE: On joining the dots and making of dashes. - by Kharon - 08-07-2017, 08:10 PM
RE: On joining the dots and making of dashes. - by Kharon - 08-11-2017, 05:49 PM
RE: On joining the dots and making of dashes. - by Peetwo - 11-28-2017, 09:19 AM
RE: On joining the dots and making of dashes. - by Kharon - 11-29-2017, 08:40 PM
RE: On joining the dots and making of dashes. - by Peetwo - 11-30-2017, 07:24 AM
RE: On joining the dots and making of dashes. - by Sandy Reith - 11-30-2017, 05:42 AM
RE: On joining the dots and making of dashes. - by Peetwo - 12-01-2017, 08:29 PM
RE: On joining the dots and making of dashes. - by Peetwo - 01-09-2018, 06:40 PM
RE: On joining the dots and making of dashes. - by Peetwo - 02-14-2018, 09:13 PM
RE: On joining the dots and making of dashes. - by Kharon - 12-02-2017, 04:33 PM
RE: On joining the dots and making of dashes. - by Peetwo - 12-04-2017, 07:06 PM
RE: On joining the dots and making of dashes. - by Kharon - 12-05-2017, 07:09 AM
RE: On joining the dots and making of dashes. - by Kharon - 12-06-2017, 07:06 AM
RE: On joining the dots and making of dashes. - by Peetwo - 12-12-2017, 09:14 PM
RE: On joining the dots and making of dashes. - by Peetwo - 01-13-2018, 10:53 AM
RE: On joining the dots and making of dashes. - by WTFIncorporated - 01-15-2018, 07:25 AM
RE: On joining the dots and making of dashes. - by Peetwo - 01-23-2018, 06:44 PM
RE: On joining the dots and making of dashes. - by Peetwo - 01-30-2018, 06:35 PM
RE: On joining the dots and making of dashes. - by Kharon - 01-31-2018, 07:41 AM
RE: On joining the dots and making of dashes. - by Sandy Reith - 01-31-2018, 10:17 AM
RE: On joining the dots and making of dashes. - by Peetwo - 02-01-2018, 06:38 AM
RE: On joining the dots and making of dashes. - by P7_TOM - 02-15-2018, 07:59 PM
RE: On joining the dots and making of dashes. - by Peetwo - 02-24-2018, 10:14 PM
RE: On joining the dots and making of dashes. - by Peetwo - 07-04-2018, 09:19 PM
RE: On joining the dots and making of dashes. - by Kharon - 07-05-2018, 09:43 AM
RE: On joining the dots and making of dashes. - by Kharon - 04-11-2019, 08:13 AM
RE: On joining the dots and making of dashes. - by Peetwo - 04-11-2019, 02:35 PM
RE: On joining the dots and making of dashes. - by Kharon - 04-12-2019, 07:43 AM
RE: On joining the dots and making of dashes. - by Peetwo - 04-12-2019, 11:31 AM
RE: On joining the dots and making of dashes. - by thorn bird - 04-12-2019, 11:40 AM
RE: On joining the dots and making of dashes. - by P7_TOM - 04-12-2019, 10:40 PM
RE: On joining the dots and making of dashes. - by Peetwo - 04-17-2019, 10:29 AM
RE: On joining the dots and making of dashes. - by Peetwo - 12-12-2019, 11:00 AM
RE: On joining the dots and making of dashes. - by Peetwo - 05-27-2020, 11:53 AM
RE: On joining the dots and making of dashes. - by Kharon - 05-28-2020, 08:28 AM
RE: On joining the dots and making of dashes. - by Peetwo - 05-29-2020, 11:37 AM
RE: On joining the dots and making of dashes. - by Peetwo - 02-19-2021, 09:06 AM
RE: On joining the dots and making of dashes. - by Kharon - 03-11-2021, 07:18 AM
RE: On joining the dots and making of dashes. - by Peetwo - 10-13-2022, 07:35 PM
RE: On joining the dots and making of dashes. - by Kharon - 10-14-2022, 08:02 AM
RE: On joining the dots and making of dashes. - by Peetwo - 05-26-2023, 09:51 PM
RE: On joining the dots and making of dashes. - by Peetwo - 06-10-2023, 11:09 AM
RE: On joining the dots and making of dashes. - by Peetwo - 06-18-2023, 10:17 PM
RE: On joining the dots and making of dashes. - by Peetwo - 01-19-2024, 08:23 PM
On joining the dots and making of dashes. - by slats11 - 02-24-2015, 09:51 AM



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