[Peetwo]

In light of the recently released MH370 interim report (08 March '15) and the more than passing strange parallels to the PelAir debacle (or as I prefer to call it cover-up); I thought now was a good time to liven up this thread as indeed MH370 is severely lacking in investigative probity and also lacking government(s) transparency in process.

To begin the conversation let us refer to the Prune post (my post) to which kharon (above) mentions - Sarcs #post2653:

...However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...

From 3.5 Report preparation (November 2010 to March 2012) of TSBC report:

At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.

They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.

But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...

However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):

1.17 Organisational and management information

The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.

Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-

1.17 .1 Fuel Policy and Practice
• Inadequate fuel policy for Westwind operations.
• Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
• No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
• No alternate requirements specified for remote area and Remote Island operations.
• The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
• Criteria to obtain weather updates not specified in Operations Manual.
• Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
• No consideration of loss of pressurisation and an engine failure.

1.17 .2 Operational Control
• No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
• Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
• The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
• In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.
• Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.

1.17.3 Training
• Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
• Inadequate documentation of training programs.
• No formal training for international operations.
• Inadequate training records for pilot endorsement and progression.
• Inadequate records of remedial training.
• Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
• No mentoring program for First Officer to Command.
• Deficiencies in training records identified.

1.17 .4 Fatigue Management
• Over-reliance on FAID as the primary fatigue decision making tool.
• Inadequate adherence to FRMS policy and procedures.
• Excessive periods of 24/7 stand by.
• Lack of FRMS policy regarding fatigue management for multiple time zone changes.
• Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).

1.17 .5 Drug and Alcohol Management
• Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.

These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.  

Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture... Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5 (PDF 6032KB)...

The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..

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

Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA? 

Well you may ask what has this all got to do with the investigative probity of the directly interested parties currently involved in the MH370 search & accident investigation?? To help explain the following is quoted from the beginning of Clive Irving's latest article on MH370:

Most airplane disasters are teachable moments that the aviation industry learns by. This is the way that flying – still by far the safest form of transportation per capita – becomes even safer. Yet in this disaster there is as yet not one piece of physical evidence to begin that process. There is however a trail of failures that expose serious lapses of responsibility across a wide range of airline and regulation practices.

& from Chapter 3.1 of ICAO Annex 13:

OBJECTIVE OF THE INVESTIGATION

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It
is not the purpose of this activity to apportion blame or liability.

 
  As signatories to ICAO both Malaysia & Australia are obliged to comply with the spirit & intent and the fundamental principles, of ICAO Article 26 & indeed Annex 13. History will eventually show whether the Malaysians have met their international obligations to ICAO - but the first signs are less than reassuring.  While in the case of PelAir & the ATSB there is no doubt that the State AAI did not meet its obligations to ICAO and therefore the greater world aviation industry and travelling public. 

Okay before we move on to Part 2 - in the search for investigative probity - I will leave you with an excellent blog opinion piece courtesy of Dan Parsons (Mid 2013): 

No Man is an Island

I’ve been a bit out of the loop over the past couple of months as I try to get a handle on my new job and the (almost overwhelming) responsibility that goes along with it. But I can’t ignore the action over at the Federal Senate’s Rural and Regional Affairs and Transport References Committee’s inquiry into Aviation Accident Investigations.

Before I comment, some disclaimers – I’m not going to comment on the particulars being discussed at the Senate hearings. While I worked with many of those involved, I never worked on anything associated with the accident event (before or after) but if I were to comment, it might look as though I have inside information, am bearing a grudge or just being an stirrer. I don’t, I’m not and maybe just a little .

I do, however, want to comment on the philosophy surrounding some of the issues at hand.

The particulars of the situation on which, I would like to comment are, basically, that an accident occurred and the resulting investigation focussed on the operating crew. In the 15th February hearing, two comments by Senator Fawcett struck me as warranting further examination. They were:

One thing the committee wants to put on the table upfront is we accept the contention by CASA that there were errors made on behalf of the pilot in command of the flight. There seems to have been some concern raised that this inquiry is all about exonerating an individual and shifting blame elsewhere. That is not the case. We accept the fact that in the view of some it was even a violation as opposed to error. (p. 1)

With the concept of a systems approach, whereby not only the operator and the pilot in command but also the regulator are key parts of the safety system… (p. 3)

For all the other problems we seem to be having in this scenario, we still seem to be stuck on the basics.

Part of a Complex System

Senator Fawcett’s second quote there and numerous others throughout the course of the hearing shows that he is quite familiar with the concept of a safety system but he, and I think a large part of the industry, can’t escape the concept of personal responsibility associated with criminal law.

The language of “exonerate” and “shift blame” suggests strongly that the old approach to investigations and safety improvement is still alive. We seem to have slid back into the days of pointing the finger at the front-line operator, stamping the label of “cause” upon them, punting them into touch, dusting our hands and declaring the world a safer place.

Okay, I’ll admit that this could be a harsh analysis of what is possibly a “throw-away” line but the language could indicate a deep-seated belief in the very concepts we are supposed to have left behind. I’m also not singling out Senator Fawcett. I think we all fight these traditional ideas, conditioned within us since an early age. How many of us still use the word “cause” despite its often misleading level of direct influence and independence?

Exonerate, Exshmonerate; Blame, Shame.

It’s a hard thing to let go of but, I think, we have to let go of the criminal view of personal responsibility when we are dealing with accidents in complex socio-technical systems, such as aviation. I’m just going to come out and say it:

No one, who participates in the aviation system, should ever go to jail, be fined or sanctioned as a criminal. Ever. Regardless of the error, violation, failing, mistake, slip, lapse, omission, commission, faux-pas, foul-up, whatever.

If we accept that aviation is indeed a system – a complex set of individuals, machines, procedures, tools, organisations – all working to achieve the objective of moving stuff from A to B – then no single part of that system can be singled out as having “failed”.

As a system there are, or should be, feedback loops. Sub-systems for checking and re-checking. There should be self-correction. If one part has failed, more parts have failed; in fact, the whole system has failed.

If you are going to blame one, you need to blame all. Jail one, jail all. Fine one, fine all.

Whoa Warden, Don’t Open that Door Yet

I am definitely not advocating some criminal reform agenda that would see society’s jails shut-down and personal responsibility disappear. I am arguing for a clear distinction between how we view undesirable events within the aviation endeavour and in society at large. I don’t think it is appropriate to look at the aviation industry as a sub-set of society and apply the same thinking.

The big differences between aviation and society are choice and intent. Pilots, ATC’ers, LAMEs, AROs and many others choose to be part of the aviation with the intent on achieving the industry’s objective of moving stuff from here to there safely.

Society on the other hand is, really, all encompassing. By definition, we don’t really have a choice to join. You could run off into the woods, build a log cabin and live as a hermit but you’d still be a part of society in the broadest sense and still, more importantly, be subject to various laws governing human relationships.

What to do with a broken part?

A while back the industry tried “no-blame” and it didn’t work. I think it was because the concept suggested there would be no ramifications, no consequences to behaviour which contributed to undesirable outcomes.

And this, of course, is untenable. If the system experiences an undesirable state or outcome, it should be able to correct its performance.

The response was to abandon “no-blame” as going too far but I think the problem was that the concept of blame actually ceases to have any meaning within a safety system approach. Much like one cannot meaningfully discuss events “before” the big bang, because time began at the big bang.

So What’s the Lesson?

The tiny lesson I’m trying to get at here is that we need to try harder to fully integrate the system approach into our thinking. It’s not so much that we can’t identify frontline operators as contributors to accidents but that there will (not might) be more to the story. Someone else, actually numerous people, will have contributed, in every case.

And in taking this approach, in identifying as many contributory factors as possible, the actions we take with respect to those people, tools, equipment, etc. will be and be perceived as appropriate. It will support actions like suspending a licence, grounding a fleet or withdrawing a certificate.

Without it, honing in on a frontline operator and booting them out of the system will never look justified regardless of how necessary it is.

MTF with Part 2 and Back to Reason...