[Peetwo]

Finally after 2185 days -

From the O&O thread

PelAir - 'Lest we forget' Part III - Six years on and the ATSB is still a basket case..

Courtesy Ben Sandilands (Planetalking blog):

Six years on, ATSB about to recover Pel-Air flight data recorder

Ben Sandilands | Nov 09, 2015 3:30PM |

In another triumph of administrative efficiency, diligence and focus the Australian Transport Safety Bureau or ATSB, is poised, after almost six years, to recover the flight recorder from the Pel-Air Westwind corporate jet that was ditched in the sea near Norfolk Island on 18 November 2009.

The small jet had intended to refuel at Norfolk Island on its way from Apia to Melbourne as part of a medical charter flight, but had insufficient fuel on board to divert to an alternative airport when despite four missed approaches it was unable to land because of deteriorated weather conditions.

All six people on board were rescued by an island fishing boat and in the course of its original and since discredited investigation into the accident the ATSB decided not to recover the recording device, which is less sophisticated than those on larger jets, and of a design which in some quarters is said to be prone to medium term salt water corrosion.

The decision of the ATSB to blame everything on the pilot, and not recover the flight recorder led to a prolonged and continuing controversy.  A peer review of the ATSB’s conduct of the first inquiry by the Transportation Safety Board of Canada found (for those who managed to read all of it) that not all of the relevant information available to the ATSB may have been taken into account, and referenced internal frustrations and divisions within the ATSB investigation.

A review of that report can be read here.

Damning review of ATSB Pel-Air investigation released

Ben Sandilands | Dec 02, 2014 12:44PM |

Memo Tony Abbott and Warren Truss. Second rate isn’t good enough in air safety investigations, and the Canadian peer review of the ATSB re Pel-Air makes us look very grubby.

The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.

This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.

The report also casts light on internal frustrations and divisions within the ATSB investigation.

It summarises some of those matters as follows.

3.10 Findings from the TSB review of the Norfolk Island investigation

1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
   
2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
   
3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
   
4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analyzed.
   
5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
   
6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
   
7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
   
8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
   

If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised report up,  as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.

This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.

The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation.

This is just a part of what the TSBC review says on such matters.

The Minister supposed to be looking after aviation, Warren Truss, has previously parrotted lines written for him by his department that there is no value in re-opening or replacing the final report of the Pel-Air investigation.

This embrace of second rate by a Minister supposed to uphold fairness and excellence in aviation safety reporting is unworthy.

The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.
Second rate isn’t good enough for Australia.

The ATSB was subsequently ‘invited’ by the Deputy PM and minister responsible for aviation, Warren Truss, to revisit its report, which the agency after a delay removed from its web site pending its in effect, being redone.

Recovering the flight recorder is part of this process.

The dysfunctional manner in which the prolonged ATSB inquiry was conducted was laid bare in the peer review by the TSBC although this was only apparent on a full reading of that document rather than in relying on the summaries offered by the Department of Infrastructure which is responsible for both the safety investigator and the air safety regulator CASA.

The crux of the Pel-Air controversy is that the pilot was framed by the ATSB and CASA while the safety regulator improperly withheld an internal report which found gross failures on its part to correctly oversight or remedy what was found to have been serious safety deficiencies by the operator.

One of the critical matters raised by the controversy is the integrity of the ATSB in relation to the first Pel-Air accident investigation report, including its disinterest in that suppressed internal CASA review of its own performance.

That internal report, known as the Chambers Review, concluded that had CASA done its job the accident might not have happened.

The ATSB website has been updated on the recovery operation.

The image below from the ATSB shows what the wreckage looked like in March this year.

Will we forget? Not bloody likely..

Well apparently the VH-NGA CVR/FDR was recovered yesterday...

Here is the update from the ATSB investigation page:

Aviation safety investigations & reports


Investigation title - Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009
 
Investigation number: AO-2009-072

Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  
  

Update
Updated: 12 November 2015

During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra. The part numbers and serial numbers of the recorders agree with the maintenance documentation for the aircraft. The recovery and storage of the recorders was witnessed by an officer of the Australian Federal Police. Examination of, and data recovery from, the recorders is expected to commence during the week of 16 November 2015.
 
 
Updated: 9 November 2015

In March this year, an underwater survey of the Pel-Air aircraft wreckage was conducted by the ATSB with the assistance of NSW state and federal police officers. The survey was conducted to establish the condition of the wreckage and to assess a viable means of recovering the flight recorders. Subsequently, a commercial marine salvage company, the Pacific Marine Group, was selected through a tendering process to contract with the ATSB to complete the operation. The salvage vessel, PMG Pride, is currently underway from her home port of Townsville and is expected to arrive at Norfolk Island in the next few days.
Early this week investigators from the ATSB, along with an officer from the Australian Federal Police will be working together with the project team from Pacific Marine Group to raise the Pel-Air wreckage and recover the flight recorders. The recorders will be transported back to the ATSB headquarters in Canberra for download and analysis. The data on the ‘black boxes’ will be used to further assist the ATSB investigators understand the sequence of events of the accident. 

The ATSB requests that all local vessels remain away from the Pel-Air wreckage site throughout next week. The PMG Pride will be at anchor and there will be divers and salvage equipment in the water....  

As "V" said on twitter - .."Interesting times ahead"..


MTF..P2