[Peetwo]

Closing the FRMS safety loop?  -  

A most inconvenient ditching.

"...There had to be a reason for the bizarre, extraordinary behaviour of CASA following the Norfolk ditching event. The life and career of one small, insignificant human became as nothing when compared to the truly shocking notion that the world may discover how seriously flawed the regulator, the regulation and the management of aviation truly was then. It will come as no surprise that nothing – absolutely nothing has changed since then; unless you count the slow, irresistible slide deeper into the pit. Do I feel sorry for the ‘good eggs’ in the CASA basket? No, I do not. ‘They’ could have spoken out, they have had ample opportunity and much encouragement to do so. Resignation and silence – honourable? Oh, I think not..."

Extract from 'Accidents - Domestic' thread post #256:

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HVH: “By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,”

Is that like the ATSB closing safety loops on serious safety issues that having been identified, in some cases nearly 2 decades ago, & despite political and aviation safety bureaucratic rhetoric, are yet to be effectively risk mitigated...

Examples from the same decade refer here: Closing the safety loop - Coroners, ATSB & CASA

And most recently and still live... : 
FRMS/SMS a lip service exercise - Part VII & FAA IASA audit, FRMS & an 'inconvenient ditching'?

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In Senate Estimates the 'closing the safety loop' as a term of reference was first adopted by Senator Fawcett in the 2012 Budget & Supplementary Estimates.

From Senate Hansard:

Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

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& answer to Supp Estimates QON 157 (note that this was 6 days before the AAI inquiry began):

Question no.: 157
Program: N/A
Division/Agency: (ATSB) Australian Transport Safety Bureau
Topic: Closing the loop on ATSB safety recommendations
Proof Hansard Page/s: 77-78 (16/10/12)

Senator FAWCETT asked:

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak: It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.

Answer:

One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed, not addressed, no longer relevant or withdrawn.

A safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation. However, experience has been that this is rarely required.

The ATSB policies and procedures for identifying and promoting safety issues, including through the issuance of a formal recommendation, is outlined in its submission to the Senate References Committee Inquiry into Aviation Accident Investigations.

The ATSB’s Annual Plan and part of the ATSB’s Key Performance Indicators specifically relate to a measurement of safety action taken in response to safety issues; in the case of ‘critical’ safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed.

As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for following up on recommendations and safety issues identified by the ATSB, as provided for in the Memorandum of Understanding between the agencies. Aviation safety agency heads will continue to monitor the present arrangements to provide an adequate system for addressing issues identified through ATSB investigations.

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Coming back to the - unclosed loop - 2 decade old identified safety issue of fatigue, as a passing strange coincidence the following was a short passage of Hansard, from May 2012, that followed Sen Fawcett's ATSB safety loop questioning:

Senator XENOPHON: I will try to make it a very quick one. I keep getting complaints from those who are in safety-sensitive positions in aviation about fatigue issues and that the fatigue issues seem invariably to accompany reports of an oppressive workplace culture, most recently in terms of air traffic controllers. How does the ATSB deal with the particular issues of fatigue management and the performance consequences of workplace culture, given the subjectivity inherent in those concepts? Do you see a role in ATSB monitoring the performance of the fatigue management systems or do you see it as a purely regulatory function? Do you think that the regulatory agencies are doing enough about fatigue risk management? I am happy for you to take it on notice.

Mr Dolan : With your indulgence, I can answer it quite quickly.

CHAIR: Yes, get to the point.

Mr Dolan : Fatigue, when it is detected as a contributing factor in any investigation we undertake, we will look to fatigue management systems to see whether they can be improved to better manage the risk of fatigue in the system. I do not have any evidence in front of me that would allow me to give you an additional comment on the adequacy of regulatory oversight. We have not seen anything that would say it is inadequate. P2 comment - Err (vomit - ) BOLLOCKS!!

Senator XENOPHON: Thank you.

Also of much historical interest was this passage from earlier in the ATSB session:

Senator XENOPHON: It has been suggested to me that, with the ATSB's pursuit of no-blame results in reports, on the one hand they are delayed by seeking high levels of consensus amongst interested parties and, on the other hand, they could potentially end up lacking human factors reporting as to risk, rendering the reports almost as historical records rather than safety enhancement tools. Could you comment on that? Is the amount of time spent on consulting interested parties detracting from the timeliness of publishing reports? I know there are some tensions here in terms of due process and fairly helping people. I have tried to set out what the concern is.

Mr Dolan : I hear two elements to your question, so I will take them sequentially. The key process of consultation is done at the point where we have a draft report. So we have examined all the facts, we have done our analysis and we have formed provisional views. We circulate a draft report under the protection of our act—so not to be released—to what we call directly involved parties. If it is domestic, we expect any comments within a month and we emphasise that we are principally seeking any corrections of factual inaccuracies in our report. We are also seeking, where we have identified a safety issue, information on any action that the relevant party may have taken in response to the identified issue. The focus is on getting something done in response to our findings. That process normally takes a month plus another week or two to make sure that the relevant concerns that may have been raised with us are integrated into the final report. I do not see it as a major constraint on our timeliness.

Senator XENOPHON: You do not think it constrains you in terms of providing more depth in human factors analysis?

Mr Dolan : That was the second part, as I was saying, of the question. There is the specific timeliness thing, an appropriate level of review to make sure that the rigour and the factual accuracy of our reports is in place, which I think is important, and it also goes to procedural fairness. Although we are a no-blame organisation, people can read our reports as pointing the finger, even though we do not intend them to. So there are no surprises for those involved.

The second point is that I am startled that there is a belief out there that we do not have human factors at the core of what we do. Our entire investigation and analytical model is based on fundamental principles of human factors—understanding human error, understanding how to minimise it, accepting that you can never remove it, and looking therefore at how you capture errors and make sure they are dealt with in the system. I am not sure, in addition to that, how much I can say.

Senator XENOPHON: I will possibly put some questions on notice about Airservices Australia. In relation to that issue of human factors, it was not a criticism; I am just saying that was a concern that has been expressed to me by those in aviation. I am thinking of the Air France 447 investigation, which of course the ATSB has nothing to do with—that terrible loss of life over the Atlantic.

Mr Dolan : We are watching it with interest.

Senator XENOPHON: No doubt you are looking at it with interest. You correctly emphasised factual information. With Air France 447, I think there is still a final report down the track?

Mr Dolan : The report is due for release next month, as I understand it, from Mr Troadec of the BEA.

Senator XENOPHON: That whole investigation seems to be looking at human factors. It seems increasingly clear that the 'what' does not so much clarify the 'why'. To what extent will the 447 investigation influence the way that air safety investigators around the world conduct their work, or is it just an instance of human error?

Mr Dolan : I suppose this might help you in explaining my puzzlement. I have had conversations from time to time with my French counterpart, Mr Troadec. I would totally agree with you that some of the key issues in Air France 447 relate to human factors—understanding why some of the various actions that were clear from the flight data recorder and the cockpit voice recorder, once retrieved, happened. The reason I remain puzzled is that the 'why' is at the heart of what we are trying to do. We normally get the 'what' in the initial occurrence report. The time we take is to try to understand the 'why' and whether anything needs to be done as a result of us having determined the 'why'.

 Q/ Can anyone else see the irony of the 'Beaker' weasel words? 

Again remember that this was approximately 5 months before the Senate PelAir inquiry began; and a year before the diabolical findings of that inquiry were made public; and about 13 months before AIPA presented their Parliamentary Brief on fatigue and the proposed disallowance motion on the CAO 48.1 legislative instrument...

Extract from PelAir MKII FR:

...On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation...

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& from Oz Aviation 8 December 2014:

ATSB to reopen Pel-Air ditching investigation


December 8, 2014 by australianaviation.com.au

Westwind VH-NGA ditched off Norfolk Island in 2009. (ATSB)

The Australian Transport Safety Bureau (ATSB) will open a fresh investigation into the ditching of a Pel-Air Westwind corporate jet off Norfolk Island in 2009.

The decision to reopen the case was made following a critical review of the original inquiry by the Transportation Safety Board of Canada (TSB), which found the ATSB did not follow proper process and had poor oversight during the investigation.

“A new investigation team will review the original investigation and associated report in the light of any fresh evidence and relevant points raised in the TSB review and other recent aviation reviews,” the ATSB said in a statement on Monday.

“At the same time, the ATSB Commission will continue to methodically and carefully work its way through the broader findings and recommendations of the TSB review, with the aim of ongoing improvements to the future work of the ATSB.”

A Senate committee also the released a scathing assessment of the original investigation.
Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss told Parliament last week he had asked the ATSB to reopen the case.

To be continued: Next I will again fast forward to the PelAir MK II Final Report to factually expose how the ATSB has once again obfuscated it's stated responsibilities to the re-investigation (see above) and the primary purpose for ICAO Annex 13 Aviation Accident Investigation. IMO the PelAir FR, in particular on the downplaying of fatigue & SMS identified safety issues, provides further proof that the ATSB is still continuing in the role of providing top-cover for the regulator CASA, the Department and indeed the Minister...


MTF...P2