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Times up for Pel_air MkII
"V" the rumour is that there is a couple of minor delays with the DIP review process and due to some DIP feedback the ATSB is now considering some changes to the DRAFT Final Report... Huh

MTF? - 'YAWN!' Sleepy - yeah eventually...P2 Dodgy
Further delay in DIP process - Confused   

Via the ATSB update fairies... Rolleyes :

Quote:Updated: 6 October 2017

Following release of the draft report to Directly Involved Parties on 23 June 2017, a number of requests for extensions to the draft comment period were received from several parties. Almost all comments were received by the end of August 2017 and the work associated with assessing those comments as part of the finalisation of the report is complete.

Comments from a further directly involved party were received on 3 October 2017. To allow the necessary time to consider those comments, it is now expected the report should be finalised and released in early-mid November 2017.
"...further directly involved party.." Note singular DIP - Hmm...wonder who that might be? Rolleyes

MTF...P2 Cool
PelAir MKII: ASA Swiss Cheese slices & bunnies - Dodgy

References: Willow brings up PelAir ditching at ISASI presentation - WTD?? 

Quote:..An amended Norfolk Island TAF that was valid for the aircraft’s ETA was issued by the Australian BoM at 0803. In that TAF, the visibility was forecast to be 10 km or more, with Broken cloud at 1,000 ft above the ARP. Those conditions indicated that the weather would be below the alternate minima for Norfolk Island at the aircraft’s ETA, but above the landing minima. The flight crew were not advised, and were not required by any international agreement to be advised, of the amended forecast and they did not request an updated forecast for Norfolk Island during the flight...

I still have to pinch myself when I re-read the above quote and then remind myself that the identified safety issue of non-provision of critical wx flight information...

  • Nadi in not providing the 0803 amended TAF, which forecast conditions below the alternate minima; plus
  • Nadi not proactively providing the 0830 SPECI, which included broken cloud below
    the landing minima and finally;

  • after responsibility for the aircraft was transferred to Auckland FS at 0835, the Auckland ATCO did not confirm that the flight crew had received the 0803 TAF and/or the 0830 SPECI.

...did not even rate a mention in the original 'Findings' and/or 'Safety Actions' sections of the AO-2009-072 Final report:

Quote:Contributing safety factors
• The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
• The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
• The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Other safety factors
• The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert. [Minor safety issue]
• Given the forecast in-flight weather, aircraft performance and regulatory requirements, the flight crew departed Apia with less fuel than required for the flight in case of one engine inoperative or depressurised operations.
• The flight crew’s advice to Norfolk Island Unicom of the intention to ditch did not include the intended location, resulting in the rescue services initially proceeding to an incorrect search datum and potentially delaying the recovery of any survivors.
• The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands. [Minor safety issue]

The irony is that if 'Staibbed in the dark' and Harfwit hadn't of given evidence at the PelAir cover-up inquiry, we may well have remained oblivious to the significance of this identified but yet to be adequately addressed safety issue.

Reference: Rural and Regional Affairs and Transport References Committee
(Senate-Monday, 19 November 2012)

Quote:Senator XENOPHON: On page 7 of the ATSB report it states:

Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew

Does that not seem to be an unsafe practice in that it is tantamount to the withholding of critical safety information that might otherwise prevent a flight from continuing into a dangerous situation, which occurred here?

Mr Harfield : Yes. However, they are the rules for Fijian air traffic control as instructed by Fiji and international agreement. Within the Australian airspace that we manage, we are required to pass that information on to the flight. Those are rules of Fiji air traffic control.

Senator XENOPHON: But we are talking about an aircraft heading into Australian territory though, are we not?

Mr Harfield : It was going to Norfolk Island, yes, but Norfolk Island is managed by New Zealand air traffic control.

Senator FAWCETT: So it is not Australian airspace?

Mr Harfield : It is not Australian airspace.

Senator XENOPHON: Are you saying because it is managed by New Zealand, there is nothing you can do about it?

Mr Harfield : I am not saying there is nothing we can do about it. We can talk to our New Zealand colleagues about—

Senator XENOPHON: Have you spoken to your New Zealand colleagues about the Pel-Air ditching?

Mr Harfield : No, we have not.

Senator XENOPHON: It has been three years and one day since the ditching.

Senator STERLE: I am interested too. You did say, Mr Harfield, that you would do that if there was a recommendation from ATSB? Would you say that?

Mr Harfield : I think we need to put a couple of things into context. You have CASA, which is the air safety regulator that provides the rules and procedures we abide by. We are there air traffic service provider. We provide services based on the rules and regulations that are set by CASA, so we apply the rules as set. When another air traffic service provider has a particular issue, we have discussions with that service provider about the issues that we see. We are surrounded by 11 different flight information regions. We are in constant contact with our neighbouring air navigation service providers. At the end of the day, we can talk about those particular issues but they also work under the jurisdiction of their safety regulator and apply the rules that their safety regulator deems. The fact is, this would be a matter for the civil aviation authority of New Zealand.

Senator FAWCETT: A string of those comments point to the fact that if there were a recommendation coming out of an accident report it would be an enhancement to safety for a neighbouring service provider to proactively push an equivalent of a hazard alert. Then you would act on behalf of the government to talk with your peer, but that would need to come from a recommendation that CASA picked up, which was then put as a requirement. Does that all lead to the fact that ATSB reports should, in fact, have recommendations? If there were no recommendation, where would you take your action from?

Mr Harfield : From our perspective, as an air navigation service provider, we do not just rely on an ATSB report. If we see any particular safety issue we have regular meetings and discussions with our neighbouring air navigation service providers, talking about the number of safety issues that come to our attention. It may not necessarily be in an ATSB report. We are constantly having those discussions with them to try to improve the integrity of the system.

Senator FAWCETT: How long has it been since this accident.

Mr Harfield : 2,00—

Senator XENOPHON: 2,097 days.

Senator FAWCETT: How many meetings have you had with your New Zealand counterparts since this accident?

Mr Harfield : We probably would have them twice a year, but this particular issue is something where we did not know the intent of what was being passed to that particular flight—because it is New Zealand air traffic control with the Pel-Air aircraft. It is the same with Fiji air traffic control with the Pel-Air aircraft. Not until the ATSB report was released were we aware that there could have been a deficiency with the passage of weather. It is something that we would normally discuss. New Zealand air traffic control would be doing their own particular review. I want to make sure it is understood where our role is, reference the rules and procedures of a foreign jurisdiction.

Senator FAWCETT: I accept that. The intent of this committee is to make sure that we have the most proactive approach to enhancing air safety. It means that occasionally we expect people to lean across the boundaries of their organisation and say, 'We see something that needs to occur' and if it is not within your current powers or within the rules, the expectation of a reasonable person is that it will be flagged so that this place, which makes rules, can take appropriate action. We would welcome discussion around what proactive steps Airservices has or can take as opposed to saying, 'That is the regulator's problem.' So forgive us if we appear a little tetchy on this, but we are hearing a lot of 'That is someone else's responsibility.'

Senator NASH: Okay, so it was not on the agenda before now. If we were not having this particular inquiry, what would have triggered the decision to collectively with your counterparts examine this issue of the fault line and the fact that there is an anomaly? Would it not have happened? What I am trying to get at is this: if we had not asked you these questions this morning—if we had not been discussing it here this morning at this inquiry—would you have raised this at the Pacific forum as an issue.

Ms Staib : My expectation is that that is why we have those sorts of forums: so that we can share lessons learned from incidents that occur.

Senator NASH: Okay. Then why wasn't it already on the agenda?

Ms Staib : I cannot answer that, because I have not seen the agenda.

Senator NASH: What?

Mr Harfield : The fact is that we do not have the agenda in front of us, so we do not know the detail.

Senator NASH: So you get an agenda and then figure out if you are going to add something?

Mr Harfield : No. The agenda is set by—

Senator NASH: No, hang on; Ms Staib just said that she has not seen the agenda.

Mr Harfield : the various coordinators that we have. For example, the manager of upper airspace, who is the manager of the airspace that abuts Fiji and New Zealand, is the representative of Air Services Australia who goes along to the forum. They set the agenda. I do not have the agenda in front of me.

Senator NASH: So do you have any opportunity to have input into the agenda from Airservices?

Mr Harfield : Yes, Airservices has—

Senator NASH: Okay. Airservices does. So who within Airservices would have responsibility for placing this issue on the agenda for the Pacific forum?

Mr Harfield : Our representative at the forum.

Senator NASH: And who is that?

Mr Harfield : It is the manager of upper airspace for Westwind.

Senator NASH: Okay. So why didn't they put this on the agenda before? Why has it taken this committee inquiry to get this on the agenda?

Mr Harfield : We will take that on notice. I am not saying that it was not already on the agenda. We are unaware whether or not it is on the agenda, and we have said that we will ensure that it is. It could already be on the agenda. I am just unaware.

Senator NASH: I find it extraordinary that you do not know whether or not this issue is on the agenda for the Pacific forum. That is extraordinary.
CHAIR: With respect, if your mum or dad or one of your k
ids was in the plane, I bet it would have been. I have one question. How many Pacific forums have we had since the accident?

Mr Harfield : We would have to take that on notice.

CHAIR: You are a perfect bureaucrat. Senator Fawcett.

Senator NASH: Mr Harfield, further to the answer you gave me before?

Mr Harfield : The question that I was asked before was, 'Who would be responsible if something happened again?' As I was saying, if the ATSB report has been passed to the New Zealand civil aviation authority and they, taking that up, have identified there is an issue then it is their regulation and their change.

Senator NASH: That is my point. There is no issue in their report for them to identify. That is my exact point.

Mr Harfield : Then there is no mechanism for the foreign jurisdiction to be aware there is an—

CHAIR: So you are the bunnies and the ATSB have, 'Do not ask, do not tell.' Senator Fawcett?

Mr Harfield : Say that again, Senator?

CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question. Senator Fawcett?

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.

We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?

Mr Harfield : That is a correct assumption.

Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?

Mr Harfield : That is a fair assumption.

Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?

Mr Harfield : In this case I do not recall and I do not think that they did. However, in other instances where things have occurred they have come to us to ask for assistance—for example, with some incidents that have happened in Indonesia.

CHAIR: But no-one cared about the prang off Norfolk Island?

Mr Harfield : That is not correct, Senator; I just do not recall the ATSB coming to us to ask us for assistance in this particular jurisdiction.

CHAIR: How long have you been at Airservices?

Mr Harfield : Nearly 25 years.

CHAIR: I think you need a change of career.
Or in pictures... Wink

The RRAT Committee's findings included the following recommendation in relation to this committee identified significant aviation safety issue:
Quote:Recommendation 22

9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

One would hope that in the context of the PelAir MKII 500+ page Final Report there will be an official recognition of this SSI accompanied by an ATSB promulgated safety recommendation issued to all regional FIR States, to proactively risk mitigate this particular mouldy slice of Swiss cheese... Huh

MTF...P2 Cool
The 0803 from Nadi.

[Image: VH_NGA-1.jpg]

The 0803 from Nadi: much like Agatha Christie’s yarn – ‘the 4.50 from Paddington’ is a tale of official denial, departmental arrogance and independent investigation to solve the riddle. Silly story of course, but entertaining nonetheless. The ‘real’ investigation into the ditching of a Pel-Air West-wind, off Norfolk Island is, like the Christie novella, slowly, but with certainty, picks up the clues and the villain is, eventually, exposed.  

P2 and the mouldy cheese. – “I still have to pinch myself when I re-read the above quote and then remind myself that the identified safety issue of non-provision of critical wx flight information...”

• Nadi in not providing the 0803 amended TAF, which forecast conditions below the alternate minima; plus:-
• Nadi not proactively providing the 0830 SPECI, which included broken cloud below
the landing minima and finally;-
• after responsibility for the aircraft was transferred to Auckland FS at 0835, the Auckland ATCO did not confirm that the flight crew had received the 0803 TAF and/or the 0830 SPECI.

If you remove (as Holmes would say) “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.”

Had there not been gaping gaps in the ‘systematic’ cheese; the Norfolk accident simply does not happen – End of. James was quiet legal; it has been clearly established that even with full tanks; the accident would have occurred. At no time, until it was far to bloody late, did James even contemplate that a landing at Norfolk would not be a happening thing.

You can’t get a bet on ‘K’s’ tote board for CASA failure, Company failure, ASA failure or BoM failure to perform; the odds against any ‘official’ agency getting a canning are astronomical. Mind you, a bet on the Senators getting involved is equally impossible. There are tales in the wind of CASA running about, desperately trying to avoid any and all ‘political’ involvement; at any cost. I reckon they are pupping blue lights at the thought of any serious, heavy weight Senators asking the awkward questions. ‘News Flash’ too bloody late boys; too late by a country mile. Read the Hansard; or, watch the movies; then ask yourselves – who do you think you have fooled with Motherhood statements, gabfests and no duckling Safety Recommendation. Jesus wept….

There are a couple of groups, probably comprised of the ‘experts’ Carmody so dearly wants charity from who can’t wait for the ‘new’ report to be released. The title of the ‘report’ has seen some fairly heavy betting; for example “Fuel related” is currently at 100 – 1 against 'Weather related', which is still at a comfortable each way 4/1. The chance of Senator non involvement is off the scale and a closed line. ICAO is still running at even money; the odds for went up a while back to some value; but a stony wall of silence has been hanging about just a shade too long. We intend to inquire of ICAO what progress, if any, has been made, but no one is holding their breath.

My old clock says ‘Ale-o;clock’. I could get used to this relaxed life style (zipper advantage); although, you know I still look at the clock, count the hours (and the counting shall be eight) to be sure before heading to the refreshment tent. Not tonight though, the Sand pit crew are scheduled for a grudge match, honour, kudos, bragging rights and ales, all to play for.

Bring it on - Taxi -

PelAir reality check - Norfolk Islander style.  Wink

While the Australian Government, the MSM and the average Aussie punter, through ignorance or denial, continue to be totally oblivious to the serious implications of the fast approaching 8 year PelAir (re-cover up) investigation; it is refreshing to see that in a historical Norfolk Island online publication - 'NON DII EN DAA (This and that)' - that there was no pulling any punches when it came to Norfolk Islander condemnation of the ATSB, CASA and the department.


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.

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.

[Image: Pel-Air-March-2015.jpg]
MTF...P2 Cool
Manning says next month for PelAir report MKII - Confused

Via Oz Flying:

Quote:[Image: Chris_Manning1.jpg]ATSB Commissioner Chris Manning. (Steve Hitchen)

Norfolk Island Report due Next Month
26 October 2017

The second Australian Transport Safety Bureau (ATSB) investigation report into the 2009 crash of a Pel-Air Westwind off Norfolk Island is due to be released in the next two weeks.

ATSB Commissioner Chris Manning today told the Regional Aviation Association convention that he had approved the report, which is expected to stretch to 500 pages.

Westwind VH-NGA with six people on board was on an aeromedical flight from Samoa to Melbourne on 18 November 2009, when it ditched off Norfolk Island because it was low on fuel, and had been unable to land after four VOR approaches had to be aborted.

All on board survived the accident.

The initial ATSB report published in August 2012 indicated shortcomings in the pre-flight and en route planning, and the crew not properly assessing the situation before it was too late to divert to an alternate to refuel.

The report became controversial because it appeared to ignore systemic issues and focused too much on the crew, and was referred to the Senate Standing Committee on Rural and Regional Affairs and Transport two weeks later. Then ATSB Chief Commissioner Martin Dolan later admitted the report was not one he was proud of.

In 2014, a Canadian Transportation Safety Bureau review of the ATSB singled out the report as an example where the ATSB did not stick to "sound investigation procedures", prompting the ATSB to re-open the investigation.

The ATSB returned to the crash site and recovered the flight data recorder in 2015

Updated 7.30 pm 27 October 2017.


MTF...P2 Cool
[Image: tenor.gif?itemid=4724569]

'Precious' Hoody sanctions DJ embuggerance - Dodgy

Dear DJ...

..Thank you for your email regarding correspondence within CASA concerning the draft report from the reopened investigation into the ‘Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009’.  The ATSB will confirm with CASA its practices for disclosure of the draft report in this matter in the context of section 26 of the Transport Safety Investigation Act 2003.  Please note that section 26 of the Act does permit disclosure and copying of the draft report necessary for:

                   (a)  preparing submissions on the draft report; or
                   (b)  taking steps to remedy safety issues that are identified in the draft report.

Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.  The email you have provided does not establish, prima facie, a breach of the Act with respect to copying or disclosure of the draft report.  The ATSB will make enquiries with CASA.

I note that you have included the ATSB’s Chief Commissioner, Mr Greg Hood, in the recipients list for your email.  As you may be aware, Mr Hood has recused himself from this investigation acknowledging his employment at CASA at the time of the accident.  Mr Hood is not involved in the ATSB’s decision making with respect to this investigation.  You may send any future correspondence on this particular matter to either myself or Colin McNamara, Chief Operating Officer.  Mr McNamara’s email address is


Before beginning to dissect the (CYA) weasel words from the ATSB Legal & Governance manager Patrick Hornby, here is a couple of what I believe are relevant quotes off two of my CASA embuggerance thread posts.

First from: The Leopard (Carmody) reveals it's spots  

Quote:DAS Carmody:"..I will not make a decision till after the ATSB report is finalised.."

Just think about that comment for a second.. [Image: rolleyes.gif]

Now although the intent by the DAS is to indicate that he not making any references or revealing any part of the DRAFT report...he does appear to be indicating that he will be referencing the ATSB Final Report to inform his decision making process on DJ's request for the conditions on his ATPL be dropped... [Image: huh.gif]

Does this indicate that the DAS is contemplating breaching the spirit and intent of section 12AA of the TSI Act?
P2 Q/ In light of the Hornby comment..
 "..Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.." wonders why Carmody has to wait for the final report to be released in order to be (ill-)informed for his decision on the continued embuggerance (CEP) case of DJ?   

Next from: The 0904 from Auckland.

Quote: Wrote:P9: ...The use of a ‘general term’ i.e. ‘weather forecast’ is not nearly good enough. I wonder has the ‘second’ Pel-Air report provided an in depth analysis of the legal/technical information conveyed to James (and his FO) or the application of that information to his decision process.

IMO - P7 nailed it – the 0803 from Nadi was pivotal. Auckland wouldn’t think to confirm that the flight had an update issued an hour ago – and so another strand of the safety net was broken. I digress...

P2: ...the 0803 amended Terminal Area Forecast (TAF) was never actually relayed to the flight crew; or that the 0904 from Auckland...

[Image: Untitled_Clipping_103017_093912_PM.jpg]

was not actually a 'weather forecast' but was really an auto METAR/SPECI and not a TAF (forecast) at all... [Image: dodgy.gif]

The 'passing strange' omissions in paragraph 6 in Hood's original ( [Image: pdf.gif]  Yesterday, 12:15 PM">Letter to Mr Dominic John ~ NOTICE OF SUSPENSION OF COMMERCIAL PILOT (AEROPLANE) LICENCE dated 24 December 2009.pdf (Size: 561.88 KB / Downloads: 1)) notice of suspension; of the 0803 amended TAF or indeed the 0801 Nadi relayed Norfolk island METAR can partly be explained by the fact that the CASA investigators & FOI's involved were yet to receive the transcript from the Fijian ATC.

This begs the question to how it was possible for the delegate Hood to make a fully informed decision when such critical information, which included a amended TAF that if received by the VH-NGA flightcrew would have automatically placed a legal operational requirement on the conduct of the rest of the flight.

From that post & my previous post - Pelair dots, dashes & the DJ TOE - coupled with the highlighted conflict of interest sensitivity 'Precious' Hood has on the matter; IMO the whole veracity of the appointment of Greg Hood as CC of the ATSB needs to be independently reviewed and I would question whether Hood's continued employment as Chief Commissioner is in fact tenable?

Did hoody miss the 0803 from Nadi?

He certainly was not on it when it arrived at Embuggerance Junction. Fact (or is it)?

The thing which amazes most is the Hood elevation to ‘top-dog’ ATSB – how, FDS can that be? When the Norfolk ditching is unresolved and don’t, not for a moment think that Manning’s little effort (a 500 page re-hash,-sans all facts) will answer all the questions. It simply will not. It dare not -

OK, for once I shall try to be crystal clear. An ‘informed, balanced decision’ is what a ‘decision maker’ is required, by law, to make. Now it seems the Hood could not – as an alleged ‘pilot’ and ‘the man’ at CASA HQ differentiate between the type of forecast which is actually legally binding and one that is not. Yet ‘he’ is ‘the’ decision maker. Making sweeping decisions based on only partial facts – in a hurry, based on Wodger ( the load master) say so. WTD?

I can understand that in the first rush of information, he could – as an inexperienced sausage – err on the side of safety. Because of the 0801 from Nadi, not the un-relayed 0803. Once the Nadi transcript was in hand though - different matter; entirely, completely and utterly.  

Consider; there you sit reading Playboy and Nadi pops up with a ‘report’:-

A) (0801) - Cloud base 6000 feet: write it down and return to Playboy. A 6000 foot cloud base for an IFR pilot is ‘seventh heaven’ stuff, a stroll in the park.

B) 0803 - Cloud base 600 feet – the Playboy is put aside and the skinny pencil appears – it's time to go to work.

Hood knows this (or) as ‘the’ decision maker should at least be aware of this. As an alleged pilot, there should have been no worries in making the decisions he made until the omitted 0803 report turns up (or doesn’t as the case maybe).

Once it became abundantly clear that Chambers was relying on Hood to sign off McConvicts edicts, that the Captain was ‘negligent’ and ignored fair warning, the stich up was complete. Except the late arrival (Fiji time) of the 0803 TAFOR, which was never delivered. Certainly not to the flight crew and, perhaps, not to Hood. Delayed decisions everywhere.

Once this ‘small’ detail was revealed, Hood weaselled out. Refused to sign anymore of Chambers little ‘gotcha’s’. Old fat Terry had to do it – although; how the hell they got him out of bed before 0630, without a glass of ‘Chardy’ and his meds, to sign off on a ‘thing’ is a matter of mystery. No matter, Terry signed that from which Hood ran away from. We must ask why?

No matter how you look at this whole sorry episode – Hood comes out as (i) gutless; (ii) brainless; (iii) ignorant or; (iv) in a position he should never, not ever been allowed to occupy. A real decision maker would have knocked this imbroglio on the head, right about the time the 0803 turned up ‘in evidence’. A real pilot would have known and realised the implications; alas, Hood is neither.

Hood is however ‘in charge’ of the nations ultimate transport safety agency. That would be the one drafting the report which; odds on bet: never mentions the 0803 from Nadi. Now I ask you, how can all this be so and have Hood in charge. It’s BOLLOCKS.

The moment Hood realised that he’d missed the train – he should have told Wodger to bugger off. HE DID NOT – he took a sickie; or, missed the bus; or, his cowboy chaps had given him a rash; or, the power was out. Anything, any lame excuse, rather than as a decision maker look and look hard at ALL ‘the facts’ and then make a balanced, cold blooded, sensible decision. But, he reneged (chickened out) instead, opting to use  any flimsy excuse he could dream up (close to being credible, that is) not  to do so and retain his  position. Dolan was a straight arrow compared to this creature - and that, boys and girls is saying a lot.  

This man lied – several times. John McConvicts pet odalisque ain’t fit, nor proper to be making sanction ‘decisions’ let alone running the nations principal safety agency.

[Image: 800px-Odalisque.jpg]

So why is he minister?  If that question is too hard for you to answer – I can, at length, explain it and provide the answer. Your problem then becomes simple; do you really want all of this in the public purview. Yes or No will suffice – we will wait until Sunday. Then, the gloves will come off. That minister, is a promise you can take to the bank.

Selah…(Look it up – Muppet).
One for the Flight Safety textbooks - err maybe??

Slight thread dread but finally a good news story on an aviation occurrence and it involves another survived ditching at sea.... Wink

Via the Daily Mercury:

Quote:Pilot set off 'mayday' signal
10th Nov 2017 6:00 AM

[Image: b881073022z1_20171109204907_000gbprv5tr4...20x465.jpg]

The helicopter which crashed off Hayman Island with four people on board. RACQ CQ Rescue

[Image: female_generic_ct30x30.png]
by Tara Cassidy

THE pilot involved in the helicopter incident north of Hayman Island did well to land safely in such choppy conditions, according to the president of a local aviation club.
Stan Wright, of the Airlie Beach Aero Club, said this sort of incident only occurred "once every 10 years”.

There were four people on board the helicopter that was forced into an emergency landing off Hayman Island Wednesday afternoon, all of them believed to be Australian tourists visiting the Whitsundays for a holiday.

About 3.40pm the pilot of the Hamilton Island, Robinson R44 helicopter made a mayday call and set off the aircraft's distress beacon, alerting AMSAR who then initiated a rescue effort.

An AMSAR spokesperson said a passenger vessel called Sea Odyssey, a local cruise boat, was then diverted by AMSAR to go and assist the four passengers who were floating in the water holding on to the aircraft.

When it landed, the helicopter activated its emergency flotation devices, allowing it to land safely upright in the water near Hook Reef.

None of the people aboard were injured in the landing.

RACQ CQ Rescue were called to the incident about 3.50pm, which occurred 25km north east of Hayman Island, however were stood down once the rescue vessel reached the passengers in the water and transported them to safety on Hamilton Island.

[Image: b881073022z1_20171110072814_000gbprv8773...60x345.jpg]

Four people that were aboard a helicopter forced into emergency landing, floating in the ocean awaiting emergency crews. Seven News

Whitsundays VMR were also on standby with a paramedic aboard, in case back up was needed, but it was not required in the end.

Water police notified the Australian Transport Safety Bureau of the incident soon after it took place, and said the owner of the aircraft would be responsible for salvaging the helicopter in the coming days, now that they were safe on shore.

With stormy weather hitting the region overnight, it is not known what the condition of the helicopter is in, or if it is still afloat.

Peter Gibson from the Civil Aviation Safety Authority said any further investigations into the incident would be run by the safety bureau, while they would review a report from the operator about the process the pilot took on the day.

"We will review that and make sure all the appropriate regulatory standards were being met,” he said.

"We need to make sure the air operator that operated that flight was meeting all the applicable safety standards so we get a report from them on that flight, what happened, how the flight was conducted and so on.

"It is stock standard for us just to make sure the right processes were followed.”

It is not yet known what caused the incident.

Pinocchio Gobson: "We will review that and make sure all the appropriate regulatory standards were being met,” he said.
Code for we'll make sure our (CASA's) ass is covered before exploring whether it will be worth embuggering either the operator or the pilot. This will depend on whether the overseeing (cross out appropriate) FOI/Middle manager/Executive Manager has some personal 'bent' against said operator and/or pilot -  Dodgy  

"We need to make sure the air operator that operated that flight was meeting all the applicable safety standards so we get a report from them on that flight, what happened, how the flight was conducted and so on.

"It is stock standard for us just to make sure the right processes were followed.” "Stock Standard" when it may be possible to get any sort of bad press (ala PelAir) from the wash up of this unfortunate pilot survived occurrence... Dodgy

MTF...P2  Cool
 The 0803 lost in White rabbit obfuscation. Rolleyes

From the highly suspect, possibly illegally extracted, 16 December 2009 CASA interview of DJ:

Quote:[Image: T-file-7.jpg]

As a reminder this was the weather update that Auckland broadcasted to VH-NGA at 09:02:

Quote:SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0
However on reviewing the whole unrecorded interview Q&A session between MALIU Richard White & co for CASA vs DJ and his legal counsel, I note that there was never any question asked of DJ regarding whether he had received the 0803 AMD TAF or the 0739 SPECI.

This was despite there being factual evidence that Richard White was aware of the 0803 AMD TAF and the operational requirement alarm bells that should have rung if the flightcrew had received and disseminated that wx forecast.

T6 extract from CASA v DJ T documents (note date at the top of the page):
Quote:[Image: Untitled_Clipping_112017_105519_PM.jpg]
& from T5 page 7 of the T-documents listed as a 'document from audit conducted':
Quote:[Image: Untitled_Clipping_112017_110154_PM.jpg]
 Note that this investigative summary and update was completed before the Hood 24 December 2009 suspension decision notice. Therefore we can only presume that Hoody was not privy to this additional information, otherwise it would have been included in the notice correspondence and by rights DJ would have had his licence cancelled rather than suspended.

This non-inclusion of this critical factual information and the fact that it wasn't a featured question in the 16 December DJ Q&A, would suggest to me that White, Chambers, Campbell and Co. were either totally inept; or already fully cognisant of the fact that the flightcrew of VH-NGA never received either the 0803 AMD TAF or the 0739 SPECI ... Dodgy

MTF...P2 Cool
A thumbnail, dipped in tar.

"And an answer came directed in a writing unexpected,

  (And I think the same was written in a thumbnail dipped in tar)

'Twas his shearing mate who wrote it, and verbatim I will quote it:

  "Clancy's gone to Queensland droving, and we don't know where he are."

This post is definitely not for the purist or the professional. However, I get asked, a lot, to explain the ‘fuss’ about fuel and ‘critical’ points along the James flight path. Operationally, the matter is not too complex – legally, when CASA get determined to prove a point, it’s a bloody nightmare. Putting aside the twisted Chambers logic and the ‘niceties’ of flight planning I shall endeavour to explain why most thinking pilots are calling bollocks’ on most of the CASA assumptions and ridiculing the Walker attempts to foist yet another flawed report on the ditching. Why Walker is determined to do this and why CASA is happy to assist is a question we cannot answer – yet. The ‘T’ documents and other supporting ‘paperwork’ read properly, with a time/date line analysis almost completely exonerate James; but more of that later. Lets take a layman’s quick guided tour through a practical examination of the flight, it may shed some light.

Fuel – a must have. There is a finite amount of fuel which may be loaded onto an aircraft and it is ‘heavy’. There is a finite amount of power which may be extracted from the engines. The eternal problem is one of aircraft weight, the amount of fuel needed to move that weight and the rate at which the fuel is consumed. Jet aircraft fuel consumption benefits from altitude; high is good; but, the engine power available must be equal to supporting the aircraft at its weight at the optimum altitude. This is why a ‘Stepped’ climb profile may be used; climb to 36,000 is acceptable, cruise for an hour, weight reduces and a climb to 38,000 may be possible; this reduces the overall fuel burn off and, has the effect of ‘making’ fuel, which may be used to calculate the ‘critical’ gateways along the route. It is standard operating practice, legal and safe to operate in this fashion – Qantas would hardly get a long haul flight completed if the crew were not skilled in managing the ‘weight/fuel/distance/ weather at destination equation.

But we need to consider the ‘en-route’ gateways. Release points if you will; each gateway is a decision point; crew are always aware of an approaching ‘gate’ they do the sums, weigh up the ‘ifs and buts’ and are prepared to make a decision at that gate. So lets place ourselves in cruise at 36, 000 feet (F360) half way between the departure aerodrome and our first gate; two items for consideration. Item one; the weight for a climb is calculated and the approximate time for initiating the climb is jotted down. Item two: action in the event of abnormal or emergency conditions arising This is a no brainer; each of the ‘standard’ scenarios is predetermined; the only variables are the wind, temperature and weather’ (which may not be exactly as forecast at the planning stage) which call for minor adjustments to the time at which the aircraft will arrive at the gateway and the actual amount of fuel available to meet the requirements. As we approach gate ‘A’ the calculations are complete; provided we do not have a failed engine; or, have not lost cabin pressure and the weather at the destination is still acceptable – there is no decision, other than to continue which needs to be made. Should any of the ‘critical’ elements change in a manner which affects the amount of fuel we have to use then the decision is simplicity itself. We divert to an alternate; this is pre planned, fuel is allocated to complete the diversion, the time taken to reach an alternate is known and – with a little luck – apart from the expense and inconvenience – all should be well. Thus, we proceed past our ‘gateways’ toward our destination; each gateway has it’s own ‘limitations’ and decision making prerequisites which influence that decision. We, finally, arrive at gateway ‘X’ and find that due to the wind conditions we have insufficient fuel to meet the requirements – we divert. Once past gate ‘X’ provided the destination weather remains acceptable we toddle along to the top of our descent; once we have passed gate ‘X’ there is no spare fuel to divert anywhere – there is fuel for the depressurised situation; for the engine fail situation; fuel to meet any holding requirements, fuel to complete at least one instrument approach; there is even enough fuel for a missed approach and a second whack at landing. But that’s all she wrote. Well, it is unless you happen to be operating under any other rule set bar the Australian ones; it is mandatory [FAA for e.g.] (and most sensible) to carry enough fuel to divert from the intended destination to an alternate airfield; with acceptable weather conditions.

It is a ramble, I know, but if we must dive into the Pel-Air debacle then it is important (IMO) that ‘muggles’ understand at least the basics. So lets look at the Pel-Air flight, from a practical standpoint.

If you grab a clean sheet of A4 the draw a line from top right to bottom left it will assist. Put a dot for Apia in the top right; a third of the way along the line put a dot for Fiji; two thirds the way a dot for Noumea and in the bottom left a dot for Norfolk Island.

James ‘radius of action’ was, on departure Apia somewhere about 180 miles past Norfolk Island, toward the mainland – assuming normal operations. The single engine ‘radius of action’ and the ‘depressurised’ radius are a good way down the line. The Point of No Return to Apia becomes academic and of no interest. Connect our flight path line to Fiji; there are two perfectly serviceable airports available there; ‘South abeam Fiji’ James could reset all his calculations; his critical gates would now be return to Fiji or divert the Noumea; he had plenty of fuel to do either until he passed the point where Noumea was the closest option. So far so good. Now, connect our flight path with Noumea; once again two suitable airports. South abeam Noumea James could reset his calculations; divert if things started to go wrong with the aircraft or, continue on toward Norfolk until he passed the point where a return to Noumea was ‘impractical’.

The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

I do, most sincerely, apologise to the purists; but unless the muggles get at least a mud map of the core issues, to explain what we’re banging on about; then, the pony-pooh from ATSB and CASA is just going to accepted as correct – well it ain’t..

Phew; wish I’d never started this post; second coffee just became a mandatory requirement.

Toot toot.

Above: ATSB Chief Commissioner Hood impersonating Buzz Lightyear - [Image: biggrin.gif]  

PelAir MKII countdown: Redemption or oblivion?

With 2 days to go before the 500+ page PelAir MK II Final Report is released the BRB punters corner is running hot with speculative bets on how the Senate RRAT committee, collectively and individually will interpret and react to this latest ATSB reiteration??

[Image: malaysia-airlines-flight-mh370-what-went...1399299315]

Therefore IMO now is the perfect time to reflect (in this case posthumously) on how Ben Sandilands, in company with many IOS/BRB members, was moved by a typical clinically informative Senator Fawcett summary speech in the Senate a month after the report was officially tabled on 23 May 2013:

Quote:Pel-Air air safety issues spelt out by pilot and Senator, David Fawcett

A parliamentary speech that everyone concerned about the safety of the flying
public, and the competency and integrity of CASA and the ATSB should read

Ben Sandilands

Earlier this week Senator David Fawcett (Liberal, South Australia) urged the upper house of Australia’s federal parliament to ‘take note’ of the Senate committee inquiry into the ATSB’s final report into the 2009 Pel-Air crash and related matters.

Senator Fawcett was a military helicopter pilot, and was the Commanding Officer, RAAF Aircraft Research and Development Unit, Edinburgh, SA, and an experimental test pilot, before being elected to public office.

He played a very measured and penetrating role in the air accident investigation committee hearings which were were instigated by fellow SA independent Senator Nick Xenophon.

This is Senator Fawcett’s address to the motion that the Senate take note of the committee’s findings. Whatever the attitude of the government and opposition benches to the Pel-Air matters, the disgrace they brought on CASA and the ATSB will neither be forgiven nor go away.

This is about the safety of the Australian public, and the functioning of the bodies charged to regulate air safety (CASA) and investigate safety issues to further air safety (ATSB). In the Hansard of Senator Fawcell’s speech some emphasis has been added by Plane Talking.

Senator FAWCETT  I move:
 That the Senate take note of the report: 
The final report of the Rural and Regional Affairs and Transport References Committee into aviation accident investigations was tabled in May this year.

It followed a long period of investigation into the inquiry by the ATSB into the accident in which a Pel-Air aircraft ditched off Norfolk Island in 2009.

The Senate report highlighted that the performance of the two government agencies that were primarily involved, the Australian Transport Safety Bureau and the Civil Aviation Safety Authority, came far short of the expectations that the Australian taxpayer, this parliament and the aviation community should have.

In 2010 a review was done into the operations of those two agencies.

Of the eight desired outcomes of that review, the committee found that actions by ATSB and CASA failed to deliver against six of the main areas.

I will list them and then talk in more detail about them.

They failed to maximise the beneficial aviation safety outcomes that could have been derived from the investigation into this incident.

They failed to enhance public confidence in aviation safety.

I think we saw that in the controversy in the aviation industry and the media around the report when it was finally released.

They failed to support the adoption of a systemic approach to aviation safety.
They failed to promote and conduct ATSB independent no-blame safety investigations and CASA regulatory activities in a manner that assured a clear and publicly perceived distinction between each agency’s complementary safety related objectives, as well as CASA’s specialised enforcement related obligations; they also failed to avoid to the extent practicable any impediments in the performance of each other’s functions.

They also failed to acknowledge errors and to be committed in practice to seeking constant improvement.

The committee made 26 recommendations to address a number of systemic deficiencies that were identified in both the investigative and regulatory processes but also in funding and reporting.

Safety outcomes is one area that I would like to touch on.

[i]Accident investigations are an opportunity for an informed and expert body to sit back and take a considered look at why an incident occurred.

That body may be expert but they are not necessarily the best judges of how the lessons from that incident may be applied to other sectors of the aviation industry.

The committee found that for various reasons and over time the ATSB processes have got to the point where much evidence can be excluded if it does not fall into the categories that they consider will impact on high-risk future operations. So we have a situation where they are making an arbitrary decision to exclude evidence, and without evidence they are not then investigating or reporting on what actually occurred.

That means that other aviation operations are not the beneficiaries of an explanation of occurrences and failures in a system safety approach and what defences failed such that the accident occurred. It has been the traditional approach to identify each of those factors and let the stakeholders make their own assessment. But the safety outcomes are no longer optimised because of this approach of trying to make that arbitrary decision at the front.

That is a significant flaw in the current approach which the committee has recommended be revisited.

The report and CASA’s statements in name supported the concept of a systemic approach to aviation safety.

But what we found very clearly was that the investigation focused very quickly on the pilot in command on the night, as opposed to looking at the raft of other factors.
Looking at the James Reason model of system safety, one sees that there are a number of defences which are in place, which include the operating company, the regulator and a raft of things—training et cetera—as well as the pilot. But many of those factors were given, at best, lip-service. They were mentioned in the report so a box could be ticked to say that they were considered, without a detailed consideration of them.
For that reason, the report was quite flawed.

What made the matter worse was that, having required both CASA and ATSB to produce documents for the inquiry, which initially they were reluctant to do, we spent some considerable time going through literally boxes and boxes of documents to find information, emails, reports and things that were relevant to the report and, having seen a report that said that the company was applying all of its regulatory requirements and CASA was auditing it and so there were no organisational factors to consider, we found that CASA in fact had done a special audit.

Not only had they done a special audit that found a range of problems within the company; they had done their own internal report about CASA’s performance of their oversight of the company and found that, in their own words, that was deficient.

So we have a situation where CASA—who have an obligation, under the memorandum of understanding, to disclose to the ATSB when they are aware of or hold, information relevant to an accident investigation—withheld the information of the Chambers report, which is their internal document, and when, as a directly interested party, they were given a draft of the report and the opportunity to say, ‘No, this is not correct; there are organisational factors both with the company and the regulator that you should be aware of,’ they chose not to do that.

That comes very close to breaching, if it does not actually breach, the transport safety act. It certainly does nothing to boost public confidence and it does nothing to enhance the safety outcomes that could have been achieved through this investigation.

It is telling that there were many organisational and systemic measures put in place by the company in order to resume operations.

That says that, in their assessment and in the assessment of those people who were auditing the company, clearly the pilot alone was not at fault for the original accident or there would be nothing else they had to change.

So the ATSB, in its approach to its report,  and CASA, by withholding that information, have done the aviation industry in Australia a great disservice.

The aviation industry relies on open, transparent and accurate reporting from the regulator and from the safety investigation agency to make sure that the organisations concerned can be ongoing learning organisations that maximise the safety outcomes for the travelling public and for people operating aircraft.

The regulatory reform process is another thing that came through from this.

The air ambulance operation, like the RFDS operation—which also has some emergency aspect to it, certainly for the helicopter emergency services—highlights that we have a category of operation here which has traditionally been put into the air work category, and that is clearly not adequate for all operations in terms of either their planning requirements or the aircraft equipment.

To put them into a higher category such as regular public transport or even charter would unnecessarily, in fact prohibitively, restrict their ability to respond and operate in emergency situations to unprepared airfields.

There is a very clear case here for industry to have a voice and a role to work with the regulator to establish a new category of operation that provides the guidance required around equipment standards and configuration of the aircraft but also provides the flexibility the operators need to perform their mission in a structured manner.

The last point I would raise is that the Chambers report indicated that CASA felt they were under resourced and their people, in many cases, did not have the requisite insight and, in some cases, skills, knowledge or background to do the auditing.

From subsequent discussions, I would argue that, in some cases, they did not have the background to be writing the regulations or standards in the first place.

I believe there is a strong requirement to look at the regulatory reform process and the role that industry should have, not just with token consultation but with a powerful voice, even to the point of veto, where they can work with the regulator to highlight what is industry best practice, and that should form the basis of regulation unless there is a very clear safety case to not go down that path.

Australia’s travelling public and our aviation industries deserve better.

I look forward to the reforms that either this government or the next will bring.

Just as a reminder here is a link - HERE - for the original AAI report and here is a list of the 26 recommendations:
Quote:List of Recommendations

Recommendation 1
3.68      The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay.

Recommendation 2
4.41      The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification.

Recommendation 3
4.43      The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.

Recommendation 4
4.69      The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.

Recommendation 5
4.78      The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.

Recommendation 6
4.79      The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in training/competence must be advised to the minister and the Parliament.

Recommendation 7
4.87      The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.

Recommendation 8
4.101      The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Recommendation 9
4.103      The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.

Recommendation 10
6.41      The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

Recommendation 11
6.52      The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.

Recommendation 12
6.55      The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.

Recommendation 13
6.58      The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.

Recommendation 14
7.15      The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:
  • advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
  • provide the ATSB with the relevant review report as soon as it is available.
Recommendation 15
7.16      The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.

Recommendation 16
8.35      The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.

Recommendation 17
9.18      The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18
9.40      The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42      The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44      The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45      The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.

Recommendation 22
9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

Recommendation 23
9.104      The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer.

Recommendation 24
9.106      The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.

Recommendation 25
9.108      The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.

Recommendation 26
10.35      The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

TICK..TOCK Hoody - "To infinity and beyond" [Image: shy.gif]

MTF...P2 [Image: tongue.gif]
The whirligig of time.

“I wish it need not have happened in my time," said Frodo.

"So do I," said Gandalf, "and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.” (Tolkien).

And we do, live in such times; for nothing has influenced change; not the Senate inquiry, not the ASRR, not stirring rhetoric, not evidence, not logic, not even the will of ‘reasonable men’. ATSB, CASA and only the gods know who else is relying on ‘time’ to heal the mortal wounds inflicted on aviation The Pel-Air incident revealed the tip of an ugly, dangerous iceberg, which, to this day remains immobile, untouched and determinedly whole.

The Senate recommendations should have brought about an immediate change in the regulator; the sins exposed would have a supplicant penitent for a good long while – the crimes committed should have seen a criminal penalty extracted, the complete lack of morality revealed demanded an immediate apology to the Australian people. Anyone notice that happening?

The grotesque pantomime continues, the ridiculous law sets become the norm, the fools and charlatans who inflict these outrages on the industry are still comfortably ensconced within the protection of the ivory towers.  

Clearly, neither ATSB or CASA have any intention of changing and why should they. They have everything set up just so and it works for them. So we must look to our politicians to enforce the changes demanded by industry. It’s all well and good for Senators to make stirring ‘speeches’ after exposing a small part of the horrors which reside deep within Sleepy Hollow; but, did they follow through. The very short answer is a long, loud ‘NO- they did not’.

Did the minister follow through – once again a resounding NO. The ministerial solution was to throw the whole thing back to the ‘accused’ to sort it out. Go figure, remember - this covers a three minister flush.

So ask not why the situation remains critical – ask why nothing, absolutely nothing, has changed since the rhetoric stopped. Is the same travesty to be repeated and will the Senate committee allow the Chimera to escape – again?

Toot – toot…;
PelAir coverup MKII - Final report released.

Quote:Media release

Media statement: AO-2009-072 (reopened)
Date: 23 November 2017

The Australian Transport Safety Bureau (ATSB) has today released its final report into the reopened investigation of the 18 November 2009 accident involving Israel Aircraft Industries Westwind 1124A aircraft, VH-NGA, near Norfolk Island.

The flight, which was conducting an air ambulance flight, took off from Apia, Samoa, bound for Australia, via Norfolk Island for a fuel stop. On arrival at Norfolk Island, low cloud prevented the crew from making a safe landing. After four unsuccessful approaches, and with insufficient fuel to divert to another airport, the aircraft was ditched into waters 6.4 km west-south-west of the airport. All six occupants evacuated from the aircraft and were rescued by boat.

The ATSB formally reopened its investigation on 4 December 2014 following criticism of its original investigation by the aviation industry and was subject to an inquiry by the Australian Senate’s Rural and Regional Affairs and Transport References Committee.

Prior to commencing the reopened investigation, the ATSB requested the Transportation Safety Board of Canada (TSB) conduct an independent peer review of its investigation methodologies and processes. Its review, which included an examination of two previous aviation investigations along with the original investigation involving VH-NGA, stated that “The TSB Review compared the two organisations’ methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization (ICAO) Convention on International Civil Aviation, and found they met or exceeded the intent and spirit of those prescribed.”

However, the review also found deficiencies in how the ATSB’s methodologies were applied in the case of the Norfolk Island investigation and identified 14 recommendations for the ATSB to enhance the quality and the way in which it conducts future safety investigations.

Special measures were taken to ensure the reopened investigation remained distinct from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, it was conducted by investigators and overseen by managers who had not been involved in the original investigation. Additionally, the ATSB’s current Chief Commissioner, Greg Hood, was not involved in any part of the investigation, as he had been in a senior role at the aviation regulator, the Civil Aviation Safety Authority (CASA), at the time of the accident.

The new investigation team reviewed evidence obtained during the original investigation and acquired a substantial amount of additional information that was not obtained or available to the original investigation team. This new material included data from the aircraft’s recovered flight recorders and over 30 additional interviews with a range of people, including a number of other Westwind pilots from the operator, inspectors from CASA, as well as re-interviewing the flight crew and medical crew who were on board the aircraft.

The Commission review and approval process of the final investigation report was led by the ATSB’s aviation-experienced Commissioner, Chris Manning.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.

The significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

Commissioner Manning added the thoroughness and level of detail in the final report was substantially more than would normally be the case for a safety investigation of this nature. The final report found 36 safety factors, including 16 safety issues. This large number of safety issues and factors was due in part to the amount of information obtained by the reopened investigation and the depth to which it was analysed.

“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Commissioner Manning. “The ATSB was mindful at all times that the people and organisations involved in this accident have been intently waiting for the results of the reopened investigation and acknowledges the time that it has taken to complete the final report.”

Commissioner Manning said the most fundamental lesson from this reopened investigation for the regulator, operators and flight crews is to recognise that unforecast weather can occur at any aerodrome and can be especially challenging at remote islands and isolated locations.

“Consequently, there is a need for robust and conservative fuel policies, planning and in-flight management procedures for passenger-carrying transport flights to these types of destinations” said Commissioner Manning.

The final investigation report, AO-2009-072 (reopened), ‘Fuel planning event, weather-related event and ditching involving Israel Aircraft Westwind 1124A aircraft, VH-NGA, 6.4 km WSW of Norfolk Island Airport on 18 November 2009’, has been published on the ATSB’s website.

Editor’s note: Broadcast video and audio grabs of Commissioner Manning are available to media outlets on request by emailing:
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Last update 23 November 2017

The following investigation crumbs IMO highlights clearly why the ATSB should be disbanded for at least the Aviation accident investigation ASAP:
Quote:ATC weather updates?

Given the huge missed opportunity by ATC to inform the co-pilot and myself of the new TAF which changed the fuel requirements for Norfolk, and that exemptions from ICAO policy have been granted in this regard re informing crew in international operations of such changes, why is a lengthy discussion on this topic missing?

ATSB IIC Dr Walker's nasty and arrogant reply to the above Captain DIP comment:
Quote:No change required

In addition to the content in The occurrence section, the draft report discusses the provision of flight service in the Nadi and Auckland Oceanic FIRs in detail (about 5 pages). The topic is also discussed in the Safety analysis (2 pages), and findings are included in relation to the Nadi IFISO and Auckland air/ground operator’s actions.

It is not clear what ‘exemptions from ICAO policy’ the captain is referring to. In relation to amended TAFs, ICAO guidance (in document 7030 for most regions) stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination. However, this did not apply to the Nadi FIR (although it did apply to the Auckland Oceanic FIR and the Australian FIRs). Overall, the Fijian and New Zealand flight information service providers’ procedures were consistent with ICAO standards and recommended practices.

Limited information about the reasons for the actions of the Nadi IFISO and Auckland air/ground controller regarding VH-NGA on 18 November 2009 were available to the ATSB reopened investigation. The ATSB discussed the topic in as much relevant detail as it could, given the available information. The importance of the meteorological information that was not passed by ATS to the flight crew has also been highlighted in the draft report.

Overall, further discussion of the topic was not considered warranted.

The dismissal by Walker of what essentially is IMO an ATSB identified significant safety issue...

ICAO guidance..(sic)..stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination extremely problematic and disturbing in an international perspective.

How hard would it have been for the ATSB to issue a safety recommendation or notice to ICAO suggesting that maybe the document 7030 guidance should be revisited and possibly amended.  

Now from the MKII report some relevant quotes from the Dr Walker referred pages.

From Pg 97:
Quote:CAAF also reported:

- The Nadi Air Traffic Management Centre normally received METARs/SPECIs and TAFs within a few minutes of them being sent by the disseminating station.
 - METARs/SPECIs and TAFs were delivered automatically to two printers, including one at the IFISO’s workstation.
 - The IFISO’s workstation was enclosed in a soundproof booth.
 - When SPECIs were received, they were displayed to both the IFISO and the controller.

On 20 November 2009, the ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI.

P2 - Note the non-inclusion of the 0739 SPECI & 0803 AMD TAF. However this was explained in the next paragraph where the timeline of investigation bizarrely seems to jump from the original investigation back to the present reiteration:

CAAF advised it was not aware of the 0739 SPECI and the 0803 amended TAF until it received the ATSB’s investigation report in 2012. CAAF contacted the ATS provider, who advised it had provided CAAF with all the weather reports it had received at the time (in 2009). The ATS provider advised CAAF it no longer held the hard copy print outs and therefore CAAF could not verify whether the 0739 SPECI or the 0803 amended TAF had been received.

Q/ We now know that the ATSB and CASA in their parallel investigation activities were both aware of the existence of at least the 0803 AMD TAF by 23 November 2009. Therefore why did the ATSB in the course of their investigations - especially after receiving the Auckland & Nadi ATC transcripts -  not query the CAAF on why it was they didn't have copies of the 0739 wx report & the 0803 amended forecast?  

Quote from "K" post above - A thumbnail, dipped in tar. - once again the significance of the non-relayed wx report and AMD TAF in the context of this 531 page re-hashed 'the pilot did it' bollocks report... Dodgy

Quote:...The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….
MTF? MUCH!..P2 Angry
8 years and 5 days for Mk2, and now, a long read.

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