Thread Rating:
  • 1 Vote(s) - 3 Average
  • 1
  • 2
  • 3
  • 4
  • 5
On joining the dots and making of dashes.
#16
Stuck in a time warp?  Dodgy - "..It's just a jump to the left.."


(05-03-2015, 06:44 PM)Gobbledock Wrote: The fallout from Lockhart is ridiculous and unnecessary, much similar to Pelair. Going back to Lockhart, Mr Barnes was correct in his analysis. The ATSB investigation was correct in its entirety. The ATSB basically said CAsA stuffed up with its piss-poor oversight of Transair, and that obviously includes some of CAsA's employees and by default includes I-Ron-bar and his mate the Submarine. Pelair is no different. The ATSB should have pulverised CAsA for its part in the accident for being a contributing factor, but instead the ATSB chose to bend over and allow itself to be anally violated by the Regulator. Naughty naughty.

The autonomy and independence of the ATSB, by it's nature, is and should be maintained. There was no need for post Lockhart 2010 hugs and kisses and reach-arounds between the two alphabet soup agencies. CAsA was a causal factor and the ATSB noted that in its report. Great work ATSB, choccy frogs for you. Unfortunately CAsA cried like a baby and the Mandarins in Government hit the cover-up button, the rest is history and the Dr Voodoo/Pumpkin Head/Chairman Hawke MOPOOH was born.

My advice is if one wishes to examine how the 'relationship' should actually work, look back to 2005. Even better, look at the FAA and the NTSB, you won't see those two organisations dry humping each other or indulging in spit swapping!

"Perhaps I-Ron-bar and L.Ron Hubbard are one and the same"??

Excellent re-call to duty Aunty Pru... Rolleyes

Where to begin, how about here via @SimoneFoxKoob from the Oz... Wink :
Quote:Air safety bodies spoke ‘more than once’ on pilot’s near-miss
[Image: 97097ee42ff2e728f69e6910c7c24e65?width=650]Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images [Image: simone_fox_koob.png]
Journalist
Sydney
@SimoneFoxKoob
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/cbd838094c278f870442ad76e8fc0bae/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
The aviation safety regulator spoke “more than once” with investigators from another agency about a 2015 near-miss involving the pilot of a doomed charter flight which crashed into a shopping centre on Tuesday, but insisted the two incidents could not be linked.

The relationship between the Civil Aviation Safety Authority, which licenses pilots, and the Australian Transport Safety Bureau, which investigates crashes and ­incidents, has been strained in the past with a 2013 senate report finding communication from one agency to another was “problematic”.

The ATSB yesterday revealed it had discovered “interesting ­facets” in its early check of the wreckage of the Beechcraft B200 Super King Air, which plunged into a DFO shopping centre on the edge of Essendon Fields airport killing all five on board.

ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.

An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.

“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed.

Mr Hood said it “is not uncommon for (CASA) to take independent action without waiting for an ATSB report”.

The Civil Aviation Safety Authority yesterday refused to say what information was shared between the agencies about Mr Quartermain, with a spokesman telling The Australian the proper safety procedure had been followed.

“The pilot passed the appropriate proficiency tests at Mount Hotham and since then,” he said. “He was properly qualified to fly.”

A 2008 review into the relationship between the ATSB and CASA found the relationship was “sub-optimal”. A further 2013 Senate review into aviation accident investigations found the relationship remained “problematic” and recommended they “remove any ambiguity in relation to shared information”.

Now to begin re-joining the dots and re-making the dashes... Rolleyes


MTF...P2 Cool
Reply
#17
Of dots, dashes, connections and spit swapping

It is so odd how in one breath the ATsB and CAsA are in bed together, spooning and rooting each other, then they apparently 'don't talk'. Sounds like a husband and wife relationship. So who is the alpha male in this safety conjugal relationship because neither partner has balls?

Then this 'nugget' from Toga boy;

"ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities".

Hmmm, funny that. Wasn't it just within the past few years that the head wobbling bearded buffoon Beaker was constantly moaning and mumbling at Senate Estimates about not having enough manpower and not enough funds? And that is where things get interesting because if we aren't getting to the bottom of accidents in a timely manner then the associated risks or causal factors remain open and until such time that the investigation is finished, root cause is determined and any outstanding risks are mitigated and are closed out, the risk remains. And let's not forget that according to CAsA's holy SMS the CEO, the accountable person, is responsible for providing adequate resources, including manpower and money, to get the job done safely!! Different set of standards for Regulators and Investigators perhaps? Just asking the question..........

Will this accident end up containing causal factors that link back to poor Government oversight of regulations and accident investigations? Don't know. But I'm sure that if there is so much as a whiff of pooh around all of this then the Senators will be on to it.

What do you think NFI Chester? You understanding any of this old mate? Nah, I didn't think so you dopey twat.

TICK TOCK (still)
Reply
#18
4D - DOT,DOT,DOT-DASH,DASH,DASH-DOT,DOT,DOT - Confused

Latest from Accidents - Domestic:
(02-23-2017, 07:03 PM)kharon Wrote: "Pilots untrained to deal with 'feathering' failure that may have caused DFO crash: experts"

Bollocks – sentence 1.

Failures in both the engine and 'feathering' system, that pilots are not trained to deal with, may be behind Tuesday's fatal plane crash, experts say.

Complete utter rubbish; the first class ‘auto-feather’ and ‘rudder boost’ system are ‘assist’ only. They are categorically not to replace a well trained pilot.  Nor should these systems  ever be totally relied on as the ‘definitive answer’ to an engine failure in the ‘low-slow’ configuration. Even if both systems failed, simultaneously at the most critical moment it would matter little to any pilot who had been ‘trained’ to actually fly the aircraft, rather one only trained to pedal ‘the box’ around the sim exercise garden circuit.

Item one – failed engine – big yaw – big rudder; balance is all. Rudder boost failed – so what, use muscle and trim, but do NOT allow the ‘yaw’ to continue.

Item two – failed engine – balanced aircraft – failed unit identified; feather and fuel off – or Fuel off and feather for fire –no matter – reduce the drag – quickly; after correctly identifying the ‘failed’ power unit.

Item three – Speed – must have – and the ‘right’ one then maintain that speed until clear of obstacles – power available from live engine; performance available from setting up the right ‘asymmetric balance’ take height with speed stabilised; clean up; sort it out then get on the radio and back to earth a.s.a.p.

There are several items which must be considered during this difficult first thirty seconds; e.g. what is there to bang into and how best to avoid it – in terms of given altitude and rate of climb being produced; it is important to remember that the undercarriage will take a longer period of time to retract, (hydraulics question) which will delay accelerating to and achieving the Single engine best rate of climb speed (SEBROC). In fact SEBROC may not be achieved initially; but, a well managed take off takes the aircraft very quickly through the ‘speed gates’. A Be 20 should, on a runway like Essendon be doing 110 -120 knots as the gear comes up before the end of the runway. The old Dash 41 models rotated at 92 (ish) knots and went very quickly through safe single engine speed 104 achieving 115 Kias* (single engine best rate of climb) with the gear retracting SEBROC 121 Kias came within seconds, followed swiftly by Multi engine best rate of climb speed @125 Kias.  In not technical short, from 80 Kias through to 160 Kias (normal climb) happens very swiftly, the only real ‘grey’ period is between 90 and 115 Kias.  ( Sorry P&W- 41 numbers; 42 not to hand). *KIAS – Knots indicated Air Speed.

It is a great mistake to sit back and do nothing while relying on rudder boost, auto feather and the gods to drag you through the very short ‘grey’ period. It is reprehensible for this reliance to become normal; it is completely irresponsible to teach this dependence as a requirement.

I want to know who trained this pilot, I want to know where his ‘retraining’ was done after the Hotham scare. I particularly want to examine the sim print outs and the check list procedures and who’s sim was used to execute these procedures.

FFS someone; get into a Be20 with a camera and a stopwatch; watch the airspeed and altimeter; you will be amazed at the speed which the aircraft achieves safe flight speeds; then do it again for an EFATO with a ‘proper’ King air pilot; use the RFDS, and, be even more amazed as the aircraft, properly handled, breezes through the event; even with the rudder boost and auto-feather disabled.

Lord I am tired to my very bones of bloody ‘experts’ and their empty headed rational.

Aye well – what can you do – except try to explain it to the ‘media’ again and again and again. The up side is they’ll have forgotten it all by next week and we can have a real look at this accident.

Toot toot.

Not wanting to pre-empt any of the good folk on the coal face of this tragic CFIT accident but I see some disturbing similarities to the fatal Darwin Brasilia training accident, that the Dr 'Ghost who walks' Walker took issue with in relation to the PelAir cover-up:  
Quote:[Image: keju1.jpg]

"There's a hole in the cheese dear Liza, dear Liza??" 

Who'd of thought? The Ferryman doing 'an evening twiddle' just short of the 'witching hour' on a Sunday night? Maybe like the rest of us mere mortals, this bollocks daylight savings has disturbed his evening routine.. [Image: huh.gif]

Anyway job well done Mr "K"... [Image: biggrin.gif]  (Ps & TY for the edit I was bit rushed with my last - [Image: blush.gif])

Ok onwards & downwards with the dot joining... [Image: confused.gif]

Quote from: Opinion :-ATSB since 2003.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they provide further examples of compromised ATSB Final Reports.

In case you need a reminder of the circumstances of the Darwin Brasilia accident, here is a disturbing ATSB simulator animation of that tragic C&T accident: 





From earlier post#33 "K" said:
Quote: Wrote:..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...
And just before the Senate PelAir inquiry, on the 6th August 2012, a certain 'senior' ATSB Transport Safety Investigator (who I believe was actually Dr (BASR) Walker), said this about the Braz tragedy:
[Image: Untitled_Clipping_100316_105643_AM.jpg]

{P2 comment - To put this in context this was just prior to the release of the original nearly 3 year, totally shambolic, politically & bureaucratically obfuscated VH-NGA ditching investigation final report}

Now in an effort to track down the 'unflattering comments' that so offended Dr (BASR) Ghost-Who-Walks, I raided the UP archives based on the timing and this is (much to my amusement..[Image: biggrin.gif]) was what I discovered: Air North Brasilia Crash in Darwin (Merged) #446
Quote: Wrote:Without this diverging into a mixture vs closed throttle vs Flight idle vs zero thrust debate has anyone noticed the gradual decay of the quality of investigation reports coming out of the ATSB?

Besides the Hempel Inquest, where the ATSB appears to have abrogated all responsibility to investigate at all, the ATSB report into the Brasilia accident in Darwin is nothing short of totally spare in its conclusions!

There also appears to be no 'Safety Recommendations' generated from a training accident that I think we could have all learnt a lot more from.

Take a look at a couple of extracts from the report:

Quote: Wrote:Quote:
Terminology used in training and checking
The operator’s documentation did not contain any specific terminology for discontinuing a manoeuvre, but did provide clear instruction as to how control of an aircraft was to be changed between crew members.
To take over control from the pilot flying, or for the pilot flying to relinquish control to the other pilot in a multi-crew aircraft, very specific terminology was used. To avoid any confusion as to which pilot was manipulating the controls, the operator’s General Policy and Procedures Manual, section 4.7.2.2 Crew Communication - Handing Over and Taking Over stated:
The process of handing over control of the aircraft shall always be conducted in a positive manner. To minimise confusion or operational risk, the following terminology shall be used.
To assume control, the pilot monitoring shall call "taking over". To relinquish control, the pilot flying shall call "handing over".
Control of the aircraft cannot be handed over until the pilot monitoring has called "taking over"...
The term ‘disengage’ that was used by the PIC during this simulated engine failure was not standard phraseology. Other EMB-120 pilots reported that they had never heard the term ‘disengage’ used for any action other than deselecting the autopilot/yaw damper and had never heard it used to discontinue a manoeuvre.
They also reported that if a training or check pilot decided to discontinue a simulated engine failure procedure, they would expect that check pilot to restore power to the ‘failed’ engine. Alternately, if the training or check pilot wanted to assume control of the aircraft, they would expect to hear the term ‘taking over’.

Which is pretty basic stuff in a multi-crew aircraft....and then in regards to the Yaw Damper....

Quote: Wrote:Quote:
The operator’s flight operations manual for the EMB-120 stated that the yaw damper was not to be used for takeoff or landing, and that the minimum speed for its use during one engine inoperative (OEI) flight was 120 kts indicated airspeed (KIAS).

.....and then more in relation to the apparent Yaw Damper activation...
Quote: Wrote:Quote:
The use of the yaw damper during asymmetric flight was introduced to the simulator testing following consideration of the cockpit voice recording references to the PIC’s command ‘disengage’ and the pilot under check’s response, ‘yeah, disengaging’. It was assumed that the reference was to the yaw damper and not the autopilot because the chime that sounds when the autopilot was disengaged was not heard on the CVR recording. Additionally, the simulator instructor reported having previously observed pilots engage the yaw damper during simulated engine failures in the EMB-120 in response to pilots ‘overcontrolling’ rudder and aileron following a simulated engine failure.

All of the above is all good factual investigative methodology a lot of which points to a number of operational issues (company SOPs etc) and regulator oversight issues....right?? Wrong, take a look at the first paragraph of the ATSB conclusion.

Quote: Wrote:Quote:
No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified as a result of this investigation.

Maybe this conclusion is a result of the regulator putting in place the Mandatory Simulator program and subsequent NPRM leading to the current NFRM, but does it excuse glossing over what was a particularly significant training accident event that, although tragic, we could all have learnt from![Image: eusa_naughty.gif]

ps ....and what gives with the no 'Safety Recommendations' issued![Image: eusa_wall.gif]

http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf

With "K" in tow, the discussion went on down the page:

Quote: Wrote:Now I'm curious


I find I am once again forced to read between the lines of an ATSB report. Technically it's spot on; for example, reading the time line analysis, there is a temptation to question the rudder v aileron input, however this is clearly resolved in the computer simulation graphics. Not having operated a Braz – there are a couple of points of interest which perhaps can be explained by someone who has.
Disengage ?? –could this refer to the Flight Director or is it the Yaw Damper ?. I note the AFM mentions –(paraphrased) FD Before take off (SET), expanded to PF select GA and check 7° pitch up; and, that the AP or YD may not be engaged during TOFF and LAND manoeuvres.

Has it been SOP for the PF to engage the YD as part of an EFATO or was this a recent innovation ?.

The V1, Vr and V2, V2 +10, etc. schedule. The AFM seems to be clear about the speed schedule and the acceleration to V2 +, then flaps up then Vfs (paraphrased). There appears to be a deliberate reduction from V2 + 4 (at – 23 seconds) to V2 (at -20.7 seconds). Is this a norm for the type or a new innovation ?.

Is the un monitored management of the OE, the over torque (124%) and the corresponding rudder/aileron excursions normal for the airborne exercise being conducted ?.

It is suggested by the ATSB final analysis that the BASI recommendations made after an investigation into the Flight Idle v Zero thrust (auto feather) scenario have been ignored. There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

P.S. Categorically not having a pot shot at the crew, the company or the simulator. Just seeking a satisfactory explanation of why and how this 'abnormal' chain of events occurred. If this was a new ME instructor and an initial twin conversion, perhaps this event may have occurred, but it wasn't – was it.
   
Which I followed with:
Quote: Wrote:
Quote: Wrote:Quote:
It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

A lot of what was covered in the ATSB report touched on the areas of operational concern and hinted to several differences in history where the Check Pilot had started to diverge from his 'norm'. This quote from page 54 of the report is significant:

Quote: Wrote:Quote:
Two of the pilots who were recently assessed by the PIC reported that he selected flight idle (zero torque) to simulate an engine failure after takeoff in their check flights. It was possible that the PIC had decided to deviate from the operator’s approved procedure in order to test the recognition by the candidate of the additional failure of the autofeather, before setting zero thrust.
 
However it isn't clear whether this 'divergence' from his 'norm' started after he had been to the simulator or before. If it was after then one may suggest that he was operating in a 'simulator induced complacency' manner i.e. it was proven that Flight idle (aircraft) or 'Autofeather Failed' engine failure (simulator) could be successfully recovered from while conducting a V1 cut.

This also appears to have been an area of concern for the regulator, as they used this accident as an example in Annex A of the NFRM for Mandatory Simulator, see here:


Quote: Wrote:Quote:
From CASA NFRM Mandatory Simulator training Annex A:

COMMENT 1.2
Some respondents proposed adding wording to allow training and checking to occur in the aircraft provided the exercise had been conducted by all pilots in a simulator in the preceding 12 months.
CASA Response
CASA is firmly of the view that where a qualified STD is available for aircraft of this size, this should be used for all training and checking activities. The ATSB has reported that the training captain of the aircraft involved in an accident in Darwin in March 2010 had undergone training and checking in a flight simulator, however the actions by the training captain in simulating an engine failure in the actual aircraft during the accident flight was not consistent with the training received during the simulator course. This suggests that doing one session of training and one check per year in an STD (with the subsequent session/check in an actual aircraft) does not satisfactorily address the risk of conducting non-normal exercises in an actual aircraft.

If the Check Captain was inducing this scenario (FI V1 cuts) prior to having gone to the simulator, whereas previously he always only induced a Zero Thrust EFATO scenario, then there must have been input from somewhere/someone to change him to suddenly start breaching the company T&C SOPs??

As 'K' suggests there has been many takes, ambiguity and debate..etc..etc..on the regulatory requirements of CAO 40.1.0:


Quote: Wrote:Quote:
There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

Maybe there is an element of rogue FOI's, that lack the necessary industry experience, that insist on adhering to the letter of the law in CAO 40.1.0. Instead of applying practical safeguards and risk management to high risk training and checking scenarios!!
 
So am I offended that 'his nibs' Dr W#*ker believes that I have no idea about what an "..organisational issue actually is, and when it is, or is not important.?"  - Not on your life I luv it...[Image: biggrin.gif] 

In light of the Kharon post and considering it is still way to early to really speculate, but reflect that this is not realistically about some spurious lack of training in a 1 in a million auto fx or rudder boost failure after EFATO. Potentially this is about why two experienced professional aviators - one a senior Training & Check Pilot with years of experience instructing and C&T; the other a 38 year experienced Charter Pilot with presumably much experience on type (B200) that was recently checked (& re-checked) by CASA - would appear to have deviated from what would be regarded as their baseline 'normal' for dealing with (simulated or real) abnormal or emergency twin turbo-prop aircraft operations - just saying... Undecided


MTF? - Definitely...P2 Tongue
Reply
#19
Delusions of adequacy??

I may be imagining things, but I recall a time when the ATSB produced a half-decent report on aviation accidents and incidents.
The 2001 Toowoomba C90 accident comes to mind. I may be completely wrong of course, and the memory does play tricks.. please correct me if they made a hash of that one too.

It seems things go from bad to worse, but surely the downward spiral of ineptitude can't continue indefinitely?
Actually.. it probably can get worse. If you were writing a performance appraisal on Chester & friends, a likely summary would read: 'He has reached rock bottom and has now started to dig'

It's to be hoped that these entities rediscover the fundamentals: Accurate reporting and relevant recommendations, produced in a timely manner.

Surely that isn't too much to wish for?
Pix :shy:
Reply
#20
(02-23-2017, 11:02 PM).Pixie P Wrote: Delusions of adequacy??

I may be imagining things, but I recall a time when the ATSB produced a half-decent report on aviation accidents and incidents.
The 2001 Toowoomba C90 accident comes to mind. I may be completely wrong of course, and the memory does play tricks.. please correct me if they made a hash of that one too.

It seems things go from bad to worse, but surely the downward spiral of ineptitude can't continue indefinitely?
Actually.. it probably can get worse. If you were writing a performance appraisal on Chester & friends, a likely summary would read: 'He has reached rock bottom and has now started to dig'

It's to be hoped that these entities rediscover the fundamentals: Accurate reporting and relevant recommendations, produced in a timely manner.

Surely that isn't too much to wish for?

Top post Pix and indeed the Toowoomba C90 fatal prang was an exemplary ATSB report... Wink : Beech Aircraft Corporation C90, VH-LQH, Toowoomba, Qld

& supplementary report: 200507077

However the issue with that report was not with the ATSB but with CASA, who effectively O&O'd most of the ATSB safety recommendations and Coroner conclusions that were addressed to them - see page 7 to 10 in PAIN report: Response to Coronial inquiry. Fatal air accidents.   

Quote:Coroner Barnes.

http://www.courts.qld.gov.au/__data/asse...070809.pdf

Relevant quote: “It is impossible to say that had CASA been more searching during the audit undertaken in the period 20 – 23 August 2001 that the problems that lead to the fatal crash would have been detected. Nonetheless the failure of CASA to make any further inquiries in relation to these aspects of the operator’s maintenance systems and performance was, in my view, less than the public could reasonably expect of the authority.”


Comment – April 2012.

CASA argue throughout the ATSB recommendations and Coroner’s inquest, that their approval, audit and surveillance systems are robust enough to capture non-compliant, rogue elements of AOC or COA holders. However the evidence would seem to indicate otherwise. Therefore, we believe, some of the causal factors in this accident have not been addressed by the regulator and remain ‘high risk’ for a similar accident scenario occurring.

MTF...P2 Cool

Ps. Maybe some interesting parallels to rake over between the C90 Toowoomba prang and the tragic B200 Essendon fatal accident - reference pg 7 para 5 & 6:

Quote:(5) The ATSB recommends that CASA consider providing formal advisory material for

operators and pilots, based on relevant research and publications, about managing

engine failures and other emergencies during takeoff in multi-engine aircraft below

5,700 kg MTOW. This material should include the factors to be considered by operators

when developing procedures for responding to such emergencies.

(6) The ATSB recommends that CASA consider and evaluate options to improve the

suitability of industry practices for training pilots to make appropriate decisions when

responding to engine failures and other emergencies during critical phases of flight in

multi-engine aircraft below 5,700 kg MTOW. This review should include an assessment of

the suitability of utilising synthetic training devices for the purpose of training pilots to

make decisions regarding emergencies.

& from Kharon Accidents - Domestic thread post:

"..Anyway - since when in this good world, was ‘V1’ ever, ever a consideration in the performance manual or even the approved certification data for the type? Never is the correct answer. Then the ‘expert’ fails to mention that the Auto feather would kick in and that saves valuable seconds at the ‘imaginary’ V1 cut; remember, V1 is but a fleeting second of time – a heartbeat. If you are using a ‘tight’ field length it is prudent to manage the T/Off speed schedule to make damn sure that you can either safely stop or safely go. This means a schedule which gets the aircraft as quickly as possible – to a ‘safe’ speed; preferably above single engine climb speeds. Why? Well if you ‘loose’ one below that speed, it is a sods job to accelerate and gain the additional speed needed for climb; but if you have obtained a better speed than minimum when you ‘loose’ it; even if the aircraft decelerates, then climb is still possible, even probable. There is that wonderful moment when the ‘Speedo’ ticks through to climb speed and the climb indicator shows a positive ‘UP’. Aside, you do realise there is a CASA mutt knocking about who even tries to insist that a reduction from a happy V2+10 to the scheduled V2 is the only ‘right’ way to manage a single engine climb.."

"K" - I did eventually remember to qualify the availability of FAR 25 performance data , with the attached conditions.Toot toot.
Reply
#21
With your indulgence – a ramble.

One of the more serious considerations attending the B200 fatal accident at Essendon (Melbourne) this week is the flavour of response to the ‘fall out’ that may be expected from the government. Major fatal accidents have, in the past, resulted in an ‘inquiry’ of some sort. Advance, Lockhart, Monarch, Seaview etc. There is a fairly substantial list which supports the notion that there may well be an ‘inquiry’ into this latest event. History shows that despite the millions spent and the huge volumes of ‘reports’ very little has changed – except the departments concerned learned how to cover up, abrogate and obfuscate; even developed it into an art form. But enough of that, if the Norfolk/Pel-Air ongoing fiasco can’t convince you that despite the sound, fury and expense, little will change, then there is little to be gained from my ramblings. There is an urgent need for an inquiry – right now. This accident brings together almost every major item of grave concern the industry has.  

Airport land being subsumed and building encroaching to the very limits of ‘safe’ areas; built up to the maximum tolerances allowed by ‘law’ is a serious matter. Take a look at the photograph of Archerfield (Brisbane satellite) aerodrome; the built up areas may well be ‘legal’ to the letter of the limitations; but I for one would be reluctant to take a ‘class’ aircraft there, particularly at night in bad conditions; the loom of the lighting alone can and does play tricks on low cloud and rain; even worse for take off. A take off procedure does not end at the runway end; in fact those few precious seconds, after becoming airborne, are the most critical time. Watch any crew taking off into the ‘murk’; the relaxation is tangible once the aircraft is climbing away, cleaned up and the obstacles have been cleared; before that, they are paying very close attention. Why? Take another look at the Essendon story.  Ten foot – three meters, is a big number margin when the aircraft is ‘low and slow’ and has a ‘problem’. Would ‘time and space’ have saved this aircraft? We don’t know, but it is a fact that the aircraft hit a building very close to the runway; 100 meters @ 180 KpH is not a big distance for an aircraft to travel – work out the time taken, it is not very long at all.

Of course much will depend on the ATSB report and findings; but, on past performance – Pel-Air and Mildura for example, (to mention the ones the public are dimly aware of) have been neither satisfactory or effective nor even timely, let alone of any value in preventing a repeat. There are many serious incidents still awaiting anything more than a ‘lip service’ acknowledgement from ATSB. It is a very long list and some of it damn scary; the Virgin ATR; the Mildura close call etc. Now we must wait for what seems to be the normal time period of two to three years for a report; even then, looking back at the most recent efforts, most will agree the wait was in vain.

Then we must consider the CASA role in the accident. Not the surface shine on the mudguard, but the accumulated crud underneath. Any inquiry mounted must be made aware of and made to understand the ‘true’ depth of CASA involvement; right down to the fine detail of the influence and pressure brought to bear on operators to do it the CASA way – or no way. This despite the muttering of protesting ‘experts’. Many hold the opinion that until CASA is completely reformed, from top to toe; maintaining the peripheral agencies is merely theatre; naught but a magicians pantomime, staged to baffle politicians and bamboozle the public.

Last; but by no means least, although excluded from the Essendon crash, are the mandarins who allow these aberrations to continue. Those who provide top cover and influence to ‘protect’ not only the minister and the public from epiphany; but generate the smoke, manufacture the snake oil and keep the mirrors very highly polished.

So, will there eventually be an inquiry into this accident? It’s a fair bet and the odds are easily determined. It is a much tougher challenge to sort out the odds for that inquiry ever producing a ‘satisfactory’ outcome; but it will be a long odds bet, be assured of that.

Aye well, ‘tis but a speculative ramble; not sure why I bothered really; it’s not as though we haven’t seen it all before. The smoke and flames, burning bodies, ground services swinging into dynamic action; the ‘media’ going nuts, politicians looking sombre, early speculation, the endless TV repeats and ‘expert’ commentary, followed by the ATSB scratching about in the rubble trying to piece it all together, CASA ducking out of the back door at a rate of knots; then - not much more. Time ticks by, the often risible report is finally produced; the politicians bang on; a report is tabled; and, just like that –reboot -  it’s all good again. Nothing has changed – not even the chance of this happening all over again in a shopping mall near you.

End of ramble; opinion expressed, my two bob, spent as pleased me best. Now, the old stable awaits me; a place where there are dogs, a work bench, a rack of sharp tools and a part finished high chair for a new soul entering this world. It is a fine place, balm for heart, hands and mind.

Selah.
Reply
#22
Tiedy the Iron Ring cleaner? - Undecided  

Reference from Mount NCN & the UP... Wink : A blast from the UP past

Quote:“..SUMMARIES OF DISCUSSIONS

Topic 2.5: Implementing new safety management process

44. There was unanimous support for the establishment of a new Annex [19] to the Convention dedicated to safety management responsibilities and processes..”


Meanwhile, in Fort Fumble’s parallel universe, the middle management minions were busy enacting their MAP to roger DJ and the ATsB, while attempting to cover up their obvious shortcomings to properly oversight the PelAir operation.

Anyone else see the irony in the two universes?[Image: eusa_wall.gif]

List of Participants

AUSTRALIA

MCCORMICK J. CD
FARQUARSON T. ACD
TIEDE A.H.R. ANC
ALECK J. D
BOYD P. D
BROOKS L. D
DOHERTY J. D
EVANS P.K. D
MACAULEY K. D


Remembering that Skidmark gave Tiede a gig back in 2015 I was curious to why he was rubbing shoulders with the likes of McComic, Tezza and Dr A way back at the ICAO HIGH-LEVEL SAFETY CONFERENCE 2010 held in Montréal, 29 March – 1 April 2010.

Well a quick background to the inestimable Mr Tiede IMO creates more of a crater than a dot... Shy

Excerpts from the Tiede CV:

Quote:Manager CNS/ATM Branch


Company Name
Civil Aviation Safety Authority  

Dates Employed
Mar 2015 – Present  

Employment Duration
•2 yrs 5 mos  

Location
Canberra, Australia    

CNS/ATM Branch undertakes regulatory oversight of Civil Aviation Safety Regulations (CASR):
 Part 65 – Air Traffic Services Licensing
 Part 139H - Aerodrome Rescue and Fire Fighting Services.
 Part 143 – Air Traffic Services Training Providers
 Part 171– Aeronautical Telecommunications Service and Radionavigation Service Providers
 Part 172 - Air Traffic Services Providers
 Part 173 – Instrument Flight Procedure Design
 Part 175 – Aeronautical Information Services



General ANS Consultancy


Company Name
Asteeds  

Dates Employed
Jul 2014 – Feb 2015  

Employment Duration
•7 mos  

Air Navigation Commissioner


Company Name
International Civil Aviation Organization  

Dates Employed
Dec 2009 – Jun 2014  

Employment Duration
•4 yrs 8 mos  

Location
Montreal, Canada    

Alternate Australian Representative on the Council of ICAO, Vice President of the ANC (2012 & 2013), member ANC Planning (Executive) Team (2010 - 2013), Chair ANC working group for the "Paperless ANC Chamber" including electronic Notice of Proposed Amendment (eNOPA), member ANC working group on "Modernisation of Panels' , Chair ANC working group preparing for AN-Conf/12 (2010 & 2011)


Air Navigation Services (ANS) Regional Officer, Asia & Pacific


Company Name
The International Civil Aviation Organization  

Dates Employed
Mar 2004 – Dec 2009  

Employment Duration
•5 yrs 10 mos  

Location
Bangkok, Thailand    

ICAO regional requirements for Air Traffic Management (ATM), Aeronautical Information Services (AIS) and Search and Rescue (SAR), ANS components of Asia/Pacific Regional Air Navigation Plan, technical secretary, technical officer and moderator to long duration ICAO international meetings including APANPIRG, regular technical assistance missions to States, acting Regional Director & long term acting Deputy Regional Director, USOAP auditor for ANS.


Air Navigation Services Management Roles


Company Name
Airservices Australia  

Dates Employed
Jan 1994 – May 2004  

Employment Duration
•10 yrs 6 mos  

Location
Sydney, Melbourne    

2001-2004 ATS Safety Manager for Melbourne FIR; 1999-2001 Manager ATS Procedures & ATS Documentation for Melbourne Adelaide & Perth; 1994-1999 Team Leader Desert GROUP including TAAATS transition - Sydney and Melbourne ATS Centres; 1991-1993 Senior ATC Instructor and Training Course Manager (SERCO, under contract to the Regie des Voies Aerienne, Belgium).




Air Traffic Controller, (all ICAO ratings)

Company Name
Airservices Australia
Dates Employed
Jan 1980 – May 2002
Employment Duration: 22 yrs 6 mos
Assistant ATC 1980-1983, ATC 1984 - 2002, Tower, Enroute and Approach ratings, operational duties in Sydney, Canberra, Melbourne, Perth, Port Hedland. ATS instructor and Course Manager for BelgoControl Brussels, Belgium
  
 Got a problem - with Airports and DFO buildings, ATC & Airspace, Air Navigation systems; or even an inconvenient ditching - who you going to call?? Dodgy  


MTF...P2 Cool

Ps Tiedy's CV certainly makes Harfwit's CV pale into insignificance... Rolleyes

Pps Is it any wonder Mike Smith got rejected this time around - the Iron Ring firmly back in control... Undecided
Reply
#23
PelAir MK II: The IIC white hat within - Undecided

In the course of re-hashing on PelAir MK II this historical ' search 4 IP' post - Ghost who walks & talks beyond Reason - I passed on the following copied email (that was tabled:10 October 2012, in the course of the conduct of the Senate PelAir Inquiry) to a DIP for thoughts on the ID of the email author... Huh  

Quote:[Image: Dr-W1.jpg]

[Image: DrW2.jpg]  

After talking to the DIP, & remembering that I originally suspected that the email may have been composed by Dr Walker, I am now firming to the opinion that the email was a desperate plea to Sangston from the original IIC. I also suspect that that email copy was sent independently of the ATSB and was part of 9 documents that were suspiciously received by the Committee Secretariat 2 weeks before the first public hearing on the 22 October 2012 - reference: Tabled docs 11 thru 18 http://www.aph.gov.au/Parliamentary_Busi...ubmissions .

The two copied emails (tabled docs 16 & 17) would also seem to support the issues the author of email to Sangston had with the drafted Final Report (at that point in time - 6 August 2012) and ironically with the findings of the Senate PelAir inquiry... Confused

Quote:[Image: AO-1.jpg]
[Image: AO-2.jpg]
  
What is also passing strange is that the infamous Chamber's report (Doc 10) was also supposedly received (10 October 2012) by the Secretariat but not tabled/PDF copied until 14 February 2013. Which happens to correspond with when the Chamber's report was publicly revealed at the 15 February 2013 public hearing:







   
 
From that extraordinary public hearing of revelations, obfuscating admissions, spin, bulldust and denials, it would now appear that some of those involved individuals must have been telling the committee porky pies. This is because the existence of the Chambers Report was known at least 12 days before the first public hearing and is listed as a tabled document from CASA (i.e. 01 CASA_Doc 3_Web - PDF). 


MTF...P2 Cool


Ps P2 comment - Personally I find it hard to believe that the Committee Secretariat took 4 months to process the 8 documents (including the Chamber's Report) received on the 10 October 2012. Huh
Reply
#24
All Pel-Air lines of obfuscation lead to?

[Image: 11.jpg]

Albo...err M&M Dodgy

[Image: Untitled_Clipping_040317_102544_PM.jpg]

Couple more dusted off dots to add to the PelAir 'ditching of inconvenience' portrait but first a reference via this week's SBG: The best laid plans of mice and men.

Quote:Note that the date they were all received by the Committee Secretariat was on the 10 October 2012. However; the date that all the offending documents were copied/tabled, therefore made available for the Senator Committee members & public consumption, was on the 14 February 2013. This fits with the extraordinary revelations in the Senate inquiry public hearing the following day:  15 February 2013 Canberra, ACT
(HTML format) (PDF 104KB) (HTML & PDF)    

First QON & OBS (so far):

Q/ What was the delay in processing those documents?

Q/ In the context of this inquiry, how is it possible that such critical information and documentation effectively have been sat on (obfuscated), when the inquiry was still some 12 days from it's first public hearing?

&..

...What this appears to indicate is that the documents were sent collectively by an individual/entity/group, independent (officially) of either the ATSB or CASA. This IMO strongly suggests that this was a whistleblower(s) initiative. 

This opinion/suspicion is reinforced by the fact that the documents were received prior to the 1st public hearing and around the date the submissions from both the ATSB and CASA were received and/or copied/tabled.

Now it could be that the normally efficient Senate RRAT committee Secretariat suddenly got swamped by other priorities; or there was some sort of administrative glitch that prevented the 9 anonymously sent and inquiry 'critical' documents, from being processed/tabled for 4 months (128-129 days). However the evidence would appear to contradict the probability of such an aberration occurring.

To begin the timing of the received documents was within the original submissions due date and 2 days before the substantial submissions from the ATSB and CASA were received (& tabled). I can also personally attest (on behalf of PAIN) that subsequent 'supplementary' in camera submissions were processed and notifications of receipt were promptly sent within days of forwarding to the committee. 

I would also add that on a quick review of the 'additional documents received' list indicates that all other documents were tabled within days of receipt. All of these documents were received after the 10 October 2012.

Which brings me full circle back to my original QON (above) with the added QON of WHO or WHAT individual/entity could subvert/obfuscate/delay a parliamentary inquiry? 

For lots of unresolved COI issues, IMO the most obvious candidate that comes to mind is the former minister Albo... Rolleyes

Reference: The tale of Karen Casey post #97

Quote:..Coming back to the bizarre REX 250K donation to the federal ALP, when REX repeatedly made claims of a deep loathing of the Labor party and it's former miniscule for non-aviation Albanese, I came across another interesting tit-bit some 6 months after the VH-NGA ditching at Norfolk Island. In reference to this link - HERE - of the official opening of the REX affiliated AAPA (Australian Airline Pilot Academy) on the 27 May 2010...

...Hmm...I suddenly remembered why that date rings a bell... [Image: undecided.gif]

From the 2nd supplementary submission by CASA to the Senate PelAir cover-up inquiry, Albo's anointed one, McComic attempted to throw the Murky handpicked Muppet Beaker under the bus (note the date):

[Image: McComic-Dolan-under-bus.jpg]
Coincidence maybe but what would the chances be that Albo & Sharpie, the very next day, would not have discussed the potential PR disaster if the so called independent ATSB were to point out systemic failures from both the operator & the regulator in their final report?? [Image: dodgy.gif]

Two years later REX was to give the highest political donation in their history (250K), not to the Nationals but to the ALP??  Yeah right - BOLLOCKS! [Image: angry.gif]

Remember this infamous CASA FOI document? https://www.casa.gov.au/files/foi-ef12-8481pdf

[Image: Albo-1.jpg]

That email exchange was bizarrely made public on the CASA FOI disclosure log and was originally one of six documents released in response to a Karen Casey FOI request addressed to the office of the former minister for Infrastructure & Transport:
Quote:Date: Mon, 12 Nov 2012 19:30:40 +1100
Subject: FOI MO 13-03 [SEC=UNCLASSIFIED]

Dear Ms Casey

Decision on access - FOI MO 13-03 – Correspondence regarding Pel Air
 
I refer to your request for access to documents in the possession of the Office of the Minister for Infrastructure and Transport in accordance with the Freedom of Information Act 1982 (the FOI Act). 
 
Your request sought access to:
 
“specific documentation, that being letter or email, with discussion on the Pel-Air ditching between Mr Anthony Albanese, Mr John McCormick (CASA), Mr Martin Dolan (ATSB Chief Commissioner), Mr John Sharpe (REX/Pel-Air), Mr Lim Kim Hai (REX/Pel-Air), and anybody else in the Minister’s Office dated 18/11/2009 to current.”
 
A statement of reasons is attached.
 
Please note that of the attached documents, Document number 1 is an email which refers to two attachments. It was only identified today that these two attachments are within the scope of your request, and therefore I have commenced consultation on these two documents with the third parties subject to this correspondence. One of the third parties was unable to ok their release today and has raised concern that their release prior to consideration could be inconsistent with the Senate proceedings (and to do so may be a contempt of the Senate). Therefore in order to consult appropriately with the third party, consistent with the intentions of the FOI Act, I have withheld one of the two documents from today’s release. However, I will endeavour to send this through by the end of this week once the third party has responded to my consultation request.
 
Please contact me if you have any questions regarding the processing of your request. 
 
Kind regards
 
MTF...P2 Cool

Ps. From one of the five other documents released by Albo's office ( & bizarrely one by the CASA LSD/FOI office - Huh ), we get a sense of the arrogance and contempt (the former aviation adviser to Albo) Craig Carmody had not only for Senator Xenophon but for the ABC 4 corners program:     
Quote:From: Carmody Craig

Sent: Friday, 24 August 2012 14:51

TO: REDACTED ; Dolan Martin

CC: REDACTED

Subject: RE: Norfolk Island Ditching. [SEC=UNCLASSIFIED]

Four Corners has investigated independently? Are they the new ATSB?

Also, if they are such great investigators – tell them to investigate the ATSB website and they will find the report.

CC
UDB! Dodgy - Must have something to do with that name... Rolleyes
Reply
#25
Spade or shovel?

What shall we call it? It’s about time we decided to call it something.  Of course it matters not what we may call it. ‘We’ may sit here for ever, ad infinitum, calling it whatever the hell we please; but will that change any damn thing – for the better? – No; it bloody well won’t.

This ‘new’ all singing, all dancing, ATSB shakedown of the Pel-Air accident will steal all the oxygen from the real story. Watch and see; hells bells, I can’t cover the bets on it being a ‘clinical’ analysis of what was, in essence, a fairly simple accident – standing alone.

How the accident came to pass is quite another, very interesting, technical story. With every hole in Doc Reason’s cheese perfectly aligned; sooner or later, someone, somewhere, was going to have ‘an event’. Sure as eggs. You will never, not in a million, hear any one of the agencies involved admit they could have done better. Not from CASA who approved (accepted) the procedures, standards and training of Pel-Air pilots; not from the BoM on how maybe their forecasting updates could be done a little better; not from the briefing or ATC services and, most certainly, not from the CASA officers who were responsible for making sure that standards were met. Forget about it – the big money says Manning will ‘oblige’ and write these elements out of the script. These matters are important; but they won’t signify.

The real story is in the Senate inquiry Hansard. Miles and miles of ‘paperwork’, shed loads of the bloody stuff – which no one had the time, inclination or briefing to examine – very carefully; let alone read and analyse, even if they knew what they were looking for. Then, if a case was supported by ‘evidence’ there would still be the need to prove ‘intent’.

Funny word that – intent – even funnier in legal terms (as in peculiar). In primus, the intent to do “what” must be defined, then that must be proven, beyond a reasonable doubt. There, boys and girls is the rub. You, me and Grand Mamma may be ‘tried’ under strict liability, which makes it difficult to defend yourself. But ATSB and CASA are not bound by the toils and nets of ‘strict liability’; no Sir. To prosecute a Dolan, a McConvict, a Hood or even a Chambers, you must be able to prove the case mounted. Deuced tricky and bloody expensive; to prove what every fool in the Souk knows; they lied through their collective teeth. No point to; or, gain from doing it. However; it must never, ever be allowed to happen again.

The Senate must see to this – gods know ‘we’ can’t change it; much as we would love to. FDS we can’t even get a DAS who knows how to spell reform, let alone make it happen. A decent, honest village idiot for a minister could make it happen; but old Turnbull has more to fuss about than the ethics, morals and practices of Australia’s much vaunted ‘aviation safety issues’ being as crooked as a dogs hind leg. Which leaves us with only ICAO to rely on.

Anyone got a number and two bob I could borrow – I’ll give ‘em a ring, talk to his ‘Excellency’ and see what can be done. Yeah, right; that’s bound to work – not.

No matter, new flights on the darts, my ale has arrived and it is my turn to throw. Best crack on and see if I can pin the tail on the donkey; in Shanghai’s at a dollar a point.

Toot – toot.  {Yus P2, us has had had a couple} – Big smile…….(he worries).
Reply
#26
Further Senate RRAT committee Secretariat aberrations.  Confused

Reference from above:
(08-07-2017, 07:00 PM)Peetwo Wrote: All Pel-Air lines of obfuscation lead to?

[Image: Untitled_Clipping_040317_102544_PM.jpg]

Couple more dusted off dots to add to the PelAir 'ditching of inconvenience' portrait but first a reference via this week's SBG: The best laid plans of mice and men.

Quote:Note that the date they were all received by the Committee Secretariat was on the 10 October 2012. However; the date that all the offending documents were copied/tabled, therefore made available for the Senator Committee members & public consumption, was on the 14 February 2013. This fits with the extraordinary revelations in the Senate inquiry public hearing the following day:  15 February 2013 Canberra, ACT
(HTML format) (PDF 104KB) (HTML & PDF)    

First QON & OBS (so far):

Q/ What was the delay in processing those documents?

Q/ In the context of this inquiry, how is it possible that such critical information and documentation effectively have been sat on (obfuscated), when the inquiry was still some 12 days from it's first public hearing?

&..

...What this appears to indicate is that the documents were sent collectively by an individual/entity/group, independent (officially) of either the ATSB or CASA. This IMO strongly suggests that this was a whistleblower(s) initiative. 

This opinion/suspicion is reinforced by the fact that the documents were received prior to the 1st public hearing and around the date the submissions from both the ATSB and CASA were received and/or copied/tabled.

Now it could be that the normally efficient Senate RRAT committee Secretariat suddenly got swamped by other priorities; or there was some sort of administrative glitch that prevented the 9 anonymously sent and inquiry 'critical' documents, from being processed/tabled for 4 months (128-129 days). However the evidence would appear to contradict the probability of such an aberration occurring.

To begin the timing of the received documents was within the original submissions due date and 2 days before the substantial submissions from the ATSB and CASA were received (& tabled). I can also personally attest (on behalf of PAIN) that subsequent 'supplementary' in camera submissions were processed and notifications of receipt were promptly sent within days of forwarding to the committee. 

I would also add that on a quick review of the 'additional documents received' list indicates that all other documents were tabled within days of receipt. All of these documents were received after the 10 October 2012.

Which brings me full circle back to my original QON (above) with the added QON of WHO or WHAT individual/entity could subvert/obfuscate/delay a parliamentary inquiry? 

&.. from the Senate Estimates thread:

Quote:The 2013 Senate RRAT committee Secretariat purge - [Image: huh.gif]  

In the course of doing some trolling into the possible culprits that aided & abetted the obfuscation/delay on nine critical PelAir inquiry documents - see HERE & HERE - I discovered some 'passing strange' deckchair shuffling at the RRAT committee Secretariat that saw most of the deckchairs shoved off the deck in the lead up to the 2013 election

Trolling through the details of this apparent Senate RRAT committee Secretariat administration glitch/cover-up, of the nine whistleblower documents; reminded me that this wasn't the only time there was such an administrative aberration inside of the PelAir inquiry... Confused   

Reference excerpt PAIN review document 2013: 
Quote:MOU – Parallel investigation discrepancy
 
While researching the enforcement process/action leading up to Mr Hood’s ‘Notice of Suspension’ correspondence 24/12/2009 to Dominic James, I came across what appears to be some very disturbing issues in regards to the CASA/ATSB parallel investigation process in regards to the Norfolk ditching investigation. 
 
Chronology 18/11/2009-24/12/2009 (incomplete).

 
18 November 2009: Ditching 3 NM south-west of Norfolk Island Aerodrome.
 
18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. The ATSB decide to carry out an investigation and CASA decide to run a parallel investigation, which was initiated on 19 November.
 
Notes:
 
  • Quotes/excerpts from Special Audit Report and CAIR 09/3:
     
    Ref: Page 3 of SAR
    [Image: MOU-1.jpg]

    Note: The audit report was released 08/01/2010 but it would appear that Mr White was already appointed in the position of MALIU, the following confirms this fact.
     
    Ref: Page 6 of CASA CAIR 09/3 heading ‘Synopsis’.
     
    [Image: MOU-2.jpg]
      
    Note:
     
  • Mr White indicates in the synopsis that he was tasked in an official capacity as MALIU on the day of the ditching. He also (if indeed he was the author of CAIR 09/3) indicates that the parallel investigation was in accordance with para 4.1.2 of the MOU.
  • However the reference was referring to the yet to be officially promulgated 2010 MOU
     
    Ref: 2010 MOU
    [Image: MOU-5.jpg]
    And:

     

  • Because I was under the impression that in terms of MOUs (* if anything) the Norfolk Investigation should have been operating under the 2004 MOU. * If anything because it had officially expired but could be subject to extension:
     
    [Image: MOU-3.jpg]
     
     
  • Therefore the reference for parallel investigations should have been:
     
    [Image: MOU-5-1.jpg]
     
    And:
     
    [Image: MOU-6.jpg]
     
     
    Note: In looking for a version of the 2004 MOU I remembered that I had copied an attachment from the CASA submission (I believe it was originally labelled Attachment D on the Senate submission page).
     
    What the original document that I downloaded (around about the 22/10/2012) contained was all three previous editions of the MOU, the 2010 MOU and hidden at the bottom the CAIR 09/3 report a total of 102 pages.
     
    As I wanted to review the 2004 MOU in particular, and not being able to initially find my downloaded copy, I decided to go back to the Senate submission page and download again. I eventually tracked the missing document (apparently re-labelled Attachment 5, see link below) and downloaded a pdf labelled b_c_ and d_CASA[1]. What I found was that there were now only 82 pages and the 2001, 2004 MOUs had disappeared.

Quote:Civil Aviation Safety Authority (PDF 397KB) Attachment 1(PDF 5395KB) Attachment 2(PDF 6218KB) Attachment 3(PDF 5596KB) Attachment 4(PDF 6528KB) Attachment 5(PDF 6032KB) 

Link for original undoctored document - see HERE.
MTF...P2 Cool
Reply
#27
No matter how much you shake and dance – etc.

Good catch P2 and a nicely timed reminder of why there is a second version of the Pel-Air report due.

Ahem: we have. I believe, mentioned not only the MoU and associated before but also some of the second tier operatives engaged at the time.

8) We respectfully suggest that the Senate enquiry could potentially be viewed
as incomplete should the testimony of the following individuals not be heard,
examined and duly considered in regard to the current Pel Air enquiry.
Mr. John Grima. CASA
Mr. Michael White. CASA
Mr. Roger Chambers. CASA
Mr. Mike Watson. ATSB.
Mr. Joe Hattley. ATSB.

9) We believe that informed inquiry made of these officers statement and
testimony, under oath could dismiss the notions that haunt the matter; such
as:-

a) The perception that the CASA ALIU team have breached s24 of the 1988
Act, within the parallel investigation in regard to radio transmission
transcript, meteorological information and the proposed enforcement action
against the pilot.

b) The perception that the CASA ALIU team have breached the AGIS 2003
Act and the CASA investigators manual within the parallel investigation.

c) The perception that the investigation was not instigated under the protocol
and prescription set down by act of Parliament.

d) The perception that there was an accommodation reached between the
ATSB and CASA to downgrade a critical safety issue to a minor safety issue.

10) In order to disprove and allay the perceptions held by industry, all E-mails,
letters, and communication logs between CASA (Grima, White, Chambers,
Farquharson, McCormick and Anastassi); and, the ATSB (Dolan, Sangston,
Hattley and Watson) be requested and independently examined against the
record and minutes of meetings between ATSB and CASA before and after
Grima became involved.

Manning’s great opus may examine, in detail the incident, down to the last packet of peanuts; but what of the questions posed by the inquiry which remain unanswered? I can’t see how anyone can walk away from them; if we are to have honesty and integrity from our safety agencies. I can’t really see how a revised report stating that the pilot ran out of fuel is even relevant anymore. What we need to know is why was the Senate inquiry mislead about a relatively simple accident investigation and why has it cost a bloody fortune to get the report which should have been published several years ago and why has nothing; and I do mean sweet sod all, changed.

Toot - toot.
Reply


Forum Jump:


Users browsing this thread: 1 Guest(s)