9. Feb, 2015

The search for investigative probity.


"Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air."


Good point; and, in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion. For sake of argument lets 'assume' (we may, safely take a small risk) that the ATSB investigators were competent and they followed the well trodden path a 'bog-standard' accident investigation should take. The report even allowing for the 'theoretical' should have got us to within a bulls roar of the why, how and wherefore; it may have even provided some peripheral causal reasons which assisted in defining the desired end result – risk mitigation. There were several valid, not overly theoretical issues which did make it into the final report; RVSM, flight and fuel planning, lack of operational support, fatigue, lack of 20.11 training, etc, (don't ever forget, CP responsible for all) from which a reasonable operator could make adjustments to SOP, in an effort to mitigate the risk of reoccurrence. I don't have too many problems with the notion of 'theoretical', provided it can be translated, by the operator into practical fixes. So far the ATSB investigators are free and clear, reputation intact.

It's what happened next that got me cranky (just a bit): Sarcs at # 2653 has gone to some trouble to point out the direction a perfectly serviceable accident 'report' was being driven and IMO, in deference to the law, he has treated the 'aftermath' with kid gloves. For the thinking man, joining up the remaining dots to form the final picture is a piece of cake. The Senate inquiry surely got there.

It has been a long, slow difficult process since then: the Senators didn't waste too much time, their report was out in a timely manner; but since then, purgatory. Forsyth, then TSBC, then miniscule response, at the end we get (headline) "Pel-Air to be reinvestigated". 

The academics and theory of 'how' to investigate an incident which happened, what ? five years and a bit ago have not changed and have had precious little to do with what transpired after the IIC report was 'edited' and produced. It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far. 

The comment below followed an article published by Australian Flying re the re Pel-Air MKII. 


Sceptical • 10 days ago

Head of Aviation Investigations at the time of the report? Ian Sangston. 

Told of factual errors prior to release of the report? Ian Sangston. 

Head of Aviation Investigations for the new report? Ian Sangston. 

Conflict of interest?


Just about says it all. The background noise? Oh, that's the playroom clock; tick, tock, tick, tock.