10. Feb, 2015

Text

No comment needed just get on with it!

Consultation Draft Proposed amendment to CAO 82.0 subsection 3A

Nearly fifteen years since the issue was first broached...

R20000040:
Quote:
SAFETY ACTION

As a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands.
Which in apparently nine years led to OS 09/13...

Project OS 09/13 - Fuel and Alternate requirements - Project approved. 21 Aug 2009

And with the PelAir ditching the project was expanded to include Aerial Work (Aeromedical flights) and then in July 2010 the NPRM 1003OS was released:
Quote:
3.3 Reasons for change

3.3.1 The application of the additional remote island fuel requirements in CAO 82.0 which is currently limited to passenger-carrying charter operations was reviewed in the early stage of the project. As the safety of passengers is CASA’s highest priority, it was considered that excluding other passenger-carrying operations in the aerial work and RPT categories from the remote island fuel requirements had no justifiable safety
reasons.

Note: The term “passenger” is defined in CAR 2 as meaning “any person who is on board an aircraft other than a member of the operating crew”. The term “operating crew” is defined in CAR 2 as meaning “any person who is on board an aircraft with the consent of the operator of the aircraft and has duties in relation to the flying or safety of the aircraft”.
Four years since then and all it took was this...

"..3A Conditions on all passenger-carrying aeroplane operations to remote islands
(1) Subject to paragraph (2), each certificate authorising 1 or more of the following operations in an aeroplane:
(a) charter operations for the carriage of passengers;
(b) regular public transport operations for the carriage of passengers;
(c) aerial work operations for ambulance functions or for functions substantially similar to ambulance functions (medical transport operations);
is subject to the condition that a passenger must not be carried under the certificate on a flight to a remote island unless:
(d) the aeroplane has more than 1 engine; and
(e) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and
(f) the nominated alternate aerodrome is not located on a remote island, unless CASA approves otherwise in writing; and
(g) when the flight commences the aeroplane is carrying not less than the minimum safe fuel for the flight; and
(h) during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its nominated alternate aerodrome if necessary, with the required minimum fuel reserves intact.
(2) Paragraph 3A (1) applies to a medical transport operation whether or not a passenger is carried on the flight to a remote island.
(3) An approval under subparagraph (1) (f) may be subject to conditions..."

{Comment: Has to be one of the smallest amendments I've seen in the last 5 years or so..}

Hmm..it must have been a busy time for FF as July 2010 was also when the infamous CAIR 09/3 & Wodgers Weport were also released (reference my post #2035). And in fact CAIR 09/3 made mention of OS 09/13 at para 4.4


Strange how the ALIU had a slightly different take on how OS 09/3 was initiated??

Oh well good to see that someone in FF is finally taking the initiative to close the loop..

Wonder when the other part of the FF intended safety actions addressing the ATsB (closed) minor safety issue will eventuate...: AO-2009-072-SI-01
Quote:
Finally, CASA also advised of their intent to regulate Air Ambulance / Patient transfer operators as follows:
Hopefully we won't have to wait another fifteen years for that to happen..

MTF...
 
Part One- The inconvenience of facts & timelines??

Again, although much belated, I applaud the initiative of FF team OS 09/13 to bring fwd, in an obvious period of uncertainty, the Consultation Draft Proposed amendment to CAO 82.0 subsection 3A ...
Quote:
Purpose/Objectives
The CAO amendment would add Cocos (Keeling) Island to the list of existing remote islands (which are Christmas, Lord Howe and Norfolk Islands).
The amendment would substitute a new subsection 3A, which provides that each AOC for passenger-carrying charter, RPT operations, or for aerial work ambulance-type functions (medical transport operations) is subject to the condition that a passenger must not be carried to a remote island unless the following requirements are complied with:
a. the aeroplane is multi-engined
b. the pilot has nominated an alternate aerodrome
c. that alternate aerodrome is not itself on a remote island (unless CASA specifically approves)
d. the aeroplane is carrying not less than the minimum safe fuel for the flight
e. during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its alternate aerodrome (if necessary) with the required minimum fuel reserves intact.
In some medical transport operations, medical and nursing staff may not be considered as 'passengers' (for example, because they have flight safety duties to perform). To protect the safety of such personnel who are, in effect, third parties like passengers, for medical transport operations the safety requirements described above would apply whether or not a 'passenger' is carried on the flight to a remote island.
...it maybe small consolation but I am sure Ziggychick and others will appreciate your efforts...

However, at the same time, I am extremely intrigued by certain aspects in the history of project OS 09/13 (Project OS 09/13 - Fuel and Alternate requirements Consultation history ).

So in an effort to join the dots let us start with the 15 July 2010 NPRM webpage (click here ). In the NPRM 1003 OS pdf in the foreword it was stated...

"I would like to thank you for expressing interest in this proposal and emphasise that no rule changes will be undertaken until all NPRM responses and submissions received by the closing date 9 September 2010 have been considered..."

And on previous page...

"...Following consideration of responses to this NPRM, CASA will prepare a Summary of Responses, and make revisions to the draft CAO amendment where considered appropriate.

CASA will conduct further analysis of the extent of the impact these changes will have on operators and pilots to ensure an adequate timeframe is given for implementation. It is envisaged that a transition period of 3 to 6 months will be allowed to ensure operators have revised procedures in respect to these changes..."

Now to the man at the back of the room the obvious question is WTF happened to NPRM 1003 OS in the interim period of nearly four years?? Do FF seriously expect the MATBOTR to accept this as an excuse...

"...Under Notice of Proposed Rule Making (NPRM) 1003OS (published in July 2010) the Civil Aviation Safety Authority (CASA) proposed changes to Civil Aviation Order (CAO) 82.0 to include Cocos (Keeling) Island as a designated remote island...

...CASA Project OS 09/13 was re-phased to allow for the inclusion of the International Civil Aviation Organization (ICAO) Standards and Recommended Practices (SARPs) developments relating to...

...With the SARP now effective, and the ICAO Fuel and flight Planning Manual (FFPM) finalised, these standards are being drafted into the Civil Aviation Safety Regulations 1998 (CASR). CASA now considers it appropriate to start to bring forward some aspects into the CAOs and the Civil Aviation Regulations 1988 (CAR) prior to the making of the Operational CASR Parts..."

Moving onto Annex A - Proposed Amendment to CAO 82.0 - Air Operators' Certificates. And a quick comparison between the 2010 & 2014 versions of the proposed amendments to CAO 82.0.

2010 version:

I, JOHN FRANCIS McCORMICK, Director of Aviation Safety, on behalf of CASA, make this instrument under paragraph 28BA (1) (b) and subsection 98 (4A) of the Civil Aviation Act 1988.

John F. McCormick

Director of Aviation Safety

July 2010

Civil Aviation Order 82.0 Amendment Order (No. 1) 2010

1 Name of instrument
This instrument is the Civil Aviation Order 82.0 Amendment Order (No. 1)

2010.

2 Commencement
This instrument commences [3 to 6 months after registration].

3 Amendment of Civil Aviation Order 82.0
Schedule 1 amends Civil Aviation Order 82.0.

Schedule 1 Amendments
[1] Paragraph 2.1, new definition, minimum safe fuel
insert minimum safe fuel has the meaning given by paragraph 2.3.

[2] Paragraph 2.1, definition of remote island
substitute remote island means:

(a) Christmas Island; or
(b) Cocos (Keeling) Islands; or

(c) Lord Howe Island; or
(d) Norfolk Island.


[3] Paragraph 2.1, new definition of reserve fuel

insert reserve fuel means the variable fuel reserve and the fixed fuel reserve to be carried by an aircraft in accordance with guidelines issued by CASA for
subparagraph 234 (3) (d) of the Civil Aviation Regulations 1988.

[4] Paragraphs 2.3, 2.4 and 2.4.1
substitute
2.3 Unless CASA approves otherwise in writing for a particular flight, the
minimum safe fuel for an aeroplane undertaking a flight to a remote island is the greater of the following:
(a) the total of:

(i) the minimum amount of fuel that would enable the aeroplane to fly,

with all engines operating, to the remote island aerodrome and then to
the nominated alternate aerodrome; and
(ii) reserve fuel;
(b) the total of:
(i) the minimum amount of fuel that would enable the aeroplane to do the
following if a critical event were to occur at the most critical point of
the flight:
(A) fly to its destination aerodrome, or an alternate aerodrome;
(B) fly above the aerodrome for 15 minutes at 1 500 feet at holding
speed under standard temperature conditions;
(C) land at the aerodrome; and

(ii) reserve fuel
2.3.1 For paragraph 2.3, a critical event for an aeroplane means:
(a) the failure of an engine; or
(b) a loss of pressurisation in the aircraft; or
(c) both the failure of an engine and a loss of pressurisation in the aircraft.

2.3.2 An approval under paragraph 2.3 may be given with or without conditions.

2.4 An amount of fuel mentioned in paragraph 2.3 is to be worked out:
(a) for an aeroplane that is a transport category aircraft, by using:
(i) the performance data and the fuel consumption data contained in the
aeroplane’s flight manual; or
(ii) the performance data and the fuel consumption data obtained from a

flight test of the aeroplane carried out in an approved manner; or
(b) for an aeroplane that is not a transport category aircraft, by using:
(i) the following:
(A) the performance data for the aeroplane provided by the
manufacturer of the aircraft’s airframe, or contained in the
aeroplane’s flight manual or the pilot’s operating handbook for the aeroplane; and
(B) the fuel consumption data for the aeroplane obtained from 1 of the
sources mentioned in sub-sub-subparagraph (A),or provided by the
manufacturer of the aeroplane’s engines; or

(ii) the performance data and the fuel consumption data obtained from a flight test of the aeroplane carried out in an approved manner.
2.4.1 For sub-subparagraphs 2.4 (a) (i) and 2.4 (b) (i), if the issue of a supplemental type certificate for an aeroplane has the effect of amending the performance data or the fuel consumption data referred to in the sub-subparagraphs, the amended performance data or fuel consumption data must be used.

[5] Subsection 3A
substitute
3A Conditions on all passenger-carrying aeroplane operations to remote islands
(1) Unless CASA approves otherwise in writing, each certificate authorising aerial work, charter or regular public transport operations in an aeroplane is subject to the condition that a passenger may be carried under the certificate on a flight to a remote island only if:
(a) the aeroplane has more than 1 engine; and
(b) at the start of the flight, not less than the minimum safe fuel is carried by
the aeroplane for the flight; and

(c) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and
(d) the nominated alternate aerodrome is not located on a remote island.

(2) An approval under paragraph (1) may be given with or without conditions.

Note 1 Under subregulation 2 (1) of the Civil Aviation Regulations 1988, passenger means any person who is on board an aircraft other than a member of the operating crew

Note 2 Subsection 3A, read with paragraph 2.3, means that an AOC holder may not conduct an aeroplane operation carrying a passenger to a remote island except in a multi-engine aeroplane, whose pilot in command has nominated an appropriate alternate aerodrome for the flight, and which at take-off is carrying sufficient fuel to reach the destination aerodrome and then the nominated alternate aerodrome without using any reserve fuel.

[6] Appendix 5, after subclause 6 (3)
insert

(4) If subsection 3A applies to an AOC holder for an aeroplane conducting an
EDTO flight, then:
(a) the amount of fuel calculated for subclause (2) must be not less than the
minimum safe fuel; and
(b) the operations manual must include the calculation of the minimum safe
fuel.

Note Subsection 3A deals with passenger-carrying aeroplane operations to remote islands.

Remote island, reserve fuel and minimum safe fuel are defined terms under this Order.

2014 version:

I, JOHN FRANCIS McCORMICK, Director of Aviation Safety, on behalf of CASA, make this instrument under paragraph 28BA (1) (b) and subsection 98 (4A) of the Civil Aviation Act 1988.

John F. McCormick Director of Aviation Safety

[DATE] 2014

Civil Aviation Order 82.0 Amendment Order (No. 1) 2014

1 Name of instrument
This instrument is the Civil Aviation Order 82.0 Amendment Order (No. 1) 2014.

2 Commencement
This instrument commences on the day after registration.

3 Amendment of Civil Aviation Order 82.0

Schedule 1 amends Civil Aviation Order 82.0.

Schedule 1 Amendments

[1] Paragraph 2.1, definitions

substitute
remote island means:
(a) Christmas Island; or
(b) the Cocos (Keeling) Islands; or
(c) Lord Howe Island; or
(d) Norfolk Island.

[2] Subsection 3A

substitute
3A Conditions on all passenger-carrying aeroplane operations to remote islands

(1) Subject to paragraph (2), each certificate authorising 1 or more of the following operations in an aeroplane:
(a) charter operations for the carriage of passengers;


(b) regular public transport operations for the carriage of passengers;
(c) aerial work operations for ambulance functions or for functions substantially similar to ambulance functions (medical transport operations);

is subject to the condition that a passenger must not be carried under the certificate on a flight to a remote island unless:
(d) the aeroplane has more than 1 engine; and

(e) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and
(f) the nominated alternate aerodrome is not located on a remote island, unless CASA approves otherwise in writing; and
(g) when the flight commences the aeroplane is carrying not less than the minimum safe fuel for the flight; and

(h) during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its nominated alternate aerodrome if necessary, with the required minimum fuel reserves intact.


(2) Paragraph 3A (1) applies to a medical transport operation whether or not a passenger is carried on the flight to a remote island.


(3) An approval under subparagraph (1) (f) may be subject to conditions

{Note: Still reviewing the subtle differences in para 3A but the obvious difference is that the 2014 version is much more condensed and provides a more distinct definition of MTO flights with the addition of sub para (2).}

Q. What happened to the 2010 responses which in the normal NPRM due process are usually published??

Still joining the dots...

Part two to follow...

ps Interesting how Phase One & Two (as quoted below) from today's version of OS 09/13 is at odds with the CAIR 09/3 version (see post #2188)...
Quote:
Phase 1 will involve amendments to the relevant Civil Aviation Orders (CAOs) and a review of CAAP 234-1 for flights to Isolated Aerodromes in light of the ICAO amendments. This phase will encompass fuel and operational requirements for flights to Isolated Aerodromes. The review will also consider the provision for flight to an alternate aerodrome from a destination that is a designated Isolated Aerodrome. The CAAP234-1 will also be expanded to provide guidance and considerations necessary for flights to any Isolated Aerodrome, in particular when, and under what circumstances, a pilot should consider a diversion.
Quote:
Phase 2 will involve amendments to the relevant Civil Aviation Orders (CAOs) and further review of CAAP 234 in light of the ICAO amendments. This phase will encompass regulatory changes related to the implementation of general fuel planning, in-flight fuel management and the selection of alternate aerodromes. This review will include the methods by which pilots and operators calculate fuel required and fuel on-board.

Last edited by Sarcs; 15th Aug 2014 at 15:49.
 
Is Sarcs Morriarty reincarnated?

Quote:
Sarcs #2190 – "Still joining the dots.."
Quote:
Thorny - "Sarcs, mate, you really are a cynical Bast..ard"
Not only that! – he's being very mischievous and setting up a weekend heads-scratcher; but I reckon he's also trying to sneak a late entry into the Senate Ordinance Cup ; which makes him a devious, crafty SOB........

I'm going to call his bluff; there is a possible entrant from overseas, little known in Oz but if the connections decide that they will run the horse, it will alter the odds. So let's see, (looking – looking) Ah, howzabout - Canadian Club; horse, out of Federal Plod by Criminal Intent.

You see, I reckon Sarcs has 'inverted' the perspective and instead of wondering why the Canadian form guide has not been published; he has tracked the MoP, backwards; from the Canadian TSB audit point of view i.e. What the CTSB would see when they investigate ICAO compliance. In that context, if Sarcs has started from the compliance with ICAO annex 13 end and worked backwards through to the ubiquitous MoU. Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB 'sovereignty' during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from 'Serious' to 'Minor'? In short, have the Pel Air books been 'cooked'?

In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF 'White hats' grab the spell book and start weaving - preparing a proper response. All good until it was realised CASA were going to have 'egg on their face', had the ATSB not backed down. Perhaps that 'GWM report' was prepared to riposte the ATSB brick bat. "We're on top of this" says Sleepy Hollow.

The consensus (among the BRB) is that the CASA 'White hats' receiving information through the MoU were preparing for a 'serious safety' call from the ATSB on three issues; (1) the serious lack of CASA action on CDP on 82.0; and, (2) CASA oversight of the operator; (3) against the operator.

Enter the FF Black hats – Instead of timely advice being used to prepare the way for a much delayed 'fuel policy' changes; the good intentions of the MoU pave the merry road to perdition. The Black hats take the early advice and set about 'subverting' it so that the mighty blow the ATSB was intending to deliverer became little more than a gentle 'well done' pat on the back. There is good support information for this to be had from the total lack of action taken on ATSB, Coronial and many other 'safety' related recommendations and there is no closed loop system for tracking, auditing or examining those changes. There is certainly no system for audit of those changes – refer CRM 82 time line. What is it now 20 years ? bad law Reg 206 and RFDS and etc. etc. What a witches brew..small wonder 'white hats' leave in droves.

The disconnect is clear enough from the Sarcs post above. Has the benefit of the MoU been grossly misused to undermine the ATSB 'sovereign' authority under the ICAO?; the 'disturbance' of the TSI Act is clearly apparent. If the AFP investigation and the Canadian audit turned up the same conclusions; possibly two things would happen (1) the minuscule would 'sit' on the CTSB report (2) the AFP information prompted Heffernan, Stearle and Xenophon to bring on the MoP. The latest gossip 'on the breeze' is that the PM's department is actively involved (Choc frog Sunny) and that the TSB 'report' is in town but the minuscule has deemed it 'low priority'.

It's a bit of a stretch but could the exposed, cynical manipulation of Pel-Air be parlayed in criminal charges? If that eventuates will Chambers and White along with McComic and possibly Sangston need a little 'legal' advice?

Sarcs you research daemon, let's have a look at part two. It's cruel to torment a curiosity bump (or hump). You can sing the verse below using the -
- as a tune – quite catchy, ain't it...

The sexual life of the camel
Is stranger than anyone thinks.
At the height of the mating season
He tries to bugger the Sphinx.
But the Sphinx’s posterior orifice
Is clogged by the sands of the Nile,
Which accounts for the hump on the camel
And the Sphinx’s inscrutable smile.

What the hell - it's Saturday, ain't it? Toot toot..

Last edited by Kharon; 16th Aug 2014 at 14:05. Reason: I curse Google Chrome - no smilies = bummer...Hey fixed it Yay!!!
Post ditching (1734 days & counting) - In the eyes of the investigator.

Kharon:
Quote:
Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB 'sovereignty' during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from 'Serious' to 'Minor'? In short, have the Pel Air books been 'cooked'?
Bugger “K” stole my thunder… …oh well relegated to gap filler yet again…

Ok before we start working through the ‘timeline of embuggerance’ (TOE) an update on the MoP Stakes from the Senate: Possible imposition of a penalty on a witness before the Rural and Regional Affairs and Transport References Committee or a person providing information to the committee

{Note the Committee Senators (Stewards) membership includes one loud, outspoken BIG MACK}

Kharon:
Quote:
In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF 'White hats' grab the spell book and start weaving - preparing a proper response. All good until it was realised CASA were going to have 'egg on their face', had the ATSB not backed down. Perhaps that 'GWM report' was prepared to riposte the ATSB brick bat. "We're on top of this" says Sleepy Hollow.
In the eyes of the TSBC: It would first be prudent to refer to what we know they have been scoped to review in regards to PelAir. From ATSB AQON 4 Senate Estimates (24/02/14) RED said:


The Transportation Safety Board of Canada (TSB) has agreed to review the ATSB’s investigation methodologies and processes. Specifically, the review is examining the ATSB’s:
• Investigation methodology and its application
• Management and governance in relation to investigations
• Process for compiling an investigation report
• Approach to communicating with persons and organisations external to the ATSB in relation to an investigation

As part of the review, the TSB has undertaken to examine the application of the ATSB methodologies to the Norfolk Island investigation and two others.
The review was instigated in response to Senate References Committee criticisms that the ATSB investigation of the Norfolk Island accident did not comply with the requirements of ICAO Annex 13 or the ATSB’s written standards. The review is also intended as part of the ATSB response to Inquiry recommendations concerning the adequacy of the ATSB’s investigation policies, procedures and training.

The exercise is not a reinvestigation of the occurrence, and hence the TSB has not sought to reinterview involved parties. Howevers part of eviewing the ATSB’s investigations, the statements and other evidence of involved parties have been available to the review team.

Therefore it would be safe to assume that the TSBC would be reviewing most, if not all, the published under privilege documentation from the Senate AAI inquiry, which would include the following 2 documents:

1. Correspondence from the ATSB to CASA regarding a critical safety issue, received 22 October 2012;(PDF 2663KB)
2. Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)

As RED indicates the TSBC will review the PelAir report against the recognised international standards for AAI (as outlined in ICAO Annex 13) and not on any domestic arrangements i.e. the MoU.

On the subject of safety issues identified, in the course of an investigation, by the AAI as needing prompt action and a SR promulgated Annex 13 states:
Quote:
Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.

RESPONSIBILITY OF A STATE RECEIVING
SAFETY RECOMMENDATIONS

Action on safety recommendations
6.10 A State that receives safety recommendations shall inform the proposing State of the preventive action taken or under consideration, or the reasons why no action will be taken.

Note — Nothing in this Standard is intended to preclude the State conducting the investigation from making proposals for preventive action other than safety recommendations.
The ATsB intent to compliance with the Annex is outlined in s25A of the TSI Act.

So in terms of 1. (Attachment one above) the TSBC would give the ATsB its 1st tick i.e. the investigators have identified a CSI and have basically
written a DRAFT of the soon to be notified SR. However it would probably be seen as passing strange, not normal practice, that the ATsB are essentially giving the intended SR addressee a ‘heads up’.
Quote:
I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect ofthe lack of regulation or guidance for pilots when exposed to previously unforecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.
But maybe this is a good initiative because the letter does goes on to say…

“….In later telephone calls to me, you suggested that the receipt of this letter would allow you to 'kick-start' CASA's consideration of, and response to the issue.

Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB's initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA's commitment to address the safety issue is appreciated…”

And indeed the ‘White Hats’ (as “K” calls them) stepped into action and started proactively addressing what they assumed would soon be a published ATsB SR, published an update to OS 09/13 (see 4.4 of CAIR 09/3) and started writing NPRM 1003 OS.

So maybe the TSBC would have given the ATsB leeway and understood that in the interests of better relations (as this was seen as a test case for the newly just minted MoU), that this little divergence from SOP could be advantageous.

However on reading the internal email at 2. this acceptance of diverging from SOP IMO would have come to a resounding conclusion (crash):
Quote:
We were discussing the potential to reflect the intent of our new MoU that describes the 2 agencies as 'independent but complementary'. We discussed the hole that CASA might have got itself into by its interventions since the ditching, and how you might have identified an optimum path that will maximise the safety outcome without either agency planting egg on the other agency's face.

Right now, I suspect that CASA is entrenching itself into a position that would be hard to support. If we were to contemplate an exit strategy, or an 'out', then CASA would need to recognise that it is 'in' something in the first place. This is my take of how I see their position at the moment.
When the aircraft ditched, both the flight crew and the operator stopped their Westwind Aeromedical operations.

CASA coached and guided the operator very well as they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pei-Air are now operating again. The same thing hasn't happened to the flight crew. While they may not have been the 'Aces of the base', they were following the relevant procedure provided by both CASA and their operator. This is an opportunity for CASA to follow the same approach with the flight crew as they have done with the operator.

As a systemic investigator, we see 3 separate slices of 'Reason cheese' with aligned holes ( flight crew, operator & rule-maker), and we want to seal all those holes. The operator has now been realigned, and I think CASA has done a very good job in helping them. For the flight crew, they do need realigning to ensure they now meet the updated Ops manual requirements. For the rule-maker, I would be extremely satisfied if they then proactively realigned everybody's understanding of this operational risk, and how it can be managed in the future.

As we discussed yesterday, following the ditching, everything went (metaphorically) 'up in the air'. CASA has done a good job in realigning Pei-Air while it was still in the air so that it returned to earth with a much better take on how to manage this risk.

Unfortunately, they took action on the flight crew without first contemplating their end-game. If they reframe their pre-emptive action with the flight crew to show that they had managed all the levels of safety management by simply putting the pilots' permissions to fly on hold until they had found the problem and remedied it, then they would look far better than if they tried to prosecute the probably indefensible and hardly relevant.

We will be telling this story in our final report, if not earlier, so why not make the most of this opportunity for both agencies to publicly work harmoniously, in a parallel direction?
IMO any good TSBC investigator could well relate and be most disturbed by the angst that this fellow investigator was feeling at this point in time. The massive conflict of interest is beyond obvious and directly in contravention of the spirit & intent of Annex 13.

Hmm…think I’m going to have to have more parts to this as I’ve just discovered a couple more errant dots and I’m yet to look through the eyes of the other investigator…

MTF…