Class-action lawsuit against CASA and ATSB........

[Captain]

Maj,

 

I was told somewhere recently that CASA offered to investigate RAA accidents, the RAA Board approved it, but RAA management failed to accept the offer while the budget was available and as instructed.

 

Does anyone else know anything about this?

 

Regards Geoff

 

 

[Guest Maj Millard]

I do see your point Error 404, and it's exactly the reason we need a report on the type of accident that occurred yesterday with the Gazzelle. I am quite familiar with the skyfox/Gazzelle aircraft and there could be several sceneros that may have led to this incident, however it would be pointless to speculate at this time with no direct imput.............................................................Maj...

 

 

[Guest Maj Millard]

Rat, Interesting...needs to be followed up, it would be money well spent in my opinion............................Maj...

 

 

[Captain]

Rat, Interesting...needs to be followed up, it would be money well spent in my opinion............................Maj...

I agree :what the:Madge:what the:

 

While it may not speed up the reporting timeframe, any of our accidents would receive more professional attention and a more rigorous reporting of cause.

 

Another of the delegated authority organisations used to have a culture of not reporting accidents extensively lest it frighten off prospective new members.

 

What we certainly don't want is accident reporting being "managed" by the Executive ......... or reports on selected accidents involving RAA luminaries being circumvented. The latter would never happen, would it?

 

Regards Geoff

 

 

[damkia]

....What we certainly don't want is accident reporting being "managed" by the Executive ......... or reports on selected accidents involving RAA luminaries being circumvented. The latter would never happen, would it?Regards Geoff

For this reason it should be the ATSB at least auditing/signing off the reports, if not actually doing them. "Keep the bastards honest"

 

 

[nomadpete]

By support I mean you and I. Hell we could easily get hundreds if not thousands behind this, and I'm sure the national press would come on board. They (ABC) had no problem covering on national radio our lack of rego drama a few weeks back..We have a right to at least the basic details............................................................................Maj...

Maj,

 

I echo your concern. There is nothing to be gained by reporting an incident to RAAus unless they can help us learn from it. The present process in totally useless.

 

Some time ago, I wrote to the Tech Manager and asked if it would be possible for RAAus to recommend a lab that could do fuel analysis. I received no answer.

 

My reasoning was spurred by the failure of me fuel tanks. However, I also mentioned the need to find out why engine failures were occurring without any obvious mechanical cause. My particular worry was about finding out if my mogas was contaminated by ethanol, but simply knowing that there was nothing wrong with a sample of fuel would greatly assist establishing cause. If the fuel was OK, then that only leaves ice.

 

This is just one more proavtive way that RAAus could assist safety.

 

 

[Gibbo]

Maybe a positive 'motion' for the meeting on Saturday.

 

'That RaAus investigate, take affirmative action, obtain recognition as 'an interested party to any judicial investigation' and budget for the further reporting and investigation of accidents (esp. fatal or serious injury) to aid the ongoing safety of other pilots and community as a whole' - But with this board it will need very clear and concise 'un-wormable' wording.

 

I'm happy to cough up an extra $10-15 per year if it results in me not making someone elses big screwup.

 

 

[ave8rr]

Maybe a positive 'motion' for the meeting on Saturday.'That RaAus investigate, take affirmative action, obtain recognition as 'an interested party to any judicial investigation' and budget for the further reporting and investigation of accidents (esp. fatal or serious injury) to aid the ongoing safety of other pilots and community as a whole' - But with this board it will need very clear and concise 'un-wormable' wording.

 

I'm happy to cough up an extra $10-15 per year if it results in me not making someone elses big screwup.

Gibbo..I second all you say incl a motion at Saturdays meeting. Even the extra $'s per year if that is what it takes to have ALL serious / fatal accidents fully reported. A brief within 30 days and full report at end of process.

 

 

[Guest Error404]

The RAA are not empowered to be able to gather and provide such information, it won't get across the line despite your best intentions. There would need to be training first plus what if the information was incorrect, then you are talking liability and lawyers. I don't believe anyone there is trained at present. Poole was to a minimum level if I'm not mistaken but that was likely it.

 

You would be better off going down the ATSB path and demanding action as discussed earlier in this thread.

 

 

[ave8rr]

The RAA are not empowered to be able to gather and provide such information, it won't get across the line despite your best intentions. There would need to be training first plus what if the information was incorrect, then you are talking liability and lawyers. I don't believe anyone there is trained at present. Poole was to a minimum level if I'm not mistaken but that was likely it.You would be better off going down the ATSB path and demanding action as discussed earlier in this thread.

I think I said in an earlier post that the RAAus / ATSB could be empowered by the use of a CASA instrument.

I agree that IF RAAus were to do the reporting then they would need the training in accident investigation.

 

 

[Guest Error404]

It's a tough one. Whatever happens, it will cost money, so I'm all for Raa to do it or ATSB or perhaps a 3rd party. I can see it might be difficult with raa not being authorized to perform certain information gathering so the police might be involved. Either way anything would be good!

 

 

[Guest Maj Millard]

I agree ATSB reports would be good, however ATSB don't investigate all accidents, in fact they are quite selective on what they do investigate. The police (and the coroner if there's a death) do attend all aircraft accidents.

 

We need some organized program within RAA possibly utilizing suitable L2s who know what to look for, maybe working in company with a local CFI to attend the greater percentage of accidents, with the support of the local police. The police reports are usually pretty basic, and don't go into the technical side of things. They, and the coroner can however bring in whatever technical assistance they need to assist, if the cause of the incident is technically outside of their experience.

 

I've never been to an accident site yet where there hasn't been some 'scuttlebut' as to what has occured. most of the time it's usually headed in the right direction also.

 

There are suitable L2s and CFIs scattered all over the country in every state. They could register their interest to participate in 'on the spot' RAA investigations, and could be quickly and easily contacted if they are the closest to an accident. Hell give them some investigative accident training so everybody is working off the same formula, and even an ID ( Offical RAA accident investigator) so that they will be permitted passed police lines. Any and all investigation could be done under police supervision and all initial report compiled on the spot. It would then be just another RAA accident or incident report filed and signed by the L2 and/or CFI so information could quickly circulated to members..........................................................Maj...

 

 

[Guest Error404]

Actually come to think of it there already are a number of investigators out there. Initially I was thinking about raa employees. I'm not sure where they sit in terms of liability when using them.

 

 

[DGL Fox]

As I said before, I am all for whatever it takes, whether it be training or a 3rd party, we need to get this discussion going within our whole group and as a group I could not think of to many more things to spend money that are more important, now and into the future.

 

 

[Powerin]

I agree wholeheartedly with the sentiments here but if you are really serious about this you need to do some reading. Start with the ATSB website and then move on to the Transport Safety Investigation Act (as I did today ). Also have a read of section 4.08 of the RAAus Ops Manual which outlines our obligations for reporting and what RAAus says it will do in relation to accident reports.

 

I'm sorry to put a damper on things, but remember we are talking about the Australian TRANSPORT Safety Board. It concerns itself with aviation, rail and marine because these are methods of mass transport and have the potential to kill a lot of people at once. It doesn't investigate car accidents. They don't investigate everything in aviation either, they don't have the funds....only those accidents which have the most potential for helping keep the maximum amount of people safe. For example they don't generally investigate aerobatic accidents, because they usually involve one person engaging in risky behaviour. UNLESS it happens at an airshow...where a lot of people could have been impacted.

 

Let's be honest, Recreational Aviation rules have been specifically designed to minimise risk to the general public. Our planes are light, reasonably slow, we can't fly in CTA or IMC (so we can't hit big jets), or do aerobatics or fly at night. In short, we can't hurt too many people if we crash. By its very nature RAAus is not on the ATSB investigation radar....until we hit a ferris wheel at a carnival or something.

 

If it is true that the ATSB offered to do investigations for RAAus, and the offer was rejected, then a very valuable opportunity was lost to us. I don't think any sort of legal action is going to help because I don't think any law has been broken. And I would be careful about trying to extend the principal of "Duty of Care" any further. I think we all have far too much duty of care as it is.

 

By the way....there shouldn't be any legal ramifications in doing investigations. The Act specifically prevents investigation reports from being used as evidence in any legal action. Also, as Scotty said, Coroners reports are usually a matter of public record. Here's some findings from the NSW Coroners Court. Google for them in your state.

 

I'm not saying do nothing...just that we need a different tack than legal action. By all means move a motion at the upcoming meeting, or the Natfly meeting, that RAAus explore methods of investigating accidents and making the information available to the membership. They used to do it (there are reports from about 10 years ago), why can't they do it now? I don't know how much it would cost to get an investigation done. If it averaged $10K per investigation ($1 per member) then I think that would be money well spent.

 

 

[Guest Maj Millard]

Thank you powerwin for your great imput, and everybody else also of course. I may not have been serious about initiating a lawsuit when I started this post, but I did want to highlight the problem, and at least get the ball rolling on discussion. I feel strongly that it is something valuable we are loosing out on, in a big way.

 

We have got the ball rolling now, and I hope it is the start of something that becomes usefull and valuable eventually, not just a subject for another post...If somebody at Saturdays RAA special meeting took the time to table the idea for further investigation, I'd be very happy indeed !..................Maj...

 

 

[Powerin]

Thank you powerwin for your great imput, and everybody else also of course. I may not have been serious about initiating a lawsuit when I started this post, but I did want to highlight the problem, and at least get the ball rolling on discussion. I feel strongly that it is something valuable we are loosing out on, in a big way.We have got the ball rolling now, and I hope it is the start of something that becomes usefull and valuable eventually, not just a subject for another post...If somebody at Saturdays RAA special meeting took the time to table the idea for further investigation, I'd be very happy indeed !..................Maj...

You never know Maj...perhaps one of us at the meeting might be in the mood to make you very happy....

 

 

[Guest Andys@coffs]

Guys I think the report of ATSB offering to DO RAAus accident reports was wrong, I think what was offered was that we could do our own investigations but be covered under the legislative umbrella that ATSB has available to it.

 

That meant that other than some legal stuff initially, we got coverage but didnt cause them costs, other than those we cause now when we ask for assitance with specific analysis.

 

I believe that the board tasked the CEO to investigate and...............</nothing>

 

There were some staff concerns so it wasnt all 100% agreement....

 

Andy

 

 

[Powerin]

Guys I think the report of ATSB offering to DO RAAus accident reports was wrong, I think what was offered was that we could do our own investigations but be covered under the legislative umbrella that ATSB has available to it.That meant that other than some legal stuff initially, we got coverage but didnt cause them costs, other than those we cause now when we ask for assitance with specific analysis.

 

I believe that the board tasked the CEO to investigate and...............</nothing>

 

There were some staff concerns so it wasnt all 100% agreement....

 

Andy

Fair enough...thanks Andy.

Here is one part of the Transport Safety Investigation Act which provides protection relating to accident reports that the ATSB release:

 

27 Reports not admissible in evidence

 

Final report

 

(1) A report under section 25 is not admissible in evidence in any civil

 

or criminal proceedings.

 

(2) Subsection (1) does not apply to a coronial inquiry.

 

Draft report

 

(3) A draft report under section 26 is not admissible in evidence in any

 

civil or criminal proceedings.

 

 

[John G]

Frankly I don’t believe there is a problem with RA-Aus accident investigation. There may be a perceived problem in the timeliness in how non-urgent information is disseminated to the general membership.

 

Firstly, I’ll declare an interest. I am an RA-Aus and ATSB trained accident investigator. I have investigated some 10 fatal RA-Aus accidents (never a pleasant task, particularly when some deceased are personally known).

 

If we accept the international norm that 99% of all accidents are “Human Error” and not aircraft related; then what everyone here is asking for is not realistic for obvious reasons.

 

I can personally assure you that in all cases that I have been involved in; where there is an “aircraft related safety issue” affected members are informed within 24-48 Hours and all members within 30 days. In one case that I was involved personally where corrosion of Drifter flying cables were the culprit; all Drifter owners were notified within 24 hours and the rest of the membership in the next edition of the magazine and the RA-Aus web site.

 

However in the case of patent “pilot error” what family or friend wants to hear that their “ace pilot” was the architect of his or her own demise. The Coronial and Police process take some 2 years to resolve for a very good reason. The raw emotions grief and hurt are given time to heal. And frankly those not involved have no business prying unless there is a very good safety case to be made.

 

As I have said before, if there is a good safety case and a need to know then the facts are very quickly conveyed to those that may be affected. As an accident investigator, my report assisting the Police is sent to the Coroner and I can’t divulge the contents until the coroner releases it. In all cases where the safety of fleet is implicated the Coroner allows specific details to be released to effect immediate remedial action.

 

I am not an apologist for many of the RA-Aus hierarchy failings and believe they should be held to account where those failings occur. However, in the area of accident investigation, I believe that they do their utmost to investigate and prevent similar occurrences where preventable.

 

The “crash- comic” mentality brought about by CASA’s ”Safety Digest” is not achievable within the regulatory and legal framework under which RA-Aus operates. If one reads between the lines of OPS Managers monthly reports, the immediate lessons learned from accident investigations are conveyed to members in a de-identified form so that no legal repercussions will result.

 

 

[Powerin]

The “crash- comic” mentality brought about by CASA’s ”Safety Digest” is not achievable within the regulatory and legal framework under which RA-Aus operates. If one reads between the lines of OPS Managers monthly reports, the immediate lessons learned from accident investigations are conveyed to members in a de-identified form so that no legal repercussions will result.

Thanks John. But why not bring RAAus under the umbrella of the Act (and especially section 27 I mention above) so that it is impossible for any legal repercussions to happen? Then we don't have to "read between the lines" but instead get a clear and concise report (as much as that is possible in an accident report).

 

EDIT: furthermore, why dismiss "pilot error" as not worthy of being reported? There are many hard lessons that can be learnt if we know about the mistakes of others.

 

 

[John G]

Thanks John. But why not bring RAAus under the umbrella of the Act (and especially section 27 I mention above) so that it is impossible for any legal repercussions to happen? Then we don't have to "read between the lines" but instead get a clear and concise report (as much as that is possible in an accident report).

If you can convince the politicians then do it; you won't get any argument from me. The ATSB have a very constrained budget but sweeping powers such as the ability to enter premises seize records and coerce witnesses to give evidence. Their main charter is for mass public transport, air , rail and ship where the public won’t accept danger to fare paying passengers. To get the same powers for investigating Recreational Flying of mainly “Informed Participants” would be highly unlikely.

 

Why did ATSB investigate the Ferris Wheel accident? To my knowledge they have never previously investigated any RA-Aus accident. They do tend to only investigate GA accidents that are “news-worthy” In a way we are far better off than GA in accident investigation and reporting.

 

In a GA accident if the ATSB declines to investigate the the local Police conduct the investigation using similar procedures to vehicle accidents. At least in RA-Aus we ensure that a trained investigator is assisting the Police to ensure that correct procedures are followed and appropriate conclusions drawn. In the case of GA accidents where the ATSB declines to investigate they have no representative body to assist the Police in their investigations.

 

 

[nomadpete]

I agree wholeheartedly with the sentiments here but if you are really serious about this you need to do some reading. Start with the ATSB website and then move on to the Transport Safety Investigation Act (as I did today ). Also have a read of section 4.08 of the RAAus Ops Manual which outlines our obligations for reporting and what RAAus says it will do in relation to accident reports.I'm sorry to put a damper on things, but remember we are talking about the Australian TRANSPORT Safety Board. It concerns itself with aviation, rail and marine because these are methods of mass transport and have the potential to kill a lot of people at once. It doesn't investigate car accidents. They don't investigate everything in aviation either, they don't have the funds....only those accidents which have the most potential for helping keep the maximum amount of people safe. For example they don't generally investigate aerobatic accidents, because they usually involve one person engaging in risky behaviour. UNLESS it happens at an airshow...where a lot of people could have been impacted.

 

Let's be honest, Recreational Aviation rules have been specifically designed to minimise risk to the general public. Our planes are light, reasonably slow, we can't fly in CTA or IMC (so we can't hit big jets), or do aerobatics or fly at night. In short, we can't hurt too many people if we crash. By its very nature RAAus is not on the ATSB investigation radar....until we hit a ferris wheel at a carnival or something.

 

If it is true that the ATSB offered to do investigations for RAAus, and the offer was rejected, then a very valuable opportunity was lost to us. I don't think any sort of legal action is going to help because I don't think any law has been broken. And I would be careful about trying to extend the principal of "Duty of Care" any further. I think we all have far too much duty of care as it is.

 

By the way....there shouldn't be any legal ramifications in doing investigations. The Act specifically prevents investigation reports from being used as evidence in any legal action. Also, as Scotty said, Coroners reports are usually a matter of public record. Here's some findings from the NSW Coroners Court. Google for them in your state.

 

I'm not saying do nothing...just that we need a different tack than legal action. By all means move a motion at the upcoming meeting, or the Natfly meeting, that RAAus explore methods of investigating accidents and making the information available to the membership. They used to do it (there are reports from about 10 years ago), why can't they do it now? I don't know how much it would cost to get an investigation done. If it averaged $10K per investigation ($1 per member) then I think that would be money well spent.

I would hope that it would be possible for RAAus to do something a little more helpful than the present vague notes in the Magazine. The Air Safety Digest used to present a "no blame" overview of incidents without taking on the whole liability problem of making judgements. We just want the basic story of the critical events and decisions that may have led up to a incident. Surely that is possible? With the present RAAus system they don't even reproduce the information that I have sent in to them in my report of an incident.

 

 

[nomadpete]

John, with respect I wish to differ on the importance of the subject of "pilot error" in aircraft accidents and incidents. In EVERY incident there is a safety case worthy of bringing to the attention of ALL pilots. As you mention, and I have no reason to disagree on this, a majority of accidents are not related to a aircraft frailty that needs to be advised to us. The present process works for that eventuality. We do need constant reminding of the human factors and decision making issues though. It should not be necessary to "read between the lines" as you put it.

 

 

[JohnMcK]

Guys, there are some silly statements here. Please ask if you don't know. This matter has been discussed on this forum in other threads in the past. I don't know if Ian has a search engine that can bring this past info up, but it would be great to have. Now adding to John Gardon's info.

 

ATSB "own" most accidents in Australia, not just Aviation. They also own "marine and railways" to list another two. Now due to budget constraints they pick and choose which accidents they can investigate on a cost benefit basis. If the accident was unusual, had a new safety matter, or was of political concern, ATSB will investigate themselves and issue a very prompt preliminary report. If ATSB choose not to investigate, the accident falls to the State Police. RA-Aus have a number of trained volunteer accident investigators who are available to assist the police in this matter. The key word here is assist. The police may choose to use RAA investigators, or they may choose not to use them. The choice is theirs, not ours. If our investigators are asked to become involved all information gained goes to the police and eventually to a Coronal Inquiry. If we find important safety matters, we can, and do, issue safety alerts to affected persons without naming the root cause. We cannot issue any accident reports. That can only come from the Police and the Court.

 

Since being on the Board, I have found this matter lacking and have made it a pet project to get our Accident Investigators back under the umbrella of ATSB. In September 2011 I had informal discussions with the Director of ATSB in Canberra about this happening. He told me it could be possible, and there was a small window of opportunity. I formally brought this matter up to the Board as an item on notice at the Feb 2012 Board meeting. (Item 12.2) I gained approval for this matter to proceed. Discussion was to be actioned by CEO Tizzard, Ops Manager Tully, and Secretary Middelton. To the best of my knowledge, only an introductory letter has been sent to ATSB. As in all things in life, there has to be a will to make things happen and you need the support of the majority. Others do not see this matter as important as I do. - Now, in the interest of balance, I do not see some projects of others as important as they do.

 

John McK