[Peetwo]

PelAir MKII: ASA Swiss Cheese slices & bunnies -

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

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

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

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By:

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

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

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

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

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

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

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

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

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

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

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

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

Senator FAWCETT: So it is not Australian airspace?

Mr Harfield : It is not Australian airspace.

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

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

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

Mr Harfield : No, we have not.

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

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

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

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

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

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

Mr Harfield : 2,00—

Senator XENOPHON: 2,097 days.

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

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

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

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

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

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

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

Senator NASH: What?

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

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

Mr Harfield : No. The agenda is set by—

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

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

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

Mr Harfield : Yes, Airservices has—

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

Mr Harfield : Our representative at the forum.

Senator NASH: And who is that?

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

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

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

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

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

CHAIR: You are a perfect bureaucrat. Senator Fawcett.

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

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

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

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

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

Mr Harfield : Say that again, Senator?

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

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

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

Mr Harfield : That is a correct assumption.

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

Mr Harfield : That is a fair assumption.

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

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

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

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

CHAIR: How long have you been at Airservices?

Mr Harfield : Nearly 25 years.

CHAIR: I think you need a change of career.

 
Or in pictures...

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

Recommendation 22

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

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



MTF...P2