Peeler, CASA, and ATSB – the movie

27 Jan

Top stuff @slats11 :

 Someone suggested this saga could be the basis for a future Australian movie. To assist any scriptwriters out there, I offer the following:

1. There was a routine CASA audit of PelAir scheduled for October 2007. This had to be re-scheduled as the organisation could not provide sufficient paperwork to allow this 2007 audit to proceed.2. The re-scheduled audit took place in March 2008. This audit was damning, finding multiple defects. Among the most serious was that the training records of 20 pilots were seriously deficient (for example, 80% of these records contained no evidence of training in emergency procedures). There were numerous other deficiencies – the full report is in the public domain. Most seriously of all, the company conceded its pilots had not been trained in fatigue management as required – this caused CASA to issue an immediate “Safety Alert” requiring the company to immediately cease operating under its existing fatigue management policy until this training was undertaken.3. During the period 2008 – 2009, the existing PelAir Chief Pilot (Wally Myer) was replaced by John Wickham. However Wally was left in charge of international westwind operations, and carried the title of “Westwind standards manager.” Although no longer the CP, Wally was ultimately responsible for westwind international operations – as stated by CASA in the 2009 audit. Presumably CASA duly gave written authorization for these normal responsibilities of the CP to be delegated to Wally.

4. The crash happened in November 2009 – 18 months after the March 2008 audit. Extremely lucky that all 6 survived the initial impact. Lucky the patient was not on life support and could survive a prolonged swim. Lucky the water temperature was reasonably warm, and it wasn’t winter. Lucky there wasn’t a shark about. Lucky the local fisherman found them given they ditched in an unexpected location and did not issue a Mayday. Lucky lucky, lucky.

5. Following the crash, CASA conducted a special audit in November – December 2009. This was much more in depth than the routine March 2008 audit. What had been wrong in March 2008 was still wrong. Furthermore, additional serious problems came to light. This audit found fault with the pilot, fault with PelAir, and fault with CASA itself. The report is truly shocking – this too is in the public domain. But it nearly wasn’t.

6. CASA apparently should have handed this special audit over to ATSB. However CASA did not do so. It is not 100% clear why. Perhaps CASA was concerned its oversight following the 2008 audit could have been seen to be deficient. There may have been international factors also. By a strange coincidence, at exactly this time the FAA were over in Australia deciding whether to downgrade Australia to Level 2 status – among other consequences, this downgrade would have terminated existing code-share arrangements between Aust and US airlines, and would also have precluded Qantas and V Australia gaining approval for new routes into USA.

Wikileaks: Australia failed US FAA air safety audit in 2009 | Plane Talking

Although Australia avoided being downgraded in 2010, there are persistent rumors the FAA have been watching subsequent events unfold and are not impressed. Time will tell.

7. By early 2010, PelAir had presumably digested the CASA special audit and must have realized it had a huge problem. They presumably decided the medevac business was finished – it would take a lot of time and money to rectify all the issues identified, and it probably didn’t make commercial sense to pursue this. In addition to all the deficiencies, the jet they crashed at Norfolk (NGA) was the only one capable of operating into Noumea. Regardless of the reason, PelAir exited the medevac business in 2010.

8. The ATSB released its report in 2012 after much delay. In fairness, they were distracted by QF32. The final report put most of the blame on the pilot, made some mild criticism of PelAir, and there was little if any criticism of CASA’s oversight over PelAir. It was almost as though ATSB had not seen the CASA special audit. And astonishingly, it appears they had not. One particular oddity of the ATSB investigation was that the ATSB did not seek to recover the CVR and FDR – from a known location only 40 metres deep. It has been suggested the local fisherman were ready to drag the jet to shallower water to facilitate the recovery. Despite this, Dolan stated this decision was made on the grounds of cost and safety, and also there would be nothing to be learned from the recorders anyway. In which case why bother having recorders – it seems a bit like the Police not bothering to obtain the security video from a bank following an armed robbery.

9. There was a significant outcry over the ATSB report. The pilot admitted he had made his share of mistakes that night, but pointed out (quite correctly) that he was not the only one. And then we had the 4 Corners report – someone had leaked the CASA 2009 special audit, and further that CASA had not forwarded this audit to ATSB.

10. In the later half of 2012, Rex (parent company of PelAir) made several large donations to political parties – Labor, Liberal, and National. Rex has apparently not made such donations before or since. Presumably 2012 was a good year for Rex.

Vague minister, generous airline, Pel-Air issues mount up | Plane Talking

11. The outcry over the ATSB report led to a bipartisan Senate inquiry in 2013. The key outcomes of the Senate report were:

a) CASA was caught not providing the special audit to the ATSB. This caused the committee to refer the Director of CASA (McCormick) to the Australian Federal Police for possible breach of legislation. McCormick subsequently did not seek to renew his appointment as Director.

An Issue of Leadership

b) The Senate stated it had no confidence in the ATSB report, and had lost confidence in the ATSB Commissioner (Dolan). Dolan himself conceded he was “not proud” of the ATSB report into Norfolk. The Senate was also infuriated with Dolan playing games with different versions of the regulations pertaining to the recovery of the recorders. Under the regulations in force at the time, the ATSB should have obtained the recorders.

Damning Senate report on ATSB, CASA Pel-Air failings | Plane Talking

c) The Senate called for the ATSB report to be scrapped, and for a new investigation to be held. Starting with the retrieval of the recorders from the plane.

12. Inexplicably, the Minister did not accept the recommendations of the bipartisan Senate inquiry.

13. Instead, due to concerns about the quality of the ATSB report and the process by which ATSB had produced this report, it was agreed that the Canadian TSB be asked to conduct an independent external benchmarking investigation of ATSB and its methodology. This was done under very narrow terms of reference. The release of the Canadian report was repeatedly delayed – there was apparently a process of the report going back and forth between Canadian TSB and ATSB. The Canadian report was released in December 2013. It was highly critical of the ATSB investigation and final report.

Damning review of ATSB Pel-Air investigation released | Plane Talking

14. So ATSB was not proud of its own report. The Senate committee was highly critical of the report. And the Canadian TSB was critical of the report. It seemed the Minister was finally spurred into action. He announced the investigation would be re-opened. There are suggestions the recorders will be recovered this time. And the Minister also announced the forthcoming appointment of a new Commissioner at the ATSB – specifically one with aviation experience.

ATSB ‘asked to consider’ re-opening Pel-Air crash inquiry | Plane Talking

ATSB told second rate not good enough in Pel-Air inquiry | Plane Talking

15. During the inquiry, the Senators expressed their concern to CASA that many people giving evidence were nervous about possible repercussions from CASA. They went so far as to remind CASA that all evidence heard was subject to Parliamentary Privilege. The latest twist in this long tale is the Senate has referred the possible intimidation of witnesses to the Committee of Privileges. We will have to see where this goes.

Intimidation motion concerning Pel-Air raised in Senate | Plane Talking

The legal action by the nurse is now imminent, and so there are a few more scenes to be added. But it would indeed seem a good basis for a movie.

5th Estate

 

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