PelAir – ‘Lest we forget’ Part III | AuntyPru.com : Home of PAIN :

Six years on and the ATSB is still a basket case.. Undecided

From off the Aunty Pru Forum thread – The Chambers Report

Peetwo Wrote: I note that in the very entertaining Estimate’s session on Monday, that there was several references to the PelAir cover-up & indeed the “Chambers Report”…

{Reference: From about 06:30 minutes}

From CASA Hansard:

Senator FAWCETT: …In coming back to your regulatory philosophy, you are saying that CASA is committed to maintaining the trust of the Australian aviation community. One of the biggest breaches of trust recently was the ATSB investigation into the Pel-Air report where CASA maintained that the internal investigation, the Chambers report, the fatigue risk management report and the special audit were not necessarily pertinent. I think the term was they were a private, internal report. Now that ATSB has reopened that investigation could you assure the committee that it is your intention to share all that information about the inadequacies of CASA’s oversight at the time with the team so that the new report reflects not just the actions of the pilot but the inadequate supervision of the organisation and the self-identified inadequacies of CASA at the time?

Mr Skidmore : I think it is fair to say that we have provided all the information that the ATSB has requested of us and we will take into account any recommendations that come out of the investigation.

Senator FAWCETT: Would it be your view that a report like the Chambers report should have been provided to ATSB voluntarily?

Mr Skidmore : I was not there at the time. It is very unfair for me to be making a statement of the organisation of the past.

Mr Aleck : One of the significant amendments we have made to the MOU with the ATSB is to put beyond doubt the kind of information that can and should be provided on request, or sometimes voluntarily. As you may recall, the existence of the Chambers report was conveyed to the ATSB. The circumstances under which that happened probably were not as concrete as they certainly will be in future.

Senator FAWCETT: Mr Aleck, I think you might recall Mr Dolan found out about it 30 minutes before he appeared before the Senate committee because he had overheard the evidence where we had dug it out of half a truck load of cardboard boxes that CASA had dumped on our doorstep. I do not accept the contention that they knew about it before the report was issued; in fact, the Canadian peer review confirms that was not the case.

Mr Aleck : I will not challenge that except to say that I believe the former director gave evidence that he had mentioned this to Mr Dolan. Now, he might not have mentioned it by the term Chambers report, because that was a term that came into existence afterwards, but I think the information about some inquiry having been made internally had been conveyed. I guess the major point is that that kind of thing should not happen again under the new arrangements.

Senator FAWCETT: I am very pleased to hear that…

From ATSB Hansard:

Senator FAWCETT: I would like to go to the information-gathering stage. Going back to an answer to a question on notice that you took at the time of the original investigation, you said:

… the Chambers Report does not contain any new evidence that organisational factors were likely to have contributed to the accident.

You go on to say:
… the Chambers Report reflected what was separately reported (and available to the ATSB) in the reports of CASA’s accident investigation and of its special audit …

I challenged that at the time, and so did your Canadian peers ,who have done an independent peer review and who have made numerous comments in their report that in actual fact regulatory systemic issues to the organisation and oversight of the organisation by CASA were significant and were omitted. They go into some detail about the process within your organisation that resulted in those being omitted even though they were significant. Can you provide me with an assurance that the rework of this report will be considering the quite detailed information contained not only in the special audit but in the Chambers report and in the fatigue report that go to the heart of how the individual ended up having that accident?

Mr Dolan : Yes, I can give you that assurance. We have acquired from CASA not just the various reports but the core material they relied on to prepare those reports as part of the process of undertaking the reopened investigation.

Senator FAWCETT: I am pleased to hear that cooperation. Could you also comment on whether you still stand by the remarks that you made in the questions on notice?

Mr Dolan : I am not in a position to comment on that until I see the results of the reopened investigation. It is entirely possible. The Canadians have already alluded to the fact that we did not give sufficient weighting as an organisation to the organisational aspects of this investigation, and that is what we hope we can determine through the reopened investigation.

Senator FAWCETT: There are a couple of points that come out of this. There is one about the trust of industry in the organisations that are supposed to be having an oversight around safety and regulation, but the other is a very real impact on people. At the time, the committee were concerned about what we saw as a breakdown in the relationship between you and CASA and the inadequacies of the report. Subsequent to the Canadian peer review, which was quite scathing about the fact that there were very clear systemic issues which were not addressed, people who have been affected by this accident—being the pilot involved and potentially the nurse—have sought some remedy for the situation they find themselves in as a result of this report. In the pilot’s case, correspondence I have seen from him has indicated that that report has essentially finished his aviation career. My understanding is that even after the Canadian report, when he has sought an act of grace payment from the Department of Finance, ATSB’s recommendation is: ‘Don’t pay it. It was his fault.’ Can you confirm that was the case?

Mr Dolan : I recall that there was some information sought from the Department of Finance in relation to an act-of-grace payment. We provided the facts as we understood them. It is not a purpose of our organisation to assign blame, and we would not have said that to the Department of Finance.

Senator XENOPHON: Can you provide the advice that Senator Fawcett has asked you for?

Mr Dolan : I beg your pardon?

Senator XENOPHON: Can you table that advice?

Mr Dolan : I cannot see any reason why we should not, so I will obtain it and table it for the committee.

Senator FAWCETT: In the light of the Canadian report, which indicates there were very clear systemic failures on the part of the company and in terms of CASA’s oversight, the whole concept of systems safety is that whilst the pilot was the last link in the chain these other considerations had a significant impact, which was borne out by the fact that the company had to cease operations after these investigations until remedial measures were put in place. With that now on the public record, with this new focus, would you consider providing the Department of Finance with alternative advice if he were to come back and seek some compensation for the fact that as a direct result of the report that your organisation issued, with all of the failings and how that was put together, his career has essentially been finished and all the financial loss that has gone with that?

Mr Dolan : That is not a matter that I can answer on the spot here. I am happy to turn my mind to that if any such request comes forward.

Senator FAWCETT: That would be very useful. I look forward to the report.

Senator EDWARDS: We will be very interested in that.

Senator XENOPHON: Mr Dolan, do you think it is inappropriate that you provide any opinion as to the appropriateness of an act-of-grace payment to the pilot involved, given your involvement in this particular matter, that there might be an issue of apprehended bias on your part and on the part of the ATSB, and that it really should be a matter that the ATSB either needs to get someone independent to comment on or not comment on it at all?

Mr Dolan : I am between a rock and a hard place here. I am being urged, on the one hand—

Senator Colbeck: If, through the administration of the act-of-grace process, the department is asked to provide some advice, that would not be an unusual process, I have to say. But during the administration of the act-of-grace payment there would be advice sought from a number of areas. At the end of the day that decision is a discretionary decision for the person making the decision.

Senator XENOPHON: But you understand the importance of the ATSB advice.

Senator Colbeck: I understand it very well.

Senator XENOPHON: If the advice were a thumbs down to the pilot, that could be quite damaging to the act of grace. I am very grateful that Senator Fawcett raised that issue.

Senator Colbeck: Having administered that myself previously, I can say there are a range of pieces of advice sought and it is at the discretion of the decision maker at the end of the day.

Senator XENOPHON: So we will get a copy of that advice. Mr Dolan has been good enough to indicate that we would get a copy of that advice in this committee as to what was said and all the correspondence in relation to that. I have a couple of questions.

Senator Colbeck: Further questions around that process probably should go back through the Department of Finance.

Senator FAWCETT: I am happy to do that. My last comment is that the other two people deeply involved in this are the person who was the patient on the flight and particularly the nurse, and part of the mental anguish that those families have suffered is the clear disconnect between the facts that have been laid out for all the public to see through that Senate inquiry and the position that ATSB has taken. So I hope, Mr Dolan, for the sake—

Senator XENOPHON: It is no longer live.

Senator FAWCETT: I know that, but for the sake of everyone involved, particularly those who are still with us, I hope that this will be a fair and accurate report of responsibilities that led to the situation where, rightly or wrongly, the pilot did what he did. But very clearly it is a result of a system failure—regulator, company and individual—and not just the individual as that original report stated. Thank you.

That last passage is quite remarkable and hopefully will now result in ‘natural justice’ for the living victims of the Pelair ditching & hopefully recompense for DJ’s anguish.

The most reassuring fact from the above Hansard excerpts is that the Senators (in particular DF & NX) will not allow the passage of time to dilute the serious aviation safety issues & deficiencies highlighted in the findings & recommendations of the Senate AAI (PelAir) Inquiry.

Courtesy Ben Sandilands (Planetalking blog 10/11/15):

Six years on, ATSB about to recover Pel-Air flight data recorder

Ben Sandilands | Nov 09, 2015 3:30PM |

In another triumph of administrative efficiency, diligence and focus the Australian Transport Safety Bureau or ATSB, is poised, after almost six years, to recover the flight recorder from the Pel-Air Westwind corporate jet that was ditched in the sea near Norfolk Island on 18 November 2009.

The small jet had intended to refuel at Norfolk Island on its way from Apia to Melbourne as part of a medical charter flight, but had insufficient fuel on board to divert to an alternative airport when despite four missed approaches it was unable to land because of deteriorated weather conditions.

All six people on board were rescued by an island fishing boat and in the course of its original and since discredited investigation into the accident the ATSB decided not to recover the recording device, which is less sophisticated than those on larger jets, and of a design which in some quarters is said to be prone to medium term salt water corrosion.

The decision of the ATSB to blame everything on the pilot, and not recover the flight recorder led to a prolonged and continuing controversy. A peer review of the ATSB’s conduct of the first inquiry by the Transportation Safety Board of Canada found (for those who managed to read all of it) that not all of the relevant information available to the ATSB may have been taken into account, and referenced internal frustrations and divisions within the ATSB investigation.

A review of that report can be read here.

Damning review of ATSB Pel-Air investigation released

Ben Sandilands | Dec 02, 2014 12:44PM |

Memo Tony Abbott and Warren Truss. Second rate isn’t good enough in air safety investigations, and the Canadian peer review of the ATSB re Pel-Air makes us look very grubby.

The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.

This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.

The report also casts light on internal frustrations and divisions within the ATSB investigation.

It summarises some of those matters as follows.

3.10 Findings from the TSB review of the Norfolk Island investigation

The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.

In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.

The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.

Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analyzed.

The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.

A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.

Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.

The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.

If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised report up, as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.

This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.

The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation.

This is just a part of what the TSBC review says on such matters.

The Minister supposed to be looking after aviation, Warren Truss, has previously parrotted lines written for him by his department that there is no value in re-opening or replacing the final report of the Pel-Air investigation.

This embrace of second rate by a Minister supposed to uphold fairness and excellence in aviation safety reporting is unworthy.

The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.
Second rate isn’t good enough for Australia.

The ATSB was subsequently ‘invited’ by the Deputy PM and minister responsible for aviation, Warren Truss, to revisit its report, which the agency after a delay removed from its web site pending its in effect, being redone.

Recovering the flight recorder is part of this process.

The dysfunctional manner in which the prolonged ATSB inquiry was conducted was laid bare in the peer review by the TSBC although this was only apparent on a full reading of that document rather than in relying on the summaries offered by the Department of Infrastructure which is responsible for both the safety investigator and the air safety regulator CASA.

The crux of the Pel-Air controversy is that the pilot was framed by the ATSB and CASA while the safety regulator improperly withheld an internal report which found gross failures on its part to correctly oversight or remedy what was found to have been serious safety deficiencies by the operator.

One of the critical matters raised by the controversy is the integrity of the ATSB in relation to the first Pel-Air accident investigation report, including its disinterest in that suppressed internal CASA review of its own performance.

That internal report, known as the Chambers Review, concluded that had CASA done its job the accident might not have happened.

The ATSB website has been updated on the recovery operation.

The image below from the ATSB shows what the wreckage looked like in March this year.