[Peetwo]

Unclosed safety loops and dots-n-dashes to a decade of a Harfwit's ineptitude?? -    

To begin let's reflect on the Govt response to RRAT References Committee Recommendation 22 to the AAI inquiry completed in May 2013:



Haven't been able to discover (at this stage) how the Harfwit presentation to the 'South West Pacific Safety Forum' in PNG 2013 was responded to by the applicable ANSP PASO nations involved. However I do find it fascinating when you reflect on the Senate AAI inquiry evidence given by Harfwit at the 19/11/2012 Senate Inquiry hearing, that inevitably led to the RRAT Committee generating  recommendation 22: (Reference video segments and Hansard)

Hansard - HERE

Senator NASH: Can we go back to this issue of the provision of the information from New Zealand? What date is the Pacific forum?

Mr Harfield : Let's take it on notice. I think it is in the second week of December, but I will advise.

Senator NASH: Okay. Fingers crossed that it does not happen, but if there were another incident of the same nature between now and a few weeks away, whose responsibility would it be that this issue had not been dealt with immediately? I am just trying to ascertain: if there were another accident and it had been, as it has been, identified that there is this fault line issue—as you said, Ms Staib, it could be addressed better in our planning and that will be done at the Pacific forum—whose responsibility is it when that has not been addressed?

Ms Staib : It seems to me—and, as you will appreciate, I am still learning—that in the first instance the New Zealand regulator would have to step in. What I am saying here is that there is an opportunity for us to work in a better community practice, and that is a good thing. But we all have our specific roles to play.

Senator NASH: I understand that. I take the point that you work within the framework that you have. I take that point completely. But what has been identified is this anomaly.

Ms Staib : Yes.

Senator NASH: I take your point that New Zealand would be responsible, but they are not required to provide this information. That is my whole point. I am trying to understand who is responsible if there is another accident before this issue is addressed—as hopefully it will be.

CHAIR: Whose head do we cut off, in other words?

Senator NASH: Somebody would have to take responsibility for the fact that this issue, having been identified, was not addressed urgently. Who would be responsible for it not having been addressed urgently?

Mr Harfield : The fact that this information is now available—and I am assuming that the ATSB report would have been given to the Civil Aviation Authority of New Zealand as well as to the regulator in Fiji—and because of their rule set or their regulations, if they have not taken action on it and something occurs then the responsibility would be with that particular jurisdiction. The point I am trying to make is that we do not own the rule set and cannot change the rule set of a foreign jurisdiction.

Senator NASH: We are not blaming you; we are trying to find a resolution. What we need from you and others who appear before us is to get all the pieces of the jigsaw puzzle so that we can put them into a picture. We are not blaming you—that is fine. We understand the rules that you work under. What we are trying to do is to figure out how to resolve it. That is where we are hitting the wall. You attended the Pacific forum. When was the decision made that you should talk to your counterparts from New Zealand and Fiji at the Pacific forum?

Mr Harfield : The Pacific forum is a regular—

Senator NASH: I know it is.

Mr Harfield : It is a regular thing. When those of us with responsibilities and areas of control in the South Pacific come together, we work through the various safety—

Senator NASH: I understand all that. When did you make the decision to raise this issue with Fiji and New Zealand at the Pacific forum? Was it this morning? Was it last week? Was it a month ago? When did you make the decision?

CHAIR: Was it six months ago? Three years ago?

Mr Harfield : Regarding the decision to put that on the agenda, without knowing what is already on the agenda, after this discussion here we will ensure that it is on the agenda.

CHAIR: So it is not on the agenda.

Mr Harfield : But there is a level of assumption that all instances—

Senator NASH: That is fine. I am just trying to ascertain information. So I am correct in saying that because of the discussion this morning at this hearing you have now decided to take this issue to the Pacific forum. Is that correct?

Mr Harfield : We will ensure that it raised at the Pacific forum.

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 kids 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 XENOPHON: You were saying, Mr Harfield, that you rely on what the ATSB says in its recommendations insofar as it relates to Airservices Australia. Is that a relevant—

Mr Harfield : Yes, in the sense that we have usually done our own investigation and we look at it to see whether it supports the findings that we found in our recommendation and whether there are any gaps.

Senator XENOPHON: I might be guided by Senator Fawcett on this if I have got this wrong, but my understanding of the ATSB report into this particular accident is that there was not much said at all about air traffic control, was there?

Mr Harfield : That is correct.

Senator XENOPHON: So, in the absence of the ATSB making recommendations about air traffic control issues, where does that leave you?

Mr Harfield : In this particular case, because this happened in a foreign jurisdiction, we would not necessarily be doing our own investigation into it.

CHAIR: The perfect mushroom!

Mr Harfield : As a result of that, we are very heavily reliant on the ATSB report, because that is our prime source of information as to whether there would be an issue, so therefore—

Senator XENOPHON: I just want to tease this out. Were there or are there any discussions between the ATSB and Airservices Australia in relation to this incident?

Mr Harfield : There would have been. We will have to take it on notice as to what they particularly were about.

Senator XENOPHON: Could you please provide—I take it I have the committee's support—details of memoranda, emails, correspondence, anything produced in writing, even records of phone conversations, with respect to those discussions in respect of this incident? In terms of Airservices Australia's role, Ms Staib—and I appreciate you have only just stepped into this role; how long has it been?

Ms Staib : Just one month.

CHAIR: By the way, we also appreciate that Airservices has been in some sort of disarray for a good while over the various problems you have had with credit cards.

Senator XENOPHON: And, if I could put it on the record, it is noted and I think we all welcome that Mr Houston is chair of Airservices Australia. I think that is a unanimously welcome appointment by the government. What role do you see for Airservices Australia to champion the change to the more proactive procedure that Senator Fawcett has quite rightly pointed out? Does it have a role? It seems to me right now that, unless the ATSB raises the red flag, there does not seem to be much of a role for Airservices Australia. Do you think that is an appropriate response?

Ms Staib : As we have discussed previously, in dealing with that incident there were various regulators involved, various service providers involved. But let us talk moving forward, because that is what I think you are asking me. In terms of looking forward, how do we look at these incidents? I see a role where we would work and talk to the other service providers in the region—and indeed, as I said before, globally—where we can learn lessons, understand what is going on. As I said before, when you have jurisdictions that abut each other, we need to be having open dialogue to make sure that we understand the roles everybody has to play and where we can work together to improve the system.

Senator XENOPHON: In terms of that open dialogue, could you provide as a matter of some urgency to the committee once you have had that dialogue with Fijian air traffic control, and indeed any communication you have with New Zealand, because I think it may well be relevant to the deliberations of this committee. Thank you.

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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.

Senator FAWCETT: Can I clarify that if ATSB did come to you in the same way they came to CASA and said, 'Here is something that potentially could be a barrier to a future accident,' that would be a sufficient trigger for you to then take that on corporately and see what action you could take with your regional partners?

Ms Staib : Absolutely.

Senator FAWCETT: That is what we are trying to look at here—we are trying to ascertain what are the things that we can drive into the relationships between departments to make sure that we wrap up the system safety to the best extent possible.

CHAIR: So you will let us know how many Pacific Forums there have been since the crash where this has not even been thought about. Have you been to those Pacific Forums in the meantime?

Mr Harfield : Not personally.

CHAIR: Who goes?

Mr Harfield : The person that reports to me in charge of the airspace that abuts those areas.

CHAIR: Who is that.

Mr Harfield : It is my Manager, Upper Airspace Services.

CHAIR: What is their name?

Mr Harfield : Mr Doug Scott.

CHAIR: He still works for Airservices?

Mr Harfield : Yes, he works with me.

CHAIR: We would be delighted to have him come here and give evidence, Ms Staib, if you would permit that—if you do not, we will subpoena him.

Ms Staib : I do not think you will need to do that.

CHAIR: I am disgusted. Thank you very much for your evidence.

Senator FAWCETT: Chair, whilst you may feel that I do not think that represents the view of the committee. I recognise that there are some failures in the system and we need to work on that—

CHAIR: Can I clarify that I am disgusted not by the officers but by the system that allows this to happen. We are in no way blaming you. I think you are the bunnies.

Senator XENOPHON: Can we get the time line on Hansard for the email trail of communications between Airservices Australia and ATSB in relation to this incident, and indeed if the regulator, CASA, was involved as well, about this incident—any correspondence, communications, notes, memoranda and whatever. How long would that take to dig up?

Mr Harfield : We will do it as soon as practicable.

Senator XENOPHON: I would appreciate that.

Hmm...I find it interesting that in neither the ATSB report MK1 or MK2 was there any safety issues or recommendations generated regarding hazard alert weather information across the FIR boundaries in the Southern Pacific region, although the issue was mentioned in MK2:

During the flight, the weather conditions at Norfolk Island deteriorated below the landing minima. Air traffic services in Nadi and Auckland did not provide the flight crew with all the information that should have been provided.

A further hmmm...so according to Harfwit back then (and presumably now) ASA rely on the ATSB to relay any identified safety issues that may have to be mitigated by ASA and other abutting ANSP authorities. Yet when a comment is made, like the above, that is supposedly disseminated by all the ANSP DIPs to this investigation (IE Fiji, NZed and Oz) there was no proactive proposed safety mitigation feedback in regards to the original and secondary ATSB Pelair ditching investigation processes??

Hansard extract:

Senator XENOPHON: Can you explain that? I am just trying to get the context here. What are our international obligations in regard to the sharing of hazardous weather information with other air traffic service organisations?

Mr Harfield : We have a monitoring system where the Bureau of Meteorology obviously monitors a number of locations around Australia and within the jurisdiction of the airspace that we manage. When we get information provided that is of a differing nature from the forecast, such as a hazardous weather event or the SPECI information that you mentioned previously, that information is then sent to the control positions. It is then relayed to the particular aircraft based on certain parameters where the weather has changed. We call that a hazard alerting service. What we would do, for example, if an aircraft which had a terminal area forecast for Sydney was flying between Melbourne and Sydney and the weather conditions rapidly changed is issue a hazard alert and notify all aircraft going to that destination of the change in circumstances.

Senator XENOPHON: Did that happen in Norfolk Island? Did they deter any traffic?

Mr Harfield : We are unaware because the flight went through different jurisdictions and was in New Zealand airspace.

CHAIR: So that is a fundamental flaw, is it? The evidence we received was that there was a deterioration report on the weather into Norfolk Island, which was not conveyed to the pilot by New Zealand. Is there nothing we can do about it, just tough tits?

Mr Harfield : We were aware of the leg of this particular flight obviously from Sydney to Norfolk Island and also on the return Norfolk Island-to-Sydney leg, which is where there aircraft would transfer to Australian airspace and air traffic control would be managed. The flight between Samoa and Norfolk Island was in another jurisdiction, so we were not aware of what was going on.

CHAIR: For future planning, so we do not have a repeat, have you been in touch with New Zealand bureau of met to get an understanding of what went wrong?

Mr Harfield : No.

CHAIR: Shouldn't you have? Would it not be in your best interest to know if the weather was deteriorating in one incident, which ended up in the sea? If it was evident that New Zealand knew the weather was deteriorating and the pilot did not have that update, wouldn't you be interested to know? Would you not think: shit, we better not let this happen again?

Mr Harfield : Yes and that is why we rely on things like the ATSB reports—to give us that information on how the system was working. If the aircraft did not ditch, we were not aware of that flight, we were not managing that flight, we were not dealing with that flight and so therefore—

CHAIR: Yes, but you would be interested.

Mr Harfield : Correct, we would be interested in the lessons learnt from the incident and we would rely on the ATSB report for that.

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.

 

Hmm..with the above Hansard extract front of mind, now consider the plight of QF28 having apparently not been issued by ASA any BOM 'hazard alert' information in regards to the rapidly changing wx (hazard)  conditions that occurred at YSSY on February 18th 2023? - 

MTF...P2