[Peetwo]

Senator Fawcett on closed safety loops and slices of Swiss Cheese? 

Those of you that have followed this thread would know the origins of the statement 'Closing Safety Loops' came from none other than Senator David Fawcett in one of his first appearances at RRAT Committee Budget Estimates:

Hansard ref: https://parlinfo.aph.gov.au/parlInfo/sea...%2F0000%22

Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

This was Murky's reply to DF's QON:

 

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you
propose to engage with the coroners to make sure that we, as a nation, close this loophole to
make our air environment safer?

Mr Mrdak: I think Mr Dolan has indicated the relationship with coroners is on a much better
footing than it has been ever before. I think the work of the ATSB has led that. I think it then
becomes a matter of addressing the relationship between the safety regulators and security
regulators, as necessary, with the coroners. It is probably one I would take on notice and give a
bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a
duty of care and an oversight to make sure that two agencies who work for you do actually
complement their activities for the outcome that benefits the aviation community?

Mr Mrdak: We certainly do ensure that agencies are working together. That is certainly
occurring. You have asked me the more detailed question about coroners and relationships with
the agencies. I will have a bit of a think about that, if that is okay.

Answer:


In terms of coordination between agencies there are in place a number of mechanisms that
ensure effective cross agency handling of issues in relation to safety matters having regard to
the specific legislative roles of each agency. These include the establishment of formal
Memorandum of Understanding between the Australian Transport Safety Bureau (ATSB) and
the Civil Aviation Safety Authority (CASA) and between the ATSB and Airservices Australia
(Airservices).

In relation to interaction with coroners this takes place in a number of ways. The ATSB
supports the coronial process by explaining the findings from its own investigation through the
provision of briefings to the coroner and giving evidence at inquests.

The ATSB also brings any aviation safety related issues identified in the ATSB investigation or
from the coroner’s findings to the attention of the Civil Aviation Safety Authority (CASA),
Airservices Australia and industry by publicising them on the ATSB’s website. Where
appropriate, comments are specifically sought from both CASA and Airservices, and that
information is also included on the ATSB’s website.

In relation to CASA, Airservices or the Department, all organisations participate in the coronial process when requested. Where coroner’s findings are directed at any of these organisations, the coroners’ recommendations are fully considered and where agreed, actions are implemented to enhance aviation safety.

(P2 comment: It is interesting to note the number and caliber of aviation safety QON that was generated in the May 2012 Budget Estimates, ref: https://www.aph.gov.au/~/media/Estimates...ports.ashx & https://www.aph.gov.au/~/media/Estimates.../casa.ashx & https://www.aph.gov.au/~/media/Estimates...ralia.ashx & https://www.aph.gov.au/~/media/Estimates..._atsb.ashx & https://www.aph.gov.au/~/media/Estimates...ponse.ashx )

 That question and answer was followed up by DF in the Supp Estimates session in October 2012, which was incidentally a week before the PelAir inquiry began:    

(From 01:50 minutes)

Hansard ref: https://parlinfo.aph.gov.au/parlInfo/sea...%2F0000%22

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.

Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.

Mr Mrdak : Yes.

Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.

Mr Mrdak : We will come back to you on that.

Bizarrely, even the question was addressed to Murky, the DF QON was answered by the ATSB:

Answer:

One of the principal safety improvement outputs of an ATSB investigation is the
identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are
intended to draw attention to specific areas where action should or could be taken to improve
safety. This includes safety issues that indicate where action could be taken by CASA to
change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues
during an investigation. Those relevant parties are generally best placed to determine the
most effective way to address a particular safety issue. In many cases, the action taken during
the course of an investigation is sufficient to address the issue and the ATSB sets this out
clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed
safety action is incomplete, the investigation report will record the safety issue as remaining
open. In addition, if the issue is significant and action is inadequate, the ATSB will make a
recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action
is complete or it is clear that no further action is intended. At this point, the issue will be

What followed after that of course was the Senate AAI (PelAir) inquiry that culminated in what was reportedly one of the most informative and incisive aviation related Senate reports delivered by the Senate RRAT Committee...

However I want to come back to this particular slice of Swiss Cheese:

Hansard ref: https://parlinfo.aph.gov.au/parlInfo/sea...%2F0000%22

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.

Which brings me to that slice of Swiss Cheese which eventually informed the committee to generate  recommendation 22 and this Govt response:



Yet here we are nearly 10 years after the Senate AAI report was tabled in Parliament and there is much evidence that particular Fawcett and Committee identified hole in the (now very moldy) slice of Swiss Cheese is still yet to be appropriately plugged??

Example reference QF28: Dots-n-dashes to: "How many minutes to bingo fuel??" 

And today: Descent below minima landing incident highlights importance of operator risk controls for unforecast weather

Finally and considering we are a decade on from the disturbing findings of the Senate AAI Inquiry which was largely endeavoring to improve the performance and transparency of both our recognised ICAO Annex 13 Aviation Accident Investigator and to a certain extent CASA. I would suggest that those endeavours have miserably failed...

Ref: Proof of ATSB delays and ICAO Annex 13 non-compliance??

Hmm...and where is Senator David Fawcett now?? 

MTF...P2 

PS: As an aside the Senate Committee are not the only one's to have failed to effect any positive reform  within the ATSB. In the thread link above, take note of the number of outstanding 'Short' investigations that go back over 2.5 years and then consider this 2019 ANAO recommendation to the ATSB:

Recommendation no.1

Paragraph 2.8

The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.