[Peetwo]

PelAir - 'Lest we forget' Part II

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"...
 
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. 

TBC..P2