[Peetwo]

Above: ATSB Chief Commissioner Hood impersonating Buzz Lightyear -   

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PelAir MKII countdown: Redemption or oblivion?

With 2 days to go before the 500+ page PelAir MK II Final Report is released the BRB punters corner is running hot with speculative bets on how the Senate RRAT committee, collectively and individually will interpret and react to this latest ATSB reiteration??



Therefore IMO now is the perfect time to reflect (in this case posthumously) on how Ben Sandilands, in company with many IOS/BRB members, was moved by a typical clinically informative Senator Fawcett summary speech in the Senate a month after the report was officially tabled on 23 May 2013:

Pel-Air air safety issues spelt out by pilot and Senator, David Fawcett

A parliamentary speech that everyone concerned about the safety of the flying
public, and the competency and integrity of CASA and the ATSB should read

Ben Sandilands

Earlier this week Senator David Fawcett (Liberal, South Australia) urged the upper house of Australia’s federal parliament to ‘take note’ of the Senate committee inquiry into the ATSB’s final report into the 2009 Pel-Air crash and related matters.

Senator Fawcett was a military helicopter pilot, and was the Commanding Officer, RAAF Aircraft Research and Development Unit, Edinburgh, SA, and an experimental test pilot, before being elected to public office.

He played a very measured and penetrating role in the air accident investigation committee hearings which were were instigated by fellow SA independent Senator Nick Xenophon.

This is Senator Fawcett’s address to the motion that the Senate take note of the committee’s findings. Whatever the attitude of the government and opposition benches to the Pel-Air matters, the disgrace they brought on CASA and the ATSB will neither be forgiven nor go away.

This is about the safety of the Australian public, and the functioning of the bodies charged to regulate air safety (CASA) and investigate safety issues to further air safety (ATSB). In the Hansard of Senator Fawcell’s speech some emphasis has been added by Plane Talking.

Senator FAWCETT  I move:
 That the Senate take note of the report: 
The final report of the Rural and Regional Affairs and Transport References Committee into aviation accident investigations was tabled in May this year.

It followed a long period of investigation into the inquiry by the ATSB into the accident in which a Pel-Air aircraft ditched off Norfolk Island in 2009.

The Senate report highlighted that the performance of the two government agencies that were primarily involved, the Australian Transport Safety Bureau and the Civil Aviation Safety Authority, came far short of the expectations that the Australian taxpayer, this parliament and the aviation community should have.


In 2010 a review was done into the operations of those two agencies.

Of the eight desired outcomes of that review, the committee found that actions by ATSB and CASA failed to deliver against six of the main areas.

I will list them and then talk in more detail about them.

They failed to maximise the beneficial aviation safety outcomes that could have been derived from the investigation into this incident.

They failed to enhance public confidence in aviation safety.

I think we saw that in the controversy in the aviation industry and the media around the report when it was finally released.

They failed to support the adoption of a systemic approach to aviation safety.
They failed to promote and conduct ATSB independent no-blame safety investigations and CASA regulatory activities in a manner that assured a clear and publicly perceived distinction between each agency’s complementary safety related objectives, as well as CASA’s specialised enforcement related obligations; they also failed to avoid to the extent practicable any impediments in the performance of each other’s functions.

They also failed to acknowledge errors and to be committed in practice to seeking constant improvement.

The committee made 26 recommendations to address a number of systemic deficiencies that were identified in both the investigative and regulatory processes but also in funding and reporting.

Safety outcomes is one area that I would like to touch on.

[i]Accident investigations are an opportunity for an informed and expert body to sit back and take a considered look at why an incident occurred.

That body may be expert but they are not necessarily the best judges of how the lessons from that incident may be applied to other sectors of the aviation industry.

The committee found that for various reasons and over time the ATSB processes have got to the point where much evidence can be excluded if it does not fall into the categories that they consider will impact on high-risk future operations. So we have a situation where they are making an arbitrary decision to exclude evidence, and without evidence they are not then investigating or reporting on what actually occurred.

That means that other aviation operations are not the beneficiaries of an explanation of occurrences and failures in a system safety approach and what defences failed such that the accident occurred. It has been the traditional approach to identify each of those factors and let the stakeholders make their own assessment. But the safety outcomes are no longer optimised because of this approach of trying to make that arbitrary decision at the front.

That is a significant flaw in the current approach which the committee has recommended be revisited.

The report and CASA’s statements in name supported the concept of a systemic approach to aviation safety.

But what we found very clearly was that the investigation focused very quickly on the pilot in command on the night, as opposed to looking at the raft of other factors.
Looking at the James Reason model of system safety, one sees that there are a number of defences which are in place, which include the operating company, the regulator and a raft of things—training et cetera—as well as the pilot. But many of those factors were given, at best, lip-service. They were mentioned in the report so a box could be ticked to say that they were considered, without a detailed consideration of them.
For that reason, the report was quite flawed.


What made the matter worse was that, having required both CASA and ATSB to produce documents for the inquiry, which initially they were reluctant to do, we spent some considerable time going through literally boxes and boxes of documents to find information, emails, reports and things that were relevant to the report and, having seen a report that said that the company was applying all of its regulatory requirements and CASA was auditing it and so there were no organisational factors to consider, we found that CASA in fact had done a special audit.

Not only had they done a special audit that found a range of problems within the company; they had done their own internal report about CASA’s performance of their oversight of the company and found that, in their own words, that was deficient.

So we have a situation where CASA—who have an obligation, under the memorandum of understanding, to disclose to the ATSB when they are aware of or hold, information relevant to an accident investigation—withheld the information of the Chambers report, which is their internal document, and when, as a directly interested party, they were given a draft of the report and the opportunity to say, ‘No, this is not correct; there are organisational factors both with the company and the regulator that you should be aware of,’ they chose not to do that.

That comes very close to breaching, if it does not actually breach, the transport safety act. It certainly does nothing to boost public confidence and it does nothing to enhance the safety outcomes that could have been achieved through this investigation.


It is telling that there were many organisational and systemic measures put in place by the company in order to resume operations.

That says that, in their assessment and in the assessment of those people who were auditing the company, clearly the pilot alone was not at fault for the original accident or there would be nothing else they had to change.

So the ATSB, in its approach to its report,  and CASA, by withholding that information, have done the aviation industry in Australia a great disservice.

The aviation industry relies on open, transparent and accurate reporting from the regulator and from the safety investigation agency to make sure that the organisations concerned can be ongoing learning organisations that maximise the safety outcomes for the travelling public and for people operating aircraft.

The regulatory reform process is another thing that came through from this.

The air ambulance operation, like the RFDS operation—which also has some emergency aspect to it, certainly for the helicopter emergency services—highlights that we have a category of operation here which has traditionally been put into the air work category, and that is clearly not adequate for all operations in terms of either their planning requirements or the aircraft equipment.

To put them into a higher category such as regular public transport or even charter would unnecessarily, in fact prohibitively, restrict their ability to respond and operate in emergency situations to unprepared airfields.

There is a very clear case here for industry to have a voice and a role to work with the regulator to establish a new category of operation that provides the guidance required around equipment standards and configuration of the aircraft but also provides the flexibility the operators need to perform their mission in a structured manner.

The last point I would raise is that the Chambers report indicated that CASA felt they were under resourced and their people, in many cases, did not have the requisite insight and, in some cases, skills, knowledge or background to do the auditing.

From subsequent discussions, I would argue that, in some cases, they did not have the background to be writing the regulations or standards in the first place.

I believe there is a strong requirement to look at the regulatory reform process and the role that industry should have, not just with token consultation but with a powerful voice, even to the point of veto, where they can work with the regulator to highlight what is industry best practice, and that should form the basis of regulation unless there is a very clear safety case to not go down that path.

Australia’s travelling public and our aviation industries deserve better.

I look forward to the reforms that either this government or the next will bring.

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Just as a reminder here is a link - HERE - for the original AAI report and here is a list of the 26 recommendations:
[/i]

List of Recommendations

Recommendation 1
3.68      The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay.

Recommendation 2
4.41      The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification.

Recommendation 3
4.43      The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.

Recommendation 4
4.69      The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.

Recommendation 5
4.78      The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.

Recommendation 6
4.79      The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in training/competence must be advised to the minister and the Parliament.

Recommendation 7
4.87      The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.

Recommendation 8
4.101      The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Recommendation 9
4.103      The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.

Recommendation 10
6.41      The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

Recommendation 11
6.52      The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.

Recommendation 12
6.55      The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.

Recommendation 13
6.58      The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.

Recommendation 14
7.15      The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:

• advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
  
• provide the ATSB with the relevant review report as soon as it is available.
  

Recommendation 15
7.16      The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.

Recommendation 16
8.35      The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.

Recommendation 17
9.18      The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18
9.40      The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42      The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44      The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45      The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.

Recommendation 22
9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

Recommendation 23
9.104      The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer.

Recommendation 24
9.106      The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.

Recommendation 25
9.108      The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.

Recommendation 26
10.35      The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

TICK..TOCK Hoody - "To infinity and beyond"


MTF...P2