[Peetwo]

TICK TOCK - Five years & counting?

Extract from the Senate (PelAir) AAI Inquiry report 23 May 2013:

Executive Summary

On the night of 18 November 2009, Pel-Air VH-NGA ditched into the ocean in bad
weather off Norfolk Island following several aborted landing attempts. The
aeromedical retrieval flight was en route to the Australian mainland from Apia,
Samoa, and planned to refuel on Norfolk Island as it had done on the first leg of its
journey, from Sydney to Samoa. Six people were on board: the patient, her husband, a
doctor, a nurse, the pilot in command and his co-pilot. All six survived.

Their survival is testament to skill and luck. The committee appreciates that the
accident has affected their lives in ways that are impossible to fully understand. What
allowed the accident to happen, however, should not be.

Although this inquiry had at its heart an Australian Transport Safety Bureau (ATSB)
report into a single aviation accident, the committee's primary focus throughout was
the adequacy of the ATSB's investigation and reporting process, rather than the
particulars of the accident itself. The committee is not comprised of aviation experts,
and although it is fortunate to have the benefit of several members who have extensive
flying experience, it did not set out to conduct another investigation of the accident.

The committee accepts that the pilot in command made errors on the night, and this
inquiry was not an attempt to vindicate him. Instead, the committee's overriding
objective from the outset was to find out why the pilot became the last line of defence
on the night and to maximise the safety outcomes of future ATSB and Civil Aviation
Safety Authority (CASA) investigations in the interests of the travelling public. This
report does so by asking:

• why errors were made;
• why, given that a pilot works within a system, the flight crew became the last
line of defence;
• what deficiencies existed in the system, with regard to the operator (Pel-Air)
and the regulator (CASA), which were not explored as fully as they could have
been by the ATSB; and
• whether the travelling public can have confidence in ATSB processes, the
agency's interaction with CASA and the systems in place to ensure safety.

The findings of the ATSB's investigation report are the starting point in untangling
and addressing these questions. The ATSB's firm position is that the ditching was a
one-off event due predominantly to the actions of the pilot, and the agency has
defended this stance without, in the committee's view, a solid evidentiary base. Over
the course of this inquiry the ATSB repeatedly deflected suggestions that significant
deficiencies with both the operator, (identified in the CASA Special Audit of Pel-Air),
and CASA's oversight of Pel-Air, (identified in the Chambers Report), contributed to
the accident. The committee takes a different view and believes that ATSB processes
have become deficient for reasons to be detailed in the following chapters, allowing
this narrow interpretation of events to occur.

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The committee also focuses on the appropriateness and effectiveness of the interaction between the ATSB and CASA. The committee notes that a systemic approach to the investigation was initially pursued, but that systemic issues were scoped out of the investigation early in the process. This led the committee to ask whether CASA exerted undue influence on the ATSB process. What is clear is that CASA's failure to provide the ATSB with critical documents, including the Chambers Report and CASA’s Special Audit of Pel-Air, which both demonstrated CASA’s failure to properly oversee the Pel-Air operations, contravened the Memorandum of Understanding (MoU) in place between the two agencies and may have breached the terms of the Transport Safety Investigations Act 2003 (Chapter 7). The committee takes a dim view of CASA's actions in this regard.

The survival of all six people on board VH-NGA means that a lot went right—this
should result in lessons for the wider industry, particularly operators flying to remote
locations. At the same time, many things could have worked better, and industry
should also learn from these. Many submitters and witnesses asserted that the ATSB's
report is not balanced and includes scant coverage of contributing systemic factors
such as organisational and regulatory issues, human factors and survivability aspects.

Given the ATSB's central role in improving aviation safety by communicating lessons
learned from aviation accidents, the committee is surprised by the agency's near
exclusive focus on the actions of the pilot and lack of analysis or detail of factors that
would assist the wider aviation industry. The committee notes warnings that the
omission or downgrading of important safety information has the potential to
adversely affect aviation safety.

The committee was understandably troubled by allegations that agencies whose role it
is to protect and enhance aviation safety were acting in ways which could compromise
that safety. It therefore resolved to take all appropriate action to investigate these
allegations in order to assure itself, the industry and the travelling public that
processes currently in place in CASA and the ATSB are working effectively.

The committee recognises that Australia has been a leader in aviation safety for a
number of years through its robust adoption of the accident causation model
developed by Professor James Reason (Chapter 3).1 This approach recognises that
people work within systems – the individual actions of the pilot in command have a
role to play, as do the actions of the operator and the regulatory environment they
work within. Each layer provides a barrier to prevent an accident and each must be
examined for deficiencies when incidents occur.

Furthermore, the committee has strong concerns about the methodology the ATSB
uses to attribute risk (Chapter 4). The methodology appears to defy common sense by
not asking whether the many issues that were presented to the committee in evidence,
but not included in the report, or not included in any detail, could:

• help prevent such an incident in the future;

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1 This strong reputation was earned by the ATSB's predecessor, the Bureau of Air Safety Investigation (BASI), in particular in terms of accident reporting and its 'no-blame' approach.

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• offer lessons for the wider aviation industry; or
• enable a better understanding of actions taken by the crew.

The committee examines how this methodology contributed to the downgrading of an
identified safety issue from 'critical' to 'minor', and finds that the process lacked
transparency, objectivity and due process (Chapter 4). The committee finds that the
ATSB's subjective investigative processes are driven in part by ministerial guidance
prioritising high capacity public transport operations over other types of aviation
transport.

The committee considers (Chapter 8) whether the lack of formal recommendations in
the ATSB report led to a lack of action on important safety issues. This absence of
recommendations stems back to the Memorandum of Understanding (MoU) between
the ATSB and CASA, which encourages concurrent safety action rather than action in
response to recommendations. The committee believes both are necessary. It is
regrettable that a Senate inquiry has had to make recommendations which should have
been made by the ATSB.

A number of changes have been made by the operator (Chapter 5) and the regulator
(Chapter 6) since the ditching. The committee is convinced that having these measures
in place before the ditching would have significantly reduced the risk of the accident
occurring. To simply focus on the actions of the pilot and not discuss the deficiencies
of the system as a whole is unhelpful. It is disappointing that CASA and the ATSB
continue to assert, in the face of evidence to the contrary, that the only part of the
system with any effect on the accident sequence was the pilot.

It also emerged in the course of the inquiry that the previous system of mandatory and
confidential incident reporting to the ATSB has been altered. Pilots have expressed
concern that CASA now appears to have access to identifying information, which may
inhibit pilots reporting incidents and will therefore undermine the important principle
of just culture within the aviation industry (Chapter 10).

Finally, the committee notes that many submitters and witnesses provided evidence in
camera due to fear of retribution, particularly from CASA, were they to go public
with their concerns. Many who chose to give in camera evidence did so in the
knowledge of protections provided by parliamentary privilege. The committee also
notes that this reticence to speak in public has been apparent for each inquiry this
committee has conducted in this area over several years, and finds this deeply
worrying. Given the positive statements made about the inquiry by CASA Director of
Aviation Safety, Mr John McCormick, the committee trusts that concerns about
retribution are unwarranted. There is an obligation on CASA to allay these concerns
that retribution could follow speaking out, which appear to be widespread within the
aviation industry. The committee stresses that it takes the protection of witnesses
under parliamentary privilege very seriously. Witnesses—whether public or in
camera—should suffer no adverse consequences from providing evidence to the
committee. Given the numerous concerns expressed, the committee will be monitoring
this situation carefully.

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If Australia is to remain at the forefront of open, transparent and effective aviation safety systems, then the goal of this committee is to help our organisations to work transparently, effectively and cooperatively. Ensuring that a systemic approach to aviation safety is in place is the best way to maximise outcomes.

Although there is no doubting the incisive dedication and passion of that particular constituted standing Senate RRAT References Committee in their attempts to rectify the many identified wrongs, inconsistencies and duplicities within the aviation safety bureaucracy; one is left asking five years later WTD has changed or been satisfactorily reformed within those self-serving, statutorily independent Government agencies??

However to be fair to the committee the following quoted extract from the report more than highlights what they were up against:

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Order for the production of documents

1.6 The committee decided that there was a need to access relevant information
from the ATSB and CASA to be able to judge for itself the internal processes
undertaken by each agency and the inter-agency dealings. Many thousands of internal
ATSB and CASA documents were received through an order for the production of
documents.1 This material was received confidentially and the committee takes the
protection of such material very seriously.

1.7 Before deciding whether to publish any of the documentation, the committee
discussed the ramifications at length. In doing so it weighed up the request for
confidentiality against the public interest of the aviation industry and the travelling
public having confidence in the key agencies responsible for civil aviation safety in
Australia. Wherever possible, the committee sought the views of the ATSB or CASA
prior to publication. The committee also considered that it needed to be able to
support its analysis and conclusions as the internal documents appeared at odds with
the evidence given publicly. The committee also wanted to provide the agencies with
the opportunity to explain key documents in public. For these reasons the committee
took the decision in the public interest to publish a small number of documents but did
so with care, selecting only those documents needed to support its conclusions.

1.8 Of the thousands of documents received from the ATSB and CASA, the
committee published 12. At the conclusion of this inquiry, the committee decided to
return all unpublished documents to their respective agencies.

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Yep..the classic bureaucratic hay stacking of evidence -    

The following FOI released email correspondence, from the former ATSB Chief Commissioner Beaker to the former Miniscule Albo, IMO truly highlights the deeply entrenched rot and corruption that the Senate committee naively believed they could reform merely by handing down their findings and 26 recommendations of the PelAir report:

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From: Dolan Martin [mailto:Martin.Dolan@atsb.gov.au]
Sent: Friday, 31 August 2012 13:28
To: Minister's Office
Subject: Four Corners and Norfolk Island [SEC=UNCLASSIFIED]

As foreshadowed, I was interviewed this morning by Four Corners in relation to the story they will be putting to air on Monday night. It is clear that their main focus will be on trying to show that the pilot was hard done by and that PelAir as operator has been let off too lightly.

The main issue for us was their view that we should have included the details of an unfavourable CASA regulatory audit of PelAir in our investigation report. Predictably, there were at least ten variations on the same basic question: doesn’t the public have a right to know from our report that PelAir had an unfavourable audit report from CASA.

I indicated as clearly – and repeatedly – as I could that we had considered CASA’s report carefully and had regard to those elements of it that related to the safety issues about fuel management that were the principal focus of our investigation. Equally, our job was primarily to focus on lessons to be learned that might improve future safety, in a framework where we are not permitted by law to apportion blame. It is likely that our report will be presented as being too soft on (if not covering up the problems with) PelAir and too hard on the flight crew.

There were other issues raised, including the delays in finalising the report (I agreed that three years was far too long, but put it in the context of all our other investigation activities) and some early correspondence we had with CASA about a potentially significant safety issue about the regulatory standards for fuel management that we had downgraded to a minor issue in our final report (I explained how we reviewed our assessment of issues over time as more information came to hand).

In essence, the ATSB part of the story will be that we unfairly blamed the pilot and let PelAir off the hook. It’s unlikely that our clear messages about ‘no blame’ and a focus on improving future safety and preventing a recurrence will get much of a run.

Martin Dolan

Chief Commissioner
Australian Transport Safety Bureau 

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As this week's SBG highlights we are on a theme of PelAir disconnections. Therefore, in light of the Beaker bollocks above, for the sake of BRB debate I thought it worth drawing attention to one more document of interest from the Senate PelAir inquiry webpages:

8 Answers to written questions taken on notice on 28 February 2013, in Canberra;(PDF 189KB)

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2. Since the Lockhart River inquest in 2007, how has the ATSB’s relationship with CASA changed? o Does the ATSB still acknowledge oversight of CASA’s role as regulator?

ATSB response: The ATSB has never had oversight of CASA’s role as a regulator. Its role is independently to investigate transport safety matters.

This was confirmed by Parliament in the passage of the Transport Safety Investigation Act 2003 and in the establishment of the Australian Transport Safety Bureau as an independent commission in 2009.

In the second reading speeches for both of these changes, it was highlighted that the ATSB must be independent from parties or actions that may have been directly involved in the safety occurrence or that had some influence on the circumstances or consequences of that occurrence. For example, the ATSB must be free to investigate and comment on any significant role of the regulator in a particular occurrence and as such must not itself play a regulatory role in the industry. Investigations that are independent of transport regulators, government policymakers, and the parties involved in an accident, are better positioned to avoid conflicts of interest and external interference.

o If so, in what practical sense does the ATSB carry out its duties in this regard?

ATSB response: The ATSB does not have oversight responsibilities for CASA.

o If not, who now has oversight of CASA?

ATSB response: The Civil Aviation Act 1988 clearly sets out accountability arrangements for CASA including reporting to Parliament and the Minister. It also sets out the role of the CASA Board which includes deciding on the objectives, strategies and policies to be followed by CASA; ensuring CASA performs its functions in a proper, efficient and effective manner; and ensuring that CASA complies with certain directions given by the Minister.

o As an oversight body, should the ATSB be aware, as a matter of principle, about internal audits of CASA and what these audits contain?

ATSB response: The ATSB is not an oversight body.

The ATSB by definition may not be an oversight body but it is worth reflecting that since the promulgation of the TSI Act 2003 and the establishment of the ATSB as an independent statutory authority in 2009, that the questions of the ATSB appearing to be captured by the regulator CASA are more, not less, prevalent and the standards of effective AAI would appear to be more politically influenced than at any other time in the history of the ATSB/BASI/DCA??

Finally it is worth reflecting on this passage of Hansard from the 22 October public hearing with Mick Quinn under questioning:

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Mr Quinn : Captain James in hindsight openly admits to aspects of the flight where his performance and the performance of his first officer could have been better. The point of the investigation is to reveal why this happened not what happened. This report really only represents the latter as a flawed narrative of the events.

I would like to point out—and I can table this government public document, if you like—this accident report from 1993 by the Bureau of Air Safety Investigation which was a groundbreaking investigation using organisational aspects. It appears that in 2012 we have got to a new low where the Norfolk report basically omits organisational aspects of this flight.

It seemed to me that in 1993 we got it right, but I am not sure where we are in 2012. This is no longer about Captain James, Zoe Cupit, David Helm, Karen Casey or the Currolls. They have physical and psychological issues to deal with for the rest of their lives as a result of the accident—that is fact. We need to ensure that this cannot happen again. My submission and that of Mr Aherne addresses these critical issues. I thank the committee for accepting my submission and, following questioning, I would like to have a brief session in camera if possible.

CHAIR: Thank you. Please clarify the document that you would like to table.

Mr Quinn : It is a Monarch Airlines accident in Young in 1993.

CHAIR: I remember it well.

Mr Quinn : I should point out that in that accident report there are nine recommendations regarding all aspects of the organisation, the regulatory side of things.

Senator STERLE: And none in this one?

Mr Quinn : In this report, ditto—no.

CHAIR: By way of history, the president of the Shires Association was killed on that plane and 10 days before he was killed he had said he was getting out of the presidency of the Shires Association and he would be pleased to get out. I asked why and he said, 'Because I won't have to travel on light planes in the way that I do.' He didn't make it.

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No comment required me thinks -


MTF...P2