Senate urges ATSB to re-open botched Pel-Air crash report



** Media Release **

23 May 2013 MR 04/13

AVIATION ACCIDENT REPORT RELEASED INTO NORFOLK ISLAND CRASH

The Senate Rural and Regional Affairs and Transport References Committee report into Aviation Accident Investigations, including the crash of a flight off Norfolk Island in November 2009, has been tabled today.

The inquiry was prompted by the Australian Transport Safety Bureau (ATSB) report into the Norfolk Island crash which has caused consternation and criticism in the Australian aviation industry.

The Senate report highlights that the performance of Government Agencies ATSB and the Civil Aviation Safety Authority (CASA) was against the objectives of a 2010 review into their operations.

Of the review’s eight desired outcomes, the Committee found actions by ATSB and CASA failed to deliver against the six main areas being:

▪ maximisation of beneficial aviation safety outcomes

▪ enhancement of public confidence in aviation safety

▪ support for the adoption of systemic approaches to aviation safety

▪ promotion and conduct of ATSB independent no‐blame safety investigations and CASA regulatory activities in a manner that assures a clear and publicly perceived distinction is drawn between each agency's complementary safety‐related objectives, as well as CASA's specialised enforcement‐related obligations

▪ to the extent practicable, the avoidance of any impediments in the performance of each other's functions

▪ acknowledgement of any errors and a commitment to seeking constant improvement

The Committee made 26 recommendations to address systemic deficiencies identified in investigative and regulatory processes, funding, and reporting. Some of these deficiencies include actions that may constitute breaches of the Transport Safety Act and decisions contrary to Australia’s obligations under our international aviation obligations.

The Committee accepted the pilot in command made errors on the night, and this inquiry was not an attempt to vindicate him. The overriding objective was to find out why the ATSB report was deficient and to maximise the safety outcomes of future ATSB and CASA investigations in the interests of the travelling public.

“The Government must respond in a timely manner to address these recommendations if Australia is to regain a role as a leader in effective aviation safety” Senator Fawcett said today.

“Government and its agencies need to work transparently and cooperatively with industry to ensure that a systemic approach to aviation safety consistently underpins all aviation regulatory, investigative and compliance activities.”

7:30 report:

Transcript

LEIGH SALES, PRESENTER: When a medical evacuation flight ran out of fuel and ditched in the ocean off Norfolk Island one night in 2009, six people were extraordinarily lucky to survive.

Air safety investigators blamed the pilot.

But a Senate committee report released today has reached a very different view. It's been scathing about the role of the regulators, saying the Civil Aviation Safety Authority was partly to blame and covered up its own failings.

The committee says it's report is going to the Australian Federal Police.

Adam Harvey reports.

ADAM HARVEY, REPORTER: A routine medical flight that ended in near disaster. This twin-engine jet, operated by Pel-Air, was bringing a patient from Samoa to Melbourne via Norfolk Island. It never made it.

After several aborted landings due to bad weather, pilot Dominic James made the toughest decision of his career. On the darkest of nights, he dropped the aircraft right into the rough South Pacific.

All onboard survived, thanks to the pilot's skill, the bravery of the local Norfolk Islanders who plucked the survivors from the sea and a very large dose of luck.

But the long-term consequences of that night have been devastating.

CareFlight nurse Karen Carey's nerves were torn away from her spine.

KAREN CAREY: I feel extremely lucky that I'm here with my family and my children, but there are days where the pain is so excruciating that I would sometimes close my eyes and wish that I would have just passed.

ADAM HARVEY: Pilot Dominic James' reputation was trashed.

DOMINIC JAMES, PILOT: I've had to sell the place that I lived in. It's cost me hundreds of thousands of dollars to defend my name and my reputation. It's been a huge cost to those around me, both professionally and my family.

ADAM HARVEY: In a report three years in the making and released last August, air safety investigators blamed the pilot. The Australian Transport Safety Bureau said Dominic James did not load enough fuel in case of bad weather and he should have diverted to the nearest runway in Fiji before it was too late.

DOMINIC JAMES: It was a popular perception that I was reckless, careless, negligent and I was none of those things. I did some things on that night that I wish I had done better, but by no means was it warranted to rest the cause of the accident solely upon me.

ADAM HARVEY: Today in Canberra, a Senate committee handed down its own report and pointed its finger at Australia's air safety authorities.

NICK XENOPHON, INDEPENDENT SENATOR: Our agencies are not up to scratch. This goes beyond one incident - let me emphasise this: this goes beyond Dominic James, who I regard and many others regard now after this report as a scapegoat for the failings of CASA and the ATSB.

DAVID FAWCETT, CHAIR, TRANSPORT COMMITTEE: The ATSB report glossed over all of the systemic factors which clearly played a role in the lead-up to the accident.

ADAM HARVEY: Pel-Air had problems and the Civil Aviation Safety Authority knew it.

DAVID FAWCETT: The company itself, their own training, their fuel policies, their supervision of the pilots, the support they provided - all of those came out very clearly in the special audit that CASA conducted after the accident. The ATSB report essentially said the company was doing the right thing, CASA was doing the oversight and there was no evidence of fatigue.

ADAM HARVEY: The report says CASA and the ATSB worked together to make each other look good.

The committee says CASA withheld crucial documents critical of Pel-Air. That's potentially a criminal offence.

DAVID FAWCETT: It could even be seen to have breached the Transport Safety Act in terms of obstructing an investigation.

NICK XENOPHON: The fact that the committee felt that this should go to the AFP for further consideration I think speaks volumes.

ADAM HARVEY: Former CASA deputy director Mick Quinn pushed for the Senate inquiry and has been supporting pilot Dominic James. He says CASA and the ATSB have gone from being rivals to conspirators.

MICK QUINN, FORMER DEPUTY DIRECTOR, CASA: So the pendulum's swung from one bad aspect where the two organisations were at each other's throat to now where it appears, according to the Senate report, that they seem to be in bed together and we need to be back at the centre. These two organisations need to be at arm's length.

ADAM HARVEY: Nick Xenophon says the safety authorities can't be trusted to act in the public's best interest.

NICK XENOPHON: This inquiry has shaken my confidence in the ATSB and CASA to the core. I no longer have confidence in them. That's why I think we need to inspector-general of aviation so that we actually have an independent body that can oversee what they do and how they do it.

ADAM HARVEY: Dominic James is back in the air and is slowly rebuilding his career. But any regulatory changes aren't much comfort for Karen Casey.

KAREN CASEY: There's the operator, there's the investigative system and then there's regulators and I feel that all three failed me. ... If the correct systems were in place for safety and the correct monitoring and auditing were in place, I believe that this would not have happened.

LEIGH SALES: Adam Harvey reporting.



Senate urges ATSB to re-open botched Pel-Air crash report

The Senate committee inquiry into the Pel-Air crash report issued by the ATSB has recommended it re-open its inquiries to focus on the contributing issues it neglected, including the poor performance of CASA, Australia’s air safety regulator.

The report also examines an apparent breach of air transport law by CASA in withholding critical documents concerning its performance and that of Pel-Air from the ATSB.

It recommends the immediate retrieval of the black box flight recorders from the wreckage of the Westwind corporate jet which lie in comparatively shallow waters off Norfolk Island, where the jet was ditched just before it ran out of fuel on an air ambulance mission in 2009.

The report also urges that the next chief commissioner of the ATSB be required to have aviation safety expertise and experience to be eligible for selection.

The report appears to be a severe embarrassment for both the ATSB and CASA, and draws attention to behavior by CASA which appeared to be intended to protect its reputation and that of the operator Pel-Air and influence the decisions of the ATSB which primarily found the cause of the crash lay with the pilot of the jet.

A detailed analysis of the report will appear later today.



Damning Senate report on ATSB, CASA Pel-Air failings

The jobs of the chief commissioner of the ATSB, Martin Dolan, and the director of aviation safety at CASA, John McCormick, are under a cloud following detailed criticism by a Senate Committee that examined their actions in relation to the ditching of a Pel-Air jet near Norfolk Island in 2009.

The committee examined the circumstances and actions that lead to the ATSB producing a crash report that primarily blamed the pilot Dominic James, but excluded material highly critical of the sub standard performance by CASA of its duties of oversight, including a suppressed document that found the operator Pel-Air was unsafe, and failed to make safety recommendations to the industry as expected of the air safety investigator.

The Senate inquiry, which was instigated by SA independent, Senator Nick Xenophon, and chaired by Senator Bill Heffernan, has among other things called for a reopening of the ATSB inquiry, in effect invalidating its final report.

It says the ATSB should focus on organisational, oversight and broader systemic issues in a renewed inquiry, and has also recommended the immediate retrieval of the flight data recorders from the wreckage of the jet, which was performing a medical repositioning mission for Careflight from Apia to Melbourne via Norfolk Island,  and which lie at an accessible depth on the sea floor not far from the island.

There is no obvious precedent for a Senate inquiry that has so comprehensively criticised two public authorities for their actions and omissions in relation to transport safety in this country.

In its executive summary the committee says:

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The committee examined Dolan (ATSB) and McCormick (CASA) as to their mutual insistence that factors other than the pilot not fueling the jet correctly for the Apia-Norfolk Island sector were immaterial to the outcome, even though the operator did not have a defined oceanic fueling policy, and it was questionable whether the pilot had received due warning of deteriorating conditions at Norfolk Island that would have caused him to divert to Nadi or Noumea rather than continuing toward the intended tech stop.

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The committee said it was ‘troubled by allegations that agencies whose role it is to protect and  enhance aviation safety were acting in ways that could compromise that safety.’

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In the body of the report the committee outlines serious claims that the motivations of the ATSB and CASA were in effect to blame the pilot for everything and conceal grave failings in the administration of air safety in this country from the public.

It said the methodology used by the ATSB to attribute risk in its investigation “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 it produced could help prevent such an accident in the future, offer lessons to the wider industry or enable a better understanding of the actions taken by the crew of the flight. ”

The committee found that the process by which the ATSB, a times in consultation with CASA, downgraded an identified safety issue in the Pel-Air Westwind operations from ‘critical’ to ‘minor’ lacked transparency, objectivity and due process.

The committee said that CASA and Pel-Air had made changes to their procedures since the ditching which had they been in place beforehand could have prevented it from occurring.

“To simply focus on the actions of the pilot and not discuss the the deficiencies of the system as a whole is unhelpful” the committee report says.

“It is disappointing that the ATSB and CASA 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.”

The committee took the unprecedented step in Senate hearings of this nature of warning CASA not to offend the protections of parliamentary privilege by causing ‘adverse consequences” to witnesses in the aviation industry who had assisted the committee with their submissions or in session, sometimes closed session testimonies.

[pic]Following the release of the committee report, Senator Xenophon issued a statement setting out key reforms that the committee had unanimously supported to render the ATSB and CASA made accountable and effective in carrying out their duties in relation to air safety rather than backside covering.

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CASA referred to Federal Police by Senate committee

CASA’s actions in withholding from the ATSB  a document relevant to the 2009 crash of a Pel-Air Westwind jet near Norfolk Island has been referred by a Senate committee to the Federal Police.

In its inquiry into the handling of the crash by CASA, the safety regulator, and the ATSB, the supposedly independent safety investigator,  it said today:

‘The committee considers that CASA’s decision to withhold important documents from the ATSB had a severe impact on the ATSB’s investigative process.”

The documents revealed serious shortcomings in CASA’s functionality and oversight in relation to Pel-Air, the operator of the Careflight aeromedical mission that run out of fuel shortly before it was ditched without loss of life after several attempts to land at Norfolk Island to refuel in deteriorating weather.

Non-disclosure of all relevant documents to the ATSB in the course of an accident inquiry is a breach of section 24 of the Transport Safety Information Act.

There are two documents that are highlighted in this regard by the Senate committee. One was a special audit of Pel-Air conducted by CASA at the time of the crash, which was not withheld by CASA but not formerly requested by the ATSB until late in its investigation.

The other was a Chambers Review ordered by CASA’s Director of Aviation Safety, John McCormick, which was suppressed by CASA, indeed unknown to the ATSB until a copy of it was provided to its chief commissioner Martin Dolan earlier this year.

This is what the Senate committee had to say about the special audit and Chambers review

[pic]Dolan was dismissive of the value of the special audit and the Chambers Review in arriving at a position where he agreed with CASA that it was all the fault of the pilot, and not in any material way, by the non-performance of CASA or the unsafe state of Pel-Air’s Westwind operations at the time of the crash.

This is what the committee said of the Chambers Review:

[pic]And again, about the fact that this was a preventible accident had CASA done its duty, and one which if the ATSB did its job, would have been a deficiency it was supposed to identify with a view to being a safety lesson that could be used to prevent future accidents.

[pic]After considering the consequences of the actions of CASA in withholding the Chambers review from the ATSB the committee says:

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The committee is much fiercer in its criticisms of the performance of the ATSB and CASA in the body of the report than it is in the executive summary sections.

These criticisms have implications for Australia’s standing as a first ranking state in terms of aviation safety when its safeguard organisations are exposed for behaving in their own organisational interests rather than those of the public.

The finding that “CASA’s actions have influenced the conduct of the ATSB investigation to the detriment of aviation safety” is a clear signal to the Minister that action must be taken to restore the integrity of public administration in air safety in Australia with urgency.



ATSB chief’s testimony lacked credibility: Senate

The Senate Committee’s inquiry into the ATSB’s handling of the Pel-Air inquiry devotes an entire chapter (3) to its dissatisfaction with the testimony of its chief commissioner Martin Dolan and the actions of the agency.

It was particularly annoyed by Dolan’s reliance under examination of a version of ICAO Annex 13 to justify his decision not to retrieve the flight data recorder from the crash jet that did not come into force until a year after the accident.

Australia is a signatory to the International Civil Aviation Organisation and this particular annex, which sets out responsibilities and expectations in relation to the investigation of air crashes.

The committee says “Mr Dolan’s evidence in this regard is questionable and has seriously eroded his standing as a witness before the committee.”

One of the committee’s recommendations is that the flight data recorder be retrieved from the seabed near Norfolk Island immediately.

This is part of the committee’s view of the ATSB’s overall performance and obvious failures to carry out its responsibilities, before it discusses the chief commissioner’s decision not to recover the data recording devices.

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It is a scathing examination of the supposedly independent air safety investigator and a mishandling of a crash investigation that is doing deep damage to Australia’s air safety reputation.



ABC news:

Senate Committee releases damning report into Australia's aviation authorities

A Senate Committee has raised serious concerns about the competency of the bodies overseeing Australia's aviation industry.

The committee has investigated the official reviews into a Pel-Air plane ditching into the ocean off Norfolk Island in 2009.

The service had been flying a patient from Samoa to Melbourne for treatment on behalf of CareFlight.

All six people on board survived but only the pilot, Dominic James, escaped without injury.

The committee has found the Civil Aviation Safety body withheld critical documents from the Australian Transport Safety Bureau and that many in the industry are reticent to speak out because of a fear of retribution, especially from CASA.

Independent Senator Nick Xenophon says of particular concern was the evidence of the head of the ATSB, Martin Dolan.

"In respect of his credibility as a witness," Senator Xenophon said.

He says the report highlights serious concerns about the oversight of the industry.

"My confidence in our aviation safety regulators and accident investigation body CASA, the Civil Aviation Safety body and the ATSB have been shaken to the core," he said.

Karen Casey was injured in the crash and says the report must be acted on.

"The truth has finally been revealed," she said.

The report has been referred to the Director of Public Prosecutions.



News Corp:

Committee critical of transport bodies

A SENATE committee has returned a scathing report into the operations of two major Australian transport watchdogs.

The 150-page document highlights failures during the investigation of a plane crash off Norfolk Island.

The Rural and Regional Affairs and Transport References Committee on Thursday tabled a report probing the Australian Transport Safety Bureau's response to a light plane crash in 2009.

Six people on board survived after the aircraft ditched into the ocean near the island east of the nation's mainland.

Committee chair Bill Heffernan said the report also highlighted "significant deficiencies" on the part of the Civil Aviation Safety Authority (CASA), through its failure to convey vital information regarding the plane's operator to the bureau ahead of its investigation.

"If Australia is to remain at the forefront of open, transparent and effective aviation safety systems, then we need our aviation safety organisations to work transparently, effectively and co-operatively," Senator Heffernan said in a statement.

"Ensuring that a systemic approach to aviation safety is in place is the best way to maximise aviation safety outcomes."

Late at night on November 18, 2009 the medical evacuation plane from Samoa ditched just off Norfolk Island after attempting to land four times to refuel in poor weather.

The pilot, Dominic James, was forced to put the plane down before he ran out of fuel after failing to update himself on the weather at Norfolk Island, a subsequent bureau investigation found.

The plane hit the water at about 100km/h and sank quickly.



And another from Ben:

Senate committee ATSB,CASA, Pel-Air wrap

For those who want it in dot points or a tiny silver screen this is what’s in or a consequence of the Senate committee inquiry into the air accident investigation (Pel-Air) report.

• CASA and thus its Director of Air Safety, John McCormick, have been referred to the Federal Police for a possible breach of the Transport Safety Information Act in relation to withholding a relevant document from the ATSB

• The chief commissioner of the ATSB, Martin Dolan, has been severely criticised by the committee for his testimony and the actions of the supposedly independent air safety investigator

• CASA has been warned not to do anything that would offend the protections of parliamentary privilege given to those who made submissions or testimony to the committee in public or in camera.

• The ATSB’s conduct of the Pel-Air inquiry has been variously described as compromised, illogical, inadequate and contrary to the interest of aviation safety or public confidence in air safety investigations in Australia

• The ATSB should reopen its inquiry into the Pel-Air crash and take into account factors its excluded in favour of blaming almost everything on the pilot

• Improvements to weather information availability on Norfolk Island should be variously made or considered

• CASA has been found to have withheld information that if published would have reflected poorly on its acquittal of its duties of oversight and regulation in relation to Pel-Air.

• Both organisations have been criticised for being more concerned with their image than public safety issues

• CASA withheld information that showed that it was aware of deficiencies in the Pel-Air operation which if acted upon may have prevented the Pel-Air crash

• The chief commissioner of the ATSB tried to rely on an international rule concerning air safety investigation that didn’t take force for a year after the Pel-Air crash to justify not retrieving the flight data recorder from the seabed near Norfolk Island

• The committee has made a series of recommendations for improving the transparency and integrity and effectiveness of the ATSB and CASA by the appointment of a powerful Inspector-General of Aviation Safety

• The Senate committee’s findings are unprecedented in the dissatisfaction expressed in the quality, integrity and effectiveness of air safety administration in Australia as in the Federal Police referral and the warning to a public authority not to take action against those whose testimony is protected by parliamentary privilege.

• There is no immediately discoverable record of a national air safety investigator even being requested by a parliamentary review committee to reopen an inquiry on the basis of it being deficient on multiple grounds including internationally accepted standards for such activities



MEDIA RELEASE: Alarming air safety failures revealed in Senate Inquiry

23rd May 2013

Independent Senator for South Australia, Nick Xenophon, has called on the Government to establish an Inspector-General of Aviation Safety after a Senate inquiry revealed serious and systemic failures on the part of CASA and the ATSB in relation to aviation safety.

The Senate Rural and Regional Affairs and Transport Committee released its report into aviation accident investigations this morning. The inquiry was prompted by industry concerns about the quality of the ATSB’s investigation into the ditching of Pel-Air flight VH-NGA off the coast of Norfolk Island in 2010.

The committee’s report revealed:

“CASA and the ATSB made the pilot of VH-NGA into a scapegoat to cover up their own inadequacies, but this goes way beyond one incident,” Nick said. “This report reveals a disturbing trend in Australia’s aviation industry, where the regulatory safety system is failing the travelling public.”

Senator Xenophon said the committee had been “the most united” one he had ever participated in.

“Everyone was shocked and in disbelief about the evidence we received,” Nick said. “I don’t think anyone expected we would uncover the fact that information had been withheld by CASA, or that the ATSB was aware of systemic issues but ignored them completely.”

“This committee report is one of the strongest I’ve ever read,” Nick said. “It outlines in no uncertain terms the serious problems with the way CASA and the ATSB operate.”

Senator Xenophon said there was an urgent need for an Inspector-General of Aviation to be established, to make CASA and the ATSB more accountable.

“There has been an abject failure on the part of these two organisations,” Nick said. “Their relationship and they way they operate is now in such a state that it can only be redeemed by an independent body that can hold them to account.”

• The ATSB had not followed its own mandate in terms of investigations, and had focussed solely on the actions of the pilot, Dominic James, instead of looking at broader problems within Pel-Air itself and with the way aeromedical flights to remote destinations are undertaken;

• CASA had failed in its regulatory oversight of Pel-Air, and only a Special Audit of Pel-Air conducted after the ditching revealed the extent of the problem;

• CASA had withheld a damning internal review from the ATSB, despite a Memorandum of Understanding between the agencies in relation to information-sharing, which outlined its own failures in relation to Pel-Air;

• The quality of evidence provided to the committee by the ATSB’s Chief Commissioner Martin Dolan called into question his credibility as a witness; and

• The ATSB inexplicably downgraded the incident from ‘critical’ to ‘minor’, with little or no reasoning to show why this was the case.

 

Aviation bodies get scathing report card

4:29pm May 23, 2013

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Australia's major aviation safety agencies operate in a cloud of incompetence and are endangering lives.

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That's the wash-up from a senate committee report which has sparked calls for urgent action after probing a 2009 plane crash off Norfolk Island.

"It's an alarming report because it outlines a number of deep concerns that the committee had about systemic and serious failures in terms of aviation safety in this country," committee member Nick Xenophon told reporters on Thursday.

"Right now my confidence in our aviation watchdogs has been shaken to the core.

"This report reveals a disturbing trend in Australia's aviation industry, where the regulatory safety system is failing the travelling public."

Aviation safety consultant and former senior Civil Aviation Safety Authority (CASA) investigator Mick Quinn said the report "really does ring alarm bells for the industry and for the government".

"... if nothing is done there could be tragic results and the details of these recommendations need to be implemented as a matter of urgency," he said.

The Rural and Regional Affairs and Transport References Committee tabled the scathing report outlining inadequacies on the part of the Australian Transport Safety Bureau (ATSB) and CASA.

The 150-page report followed the committee's review of investigations into a November 2009 plane crash off Norfolk Island.

The committee found a raft of shortfalls on the part of CASA and ATSB, including poor channels of communication, which failed protocol.

"The question that has to be asked on behalf of every member of the travelling public who jumps on a plane in this country is: if they've stuffed up in relation to this, where else are they going wrong?" Senator Xenophon said.

Pilot Dominic James was forced to ditch a Pel-Air medical evacuation flight in the ocean near Norfolk Island on a stormy night after repeated attempts to land failed.

All six people on board survived.

While the captain admits "there were things I wish I did better on the night", Senator Xenophon said the ATSB used him as a "scapegoat" to cover up its own inadequacies.

"This is not just about one flight that ditched in the sea and the investigation that ensued. This is about some serious systemic concerns and the committee has made it very clear ... that there are serious issues with respect to aviation safety in this country as a result of the inactions and incompetence of both CASA and the ATSB," Senator Xenophon said.

Nurse Karen Casey was working on the medivac flight on the night of the crash and was seriously injured.

She has not worked since and suffers from ongoing physical and psychological trauma.

"I really do hope that the recommendations that are in this report will be noted and acted upon for the public who fly every single day, which I think is around two million people per month," the 42-year-old Queensland mother of three told reporters.

"It's time for safety to come first."

Senator Xenophon called for the appointment of an inspector general of aviation to oversee the operations of the CASA and ATSB.





Senate committee hands down poor verdict on performance of safety regulator and ATSB

Item by .au at 5:40 pm, Friday May 24 2013   1 Comment 

The ATSB's investigation into the Pel-Air ditching has been called into question.

A near-unprecedented attack on the nation’s aviation safety authorities has been handed down by the Regional and Rural Affairs and Transport References Senate Committee following its enquiry into ‘Aviation Accident Investigations’.

The committee’s 153-page report, which was instigated by the release last August of the ATSB’s findings on the 2009 Pel-Air Westwind ditching off Norfolk Island, contained 26 recommendations that aim to address what the committee sees as deficiencies in the performance of the Civil Aviation Safety Authority (CASA) and the Australian Transport Safety Bureau (ATSB), and importantly, the relationship between them.

Contained in the summary of the committee’s findings is an overarching statement that sets the tone for a scathing attack on the safety regulator and the safety bureau:

“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 industry, the committee report should signal relief, with recognition that undermining confidential reporting would be anathema to sustained safety improvement:

“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.”

Robustly, it added: “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.”

With specific reference to the Pel-Air incident, the committee appeared to effectively suspend the existing ATSB findings and has recommended the investigation be re-opened, supported by a review of the memorandum of understanding between the ATSB and CASA.

Read the full story and list of recommendations in the July issue of Australian Aviation.





















May 25, 2013

Australian Senate: Norfolk Island Crash Investigation Could Lead To Criminal Probe

By Paul Bertorelli, Editorial Director

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In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia’s Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air’s operation that directly contributed to the accident. CASA’s action, says the Senate report, may have violated Australia’s Transport Safety Investigations Act. “It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation,” said Sen. David Fawcett.

The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island enroute from Samoa with a critical but stable patient. The Westwind’s ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight’s captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. Enroute, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB’s accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.

Following the ATSB’s findings, James challenged some of the investigator’s findings but his queries were dismissed by the ATSB. The Australian Senate took up James’ case last year and its probe revealed widespread flaws in the ATSB’s investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that “unequivocally concluded…that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies.” Yet no mention of this report appeared in the ATSB’s findings blaming the pilot.“In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies,” the Senate report said.

Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. “This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That’s why I think we need an inspector general of aviation,” Sen. Nick Xenophone told Australia’s ABC News. “This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB,” he added.

The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB’s chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. “CASA's internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses' evidence that they did not think surveillance was adequate, when CASA's own internal investigations indicate that CASA's oversight was inadequate,” the report said.







Earlier today the Senate Rural and Regional Affairs and Transport References Committee tabled its report into the adequacy of the Australian Transport Safety Bureau's (ATSB) investigation and reporting process.

This inquiry was prompted by an ATSB investigation and report into the ocean ditching of an aeromedical flight off Norfolk Island in 2009. Six people were on board the flight and all are lucky to have survived.

The Chair of the Senate Committee, Senator Bill Heffernan said that "the aim of the Committee's inquiry was not to investigate the particular circumstances of the accident. Instead it was to maximise the safety outcomes of future ATSB and Civil Aviation Safety Authority (CASA) investigations in the interests of the Australian travelling public."

During the course of the inquiry, the Committee found that there were significant deficiencies with both the operator Pel-Air (identified in the CASA Special Audit), and CASA's oversight of Pel-Air (identified in the Chambers Report). "What is startling is that CASA did not provide the ATSB with these critical documents in clear contravention of the agencies' Memorandum of Understanding" said Senator Heffernan.

The Committee's report notes the warnings that the omission or downgrading of important safety information by the ATSB has the potential to adversely affect aviation safety.

Senator Heffernan said that he "hopes that the Committee's report will raise the bar on the ATSB's standard of aviation safety reporting. The ATSB should return to the previous pattern of aviation safety reporting by providing valuable learnings for the aviation sector in order to minimise the risk of a similar traumatic incident occurring in future."

Senator Heffernan concluded that "if Australia is to remain at the forefront of open, transparent and effective aviation safety systems, then we need our aviation safety organisations to work transparently, effectively and cooperatively. Ensuring that a systemic approach to aviation safety is in place is the best way to maximise aviation safety outcomes."

END



|Air crash investigation needs full throttle response | 27th May, 2013 |

|“MINISTER Anthony Albanese must urgently respond to the recommendations flowing from a Senate Committee investigation into a |

|ditched Pel-Air flight off Norfolk Island in November 2009,” Nationals leader and Shadow Minister for Infrastructure and |

|Transport Warren Truss said today. |

| |

|“The recommendations, handed down last Thursday by the Senate Rural and Regional Affairs and Transport References Committee |

|in their Aviation Accident Investigations Report, make disturbing reading. |

| |

|“The Senate Inquiry was established following the release of the Australian Transport Safety Bureau’s (ATSB’s) report into |

|the Norfolk Island incident almost three years after the event. |

| |

|“The circumstances of the flight were both a disaster and a miracle. Despite mistakes being made by the pilot on the air |

|ambulance trip from Apia (Samoa) to the Australian mainland, all four passengers and two crew were saved, the aircraft |

|successfully ditching at night off the coast of Norfolk Island during bad weather. |

| |

|“However, the purpose of the Senate Inquiry was not the incident itself, but the alleged breakdown in investigation and |

|reporting by the ATSB and the Civil Aviation Safety Authority (CASA). |

| |

|“Specifically, the report states: |

| |

|‘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 CASA investigations in the interests of the |

|travelling public’. |

| |

|“The report makes 26 recommendations to improve the conduct, regulation and procedures governing aviation incident |

|investigations, which the Committee argues were not up to scratch. |

| |

|“People have every right to expect world’s best practice when it comes to aviation safety, which includes comprehensive |

|investigation and reporting of incidents. The community is entitled to have confidence in our aviation safety regulations and|

|the conduct of our regulators. |

| |

|“Similarly, it is vital that through comprehensive incident investigations and reporting, industry and regulators are |

|accorded the opportunity to learn from past mistakes and improve systems to overcome existing weaknesses. |

| |

|“The Report raises serious issues of process that must be addressed. Minister Albanese must restore public confidence in our |

|accident investigatory bodies and deal with the concerns raised in the Inquiry as a matter of urgency.” |

| |

|[ENDS] |









ATSB: A bulletin from a rotten organisation?

• Ben Sandilands | May 29, 2013 9:06AM |

Less than a week after a unanimously scathing Senate committee inquiry into the ATSB’s deficient and deceitful investigation of the 2009 Pel-Air crash, the ATSB is on a PR offensive.  And it is offensive.

Why is the ATSB spending money producing the so called ATSB Investigator Bulletin when it claims it can’t even afford to raise the flight data recorder from the wreckage of the Pel-Air Westwind from its comparatively shallow location on the sea floor near Norfolk Island?

What is the ATSB frightened of?

How can anyone trust this organisation after reading and considering this report into the ATSB, and its relationship with CASA when the so-called Investigator, below, starts popping up in their email?

[pic]

How can anyone trust a national air safety investigator that doesn’t make safety recommendations after an accident in which six people had to escape from a ditched corporate jet, a Westwind, contrary to Australia’s international air safety obligations in relation to such accidents?

How can a body whose chief commissioner, Martin Dolan, lost the confidence of the Senate inquiry through his dubious testimony, be considered to be under appropriate and responsible administration?

How is an ATSB report, which is crafted in concert with CASA, to frame most of the blame for the accident on a pilot, in keeping with Australian expectations of fair, thorough, comprehensive and diligent investigation after Mr Dolan dismissed the relevance of a suppressed internal CASA audit which found the operator Pel-Air to have been in serious breach of dozens of safety standards?

Why is it tolerable in Australian government for the ATSB to dismiss as irrelevant such systemic and organisational factors as a CASA audit that found that it had failed very comprehensively to carry out its duties of oversight and intervention in the Pel-Air operation, when such actions by CASA could have prevented the accident?

Since when can an individual be comprehensively scapegoated for the failures of two once trusted aviation safety bodies in Australia to properly ensure the safety of the public through the enforcement of rules, the carrying out of duties, and the independent investigation of accidents?

We hear a lot of talk about social justice and equity from all political parties in this country.

Whether the terminology refers to ‘the Labor way’ or coalition insistence of open, transparent and responsible public administration, why would something as rotten as the conduct of the ATSB and CASA in the Pel-Air accident be tolerated  for even another day?

• David Klein

Posted May 29, 2013 at 10:50 am | Permalink

Ben,I agree with your comments and having witnessed many of the activities of both BASI and the ATSB first hand as a CASA inspector, the slide in flight safety oversight performance over the years apears to have been commensurate with signficant government cost cutting and ineffective management. My confidence in the ATSB sharply declined after it was restructured from its predecessor BASI and questionable investigation findings were released. As an example the attached AVweb link



on the Whyalla Airlines fatal accident over 10 years ago, the ATSB inspection analysis was viewed as “junk science” in a USA newsletter and many of my CASA airworthiness colleagues agreed.

• 2

[pic]Tomcat

Posted May 29, 2013 at 11:06 am | Permalink

The quietness and lack of public activity on this report is deafening. The report itself is explosive in its damning of the agencies involved and yet it appears the heads of CASA and the ATSB are going to tough it out to survive. More alarming is the lack of response from the Government and Opposition and yet the report was unanimously. What has to be done or how many more have to die in this country before these issues are addressed? Even the mainstream media are behaving as though the report never existed.



| | |

May 28, 2013

Accidents: The Pilot as Last Defense

By Paul Bertorelli

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|i| |

|c| |

|]| |

For a number of months now, I've been reporting on the November 2009 Norfolk Island ditching of a Westwind jet. The Australian Transportation Safety Board's investigation of this accident has been widely regarded as a mess, criticized equally by the Australian pilot community, the press and lately, by the country's Senate. As we reported over the weekend, the ATSB's report (PDF) was cited for numerous omissions related to how regulators oversaw Pel-Air, the company that owned the Westwind.

Thorough as the Senate report is, I found one phrase in it that suggests it wasn't written by pilots. Or maybe by pilots with a different view of PIC responsibility than I have. In citing numerous deficiencies in how regulators oversaw Pel-Air, the report said these failings left the pilot "as the last line of defense against an accident."

I found this utterly jarring and the report repeated it several times. The gist of it is this: It's the regulations and operations specs that make flying safe, the pilot is only there if those don't cover all exigencies or novel situations otherwise arise. It's not quite the dog-and-autopilot concept, but it's close. To a degree, it's a semantical distinction, but an important one, nonetheless. To take it to an extreme, when you put on your PIC hat, you are the first thing and the only thing between you and your passengers and an accident—not instruments, not traffic boxes, neither radar nor datalink weather, GPWS, glass panels or BRS parachutes or ATC. And definitely not regulations and ops specs, although they undeniably play a critical role in safety.

Those things provide a basic structure by which to frame decision making, yet they don't help with the novel situations which are perfectly legal, but if not entirely unsafe, are only safe with no margins worthy of the name. The Peli-Air flight fit that latter description to a T. Given the weather forecast, fuel loads and distance, it was legally dispatched to a remote island with notoriously difficult-to-forecast weather, at night, with the closest airport some 400 miles away and hopelessly beyond fuel range. There was no legal requirement for an alternate, thus one wasn't filed or planned.

So at the outset, what the Senate calls the first line of defense—the regulations and op specs—was functionally non-existent, which is the core of the scandal here, in the Senate's reasoning. The Civil Aviation Safety Authority knew this, yet scape-goated pilot error as the primary cause of the accident. The pilot was hardly blameless; you can decide for yourself how to apportion responsibility. As is the case with so much in flying, survival—or at least accident avoidance—turns on pilot instincts and skills and all the regulations and cockpit gadgets do is provide entertaining diversion and, okay, some helpful data. If all that stuff fails to keep you from extremis in the first place, you fall back on your lowest level of training and hope it's high enough.

What informs the skill and instincts in part is knowledge of previous accidents. Systemic safety evolves from unbiased understanding of accident causes and on this point, the ATSB dragged the entire safety edifice backwards. In blaming the pilot for the accident almost entirely, it failed to account for known failings in CASA's oversight that, in an ideal world, might have shaped or at least informed his judgment or simply flat-out prohibited the flight in equipment suited to the task only if everything went just right. This kind of flawed accident investigation sows mistrust and is an absolute menace to advancing safety based on known flaws.

I suspect the Australians will have their hands full fixing this because the Senate report gives the impression that it's a cultural shortcoming within the agencies themselves. At least the investigation into the investigation gives them a good start.



Ben’s QONs

▪ Why is the ATSB spending money producing the so called ATSB Investigator Bulletin when it claims it can’t even afford to raise the flight data recorder from the wreckage of the Pel-Air Westwind from its comparatively shallow location on the sea floor near Norfolk Island?

▪ How can anyone trust this organisation after reading and considering this report into the ATSB, and its relationship with CASA when the so-called Investigator, below, starts popping up in their email?

▪ How can anyone trust a national air safety investigator that doesn’t make safety recommendations after an accident in which six people had to escape from a ditched corporate jet, a Westwind, contrary to Australia’s international air safety obligations in relation to such accidents?

▪ How can a body whose chief commissioner, Martin Dolan, lost the confidence of the Senate inquiry through his dubious testimony, be considered to be under appropriate and responsible administration?

▪ How is an ATSB report, which is crafted in concert with CASA, to frame most of the blame for the accident on a pilot, in keeping with Australian expectations of fair, thorough, comprehensive and diligent investigation after Mr Dolan dismissed the relevance of a suppressed internal CASA audit which found the operator Pel-Air to have been in serious breach of dozens of safety standards?

▪ Why is it tolerable in Australian government for the ATSB to dismiss as irrelevant such systemic and organisational factors as a CASA audit that found that it had failed very comprehensively to carry out its duties of oversight and intervention in the Pel-Air operation, when such actions by CASA could have prevented the accident?

▪ Since when can an individual be comprehensively scapegoated for the failures of two once trusted aviation safety bodies in Australia to properly ensure the safety of the public through the enforcement of rules, the carrying out of duties, and the independent investigation of accidents?

▪ Whether the terminology refers to ‘the Labor way’ or coalition insistence of open, transparent and responsible public administration, why would something as rotten as the conduct of the ATSB and CASA in the Pel-Air accident be tolerated  for even another day?

Pel-Air update: Minister wants to respond with urgency

Ben Sandilands | May 29, 2013 7:23PM | EMAIL | PRINT

It’s rare for departmental secretaries to volunteer information about Ministerial reactions to issues in advance, but Mike Mrdak, Secretary of the Department of Infrastructure and transport, did this for his Minister, Anthony Albanese tonight.

Mrdak, who appeared with CASA Director of Safety, John McCormick at Senate Estimates hearings, said he could confirm that the Minister “certainly understands the urgency of the need to respond to the report”, referring to last weeks highly critical Senate committee inquiry findings and recommendations in relation the ATSB final report into the Pel-Air ditching near Norfolk Island on 18 November 2009.

He said he had held a preliminary meeting with Minister Albanese concerning the report, and would meet again within a week in relation to an initial response to its contents.



Pel-Air update 2: ATSB to consider Senate report on 24 July

Ben Sandilands | May 29, 2013 9:05PM | EMAIL | PRINT

Full fathom five, or more, the Pel-Air mystery lies: ATSB photo

 

In Senate Estimates hearings tonight the chief commissioner of the ATSB, Martin Dolan, said that he and its two part time commissioners would consider the Senate Committee report and recommendations concerning the disputed  final report by the ATSB into the Pel-Air crash of 2009 on 24 July.

Dolan told the hearing that the meeting of the commissioners was obliged to consider retrieving the flight data recorder from the wreckage on the sea floor near Norfolk Island and reopening its inquiries to consider broader matters other than the actions of the pilot because they were parliamentary recommendations.

He resisted the suggestion by Nick Xenophon, independent Senator, SA, that the ATSB should engage an independent aviation safety expert to impartially assess whether or not it should accept these recommendations in order to avoid the appearance of ‘Caesar judging Caesar’.

During the hearing the Mike Mrdak, the Secretary of the Department of Infrastructure and Transport, spoke up to say that the Senators were putting to Mr Dolan matters that clearly had to be considered by the government.

This evening’s estimates hearings proceedings need to be checked against Hansard tomorrow for any nuances that were inaudible in the on-line broadcast of proceedings.

Not only was it hard to hear what was being said for those watching on-line, but even in the room, with Senator Fiona Nash, Nationals NSW, who was only metres away from Dolan, mentioning that she was having difficulty hearing him.



Plane Ran Out Of Fuel And Ditched Of The Coast Of Norfolk Island In The South Pacific

The Australian Senate has released a committee report focusing on an accident which occurred in 2009 involving a medical evacuation flight from Samoa.

The Australian Broadcasting Company (ABC) reports that all six people aboard the flight survived ditching in the South Pacific Ocean, though some were seriously injured. Australian air safety investigators said that the plane ran out of fuel, laying the blame on the pilot for the accident. The ATSB said that pilot Dominic James did not load enough fuel on board the twin-engine jet for the flight and should have diverted to the nearest airport in Fiji before the fuel situation became critical. James reportedly made "several" landing attempts in very poor weather conditions on Norfolk Island before ditching the airplane.

But the Senate committee report places at least some of the blame on Australia's air safety authorities. Transport Committee Chair David Fawcett said that the ATSB report "glossed over all of the systemic factors which clearly played a role in the lead-up to the accident."

Fawcett told the ABC that the company, Pel-Air, was known to have problems, but the Civil Aviation Safety Authority (CASA) and the ATSB "made each other look good" after the accident. The committee said CASA "withheld crucial documents critical of Pel-Air," which is potentially a criminal offense.

The two agencies have often been at loggerheads, but in this case, members of the committee say they have been "working together." Australian Independent Senator Nick Xenophon said that the situation calls for an inspector general of aviation "so that we actually have an independent body that can oversee what they do and how the do it."



An Australian Senate Committee inquiry criticised the Australian aviation regulator CASA as well as Australian Transport Safety Bureau (ATSB) on their role in a 2009 accident investigation.

The Senate Committee on Aviation accident investigations was initiated in the wake of an accident involving the ditching of a medical evacuation IAI Westwind jet in November 2009.

The airplane was en route from Apia, Samoa to Norfolk Island in the Pacific Ocean. Headwind was greater than expected and the weather conditions at Norfolk Island deteriorated. The crew had increasing concerns about their fuel reserves but did not divert to an alternate airport. Following four missed approaches to Norfolk Airport in poor weather, the pilot ditched the plane close to the shore. All six on board were rescued.

ATSB concluded that the pilot of the accident flight amongst others “did not plan the flight in accordance with the existing regulatory and operator requirements”.

An episode of the Australian current affairs tv programme Four Corners indicated that there were inconsistencies between the ATSB investigation report and a Special Audit from the Civil Aviation Safety Authority into the operator of the medevac jet.

In September 2012, Independent Senator for South Australia, Nick Xenophon, successfully called for the establishment of a Senate inquiry. The committee’s objective was to find out why the pilot became the last line of defence and to maximise the safety outcomes of future ATSB and Civil Aviation Safety Authority (CASA) investigations in the interests of the travelling public.

Many submitters and witnesses in the inquiry asserted that the ATSB’s report was not balanced and included scant coverage of contributing systemic factors such as organisational and regulatory issues, human factors and survivability aspects.

The Committee stated that CASA failed to provide the ATSB with critical audit documents regarding the operator of the airplane. These documents “demonstrated CASA’s failure to properly oversee the Pel-Air operations,” according to the Committee.

Parts of the ATSB investigation process lacked transparency, objectivity and due process. The committee finds that the ATSB’s subjective investigative processes were driven in part by ministerial guidance prioritising high capacity public transport operations over other types of aviation transport.

The inquiry has made 26 recommendations, including redrafting the information sharing agreement between CASA and the ATSB, and re-opening the Pel Air inquiry.

• Senate Committee Report

• Four Corners tv programme

• ASN Accident Description Westwind accident at Norfolk Island

 



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