May 23, 2013
The nation’s air safety infrastructure is headed for a historic renaissance in the wake of the Senate committee report on aviation accident investigations, released today in the wake of the Pel-Air ditching at Norfolk Island in November 2009.
Leading among the committee’s recommendations are the urgent recovery by the ATSB of the aircraft’s cockpit voice and flight data recorders, a rerun of the entire investigation, a drastic rearrangement of the structures within which ATSB and CASA operate, the establishment of an ICAO Annex 13 independent panel to oversee ATSB investigations and reporting, as well as a referral to the Australian Federal Police to investigate whether CASA breached the Transport Safety Investigation Act by withholding critical documents during the investigation.
Liberal Senator David Fawcett, who has a strong aviation technical and flying background as a former Commanding Officer of the RAAF’s Aircraft Research & Development Unit (ARDU), was a key participant in the enquiry. He says the report highlights that the performance of the two agencies does not conform with the objectives of the 2010 review titled Australia’s State Aviation Safety Program:
“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 specialized 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,” added Sen Fawcett. “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.
“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.”
In supplementary comments circulated with the report from the Rural & Regional Affairs and Transport References Committee, Sen Nick Xenophon says: “The evidence given by Mr McCormick of CASA and Mr Dolan of the ATSB was both shocking and disturbing. What at first seemed a fairly straightforward enquiry, instead turned up evidence of withheld documents, poor reporting standards, institutional blindness and what appears to be CASA’s undue and potentially dangerous influence over the ATSB and its investigation processes. It is clear to me that both agencies have been allowed to operate to a sub-par standard with little knowledge or intervention for too long.”
The committee’s recommendations (in blue) and our commentary
1. The committee recommends that the ATSB retrieves VH-NGA flight data recorders without further delay.
Throughout the enquiry, the ATSB ‘s decision not to recover the cockpit voice recorder and flight data recorder had been denounced by air safety practitioners. The fitment of CVRs and FDRs is mandatory in this category of aircraft, and the International safety community relies heavily on those systems as a readily available tool for enhancing air safety even while investigations are still in progress.
The report comments: “the committee understands that retrieval of the recorders would be particularly useful in this instance [and] that the ATSB has certain responsibilities, set out in ICAO Annex 13, when it comes to retrieval of aircraft involved in accidents. It is an assumption throughout Annex 13 that, where a FDR exists, the accident investigation body will prioritise its retrieval.”
The vital role of these investigative aids was highlighted by Air France’s Airbus A330 accident over the Atlantic in June 2009. Although in their absence the investigation reached sound provisional conclusions, the full resolution of the disaster was not achieved until two years later when the recorders were recovered from the ocean floor.
The committee was visibly unsatisfied about the non-retrieval of the recorders, and even about the international legality of the decision not to recover them. ICAO Annex 13 specifies: “the State conducting the investigation shall arrange for the read-out of the flight recorders without delay.”
2. 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 classifications.
The issue has received scant attention over many years, because current regulation fails to provide equivalent regulatory protection for a huge variety of air passengers who are not protected by current airline regulation. They range from corporate executives, to fly-in-fly-out resource workers, to medevac and air rescue passengers, to police officers and prisoners (some not yet convicted.)
3. 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.
The ATSB and CASA have long been criticised on this issue. Proactive ATSB research and CASA safety education programs/publications appear to have an aversion for discussing current domestic air safety issues.
4. The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.
Such a measure would certainly have aided the committees deliberations: “The committee is concerned by the fact that no paper trail exists clearly documenting the ATSB’s decision to downgrade the issue [to a “minor safety issue”] should a similar accident occur in the future, this fact will surely be seen as a missed opportunity to enhance safety. The reasoning behind the downgrade, and the process and evidence leading to it, appears at the least unclear.”
The committee said it had considered a number of ways to encourage improvements in the conduct of safety investigations and production of reports, and foreshadows close scrutiny of issues that are causing daily increasing industry concern: “These resolve around the remit of the agency, the expertise of its leaders and quality control of its product.”
5. 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.
An aspect that attracted the committee’s scrutiny was the history of the ATSB’s formation with civil aviation as just one element of a multi-modal investigator that also covers the maritime and rail environments – an aspect that may have diluted the level of aviation expertise as air safety experts transferred from the regulator to the newly established ATSB. The committee comments: “to address these shortcomings, the committee was told that the theoretical internal investigator courses the ATSB conducts simply cannot replace technical experience, and should be supplemented with training offered by the NTSB [USA] and AAIB [UK]. The committee supports this view.”
6. The committee recommends that as far as available resources allow, ATSB investigators be given access to training provided by the agency’s international counterparts. When this does not occur, resultant gaps in training competence must be advised to the Minister and the Parliament.
Interaction with international counterparts has always been a popular concept at the workface both in regulation and accident investigation. The notion of learning from other agencies however has not been embraced to the same degree, and in some cases has been scornfully rejected. A senior NZCAA official once recounted to us that when both New Zealand and Australia were setting out on the path to regulatory reform and New Zealand was already leading by a couple of laps, the offer was made to the Australian regulator to sell us the entire NZ program on a floppy disk for $1 million. It is some time since the ongoing programme in Australia has been costed, but it must by now be close to $½ billion.
7. 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.
8. 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.
Industry identities are already applauding this proposal, which the committee noted would “go a long way to increasing public and industry confidence. It would also provide an independent advocate to indicate to the government when budget pressures, combined with workloads, are putting pressure on the ATSB to take shortcuts which are in breach of best practice and Australia’s international obligations.”
9. The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the Minister.
If all the committee’s recommendations are taken up, supplementary funding will be an early imperative because……..
10. The committee recommends that the investigation be reopened by the ATSB with a focus on organisational, oversight and broader systemic issues.
Stakeholders are confident that this will happen, that a fully ICAO compliant model investigation will ensue, and that the process will become a new landmark in Australia’s air safety investigation history.
11. The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This would involve an evaluation benchmarked against a credible peer (such as the FAA or CAA) [USA and UK] of regulation and audits with respect to:
- non-RPT passenger carrying operations;
- approach to audits; and training; and
- standardisation of FOI [flight operations inspection?] across regional offices.
CASA processes as highlighted by the committee’s enquiry are certain to receive close investigation, and there is an expectation that the three dot-pointed issues, each of which have been incessant industry irritants for years, will soon be amply scrutinised, dealt with, and put to rest.
12. The committee recommends that CASA, in consultation with an emergency medical services industry representative group (e.g. 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 with standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.
Emergency air services of all kinds have always faced the challenge of elevated risk levels, often by nature of their suddenness, urgency, remote location, randomness of occurrence, and in some cases limited operational experience that comes with low annual flying hours. An industry plan as proposed, including involvement in the audit team, would be welcome, with the caveat that it should not be seen as an opening for regulatory micromanagement.
13. The committee recommends that a short enquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess their direction, progress and resources expended to date to ensure greater visibility of the process.
This is an issue which is creating near-desperation in several industry sectors, with the near-certainty that the whole regulatory structure will eventually have to be rebuilt because industry is finding it a dysfunctional and unworkable.
14. The committee recommends that the ATSB – CASA memorandum of understanding be redrafted 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.
The Senate committee closely examined the ATSB/CASA MoU and whether it was achieving its goals, And was less than fully impressed.
“The committee is of the view that CASA has adopted a rather self-serving interpretation of the MoU, which allows the agency to laud the spirit of the document whilst simultaneously failing to adhere to its contents when convenient. Whilst aware that the MoU between the ATSB and CASA is not a legally binding document, it nonetheless has an intended aim, and therefore fails to serve its purpose is not adhered to. The committee concludes that CASA’s decision to withhold important documents from the ATSB has……… had a severe impact on the ATSB’s investigative process.”
15. 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.
That recommendation was a reminder that the two organisations had been blindsided by the unexpected appearance during the enquiry, of e-mail communications between them;
Evidence received by the committee would appear to suggest that senior ATSB staff may have intervened to alter the final report in order to secure a desirable outcome for both the ATSB and CASA. An excerpt from the internal e-mail outlining an early discussion reads:
We [ATSB officer and ATSB chief commissioner] were discussing the potential to reflect the intent of our new MoU that describes the two agencies as ’independent and complementary’. We discussed the hole that CASA might have got itself into by its interventions since ditching, and how you [Mr Martin Dolan, ATSB Chief Commissioner] might have identified an optimal path that will maximise the safety outcome without either agency planting egg on the other agency’s face.”
Air safety experts share our impression that the remainder of the committee’s recommendations are equally incisive and relevant to the committee’s terms of reference, and that each identifies and prescribes a remedy for an observed deficiency or a potential booby trap:
16. The committee recommends that where relevant, the ATSB include the human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.
17. 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 six months and report every 12 months to Parliament.
18. 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.
19. 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 is should be made public, and provided to the Senate Regional & Rural Affairs and Transport Committee prior to each budget estimates.
20. The committee recommends that where the consideration and implementation of ATSB recommendation may be protracted, the requirement for public updates (for example six monthly) should be included in the TSI act.
21. 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.
22. The committee recommends that Air Services Australia discuss the safety case for providing a hazard alert service with Fiji and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.
23. 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 approved meteorological observer.
24. The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, folk Island is available to assist flight crews and operators managing risk that may result from unforeseen weather events.
25. The committee recommends that the Australian 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.
26. The committee recommends 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.
Mick Quinn, a highly experienced air safety investigator and witness participant in the enquiry, comments:
“It’s as good a report as you can get and I think it’s going to be a catalyst for a lot of improvement. It’s so good that it should be used in universities to teach how not to do air safety investigation in the future. The technical experience that Sen David Fawcett brought to the committee, and the acuity of Sen Nick Xenophon and all the others, was remarkable. It’s a credit to all of the senators and the Secretariat has also done an amazing job. I’ve gone through the whole thing and I can’t find a mistake in it, and with such solid evidence and 26 recommendations, it’s going to be very hard for the government to ignore it. I believe that David Fawcett, if what we expect happens in September, could be a huge asset to the incoming government in sorting out the mess.
“No enquiry of this kind has ever presented such a finely-tuned, responsive and dynamic report.”
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