Canadian study identifies flawed processes and policies

An independent review of the ATSB’s investigation processes and methodologies delivered its report on schedule this week. But it won’t bring much comfort to industry, nor to a travelling public already uneasy over the revelations of the Aviation Safety Regulation Review; and last week’s grilling of Airservices Australia executives in Senate Estimates over top-level management conflict, concerns over possible whistle-blower abuses and the non-resolution of long-standing operational safety issues.

ATSB had commissioned a “peer review” by its Canadian counterpart, the Transportation Safety Bureau of Canada, in the wake of a series of adverse findings by a Senate committee and widespread media coverage centred on the ATSB’s investigation into the ditching of a Pel-Air Aeromedical Westwind jet at Norfolk Island in November 2009.

The TSB’s terms of reference were to conduct a new and independent objective review of ATSB’s investigation methodologies and processes, working independently of any other person or organisation.. The reviewers were not asked to revisit the Norfolk Island findings, but to review the way the investigation was conducted, and also to review two other investigations – an Augusta helicopter winching accident in December 2011 at Kangaroo Valley, and a Piper Chieftain crash at Canley Vale near Bankstown airport in June 2010.

That meant that at least for now, the deeply flawed Norfolk Island investigation report would remain on the public record indefinitely, presumably as a standing reminder of how not to go about meeting the ATSB’s and CASA’s obligations.

The other two accidents were added to the assignment “in order to provide a useful comparison” of ATSB’s procedures over a wider spread of events.

Perhaps also to identify whether the Norfolk investigation was a random aberration, or par for the course. ProAviation is in contact with several parties who have been equally injured by the arrogance and overconfidence of both organisations.

On the Norfolk Island investigation, the TSBC commented:

The TSB Review of the Norfolk Island investigation revealed lapses in the application of the ATSB methodology with respect to the collection of factual information, and a lack of an iterative approach to analysis. The review also identified potential shortcomings in ATSB processes, whereby errors and flawed analysis stemming from the poor application of existing processes were not mitigated.

Problems identified by the Canadians included “misunderstandings” about the respective responsibilities of CASA and the ATSB, leading to the ATSB collecting insufficient information from the operator, which in turn also hampered the analysis of specific safety issues; weaknesses in the application of the ATSB analysis framework, lapses from normal accident investigation procedure; and the re-categorisation of a ‘critical’ safety issue to ‘minor’, which shifted the focus away from the issue itself – and the potential for its mitigation.

In contrast, the TSB was less critical of the Kangaroo Valley and Canley Vale investigations, despite considerable industry disquiet with their findings.

The TSB Review made 14 recommendations to the ATSB in four main areas:

  •  “Ensuring the consistent application of existing methodologies and processes;
  • “Improving investigation methodologies and processes where they were found to have deficiencies,’
  • “Improving the oversight and governance of investigations , and
  • “Managing communications challenges more effectively.”

Findings from the TSB review of the Norfolk Island investigation were:

1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.

2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.

3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.

4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analysed.

5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.

6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.

7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.

8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.

9. At the ATSB, the Commission does not formally review some reports until after the DIP [directly interested parties] process is complete. This increases the risk that issues with the scope of the investigation and the quality of the report will be identified too late in the process to be resolved.

10. The lack of a robustly documented feedback process after the Commission review increases the risk that issues with the scope of the investigation and the quality of the report will not be addressed.

11. Ultimately, the lack of a process for the Commission to review the DIP responses, ensure the DIP comments were addressed, and provide DIPs feedback reduced the effectiveness of the DIP process in improving the quality of the Norfolk Island report.

12. Although senior managers were aware of the possibility that the report would generate some controversy, communications staff were not consulted and no communications plan was developed.

13. Once the investigation became the subject of an external inquiry, the ATSB could no longer comment publicly on the report, which hampered the Bureau’s ability to defend its reputation.

The report’s recommendations offer comprehensive fixes to identified problem areas as well as throwing further light on the deliberations of the Canadian team.

The review reported on, but did not criticise the ATSB’s controversial decision not to spend $200,000 on recovering the cockpit voice and flight data recorders, notwithstanding that there were several unique lessons to be learned from a successful night ditching of a light jet in a remote area which was survived by all six occupants.

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About Paul Phelan

Paul Phelan flew for over 50 years in private, charter, corporate and regional aviation, worked in senior management roles with a major regional airline, and retains his license. In parallel he has been writing for Australian and international aviation journals for well over 20 years on all aspects of aviation including aircraft evaluation, flying, industry affairs, infrastructure, manufacture, regulatory affairs, safety, technologies and training. He has won three separate National Aviation Press Club awards for "best technical aviation story of the year."

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