** 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.
http://www.abc.net.au/7.30/content/2013/s3766257.htm
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.
http://blogs.crikey.com.au/planetalking/2013/05/23/senate-urges-atsb-to-re-open-botched-pel-air-crash-report/
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:
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.
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.’
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.
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.
http://blogs.crikey.com.au/planetalking/2013/05/23/damning-senate-report-on-atsb-casa-pel-air-failings/
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.”