Deficient?

The strength of criticisms and recommendations stand to result in a redefining of the framework within which aviation safety regulation in Australia is managed. Accordingly, they should not be under-estimated for their future value.

For industry, they echo sentiments roundly expressed for a considerable period about the method of management and indeed the safety culture of CASA and its influence on industry and, in the case of the committee enquiry, on the ATSB.

In this regard, committee chairman Senator David Fawcett told Australian Aviation : “The report provides evidence there are deficiencies to be overcome in both agencies and to that extent it will provide some relief to individuals and those in industry who have been struggling to establish that the system is not without fault,” while noting, however: “To be fair to CASA, I have also seen cases where I think demands from some individuals and companies have not been supported by good evidence or reasoning and so I’m sure that there will remain some who are unhappy with any regulator that does not allow them to act as they see fit. ” 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 investigator: “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…” Senator Fawcett said further: “The committee noted in the report that both the ATSB and CASA continued to deny the existence of any problems during the hearings despite conclusive evidence drawn from their own records being placed before them.

“That says to me that whether it is an entrenched inability to recognise the need for change or a deliberate choice to avoid change, it is clear that strong political leadership will be required to bring about change. ” Another key area of concern for the committee was the apparent influence CASA has exerted on the ATSB.

“The committee also focuses on the appropriateness and effectiveness of the interaction between the ATSB and CASA. The committee notes that a systemic approach to the investigation was initially pursued, but that systemic issues were scoped out of the investigation early in the process. This led the committee to ask whether CASA exerted undue influence on the ATSB process.

“What is clear is that CASA’s failure to provide the ATSB with critical documents, including the Chambers Report and CASA’s Special Audit of Pel-Air, which both demonstrated CASA’s failure to properly oversee the Pel- Air operations, contravened the Memorandum of Understanding (MoU) in place between the two agencies and may have breached the terms of the Transport Safety Investigations Act 2003 (Chapter 7). The committee takes a dim view of CASA’s actions in this regard. ” For industry, the committee’s report should signal some relief from a highly contentious proposal by CASA to make hitherto confidential safety reports – under the ‘just culture’ of mandatory reporting – available to the regulator to enable it to take action against operators, a move industry has said would be anathema to sustained safety improvement.

The committee commented: “… 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. ” Even more robustly, the report stated: “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 ATSB findings and has recommended the investigation be re-opened, supported by a review of the memorandum of understanding between the ATSB and CASA.

“On the basis of evidence received and the committee’s own assessment of the ATSB report on the Norfolk Island accident, the committee has formed the view that the investigation report does not provide sufficient information about the system within which the flightcrew operated. The ATSB’s almost non-existent analysis of the organisational and regulatory environment does not provide a balanced report, nor does it appear to comply with the requirements of ICAO Annex 13. Ultimately, the report does not meet the ATSB’s own written standards, nor does it help the industry learn from this accident, which is a fundamental and vital aspect of ATSB investigation reports.

“Because of the unbalanced nature of the ATSB report, the only conclusion that a reader could plausibly reach is that the accident in question was caused by pilot error. In turn, this appears to imply that the suspension of that particular pilot’s licences by CASA was the only action necessary to enhance safety and reduce future risk.

“On the basis of evidence presented, however, the committee does not accept this analysis or conclusion. Decisions made and actions taken by the crew are certainly important and are often the last line of defence in terms of aviation safety. This instance was no exception, and the committee is aware of errors that may have been made by the pilot. However, all flightcrews clearly operate in circumstances significantly structured and influenced by the regulatory and operational environment.

“As put by the pilot in command on board Pel-Air’s VH-NGA: ‘As the pilot in command, I wish to make it clear that on that night I was not operating by myself in a vacuum. I was licenced by CASA, trained by structures that CASA created and worked for a company [Pel-Air] using procedures CASA had approved, and yet CASA found I was the problem. ’ ” For former Pel-Air pilot Dominic James, who was one day a hero and the next castigated for his actions and in the process losing his licence and professional credibility, the suspension of the ATSB findings and recommendation the investigation be re-opened will be endorsement of his stated views.

Independent Senator, Nick Xenophon, told the ABC’s 7. 30 Report : “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. ” Not surprsingly then, CASA and the ATSB fared badly in the report for the litany of failings to recognise the deficiencies in the Pel-Air safety management systems and culture that contributed to the accident in 2009.

“Ultimately, the (Pel-Air) report does not meet the ATSB’s own written standards, nor does it help the industry learn from this accident, which is a fundamental and vital aspect of ATSB reports. ” For its part, in response to the report, CASA said simply: “CASA is aware of the Senate report… and will give it due consideration. ” Perhaps coincidentally, on the day of the release of the committee’s report CASA head John McCormick issued his monthly news update to industry, in which he was defiant against public and industry criticisms.

“Comments and remarks about CASA’s actions often appear in various news media that are incomplete, inaccurate and sometimes misleading. I believe this is unfair and unhelpful. Despite these comments I am confident that CASA’s enforcement and safety-related decision-making processes are rigorous, transparent and fair. We are held to account for our actions by the Federal Court and the Administrative Appeals Tribunal and this means the propriety of our actions are routinely and independently tested, and rarely found to be deficient. ” However, CEO of the Aerial Agriculture Association of Australia (AAAA), Phil Hurst, remained unconvinced about CASA’s direction, saying he was “deeply concerned” by the findings of the Senate Committee on a number of levels.

“Firstly, it validates growing industry alarm at the way CASA now does business that is destroying any cooperative relationship between industry and the regulator. Secondly, it focuses on the systemic issues around accountability and transparency of decision-making in both ATSB and CASA and the disconnect that appears to be growing between those in industry with the relevant experience and those who seek to regulate,” Hurst told Australian Aviation .

“Finally, the lack of detailed comment or action from the Minister or the Shadow Minister underscores the need for our elected representatives to re-engage with aviation policy and to paint a vision for getting back to world class aviation regulation,” he explained.

Concluding its report, the Senate committee said: “If Australia is to remain at the forefront of open, transparent and effective aviation safety systems, then the goal of this committee is to help our organisations to work transparently, effectively and cooperatively. Ensuring that a systemic approach to aviation safety is in place is the best way to maximise outcomes. ” Senator Fawcett said further to Australian Aviation : “The government has three months after receiving the report to respond to the Senate so in a sense there may be no immediate actions forthcoming. I would hope given the safety issues involved that their response will be quicker than this.

“When it does respond, the government will indicate which (if any) of the recommendations they support. Some could be decided and acted on quickly (for example, recover the CVR) while others (reforming the way CASA engages with industry over regulations, standards and audits) could take some time to decide upon the form of such engagement.

“The most critical thing is that the government is not allowed to just ignore the report and its 26 recommendations. If the recommendations for a stronger industry voice in the process of developing regulations, standards and auditing practices are adopted, I believe the safety and operational outcomes will be better overall for more stakeholders in Australian aviation,” Fawcett said.

Political support for change, however, seems to be absent thus far. Incumbent federal transport minister Albanese seems satisfied CASA and the ATSB are doing their job, and indeed has approved budget cuts for the ATSB of around $2 million annually.

In late May ATSB chief commissioner Martin Dolan told a Senate estimates committee the cuts would mean “we have to be very focused on what matters we choose to investigate in the future, conscious of the risk of missing something important to safety, and in some cases we may need to constrain the investigation because of the call on our resources. ” Should the government fail to recognise and uphold the findings and recommendations of the Senate committee, Australia will have lost a singular opportunity to recast what is clearly a troubled safety framework. And should it choose to ignore the recommendations, the government will be complicit in sustaining a broken system.

The ATSB and CASA continued to deny the existence of any problems during the hearings. senator fawcett