ATSB Pel-Air report damned by FOI release of full CASA audit
Freedom of Information release of full CASA audit of Pel-Air sinks ATSB report into ditching of air ambulance flight in 2009.
The special audit of Pel-Air conducted by CASA in 2009 after one of its Westwind corporate jets was ditched in the sea near Norfolk Island while performing an ambulance mission for Careflight found that it gave no fuel planning guidance to its pilots when they were using airspace that could be denied to them mid-flight if their jet wasn’t equipped to use Reduced Vertical Separation Minima or RVSM rules.
Such a mid-flight denial was issued to the pilot of the Pel-Air jet involved in the crash, when it was directed to descend below or climb above the restricted zone, between 27,00 feet and 39,000 feet on its ill fated flight between Apia and an intended refueling stop at Norfolk Island en route to its ultimate destination Melbourne on 18 November 2009.
However the 30 August 2012 ATSB report into the crash, which is to be investigated by a Senate Committee instigated by Senator Nick Xenophon, wrote out any reference to the inability of the jet to remain at its most fuel efficient altitudes at the behest of air traffic controllers, and by omission, misrepresented the situation that confronted the pilot flying a jet that Pel-Air knew was inadequately equipped to handle RVSM airspace prohibitions or a diversion to Noumea, which required the pilot to have been trained in the European air space protocols applicable to New Caledonia.
The finding by the post crash CASA audit that Pel-Air was in extensive breach of its safety obligations including the defective fuel policy its pilots were instructed to adhere to is included in 60 additional pages of the CASA audit released under a Freedom of Information request.
The relevant page is published below.
This information is evidence that the ATSB final report into the accident was framed to withhold information which is seriously critical of the operator Pel-Air and its deficient fuel policies for oceanic flights and to improperly place undue or undiluted blame for the accident on the flight’s captain, Dominic James.
The small jet, carrying two pilots, two medical support staff, and the patient and the patient’s partner, encountered deteriorating weather conditions as it was approaching Norfolk Island from Apia in darkness and was ditched in the sea after four attempts to land during which its fuel reserves fell close to exhaustion.
The first 43 pages of the CASA audit into Pel-Air were circulated by an ABC 4 Corners program exposé of the truth about the flight on 3 September and are posted on its website together with unedited videos of interviews with the chief commissioner of the ATSB, Martin Dolan and the director of aviation safety at CASA, John McCormick.
It is the legislated obligation of CASA and the ATSB to respectively regulate and investigate all of the material influences on safety performance and safety outcomes, with specific reference to the adequacy of safety oversight and recurrent training , which in this instance, meant the training, standards and fitness of the Westwind’s pilots, and the operating procedures that applied to them making this particular flight.
The Senate committee inquiry into the ATSB report and CASA response to the accident is expected to report by the end of November, and has terms of reference which will allow it to explore the fairness, honesty and competency of the public administration of air safety regulations and safety investigations.
However the audit observations of Pel-Air, which are material to the inquiry, but rejected out of hand as having any relevance to the ATSB inquiry by its chief commissioner Martin Dolan, include this damning summary (below):
Those findings are supported by a further note included in the additional material released under an FOI application supplied to Plane Talking by an interested party.
The revelations contained in the full release of the CASA special audit are a clear indication that the ATSB report is a deeply flawed abuse of process.
But why? What is it about Pel-Air that makes it untouchable? Why didn’t CASA act against its AOC?
If CASA was performing its duties of oversight including regular audits over a period of time, why didn’t the manifestly serious failings in the special audit of 2009 become apparent in the previous audits?
Is it in fact a situation in which the unsatisfactory safety performance of holders of Australian AOCs are to be kept from view and withheld from public knowledge until such time the operators like the now defunct Transair, are knowingly allowed to kill large numbers of people, as it did in the Lockhart River disaster in 2005?
There is something both entrenched and rotten in the public administration of air safety in Australia, and it needs to be dragged into the open and corrected before there is massive loss of life, rather than after the event.
The pilot of the Westwind jet that ditched off Norfolk Island merits criticism, and has copped it in spades, here and elsewhere. But there should be no doubt that the deliberate and contrived failure of the ATSB to follow due process in its report into the Pel-Air accident by framing the report to deflect any attention to the RVSM and fuel policy issues itself constitutes a threat to public safety in this country.