ATSB chief admits not proud of Pel-Air report
A dossier full of confidential emails, and a day full of tough questions, kick off Senate committee hearings into ATSB report into the ditching of a Pel-Air Westwind into the sea near Norfolk Island while operating a Careflight medical charter
Toward the end of the public testimony given to the Senate committee on Aviation Accident Investigations today Senator Sean Edwards drew the attention of the chief commissioner of the ATSB Martin Dolan to a thick folder of confidential information including emails between the supposedly independent air safety investigator and CASA.
Commissioner Dolan said he didn’t think the contents of the folder would change his answers to questions.
But that moment was indicative of intensive questioning of Dolan as to why the ATSB had produced a final report into the ditching of a Pel-Air Careflight medical charter off Norfolk Island on 18 November 2009 that made no safety recommendations, and contained no analysis of organizational, human or systemic issues with the operator.
The day of hearings included repeated questioning of the ATSB and CASA concerning the propriety of the latter hiring the Pel-Air chief pilot John Wickham, who was organizationally responsible for the operator at the time it failed a special CASA audit after the crash, as a Flight Operations Inspector during the prolonged period it took the ATSB to conclude its investigations and publish the accident report.
The contents of the emails and other material is likely to be influencing the lines of questioning raised by the committee even though they will not form part of its report which is due by 29 November unless released by the sources that have provided them.
Earlier posts from today’s proceeding have appeared here and then here.
Senator Nick Xenophon, who instigated the Senate inquiry, told the ATSB head Dolan that the “only reason this didn’t go to the Coroner’s Court was that a flashlight in the jacket pocket of the pilot Dominic James was spotted from Norfolk Island”, leading to the rescue by boat of the six people on board the small Westwind corporate jet, which sank after they managed to escape from its mostly submerged and fractured hull.
Dolan admitted that he was not proud of the report.
He conceded that it took too long to produce (1015 days) and that the focus on the immediate reason for the crash, which was imminent fuel exhaustion the ATSB found was caused by poor flight preparation and decision making by the pilot, had neglected some other safety lessons.
He was criticised strongly in exchanges with the the committee members for the report totally disregarding an adverse special audit by CASA of Pel-Air made immediately after the accident which found numerous serious safety breaches by the operator, as well as removing from a privately circulated draft of the final report of references to Pel-Air having voluntarily grounded its fleet of Westwinds on 7 December.
Senator Fiona Nash took Dolan up on his admission that at no-stage did the ATSB inquiry refer to the failure of the safety equipment on board the jet, ranging from an unsecured life raft that was lost inside the partly submerged hull, to life jackets on which the torches and whistles didn’t work, or couldn’t be reached because of poor design.
Dolan was unable to answer her question as to whether the six people on board were actually asked if the emergency equipment worked, although he insisted each was interviewed.
Senator Fawcett tried to engage Dolan as to why the ASTB couldn’t make commonsense recommendations such as suggesting that Australia ask New Zealand air traffic controllers who were responsible for some of the air space transited by the flight that crashed couldn’t ensure that aircraft were advised of deteriorating weather conditions at their intended destinations.
Dolan was preceded in the afternoon session of hearings by CASA’s Director of Aviation Safety, John McCormick, who insisted that the full responsibility for the accident would ‘come back to the pilot Mr James’.
McCormick said ” There is not a pilot in Australia who would not say that the responsibility for correctly loading the fuel on a jet is the responsibility of the captain. ”
He described some of James’ actions as ‘bordering on the reckless’ and rejected suggestions that CASA had colluded with the ATSB to protect Pel-Air from criticism or exposure for its unsafe operations, or that it had unfairly treated James by singling him out for criticism.
However in his answers McCormick said that James should have calculated fuel based on contingency planning for deteriorating weather and such things as cabin depressurisation or engine failure, even though documents released under a Freedom of Information request show that Pel-Air did not have a fuel policy which covered such events affecting its Westwind fleet.
In an exchange with McCormick, Senator David Fawcett said “There are significant human factors issues here that are critical to this report. Yet you have taken a very black and white view.
“The concern raised here significantly is that the regulatory, human and procedural factors that are writ large across this issue have been written out of this report.
“Why weren’t they included in report?”
McCormick said the contents of the report were a matter for the ATSB. He added that “I doubt you would see a different outcome if they were (included).”
The dossier of confidential emails may have received a further workout in the last testimony of the day, which was taken in camera.
There is no indication at this stage as to when there may be further public hearings.








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Ben – This is dangerous stuff. To state the obvious, if the FAA and EASA decide that CASA cannot be trusted to oversight Australian Aviation then our airlines will find themselves banned from US and European airspace.
Impossible? I hope so.
The FAA should class Australia as Category 2 (third world) standard and ban Australian airlines entering United States airspace.
The FAA wanted to do this a few years ago, but didn’t due to political pressure. Yet CASA and the ATSB (and the minister) didn’t heed that warning. Just the opposite. Standards got worse.
It will take a shock to the industry before things change. That shock can be an FAA grounding, or alternately a serious crash. I’d prefer the former.
I agree Geoff, this IS dangerous stuff and a Senate Committee might not be able to handle the fallout. What on earth is the Minister doing?
The body which is responsible for sheltering Pel-Air, which is most likely to be the RAAF- a major customer. They are the ones who have the clout to have a report like this steer away from the obvious.
Ghostwhowalksnz is probably close to the mark. There would be much political embarrassment should pel air be brought down, especially considering they were also granted the Vic air ambulance contract, over the very well run RFDS…
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