ATSB ‘leads’ air safety into a retreat from Reason?
The Hansard record has caught Australia’s air safety authority diminishing the role of James Reason in crash causes, raising more questions about how far it will go to cover up deficiencies in CASA’s oversight of air ambulance operator Pel-Air
Has Australia been dragged back toward the dark ages in air accident investigations in order to cover up gross deficiencies in the performance and professional integrity of CASA, the air safety regulator?
There is a section of the testimony given by Martin Dolan, the chief commissioner of the ATSB, the investigating authority, to a Senate inquiry last week that suggests this is the case.
The Senate committee concerned was inquiring into the final report issued by the ATSB on 30 August into the ditching of a Pel-Air Careflight air ambulance charter near Norfolk Island on 18 November 2009.
This is the critical passage of that hearing, last Wednesday, as reported in Hansard, which can be found in full at the inquiry’s web page under transcripts.
Mr Dolan: We see our job as a different job from CASA’s. The special audit was in relation to CASA’s views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB’s final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason’s model of investigation—though we think we have come a long way since Professor Reason’s initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason’s model, would be viewed as violation; and that is principally the responsibility of the regulator.
Professor James Reason is the UK psychologist whose work in the causes of preventable accidents, in aviation, and industry and health care more broadly, both revolutionised and underpins to this day the methodology of air safety investigations and safety enhancement. He is often credited for enunciating the Swiss cheese model for accident causes, where a range of issues, each of them insufficient to cause a crash on their own, align, like the holes in the cheese, allowing a disaster to occur.
To have it demeaned in the manner that it was in the Senate inquiry, without any obvious reason other than an unannounced policy retreat by the ATSB in order to protect CASA from being exposed as derelict and incompetent in the discharge of its duties of care and oversight is to be blunt, a national disgrace and embarrassment.
The Minister responsible for both CASA, and the supposedly independent safety investigator, Anthony Albanese, is a busy man. He appears to be too busy to deal with these issues, other than to brush off through a spokesperson any suggestion that the ATSB ought to have, at the least, told him it was changing its supposedly world leading methodology to avoid issuing safety recommendations, the function which the rest of the world, and Australian air operators, actually rely upon to be alerted to issues which may be of wider relevance to their activities than Pel-Air alone.
Those unannounced policy changes by the ATSB resulted in a report which makes no reference to a special CASA audit of Pel-Air that found it unsafe in its Careflight operations at the time of the accident through multiple breaches of the applicable aviation rules.
The focus on errors rather than violations by the operating company also produced a report that cast no light on fatigue issues, or the failure of air traffic control to pass on a warning of a serious deterioration in forecast conditions for the arrival of the jet at Norfolk Island, or pilot fatigue, or the suitability of the jet to even embark on the mission it was flying, or the failure of all of the safety equipment on board.
It makes no reference to the disclosure in the CASA audit to the lack of fuel planning guidance by the operator Pel-Air for the Westwinds in its fleet, nor to glaring discrepancies between what CASA had discovered about the operator in previous audits compared to what it uncovered after the loss of the jet in question.
The report effectively suppressed disclosure of significant concerns within CASA over regulatory confusion as to whether such flights should turn back or press on when conditions deteriorated on charters such as the one that crashed.
The real danger in the situation touched upon by Dolan however, is that Australia has allowed its two aviation bodies to trash the standards of disclosure, enforcement and investigation that its public, and its air operators, and the rest of the world wide aviation safety community, previously took for granted.