Pel-Air: Industry identity critiques ATSB safety retreat
Further evidence of the disquiet the ATSB Pel-Air report is causing here and abroad.
A highly experienced industry figure has written as follows concerning the ATSB Pel-Air report problems in response to today’s earlier post:
To answer your question, “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?” the short answer is an emphatic “Yes.”
Let us deal with the core finding of the ATSB report of pilot error as the principle cause of the Pel-Air accident. This type of finding is indeed from the dark ages and was put to rest by Hon. Peter Mahon in his Royal Commission into the Air New Zealand DC10 accident at Erebus in 1979 and Justice Virgil Moshansky in his Commission of Inquiry into the Dryden accident in Canada in 1989. Since those inquiries there has been a greater focus latent system failures, local conditions, local triggers, active failures (including pilot error/violation) and most significantly organisational factors in aviation accident investigations. An organisational factor includes not only factors within the operator but the regulator as well and it is these organisational factors that get up the nose of operators and regulators. The CASA special (secret) audit revealed very clearly some of the operator organisation factors that resulted in this accident and the organisation factors of the faults within CASA that also resulted in the accident.
Was the Pel-Air pilot flying in accordance with CASA regulations and Pel-Air standards approved by CASA? I believe so. If it was not for the local triggers i.e. the Norfolk weather conditions there would not have been an accident (no pilot error) however all the other condition would have remained present just waiting for a trigger. CASA would not have conducted their special audit and the organisational factors would not have been addressed due to CASA’s lack of oversight.
The Bureau of Air Safety Investigation (BASI) was the world leader in accident investigation and their expertise under Dr Rob Lee was sought from similar aviation accident investigation organisations worldwide as well as ICAO. Mr Dolan’s response concerning Professor Reason’s model is a disgrace and demonstrates a complete lack of understanding as the factors that cause accidents outside of the pilot making an error or committing a violation. The aviation safety system, including the role of the regulator, should be such that these pilot errors or violation are trapped thus preventing the accident. Much has been written on this subject but the bible is “Managing the Risks of Organisational Accidents” by Professor Reason. I recommend it to Mr Dolan.
Two good studies of aircraft accidents that involved organisation factors are the BASI investigation report into the Ansett B747 accident at Sydney in 1994 (Investigation Report 9403038) and the ATSB report onto the Qantas B747 accident at Bangkok in 1999 (Investigation Report 199904538). Both investigations taking place before the unannounced ATSB policy change.
What has caused the ATSB policy change? It was not too long ago that the ATSB did not hesitate to address factors within CASA and making appropriate recommendations for corrective action in their investigation reports. This fearless and appropriate response in ATSB investigations strained their relationship with CASA that resulted in the ‘Miller Report’. Did this report result in the ATSB becoming a subservient organisation to CASA instead of remaining an independent investigator?
The last point to be addressed concerns the last paragraph of your blog where you mention ‘enforcement’ by CASA. This is the problem, CASA do not do enforcement. They are not the ‘Policeman on the Beat’ giving out tickets, all they do is audit and recommend corrective action. Their special audit of Pel-Air demonstrates this lack of enforcement that is essential as one part of ensuring a national system of safety. They should not hide behind the ‘Just Culture’ principles, even Professor Reason espouses that violators need to be tackled.