*Publication of this post has produced a categorical denial from a Ministerial spokesperson that the ATSB report in question is being replaced or amended.

Of course those who read this post will become aware that this is not the real issue, which is the disgraceful quality of the report that the ATSB issued. 


There are rumors circulating that the ATSB final report into the Pel-Air medical evacuation flight ditching near Norfolk Island in November 2009 is to be withdrawn and replaced with a new report.

The Minister for Infrastructure and Transport, Anthony Albanese’s media officers have not responded to a query about the validity or otherwise of this rumor since Saturday morning.

If the rumors are true, it will an heroic admission of exceedingly serious failures on the part of the ATSB, the air safety investigator, and reflect very adversely on CASA, the air safety regulator.

It would also follow from such an admission that both bodies would undergo some serious changes in management and conduct in order to restore Australia’s reputation as a level one state in terms of air safety administration.

If however the rumors are untrue, or there is instead a ‘final’ final report being prepared, which will attempt to repair the damage to process and institutional reputation done by the ‘no longer final’ final report,  as well as to the captain of the flight, both bodies will struggle to regain credibility and respect from many stakeholders in aviation in Australia, as well as in the eyes of peer organisations, including ICAO and the FAA.

One way of analyzing the performance of the ATSB and CASA in relation to Pel-Air is to look at how the final report was constructed to load almost the entire blame for the accident on the captain for having inadequately fueled the small Westwind jet for first stage of its medical retrieval flight which was from Apia to Norfolk Island, where it was to refuel and continue to Melbourne, carrying the two pilots, two passengers and two medical professionals.

But even though the ATSB quoted at length Pel-Air’s operating manual for the flight, including the fuel calculations based on its flying at an optimal altitude, it fails to mention anywhere that the jet had not been upgraded to allow it to fly through much of the oceanic airspace it was to traverse at such altitudes under the rules applying to reduced vertical separation minima or RVSM.

Nor could the jet legally plan for or make a fuel diversion to Noumea as it encountered stronger than expected headwinds and higher fuel use because of the RVSM issue because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.

Neither of these critical matters are mentioned anywhere in the report. But they were raised with the investigating officers. The significance of both matters could not fail to be apparent to CASA or the ATSB, making inescapable a conclusion that both bodies were averse to making detrimental findings about the operator and had thus unjustly and deliberately focused all of their negative findings on the pilot.

For the two most important bodies in the public administration of aviation safety in Australia to conduct themselves in this manner is grossly improper.

The captain, Dominic James, was being directed by an airline CASA failed to properly regulate, to fly an oceanic route according to a fuel rule that CASA ought never to have approved, according to standard operating procedures for an altitude unavailable for much of the distance because it wasn’t RVSM equipped, and had not been trained to the regulatory standard required to use New Caledonia airspace in the event a diversion to Noumea, which some have criticised him for not using.

Much of the context for this is made lay friendly by the ABC TV 4 Corners report into the crash. But on its website, under background documents at the above link,  4 Corners also posts a CASA audit of Pel-Air which took place, as had been scheduled before the crash, shortly after the crash.

This audit found multiple serious safety deficiencies in Pel-Air’s operations at the time of the crash.  Yet in its previous audit of Pel-Air CASA didn’t find much at all, leaving viewers to wonder whether the operator suffered a precipitous decline in standards in that period, which would surely have required an immediate grounding Tiger style, in the interests of public safety, or whether CASA audits are fundamentally useless before the fact.

The 4 Corner’s program site also hosts uncut videos of interviews with CASA’s director of safety, John McCormick, and the chief commissioner of the ATSB, Martin Dolan. Both interviews are shocking reflections on the processes and attitudes at these vital aviation authorities.

Dolan’s performance is more than 18 minutes of severely compromised testimony, in that he seems utterly unwilling to even acknowledge that CASA found more than 20 safety deficiencies were in effect at Pel-Air at the time of the crash or that they had anything to do with the accident.

Dolan and McCormick are well aware, and on the public record as being aware, that it is the airline or the operator that is ultimately responsible for the flight standards that are delivered to, or upon, the public.

This concept of airline or operator responsibility is the foundation stone of air safety regulation in the developed world. It has been trashed in Australia by this disgraceful ATSB report into the Pel-Air crash.

The performance of CASA and the ATSB in particular has been exposed as severely and dangerously deficient by the Pel-Air report and its aftermath.

One way or another, and without delay, these deficiencies must be remedied.

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