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air safety

Nov 19, 2012

Pel-Air hearing stunned by ATSB decision not to make safety recommendations

There are some extraordinary and serious implications for air safety administration in this country contained in this morning’s testimony  by AirServices Australia to the Senate comm


There are some extraordinary and serious implications for air safety administration in this country contained in this morning’s testimony  by AirServices Australia to the Senate committee inquiring into Aviation Accident Investigations.

At its heart, the evidence says that  the ATSB, in which ‘S’ stands for safety, has decided to limit issuing safety recommendations in its final reports, unless they become devalued!

The ATSB even says so in its supplementary submissions to the inquiry which can be accessed here.

But did the ATSB tell the Minister*? If it did, did the Minister understand what it was doing? Why wasn’t there a ministerial statement to the parliament, and even to the media and the aviation industry in general?

What exactly is the role of the ATSB going to be, going forward  (cough), if it is now just the ATB, and doesn’t make the safety recommendation that are the internationally accepted basis for alerting aircraft operators and other sovereign regulators of issues, as described in big print and simple words in ICAO’s Annex 13?

Could it be that this latest policy initiative by the ATSB is just an incredibly disingenuous attempt to shield CASA, the safety regulator, and the operator, Pel-Air, from being expose as incompetent, if not in their own right threats to the safety of flight in this country, by framing the final report into the ditching of a Careflight charter using a Westwind corporate jet into the sea near Norfolk Island on the night of 18 November 2009, three years and one day ago, to lay the entire blame on the pilot?

But let’s take this morning’s evidence from the top.

The executive general manager ATC at AirServices Australia, Jason Harfield, told the Senate committee inquiry into  Aviation Accident Investigations that without any safety recommendations in the ATSB final report into the Pel-Air ditching near Norfolk Island in 2009 which was published on 30 August, there was no way he could raise a serious factor in the crash with the air services providers in Fiji and Auckland.

That factor was a serious deterioration in the terminal area forecast of TAF for Norfolk Island for the projected arrival of a Pel-Air ambulance charter flight for Careflight carrying a total of six people from Apia to their ultimate destination in Melbourne. However that information, supposed to be passed on by Auckland traffic control, which was responsible for the air space across most of the charter’s flight path, never reached the jet.

The flight has passed its point of no return in terms of diverting to an alternative airfield when it made four missed approaches in bad weather at Norfolk Island and was ditched in the sea immediately before the remaining fuel in its tanks was exhausted.

All six persons on board the flight survived the impact and were rescued by boat.

The point of the Senate inquiry is how the final and much delayed report into the incident by the ATSB was written in a manner which excluded such major issues as the serious safety failings in pilot training, and oversight, as required of both the operator and CASA the regulator, as well as the suppression of a CASA audit which found Pel-Air in breach of more than 30 fundamentally important safety requirements.

The report not only abandoned the issuing of safety recommendations by the ATSB, but failed to recognize the legal responsibility of air operators for the competency and recurrent training of their pilots.

Instead it described the events of the night as being exclusively the failure of the pilot to properly fuel the jet, something which has been established by other evidence before the committee as significantly influenced by the abysmal if not non-existent standards of Pel-Air in relation to such matters as fuel planning, which in turn was a situation tolerated by incompetent regulation and oversight by CASA.

This is a very nasty, yet very important insight into the performance of CASA and the lengths to which it will go to risk offending operators, or exposing itself to public scrutiny.

During this morning’s hearing, the committee’s members grilled two longer serving AirServices Australia executives, Harfield and Peter Hobson, the acting general manager of Network Management Services, over the apparent bureaucratic indifference to the safety issues involved in the Pel-Air ditching in that the air services in Fiji and ultimately Auckland had not proactively warned the pilot that the weather conditions at Norfolk Island had deteriorated well below those originally forecast.

Harfield took most of the flack, explaining why AirServices had not been proactive in leaning across the boundaries between itself and the Fiji and NZ air traffic control systems to address the non-forwarding of the information of the deteriorating weather conditions at Norfolk Island.

Under questioning, Harfield, at times assisted by Hobson, said that his hands were tied until the ATSB finally reported on 30 August, when he would have acted on its safety recommendations, but under even further questioning he admitted that he didn’t even know that the ATSB was no longer in the business of making safety recommendations.

It was an awkward performance on Harfield’s part, who seemed challenged by the notion that he might have exercised any initiative in dealing with the issue of non-forwarded weather changes to flights that were going to an Australian airfield in which the air space was controlled by another state.

The committee acknowledged that while the withholding of that information was not the actual cause of the crash, its availability to the captain of the flight on a timely basis would have alerted him to the need to divert to an alternative airport in Noumea or Fiji at a time when the jet was sufficiently fueled to reach either.

In other words, it was a safety failing that could have prevented the jet flying onwards into serious and unanticipated danger.

The new CEO of Airservices Australia, Margaret Staib, assured the committee that such issues would be more proactively addressed in the future.

Those who enjoyed reading rapid fire and at times heated and sarcastic exchanges in Hansard may find this morning’s transcript entertaining when it is published. However not all of the words used in the live videocast from the committee room are likely to make it from the ‘pink’ or draft Hansard into the ‘white’ and epithet deleted final version of Hansard.

There is a further public hearing scheduled for Wednesday afternoon, featuring among others the ATSB.

The committee will report by 29 November.

*A spokesperson for Anthony Albanese, the Minister for Infrastructure and Transport, says there has been no policy change at the ATSB.  The spokesperson said “Where appropriate, the ATSB is continuing to make safety recommendations.”

I think that the committee members may try to assist the minister to understand that after three years Australia’s safety authorities have not only taken any no appropriate action to further safety in the aftermath of this crash, but have been caught doing blatantly inappropriate things that have undermined air safety and trust in the public administration of air safety matters in this country.


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