air safety

Nov 21, 2012

Pel-Air inquiry to get critical CASA-ATSB attitude adjustment documents

A late session by the Senate committee inquiry into the Pel-Air crash report hears ATSB say it was focused on pilot errors not violations of the rules by the operator, and sees a perceived insulting email about them from CASA head John McCormick

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

The Senate committee inquiring into the final report the ATSB issued on  30 August about the 2009 Pel-Air medical charter ditching of a Westwind jet near Norfolk Island last night asked the safety investigator to provide full correspondence as to how CASA the safety regulator persuaded it to change its mind about the seriousness of the safety issues the crash raised.

The chief commissioner of the ATSB, Martin Dolan has previously told the committee that the safety investigator had originally come to the view that there were ‘intolerable’ safety risks arising for the circumstances leading up to the crash, but in consultation with CASA had downgraded its assessment to ‘broadly acceptable’.

The general manager aviation safety investigations at the ATSB, Ian Sangston, after being pressed to answer a line of questioning by the chair Senator Bill Heffernan, confirmed that the evidence on which the investigation reached its initial conclusion didn’t change, but its view of its seriousness did.

In the first of a series of unpublished drafts of the final report circulated to affected parties about 23 March this year the ATSB view was that the crash was very serious. But when the final version of the final report was released in August the safety risks it raised were described as ‘broadly acceptable’ and all of the material blame for the crash was attributed to the captain of the flight Dominic James.

The jet was flying from Apia to Melbourne via Norfolk Island when it was first banished from cruising at its fuel optimum altitude because it wasn’t equipped to maintain safe separation from crossing traffic, and having passed the point at which it could have diverted to Noumea, it made four missed approaches to the island in poor weather and was then ditched by the pilot immediately before the remaining fuel in its tanks was exhausted.

The six people on board were able to escape from the sinking jet and were fortuitously rescued by a boat from Norfolk Island.

In his testimony Dolan also acknowledged that the pilot community was divided as to whether James was correct in proceeding to the island, unaware of an amended weather forecast that warned that conditions had deteriorated to below the required minimum conditions, or should have diverted on a mandatory basis.

He would not be drawn about an email between two senior people in CASA management in which one says that there was legal risk for the regulator in a situation where its Flight Operations Inspectors were divided as to whether James should have diverted or continued, and that this uncertainty which the regulator had left unresolved for years was ‘untidy’ and potentially embarrassing.

Under questioning by Senator Nick Xenophon, Dolan said he hadn’t asked until 4 July this year for the special audit of Pel-Air conducted by CASA shortly after the accident, which found the operator in breach of more than 30 safety rules and variously deficient or unsafe in its lack of fuel planning policies for its Westwind fleet at the time of the crash.

In subsequent answers Dolan declined to confirm that he had actually read the document, even though he had insisted elsewhere on the public record that it was irrelevant to the ATSB inquiry.

He could not explain why something he hadn’t read could be ‘irrelevant’ but described the focus of the ATSB investigation as being into ‘errors’ while the audit report, which was the business of CASA was about ‘violations’.

Dolan agreed to find out the date at which the chief pilot for Pel-Air at the time CASA found its Pel-Air fleet operations to be critically unsafe or in breach of important safety regulations was recruited to the regulator but according to earlier testimony by the Director of Safety at CASA, John McCormick, to have played no role in the ‘consultations’ in which CASA persuaded the ATSB that the intolerable situation at the charter operator was in fact acceptable.

Dolan evaded a concise answer as to whether or not it was the responsibility New Zealand Airways, which provides air traffic control for most of the route flown by the Westwind jet from Apia to the sea near Norfolk Island, to ensure that it informed the pilot of the deterioration in the forecast weather for its intended arrival.

Senator Xenophon told Dolan that the committee had information that the weather warning, which would almost have certainly made James divert to Noumea when he was in a position to do so,  was not passed on to the pilot.

However as disclosed in a hearing this Monday,  AirServices Australia sat on its hands unaware of this issue of weather warnings not being passed on to an Australian jet approaching an Australian airport because it was awaiting a safety recommendation in the ATSB final report.

That same hearing heard that the ATSB had suddenly decided to stop ‘overusing’ safety recommendations and had made none in the case of Pel-Air, a change in policy not announced by the Minister, and unknown to AirServices Australia, until this information was dropped on Monday.

Dolan also agreed that had the pilot of the flight, Dominic James, fully fuelled the Westwind before its departure from Apia, it would have been too heavy to have climbed to an altitude above the region of airspace the NZ control asked it to vacate as it wasn’t equipped to remain in its optimum altitude band while modern better instrumented aircraft were in the same airspace.

He agreed to release the entire paper trail generated by the ‘consultations’ between CASA and the independent air safety investigator which lead to its changing its assessment of the risks revealed by the Pel-Air flight.

Dolan was excused from answering a question as to whether he agreed with assessments made by CASA’s current director of safety, John McCormick, in an email considered by some members of the Senate committee to be personally insulting.

That email as seen by at least two Senators is  published below:

 We recently appeared at a sitting of the Senate Rural and Regional Affairs and Transport Reference’s Committee Inquiry into the ‘PEL-AIR’ ditching report and ‘other matters’. I wish to pass on my personal thanks for the outstanding effort everyone made to meet the requests of the Senate Committee inquiring into the PEL-AIR ditching report. I fully appreciate the time and effort that was required and on behalf of everyone else at CASA, thank you and well done! That sort of spirit is very humbling to me.

As for these Inquiries themselves, they are an important part of Westminster Democracy in this country and, as such, are not events to be feared or avoided. I personally welcome the opportunity to present CASA’s positions at any venue.

However, do not be dismayed by our vocal but largely uninformed minority of critics; they are symptomatic of other ills in society. I prefer ‘facts’ when engaged in discussions; not hearsay and tautological rubbish that some others seem to regard as promising material.

I look forward to assisting the Committee conclude its investigations. At the completion of this Inquiry there is a report produced. That report becomes a ‘Report of Parliament’ and will be forwarded, by established process, to the Minister for his consideration.

Comment. The McCormick email, like the ATSB final report, and its failure to deal openly and in detail with the systemic failings of CASA and Pel-Air, brings the administration of air safety in Australia into disrepute.

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2 thoughts on “Pel-Air inquiry to get critical CASA-ATSB attitude adjustment documents

  1. Fueldrum

    I love that a “Report of Parliament” is forwarded to the Minister “for his consideration.”

    Parliament is supposed to be supreme. The Ministry exists at the pleasure of Parliament. An instruction by Parliament is not a suggestion or request, for the Minister’s consideration.

  2. David Klein

    Unfortunately the inquiry only highlights the politics between ATSB and the CASA, with an accentuation on no blame reporting and pathetic regulatory oversight without appropriate enforsement action.

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