air safety

Feb 15, 2013

Pel-Air Senate hearing sensation: CASA hid key safety audits from ATSB

In a set of extraordinary disclosures in the Senate inquiry into the Pel-Air crash report today it was revealed that two key safety audits were kept secret by the safety regulator CASA

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

In a set of extraordinary disclosures in the Senate inquiry into the Pel-Air crash report today it was revealed that two key safety audits were kept secret by the safety regulator CASA from the safety investigator the ATSB in contravention of a cooperative memorandum of understanding between the two bodies. The two most senior officers in the Australian Transport Safety Bureau, its chief commissioner Martin Dolan and its GM air investigations Ian Sangston did not know of the existence of the audits, one of which was scathingly critical of CASA's oversight of Pel-Air, until about 30 minutes before they appeared at the inquiry immediately after an often intense examination of CASA's Director Aviation Safety John McCormick. One document, the Chambers Review of CASA, ordered by McCormick and kept secret from the ATSB, found that the ditching of a tiny Westwind air ambulance flight near Norfolk Island in November 2009 might have been avoided had the regulator been doing its job properly. The other, a fatigue management review of the ill fated flight commissioned from the UK safety regulator, suggested that the captain of the flight Dominic James may have been unfit to fly the Careflight mission under its rules. CASA's director of air safety John McCormick said he didn't consider either of them relevant to the cause of the accident, which he says was entirely the fault of the captain, but would have been made available to the ATSB if it has asked for them. Senator David Fawcett, an experienced pilot, and Senator Nick Xenophon, the instigator of the hearing, pointed out to McCormick repeatedly in the exchanges between them and him that the ATSB could not ask for audits it didn't know existed, and that under the rules of co-operation between the two bodies, their existence had to be disclosed. What then followed was a lengthy spectacle in which the most senior executive in CASA, McCormick, denied understanding or recognising the most basic and clearly written obligations that exist in the MoU between the two bodies concerning the exchange of information between them. The Senate committee is inquiring in the final report by the ATSB into the accident, and how it became changed from one dealing with serious issues concerning the rules relating to fuel and route planning to one that blamed the crash almost entirely on the actions of the captain. Senator Xenophon told ATSB chief commissioner Dolan that the Pel-Air report the ATSB had finally issued was less compliant with the standards of ICAO Annex 13 than those produced by its counterparts in Nigeria and Lebanon, a comparison strongly rejected by Dolan. Both the fatigue audit and the CASA audit, which is separate from the CASA special audit into Pel-Air shortly after the crash, will be posted online on the Senate Committee website later today. At the outset of today's hearing Senator Fawcett speaking for the committee said it accepted that errors in fueling the jet that was ditched off Norfolk Island were made by the captain, and that the purpose of the inquiry was not to exonerate the pilot but to examine more deeply how the ATSB report was arrived at, and among other things, understand why it said little to explain why the pilot might have made the errors he did. The committee repeatedly sought information from the CASA team lead by McCormick as to why the regulator had not disclosed the Chambers Review, commissioned by McCormick, to the ATSB, quoting passages in which it found that had there been more effective auditing and oversight of Pel-Air, the operator of the jet, it would have discovered key failings in its performance and pilot training from interviews with the line pilots that if acted upon in a timely manner could have prevented the accident ever happening. McCormick said he considered the Chambers Review a private document, which made no findings which would have altered the ATSB's eventual findings that the accident was caused by pilot error if not violations of the rules by him. He said "I did say at the time that I wanted it warts and all." Xenophon told McCormick his explanation for withholding the Chambers Review's existence and findings from the ATSB to be "curious and bizarre." McCormick told the hearing that CASA had kept the findings of the Chambers Review from the ATSB in order "not to contaminate its decision making." He stressed the importance CASA placed on the ATSB reaching its own conclusions. However during the course of the hearing committee members read from emails which said, among other things, that the two bodies needed to avoid "putting egg on each other's faces", that a consistent policy was desirable as to whether flights should immediately divert to alternative airports when the weather deteriorated below minimums at destination airports, and other email discussions as to how the initially divergent views of CASA and the ATSB about the seriousness of the accident and were coming into alignment. Senator Fawcett put it to McCormick that he had in his possession information that the surveillance and processes of CASA in relation to Pel-Air were inadequate, and that in not disclosing this to the ATSB he had shaped its report, which had found that there were no systemic operator or regulator failings that had contributed to the accident. McCormick replied that the findings of the Chambers Review were not considered relevant to the ATSB's inquiries or findings, to which Senator Xenophone asked without audible answer "How would you know?" Xenophon said "there is a positive obligation on CASA to disclose the document to the ATSB for its consideration. " The SA Independent Senator said "You wanted this report to be downgraded in its safety important to protect CASA from the criticisms in the Chambers Review .... which found that if you had done the job the accident might have been avoided was much more convenient to put all the blame on the pilot've actually covered things up by not releasing the document." McCormick strongly denied this, repeating that in his opinion this was a private document commissioned by him while he was early in the job to understand what was happening in CASA. He conceded at one stage that he might have been wrong in this, and said that he apologised if he was wrong, and defended the now more advanced reform process he had undertaken at CASA describing it as a now much more efficient, competent and effective body that it had been at the time of the accident. Senator Fawcett said several times that he accepted that progress had been made at CASA but also pointed out that this wasn't what the committee was set up to do in its examination of the ATSB final report into the Pel-Air crash and the relationship between the safety regulator and the safety investigator. When the ATSB team began its appearance before the committee, having only just learned of the existence of the two CASA documents, its chief commissioner Martin Dolan said he could not give answers as to the effect on its Pel-Air report of not receiving that information 'on the run'. Dolan said he would be able to give considered replies to such questions at a later date. However in an exchange with the committee Dolan explained that the ATSB's starting point in its investigation was the factual evidence available at the time. Senator Fawcett said "There is concern in the committee that there is some serious dsyfunctionality in your starting point because the evidence that you started with was not as complete as it should have been for the public or for you." Dolan said "I'd prefer to give due consideration to this than make it on the run."

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8 thoughts on “Pel-Air Senate hearing sensation: CASA hid key safety audits from ATSB

  1. ltfisher

    OMG! Can this get any worse?

  2. Mark Skinner


    Tip. Iceberg. Yes.

  3. comet


    To hide a report critical of oneself, and to blame a scapegoat for the purposes of deflecting criticism away from oneself, is a monumental conspiracy.

  4. Agfox

    As a former public servant who appeared before Senate Estimates Committees in Australia & their equivalent overseas, the kindest phrase that comes to mind after following this Hearing since it commenced is ’embarrassingly unprofessional’.

  5. ltfisher

    To answer my own question it looks like a big YES it did!

  6. Karen Casey

    CASA, ATSB, Pel-Air. Shame, shame, shame. How dare there be people in positions that knowingly put the public at risk. When I hear that this crash could have been prevented if more pro-active safety follow ups were insitu, my stomach churns. The hell myself and others on board have experienced in many forms, is too difficult to adequately express. The ditiching was positively preventable had our trusted systems had honest, thorough scaffolding, starting at the top. CASA audited Pel-Air in April 2007, they found the operator was not adhering to numerous rules. Audited again March 08, safety alert issued. No further audit follow up until after the ditching. Then a dodgy ATSB report, the Chambers report sitting south under McCormick. How dare all involved shake our lives to the core…their turn to shake now. Lies always unravel. I hope this is the start of real change.

  7. John Thomas

    “The screaming skull” as he was known at Cathy Pacific has obviously got it in for the pilot or is trying to protect CASA for its failings. To unreservedly apportion blame to one individual for this accident is absurd and archaic.

  8. Black Hand

    Really well done.
    Latest message from my FOI after a 3 hour meeting is that aerial work aoc and Ops manual are now for all intents being treated like Charter.Must have Fatigue managemant plan, must have fuel management plan, reference to flight manual no longer acceptable. Proving flight for new type single engine being placed on AOC. APPROVAL HAS BLOWN OUT TO SIX MONTHS. Previously accepted Ops Manual now requires complete rewrite.
    Thanks Ben, Xenophon and the rest.

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