The jobs of the chief commissioner of the ATSB, Martin Dolan, and the director of aviation safety at CASA, John McCormick, are under a cloud following detailed criticism by a Senate Committee that examined their actions in relation to the ditching of a Pel-Air jet near Norfolk Island in 2009.
The committee examined the circumstances and actions that lead to the ATSB producing a crash report that primarily blamed the pilot Dominic James, but excluded material highly critical of the sub standard performance by CASA of its duties of oversight, including a suppressed document that found the operator Pel-Air was unsafe, and failed to make safety recommendations to the industry as expected of the air safety investigator.
The Senate inquiry, which was instigated by SA independent, Senator Nick Xenophon, and chaired by Senator Bill Heffernan, has among other things called for a reopening of the ATSB inquiry, in effect invalidating its final report.
It says the ATSB should focus on organisational, oversight and broader systemic issues in a renewed inquiry, and has also recommended the immediate retrieval of the flight data recorders from the wreckage of the jet, which was performing a medical repositioning mission for Careflight from Apia to Melbourne via Norfolk Island, and which lie at an accessible depth on the sea floor not far from the island.
There is no obvious precedent for a Senate inquiry that has so comprehensively criticised two public authorities for their actions and omissions in relation to transport safety in this country.
In its executive summary the committee says:
The committee examined Dolan (ATSB) and McCormick (CASA) as to their mutual insistence that factors other than the pilot not fueling the jet correctly for the Apia-Norfolk Island sector were immaterial to the outcome, even though the operator did not have a defined oceanic fueling policy, and it was questionable whether the pilot had received due warning of deteriorating conditions at Norfolk Island that would have caused him to divert to Nadi or Noumea rather than continuing toward the intended tech stop.
The committee said it was ‘troubled by allegations that agencies whose role it is to protect and enhance aviation safety were acting in ways that could compromise that safety.’
In the body of the report the committee outlines serious claims that the motivations of the ATSB and CASA were in effect to blame the pilot for everything and conceal grave failings in the administration of air safety in this country from the public.
It said the methodology used by the ATSB to attribute risk in its investigation “appears to defy common sense by not asking whether the many issues that were presented to the committee in evidence but not included in the report it produced could help prevent such an accident in the future, offer lessons to the wider industry or enable a better understanding of the actions taken by the crew of the flight. ”
The committee found that the process by which the ATSB, a times in consultation with CASA, downgraded an identified safety issue in the Pel-Air Westwind operations from ‘critical’ to ‘minor’ lacked transparency, objectivity and due process.
The committee said that CASA and Pel-Air had made changes to their procedures since the ditching which had they been in place beforehand could have prevented it from occurring.
“To simply focus on the actions of the pilot and not discuss the the deficiencies of the system as a whole is unhelpful” the committee report says.
“It is disappointing that the ATSB and CASA continue to assert, in the face of evidence to the contrary, that the only part of the system with any effect on the accident sequence was the pilot.”
The committee took the unprecedented step in Senate hearings of this nature of warning CASA not to offend the protections of parliamentary privilege by causing ‘adverse consequences” to witnesses in the aviation industry who had assisted the committee with their submissions or in session, sometimes closed session testimonies.
Following the release of the committee report, Senator Xenophon issued a statement setting out key reforms that the committee had unanimously supported to render the ATSB and CASA made accountable and effective in carrying out their duties in relation to air safety rather than backside covering.