More than a week after the ATSB was to consider the unanimously scathing Australian Senate report into its handling of the Pel-Air crash investigation, it has announced an independent and external review of its investigation processes by the Transportation Safety Board of Canada (TSB).
The TSB will, it is to be hoped, consider the evidence tendered to that Senate inquiry by the chief commissioner of the ATSB which lead to the committee devoting an entire chapter of their report to their dissatisfaction with his testimony.
The very things that the TSB review will consider have already been examined in detail by the Senate inquiry with specific reference to the Pel-Air accident investigation, which can be downloaded and read here, with a measured and detailed commentary from one of the committee, Senator David Fawcett, here.
This is the ATSB statement in full:
The Transportation Safety Board of Canada (TSB) will conduct an independent external review of the ATSB’s investigation processes and publish the results. The review was announced today by TSB Chair, Wendy A. Tadros and ATSB Chief Commissioner, Martin Dolan.
The review, to begin with an initial visit by the TSB team this month, will provide an independent and objective assessment of the ATSB’s investigation methodology and processes.
The review team will benchmark TSB investigation methodologies with the ATSB’s and compare them with international standards. The review will also examine how ATSB methodologies and processes have been applied to ATSB investigations and compare them with TSB approaches.
Mr Dolan said the review is a new step in the ATSB’s continuing close cooperation with other international investigation agencies. It will provide both organisations with a significant learning opportunity.
“I invited the TSB to conduct the review because we are always looking to improve our investigation systems and approaches,” Mr Dolan said. “I’m grateful that our Canadian colleagues have agreed”.
“The review will identify best practices from both organisations that we can adopt to improve how we investigate accidents and occurrences and improve transport safety.
“The TSB is well placed to conduct this review as they have a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.”
It is anticipated that the TSB will produce a final report early in the northern spring of 2014. The report will be published by the TSB and available on the TSB website.
The reputation and conduct of the ATSB is very much in question following the Pel-Air inquiry, including its failure to make safety recommendations following the world’s first ever survivable ditching of a Westwind corporate jet, but in which none of the safety equipment on board the small jet worked as intended.
The ATSB also failed to retrieve readily recoverable flight data recordings which would have shown whether or not appropriate weather warnings concerning conditions at Norfolk Island where the jet was to refuel were sent and acknowledged by its pilots in time for them to divert to an alternative airport in Fiji or Noumea.
(The flight was ditched in the sea after a set of missed approaches to the Norfolk Island airstrip, and all six people on board were subsequently rescued by boat after an observant islander spotted the dim flicker of a life vest flashlight in the darkness of a stormy ocean.)
Detective work by the Senate committee unearthed documents suppressed by CASA, the Australian safety regulator, contrary to the requirements of the Transport Safety Investigation Act, which detailed its own failings to effectively oversight the operator Pel-Air.
However the chief commissioner of the ATSB, Martin Dolan, dismissed the importance of the documents withheld from him by CASA, even though they included the observation that had CASA done its job the accident could have been avoided.
Whether the very bad smell created by the conduct of the ATSB and CASA in relation to the Pel-Air investigation can be removed by the independent and external review by the TSB remains to be seen.
The ATSB statement makes no direct mention of Pel-Air, and doesn’t disclose any response to the recommendations of the Senate committee that was so dismissive of the worth of Dolan’s testimony.
Those recommendations included, in short, the ATSB re-opening the crash inquiry and doing its job fully and diligently.
The TSB’s report will be published.
It isn’t know whether that publication will be preceded by the ATSB reviewing the final draft and having an opportunity to change it.
For the the sake of an external and independent review, it is to be hoped that this will not be the case, lest its independence and externality be cast into doubt.