The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.
This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.
The report also casts light on internal frustrations and divisions within the ATSB investigation.
It summarises some of those matters as follows.
3.10 Findings from the TSB review of the Norfolk Island investigation
- The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
- In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
- The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
- Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analyzed.
- The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
- A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
- Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
- The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised report up, as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.
This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.
The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation.
This is just a part of what the TSBC review says on such matters.
The Minister supposed to be looking after aviation, Warren Truss, has previously parrotted lines written for him by his department that there is no value in re-opening or replacing the final report of the Pel-Air investigation.
This embrace of second rate by a Minister supposed to uphold fairness and excellence in aviation safety reporting is unworthy.
The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.
Second rate isn’t good enough for Australia.