We can only hope that the coronial findings and recommendations are presented in a way that can be implemented to ensure such an accident like this could be avoided in the future
Good sentiments to have Bedderseagle, but unfortunately history points otherwise. Franks 'frank' assessment is so true:
My guess is, CASA get .05% blame and BH gets 99.95%. If these figures work out it's an indictment on CASA for being reactive instead of PRO-active.
The regulator's legaltocracy are only ever employed when they feel they maybe exposed, as Frank points out, even if it is only .05% exposure!
History also shows, time and time again, that they (the regulator) also have this part of the legal process totally 'sussed', they even employ the same counsel 'dude' to train all possible expert witnesses in the ways of the Coroner's court or AAT hearing. There is a pile of Coroner's findings that highlight this status quo, the Lockhart River inquest was a classic example.
In the LHR Inquest the Coroner didn't apportion any responsibility to the regulator, however he did make the following observations and recommendation:
The families of the victims of this crash, understandably want someone to blame for their loss. The passengers were entirely blameless and their deaths have caused extensive and on-going suffering. The pilots are dead; the company is in liquidation and its chief pilot has left the country. It is tempting for those bereaved by the deaths to identify numerous deficiencies or departures from proper standards that Transair had been guilty of in the various operations it was conducting around the country and internationally for five or six years leading up to the crash, aggregate those issues into a cumulative list of failings and say that CASA should have detected them and acted to prevent Transair from operating. With all due respect to those families, the making of scape goats in that manner is not part of my function. I find that CASA could have done more to insist that Transair improved certain aspects of its operations but I do not believe that the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash.
Interaction between the ATSB and CASA
Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.
Recommendation 4 – Ministerial assessment of interagency relations
Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted.
However it appears it isn't all doom and gloom, as the recent Senate Estimates highlighted:
Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR orsomething is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now,nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?
Mr Dolan: We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by which ever the relevant party may be. I think that would be stepping beyond our brief.
Senator FAWCETT: Who should have that role then?
.........so maybe the tide is turning!
