Senator FAWCETT: Going to that exact point, if you go to 4.1 of the Chambers report, it states that it is likely that many of the deficiencies identified after the accident would have been detectable through interviews with line pilots and through the conduct of operational surveillance of line crews in addition to the surveillance, the management checks.
It strikes me that the Chambers report is quite specific, and that is only one example. There are a number of other areas where it is fairly clear that there were deficiencies in the oversight that had they been addressed through effective audit the accident may well have been prevented. The point though, Mr McCormick, is not so much to say that the surveillance was deficient therefore the world is about to end.
Commissioning the Chambers report was commendable upon your taking control of the organisation. The point is, for the public to have confidence that there is transparency and due process, where there is a report in existence, a formal report conducted by a senior manager, it would be the expectation of the public—and indeed, as Senator Xenophon has pointed out, it is clearly highlighted in the MOU—that the information pertinent to an investigation by ATSB would be made available.
With the concept of a systems approach, whereby not only the operator and the piloting command but also the regulator are key parts of the safety system, where there is written evidence in the possession of one department prior to the publication—in fact, prior to even the review of the draft report coming out—it seems inappropriate to the committee that the spirit and letter of the MOU was not implemented to make that information available.
Mr McCormick: As I said, the CASA Chambers report was a report that I started. It did not even require to be done. It was not something that was in our normal procedures. Following the MOU—
Senator FAWCETT: We appreciate the fact that you started it. Our concern is the fact that, having initiated the report and having it in your possession, the report was not then made available—as required by the MOU, in writing let alone in spirit—to assist the ATSB with their subsequent investigation.
Mr McCormick: It is a balancing act tiered between what is required to be provided to the ATSB and what is an internal CASA document. I took the view that that did not, in any way—the Chambers report—should not be influencing ATSB in their deliberations. We were very specific in not allowing our report, or any of our information, to be available to the ATSB where we had reached conclusions in a parallel investigation. In actual fact, we did not provide our report, or the accident report and our special audit reports, until we received section 32 demands from the ATSB, which we did receive on 25 March 2011 and 3 August 2012 respectively. I am very aware that we do not want a contagion effect on the ATSB.
We conducted this in the best possible way we could. We did it with the most probity and the best goodwill that we could muster at the time. In retrospect, should the ATSB have an internal CASA document? That is something that I will take away and consider again. I do not think we are in violation of the MOU in that we provided the information as we were required, and we were scrupulous in avoiding telling the ATSB our conclusions or where our investigation was going—a parallel investigation but for different reasons.
As I think Mr Dolan said before, he did not want to be involved in a CASA inquiry, nor was he inquiring into possible regulatory breaches or effects that rightly fall under our jurisdiction. So in a lot of ways, to release that report would have put, I would think, the ATSB in a different position. That is a question you could ask Mr Dolan. From my point of view, if I put myself in Mr Dolan's shoes, that would have given me a great deal of difficulty from the point of view of establishing my line of inquiry and my line of decision.
Senator FAWCETT: We will come later to the issues of collaboration—I will use that word as opposed to 'cooperation'—between the ATSB and CASA.
But there is evidence and there are documents, which we will discuss, that indicate there was relatively frequent and open discussion about the content of reports and alignment between the two organisations, and yet a report that (a) would obviously embarrass CASA was not made available, despite other because they say 'there is a lack of evidence that this is a serious safety concern'—and they take the fact that there have been audits done of the FRMS system used by the company. In the audit that CASA put together, it said:
… it is considered that the oversight by CASA has been inadequate as there is evidence to support that many of the problems identified by CASA during the surveillance audit of March 08 were never appropriately actioned.
There is a lack of any clear evidence to support corrective actions have been implemented, confirmed by CASA or that there were effective. If this process is indicative of broader practices of CASA, it is considered that CASA is exposed to unnecessary risk, particularly if required to provide evidence to support how it approved and operated a system, in this case their FRMS …
Given that the ATSB chose to ignore the whole issue of fatigue and how that might have affected the errors that were made by the pilot, because of a lack of evidence, and CASA had a formal report within their system dealing with the issue of fatigue and chose not to disclose that to the ATSB as required by the MOU, I think you would have to agree Mr McCormick that that would seem a little unusual to the reasonable man on the street.
Mr McCormick: The issue of FRMS, or the issue of fatigue, at the time was in its infancy, shall we say—even today, the FRMS rules, where they lie and how we are going forward is a matter we can discuss at some length; we are in a regulatory development process at the moment for fatigue risk management. Put in one score forward from a FADE system, which I believe Pel-Air were using, and which is used by many others around the world, gives an answer. Using some other esoteric system, or some other mathematically based system, may give you another answer.
Mathematically based systems have not been proven to be accurate in any way, shape or form. I think the important thing is, on page 21 of the Pel-Air Aviation Safety Audit Report from CASA, where we interviewed Pel-Air pilots, under the 'Policy and application of fatigue practices', it says:
All crew interviewed stated that they felt that would be no issues in stating that they were fatigued and pulling out of duty, but also felt that they had limited opportunities to fly and had to take these opportunities when they arose.
Err good try but I'm afraid I don't think there'll be many that will swallow that codswallop!
And you guessed it Hansard is out....