Aviation safety failure
3rd December 2014
Independent Senator for South Australia, Nick Xenophon, has called for a major shake-up of Australia’s air accident investigation system after an independent review found systemic problems with the botched investigation of the Pel-Air ditching off Norfolk Island in 2009.
Senator Xenophon called for the removal of head of the Australian Transport Safety Bureau (ATSB), Martin Dolan, and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and the Civil Aviation Safety Authority (CASA).
The Transport Safety Board of Canada (TSB) conducted an independent review of the ATSB’s investigation of three serious incidents and its report was released yesterday. It found that the ATSB’s investigation of the Pel-Air crash “did not address key issues in the way that the Australian aviation industry and members of the public expected”.
Today Transport Minister Warren Truss called on the ATSB to re-open the Pel-Air investigation because of the serious flaws identified by the TSB.
“The Canadian report and the Minister’s statements are further testament to the ATSB’s incompetence. The Minister is right to call for a re-opening of the investigation, but he’s wrong to ask the ATSB to do it. It needs to be done independently,” said Nick.
The TSB report found:
- The ATSB was unaware of Pel-Air’s systemic fuel and fatigue management problems that contributed to the crash because “insufficient data were collected”
- The ATSB investigation led to an organisational focus on “risk level labels” rather than factors that “contribute to advancing safety”
- Evidence of insufficient oversight by CASA of Pel-Air flight planning and monitoring practices
The TSB report says: “A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved”.
The TSB report supported the findings of the Senate inquiry instigated by Senator Xenophon by the Rural and Regional Affairs and Transport Committee. The Committee, in its 176-page report last year, found that CASA had withheld from the ATSB evidence of its failure to oversee Pel-Air. The Committee found that evidence from the Martin Dolan, head of the ATSB, was “questionable”.
Senator Xenophon said the Government was yet to act on the findings of the Senate report, and criticised the Aviation Safety Regulation Review report, launched last November and completed in June, as “a missed opportunity for reform”.