Mr Dolan : As I tried to state—and perhaps I am not making myself clear—the principal purpose of an accident investigation, or an occurrence investigation, is to understand 'cause', which in our case we do by way of identification of safety factors and safety issues. Our attention, quite reasonably, remains on that. Our mandate is really to look at, and to understand to the extent necessary, the context and the relevance of the context within which the occurrence happened. There is still nothing in our assessment that we could see, acknowledging that there were deficiencies in CASA's surveillance and activities, and acknowledging that there were problems with the way Pel-Air operated its safety management system, that was going to lead us to the question of
contributing safety factors and, more particularly, to the identification of areas for safety improvement. We were conscious that CASA, for it is regulatory purposes, was undertaking steps in relation to the pilot, in relation to Pel-Air as the operator and, indeed, in relation to itself in terms of those improvements, so the question was: if there is an intervention from CASA in terms of rectifying some problems of noncompliance, what is the extent to which we have to retrace that territory in the interests of safety improvement? They are the balances we are undertaking in the course of scoping and re-scoping our investigations.
Senator FAWCETT: I understand your talk about balancing and not going over the same ground, but where another agency has already done the work, and that report is now presented to you, and that agency has identified—again I go back to paragraph 4.1:
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 of management and check and training personnel.
It says here:
If a systems audit is conducted with inadequate product checking—
that is, the line pilots—
CASA is unable to genuinely confirm that the operator is managing their risks effectively.
Are you still maintaining the position that that is not an
organisational influence or a risk control that was a contributing safety factor, in terms of not only the incident pilot but also the fact that the rest of the line pilots indicated similar lack of compliance and lack of understanding, to this incident and potential like incidents?
Mr Dolan : That is our position, Senator Fawcett, and clearly you disagree with it. It is the influence of those factors on the accident flight in particular which always has to be the principal but not the only focus of our investigation. It is the influence of those known factors in the events of this flight that we always have to come back to, because of the task that we have been given as the accident investigator.
Senator FAWCETT: You have used the term 'known factors'. I put it to you that, had you received this report before the issuing of your final accident report,
they would have been known factors because they are spelt out in black and white. I take you again to the diagram you have on page 13, where you look at risk controls and you ask question: what could have been in place to reduce the likelihood or severity of problems at the operational level?
Again, I go to the Chambers report, where it talks about inspector capability and performance. It talks about the fact that an inspector needs to have a level of investigative skill to drill down to find the deficiencies that are genuinely serious and often complex. Not all inspectors have this capability and it seems that this characteristic is assumed to exist in an inspector. It then goes on to talk about the scratching-the-surface approach and the fact that the inspectors, in Pel-Air's operation, were not even aware of the routes that they flew, or the fact that the majority of their operation was EMS as opposed to cargo.
Coming back to your table, surely what could have been in place were inspectors who were competent and informed, as well as an appropriate oversight program. Does that not fit the definition of your risk control?
Mr Dolan : Those sorts of circumstances certainly fit in to the picture of what would constitute
organisational issues. Where we appear to be at odds is in the question of the level of
contribution of those factors in the particular occurrence that we were investigating. That is why we have the position that we have taken. We carefully reviewed the chamber's report, and the basis on which we responded as we did was the issue of influence, contribution, cause.