Thursday, 20 March 2014
Rural and Regional Affairs and Transport References Committee; Government Response to Report
I seek leave for the Senate to reconsider the matter relating to the Rural and Regional Affairs and Transport References Committee report into air safety and accident investigations.
by leave—I move:
That the Senate take note of the document.
At the outset, I would like to acknowledge the incredible work of the committee secretariat on this report. It is a very complex, technical area, and I believe this report should be held up as the gold standard of what a dedicated Senate committee can achieve. At the risk of embarrassing her, I would like to acknowledge my legislation and policy adviser, Hannah Wooller, who did extraordinary work on this, and who probably knows more about air safety investigations and air accident investigations than she ever thought she would want to know when she started work with me.
I fear that I may not be able to say the same about the government response, in comparison to the way that the secretariat has dealt with this. I note that the government has already established its review into aviation safety, and that the ATSB has already invited the Canadian transport safety board to consider its investigative and reporting processes in relation to the Pel-Air incident and other matters. But I do have serious concerns about the Canadian process. Those concerns are not about the integrity of the Canadian transport safety board, but about the fact that it seems that their terms of reference are so circumscribed. They have yet to interview or obtain information from the Senate committee, from the pilot involved in that incident or from experts who gave evidence to that committee.
What is vitally important about the recommendations from this report is that they do not stand alone. They were made in the context of evidence that showed a serious and systemic lack of rigour from both the ATSB and CASA. Any responses from the government that claim that existing policy or procedure addresses the committee's concerns cannot be accepted, because this report clearly shows that existing policies and procedures do not work. Instead, the flight crew of VH-NGA were made scapegoats for regulatory failures.
I note, in particular, the comments from ATSB Chief Commissioner Mr Dolan, who admitted during questioning that he was 'not proud' of the ATSB's report into the Pel-Air incident. The committee even went so far as to state that Mr Dolan's standing as a witness before the committee had been eroded by his evidence relating to the ATSB's failure to retrieve the flight data and cockpit voice recorders. Mr Dolan justified this position by quoting a version of the statement that sets out the ATSB's international responsibilities in this regard—ICAO Annex 13—that was not in force at the time of the accident or investigation. I pay tribute to Senator David Fawcett's cross-examination of Mr Dolan in this regard, which elicited very valuable information. A reading of the current Annex 13 may leave some room for discretion as to whether the recorders are to be retrieved. A reading of the annex that was in force at the time of the incident and subsequent investigation—and therefore should have been the one used by the ATSB to reach a decision—does not provide for this discretion. The committee report states:
The committee does not accept this argument—
that is, the argument of Mr Dolan.
At the time the decision against retrieving the FDR was made the imperative existed for the ATSB to do so. To ignore this imperative by arguing that the benefit did not justify the cost appears disingenuous. To imply that the revised wording in the current version of Annex 13 was the basis for the ATSB's decision in 2009/2010, before this version was in force, is even more disingenuous.
This report also called into question the relationship between the ATSB and CASA, and whether the intention of the memorandum of understanding between them is being met. The purpose of CASA is to ensure Australia's aviation safety regulations are being met and are serving their purpose. Therefore, if an incident investigated by the ATSB reveals a gap in that oversight, it is the ATSB's duty to report it.
I would like to share an email from an ATSB officer to Mr Dolan and Mr Ian Sangston of the ATSB regarding the investigation, which reads in part:
We were discussing the potential to reflect the intent of our new MoU that describes the 2 agencies as 'independent but complementary'. We discussed the hole CASA might have got itself into by its interventions since the ditching, and how you might have identified an optimum path that will maximise the safety outcome without either agency planting egg on the other agency's face. Right now, I suspect that CASA is entrenching itself into a position that would be hard to support. If we were to contemplate an exit strategy, or an 'out', then CASA would need to recognise that it is 'in' something in the first place.
It is important to note that the final ATSB report makes no reference to the officer's concerns. What this email clearly indicates is that there was a belief inside the ATSB that CASA had 'got itself into a hole', and that the ATSB's priority was avoiding conflict between the two agencies, rather than holding CASA to account.
On its own part, CASA concluded a special audit of Pel-Air after the ditching and found multiple significant safety breaches on the part of Pel-Air. A further audit CASA undertook on its oversight of Pel-Air found that CASA had failed in its role as regulator. CASA did not share this information with the ATSB, despite the MoU between them requiring it. As such, the ATSB did not have access to information that showed the broader context in which the incident occurred. What is even more concerning is that, after receiving the information as part of the committee process, the ATSB defended its investigation and stated that access to that information would not have changed their conclusion. Again, this is the report of which the chief commissioner of the ATSB is 'not proud'.
In aviation safety, it is vital to look at the contributing factors to consider the bigger picture in which an incident occurred. For example, were the staff adequately trained? Did the company employing them provide appropriate and continuous access to training and other support? Was there a safety culture in the organisation, or did the operator encourage their staff to take risks and 'just get the job done', so to speak? All of these questions, and more, should be asked so investigators can understand the environment in which an incident occurred. In that way, the environment itself can be addressed to prevent that same, or similar, incidents happening again.
The government should take a similar approach to considering this report. Sadly, it has not. In what environment is the ATSB and CASA operating? What are their cultures like? Are they likely to enforce the systems and procedures already in place, or do changes need to happen? This report gives us the answer to many of those questions. The next question is whether the government will take them into account and act appropriately. I seek leave to complete my remarks later.
I want to follow Senator Xenophon with a couple of brief comments. I welcome his contribution to this and the role he has played, along with Senator Sterle and Senator Heffernan, in the committee inquiry that led to this report. I welcome the fact that the response to this report from the government has finally come. It is a report that deals with a range of serious safety issues. As a member of the committee, and not of the executive government, I have yet to read the response. I intend to do so and look seriously at how these recommendations, which go to serious safety issues for the aviation community, have been responded to.
Recommendation 7 goes to the issue of competence in terms of the governance of organisations. We saw legislation tabled this week in the lower house and we are here in the Senate today looking at a bill for increasing governance on the board of CASA. The minister commented that he is looking to have people with both operational and technical experience on the board. That was a strong theme that came through this inquiry—the need to have appropriate, competent guidance for both CASA and the ATSB so that we have leadership that recognises what is important and gives appropriate direction to the practitioners.
Recommendation 13 is that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport. The government has essentially pre-empted that recommendation with the review being led by Mr David Forsyth into the regulatory reform process. That has been widely embraced by the aviation community. I look forward to the tabling of that in the implementation.
While the response by the former government, and even this one, is far later than should have been the case for something that is so important, I welcome the fact that the response has been tabled and I look forward to reading it in detail. I seek leave to continue my remarks later.
Leave granted; debate adjourned.