Chapter 9
Key issues around recommendations and ensuring action
9.1
The ATSB report contains no formal recommendations. Instead it identified
two 'minor safety issues'. This chapter will discuss the reasons provided by
the ATSB and the concerns raised with the committee in relation to the lack of
recommendations. The committee will then outline the areas where it believes
recommendations should have been made. It also includes a range of related
matters such as the difficulties with tracking actions and recommendations, as
well as delays in CASA responding to recommendations.
Fulfilling legislative requirements
9.2
Several witnesses seemed genuinely bewildered at the lack of any formal safety
recommendations in the report, expressing the view that it is the function of a
safety report to make recommendations for improvements in safety[1]
as detailed in the Transport Safety Investigation Act 2003 (TSI Act). Section
12AA of the TSI Act details the functions of the ATSB which includes 'making
safety recommendations' as a way of communicating factors that contribute to or
have contributed to or affect or might affect transport safety.[2]
Minister's requirements
9.3
The committee notes the statement of expectations by the minister issued
under section 12AE of the TSI Act which mentions the ATSB making safety
recommendations and 'providing [the minister], as part of its Annual report, a
status report on formal safety recommendations issued by the ATSB'.[3]
Why are there no formal recommendations included in the ATSB report?
9.4
The committee notes the Memorandum of Understanding (MoU) with CASA
outlines the ATSB's approach towards recommendations for CASA:
The ATSB understands actions may be taken by CASA in response
to safety issues during the course of an ATSB or CASA investigation, and the
ATSB will include this information in the investigation report to the extent it
is practicable to do so. The ATSB encourages safety action that obviates the
need to make safety recommendations.[4]
9.5
The ATSB indicated that in relation to ICAO Annex 13, Paragraph 6.8 requirements,
it has filed a difference regarding the use of recommendations arising from
safety investigations:
The definition of safety recommendation (Chapter 1): The
essence of the definition is adopted in legislation and in policy and
procedures documents. However, Australia reserves the term safety
recommendation for making formal recommendations which are used as a last
resort.[5]
9.6
The ATSB explained the rationale for its position is that the overuse of
safety recommendations tends to devalue them and its policy is to reserve them
as a tool of last resort for addressing significant safety issues where safety
action has not been taken.[6]
Another part of its justification is that the ATSB has no power to enforce the
implementation of its recommendations.[7]
The ATSB explained its process around using recommendations as a last resort:
The ATSB has moved away from this traditional view of making
recommendations in final reports and instead identifies Safety Issues during
the course of an investigation, communicates these issues to the relevant
organisations for consideration, and then reports on the safety actions taken
to address the issues. In this regard, the ATSB prefers to encourage proactive
safety actions that address the safety issues identified in its reports. Other
benefits of this approach are that the stakeholders are generally best placed
to determine the most effective way to address any Safety Issues and the
publication of the Safety Actions undertaken is generally viewed very
positively.
This approach has marked benefits in regard to improving
safety, in that identified safety issues are usually addressed before the final
report is issued, and all safety actions taken by organisations are reported in
the ATSB final report. In the event that no, or limited, safety actions are
taken, the ATSB can still issue a formal safety recommendation. This process is
identified in the ATSB’s Annual Plan and forms a part of the ATSB’s Key Performance
Indicators.[8]
9.7
The ATSB defines a safety issue as:
A safety factor that: can reasonably be regarded as having
the potential to adversely affect the safety of future operations, and is a
characteristic of an organisation or a system, rather than a characteristic of
a specific individual, or characteristic of an operational environment at a
specific point in time.[9]
9.8
The ATSB highlighted its view that the response to a safety
recommendation is unlikely to differ from the response to an identified safety
issue which, according to the ATSB is likely to be more proactive and timely.
The ATSB advised this was its view regarding the Norfolk Island investigation.[10]
Ability to track action taken in relation to safety issues
9.9
Several witnesses expressed concerns about the reduced number of
recommendations[11]
and the effect of the preference of the ATSB not to issue safety
recommendations. These concerns centred on the ability to transparently track
progress with the actions being taken.
9.10
Capt. Geoffrey Klouth, Australian and International Pilots Association
(AIPA), told the committee that the use of safety issues instead of
recommendations appears to indicate a reliance on the regulator or operator to devise
solutions to any safety issues identified. Also, unlike formal safety
recommendations, there would appear to be no formal process in the system to
monitor and follow through on safety actions.[12]
AIPA noted:
One point worth reinforcing from a previous comment relates
to promising to implement something just to avoid a safety recommendation being
made – in that case, is the proposed action tracked by anyone?[13]
9.11
First Officer Ian Whyte, AIPA, pointed out that future actions, which have
not yet occurred, are being accepted as safety actions:
One of our areas of greatest concern is that there are no
formal recommendations that can be opened and then accepted as complete or
remain open. And who is reviewing that goes even further in that the safety
actions that are listed are not actually actions. They are things that are going
to happen sometime. If they were actually in place, I would accept that it is a
safety action and can be closed off, but at the moment they are not. It is, 'We
are going to issue a notice of proposed rulemaking at some point in the
future.' They have not yet, so how can it be a safety action when it has not
happened? In terms of improving safety, which is why we are here, certainly one
of our greatest concerns is who is developing those recommendations and then
monitoring the implementation or accepting that we cannot go there and
assessing that process.[14]
9.12
The committee notes from the ATSB submission that there appears to be an
internal mechanism to review safety actions, however unlike the formal process
with recommendations, this appears to be an internal process which is not
transparent to the industry, the broader public, other agencies or the
Parliament:
Where the ATSB is advised that safety action is in progress
or is proposed to be undertaken, the safety action is placed on ‘Monitor’
pending finalisation/implementation of the safety action. Tools within the
analysis module of SIIMS [Safety Investigation Information Management System] enable
recording and monitoring of all aspects of safety issues, including setting of
alerts to prompt checking of progress on safety action in circumstances such as
when a safety action is on ‘Monitor’.
As noted above, once an organisation has taken safety action
(whether pro‑active after communication of the safety issue by the ATSB
or as a result of a recommendation), the ATSB conducts another risk assessment
to determine if the level of risk has reduced to an acceptable level. If it
has, then no further action is taken. However, if the level of risk remains at
the significant level, the ATSB will consider whether there is a realistic
prospect of reducing the risk further and if necessary pursue further safety
action.[15]
9.13
Mr McCormick spoke about CASA's process to track formal ATSB
recommendations:
With the tracking of legal outcomes, coroners'
recommendations and ATSB recommendations, we are scrupulous about that, and we
have the numbers and we can tell you exactly why we have done it. Sometimes we
do not implement some recommendations, for various reasons. Sometimes it is
overtaken by time, because it is already regulated in that area. Sometime[s] it
is just out and out impracticable and not possible, particularly some of the
motherhood type statements we occasionally see. But the legal division tracks
all of those recommendations, we know the status of every one and we take them
very seriously. Whether this was done in the past—and I will go back numerous
years, I suppose—I agree with you that that is a question for others. But I can
guarantee you we certainly do now.[16]
9.14
However, it appears this process was only put in place since 2009[17]
and the committee is unclear whether CASA also tracks safety issues.
Committee view
9.15
The committee notes the ATSB's view regarding the overuse of safety
recommendations and its policy to use them as a last resort. The committee has
concerns with this approach given the lack of ability to rigorously and
transparently track actions taken in response to safety issues which are the
ATSB's preference to issuing recommendations.
9.16
As an example, with some issues such as those around the safety of lifejackets,
ATSB documentation indicated an assumption that the regulator would act so no
recommendation was made[18]
but no safety issue was identified either. If the ATSB are not making public
recommendations, the committee is concerned whether every safety issue is being
appropriately documented so that there is a formalised way of tracking
identified safety issues that may or may not be passed on to CASA or others.
The committee is concerned that there are potentially safety issues being
missed or overlooked by the lack of a structured transfer of such information.
9.17
From the evidence received, the committee believes that the formal
process used to track recommendations better supports transparency and
accountability to assure Parliament and the public that issues of aviation
safety are being or have been addressed. This is clearly demonstrated by the
fact that it is possible to follow regulatory recommendations made by the ATSB
to CASA over 10 years ago that have not been implemented and affected this
flight. These are discussed below. The committee wants to assure itself, the
Parliament and the travelling public that safety issues/recommendations are
appropriately captured and that safety actions can be tracked transparently.
Recommendation 17
9.18
The committee recommends that the ATSB prepare and release publicly a
list of all its identified safety issues and the actions which are being taken
or have been taken to address them. The ATSB should indicate its progress in
monitoring the actions every 6 months and report every 12 months to Parliament.
Safety issues only relevant to specific operators
9.19
Another criticism of the ATSB's approach was that safety actions would
only be relevant to a specific operator when the lessons should provide a
learning opportunity for the industry as a whole. Mr Mick Quinn highlighted
this issue:
The Norfolk Report not only had significant omissions in
factual information and analysis, it also contains no recommendations. Instead,
the ATSB rely on Safety Actions that have been taken by relevant bodies
involved. Part of the reason this takes place is that often by the time a
report is released, the industry has made fixes and moved on. I challenge this approach
as the Safety Actions are only relevant to a specific operator, in this case
Pel-Air. The lessons from Safety Recommendations are relevant to the entire
industry and not just the operator in question. Therefore the safety system is
improved for the travelling public.[19]
9.20
The Pilot-in-Command also voiced his concern that only Pel-Air has
changed its operating procedures:
I know Pel-Air has modified their procedures. However, they
no longer undertake aeromedical operations, but for all those operators out
there that operate in a similar capacity to Pel-Air or operate in an
environment that resembles the one that I operated under, none of those
operators have been compelled to make changes, and no outcomes have been
distributed into the industry that reflect what has been learnt from the
accident. So as for the generic issues that affected me on the night, nothing
has been changed.[20]
Significant delays implementing ATSB recommendations
9.21
A broader issue appears to be that even when recommendations are made,
there is no effective closed loop system to track recommendations to ensure
they are addressed in a timely fashion. AIPA highlighted concern when CASA does
not act in a timely manner or not at all:
AIPA presumes that, if and when the ATSB fails to adequately
‘influence’ CASA to do something that it undertook to do, the matter would be
resolved by the Secretary of the Department of Infrastructure and Transport
(DIT) in the first instance and eventually by the Minister. Ultimately, given
the constant tensions of priorities and resources, the resolution of the issue
will be driven only by the politics of the inaction, i.e. as a function of the
length and strength of public attention.[21]
9.22
The committee found two regulatory areas, directly relevant to the
Westwind flight, where recommendations by the ATSB had been made and over a
decade later the issues remained. These two areas are:
- upgrading aeromedical flights from 'aerial work' to 'charter' in
order to afford passengers greater protection (recommended by the ATSB in September
2001). CASA has not implemented this change; and
-
to be more prescriptive about fuel requirements for remote
islands (recommended by the ATSB in February 2000). This was implemented by Pel-Air
following the accident and the CASA Special Audit and CASA has undertaken to
again look at the issue.
Categorisation of aeromedical
flights
9.23
The committee heard that aeromedical evacuations involve many unknowns, variability
and a dynamic environment. Such operations:
- are done on the run;
- are reactive to requests such as EMS (emergency medical service) work;
- have crews going into unfamiliar areas and facilities may be
basic;
- can involve limited airports in the area;
- have unplanned and unexpected things happen such as no suitable
lighting and deterioration of patients.[22]
9.24
Given these factors, the committee was surprised to hear the classification
of such flights has a long history. The activity was classified as Aerial Work
which includes operations such as agricultural spraying. It has lower safety
requirements than passenger carrying operations. Given the high risk involved
in aeromedical flights, the committee was surprised to hear that the reclassification
of such operations has been an issue for over 10 years.
9.25
Mr Aherne drew attention to the ATSB recommendation issued 7 September
2001 to CASA regarding improving protections for non-fare paying passengers in
aerial work activities.[23]
In 2002 CASA advised consultation would take place in 2003. On 2 February 2009,
CASA's response,[24]
indicated the proposed amendment to CAR 206 was 'problematic'. However, under
the new Civil Aviation Safety Regulations (CASR) corporate operations will be
classified as Aerial work and will be regulated under CASR Part 132. The carriage
of patients and other personnel (other than air transport operations) will be
regarded as Aerial Work under subpart of Part 136 to be titled Emergency and
Medical Services Operations.[25]
The recommendation was listed as closed – partially accepted.[26]
9.26
Mr McCormick told the committee that nearly 12 years since the
recommendation was issued, such flights are still classified as aerial work
under CAR 206.[27]
CASA indicated that it is currently consulting with relevant stakeholders with
a view to the reclassification of aerial ambulance operations as passenger
transport operations once the new operational regulation suite is enacted.[28]
Mr McCormick informed the committee the work in this area continues:
There are significant issues around charter and aerial work.
My personal view is that there should be no difference between aerial work and
charter when it comes to these matters. Public transport will disappear under
its current guise in the new ops regulations.[29]
9.27
Mr Aherne highlighted that it is over 10 years since the ATSB
recommendation was made and change is still some time away. He argued that if
the operator had had to comply with the flight as a charter flight, it could
not have been conducted in a Westwind as it is not capable of uplifting enough
fuel to hold an alternate for Norfolk Island on a flight from Samoa.[30]
9.28
He also highlighted that passengers on an aeromedical flight do not have
the choice of whether they go on an aircraft or not and most of the time they
are not in a fit state to make that choice. Medivac passengers assume they are
being provided with high safety standards.[31]
CASA informed the committee that following the accident, it audited all
aeromedical operators and confirmed that operations manuals were appropriate
for these flights.[32]
9.29
Mr Quinn advised the committee that he was involved in trying to address
the categorisation issue in 2009. A policy was developed by the former CEO of
CASA and others including Mr Quinn. The policy paper recognised that:
...in air ambulance flights there are crew, there are task
specialists, there are participants and there are passengers, and therefore
they should be treated exactly the same whether they are charter or RPT
[Regular Public Transport], even. The plan of this policy was to take this type
of operation out of the air work category, recognizing that there were
participants on board. Unfortunately that policy...never saw the light of day,
and we are still in a situation now where this has not been addressed.[33]
9.30
The Royal Flying Doctor Service highlighted the operational environment
and conditions that need to be taken into consideration for providing aeromedical
operations to remote, rural and regional Australia.[34]
AIPA expressed the view that the investigation was a missed opportunity to
examine the appropriateness (as distinct from legal availability) of the aerial
work classification for sophisticated air ambulance operations and the
operational decision to use a lower standard.[35]
9.31
Pel-Air supported the change to bring passenger carrying aerial work
operations in line with regular public transport operations to remote islands,
including the requirement to carry an alternate.[36]
Fuel requirements for remote
islands
9.32
In February 2000, the ATSB made a recommendation for circumstances
similar to the Westwind flight, noting the difficulty in forecasting the
weather at Norfolk Island. The ATSB recommended that BoM review the methods and
resources for forecasting at Norfolk Island to make them more reliable.[37]
The recommendation was recorded as 'Closed – Accepted'[38]
and this appears to be on the basis that BoM is 'actively participating in the
review of fuel requirements for flights to remote islands being undertaken by
CASA'.[39]
The issue about forecasting weather is discussed further below but the
committee asked Mr McCormick about the status of this review of fuel
requirements. Mr McCormick explained that CASA has reviewed the fuel
requirements for remote islands but not Norfolk Island.[40]
Subsequently, CASA advised that the:
...review of fuel requirements for flights to remote islands
referred to a CASA review for flights to remote islands which resulted in an
amendment to Civil Aviation Order (CAO) 82.0...Regular Public Transport operations
were not included in the amendment to CAO 82.0 as it was already a condition on
an RPT [Regular Public Transport] Air Operator's certificate (AOC) that CASA
approved both the route over which an RPT was flown and the fuel policy of the
operator. Thus for RPT operations, CASA already had in place a means to
regulate the carriage of adequate fuel...CASA initiated a project (OS 09/13) in
2009 to address ATSB concerns that fuel quantity issues were becoming
problematic. That project remains in place and CASA agreed action in the Pel
Air accident report is to review in part the fuel and alternate requirements for
operations to remote islands.[41]
9.33
The committee notes that as a result of the CASA Special Audit, Pel-Air's
fuel policy was revised to require an alternate for Norfolk Island. This
appears to be a lesson that would be relevant to the broader aviation industry.
Committee view
9.34
Both of these unaddressed recommendations point to a regulatory issue and
it was put to the committee that if either of these had been addressed 10 years
ago when recommended, then this accident probably would not have happened. The
committee is therefore puzzled as to why these broader regulatory issues are
not mentioned in the report. It also highlights the need for a more robust and
proactive system to implement and track recommendations and to ensure recommendations
translate into action in a timely manner.
9.35
To illustrate the danger of this process, the committee notes that AIPA
pointed out that it appears that none of the safety actions attributed to CASA
have yet been completed. While it may be a function of the regulatory review
program, it is not apparent what other defences have been put in place. AIPA
pointed out that as things stand it is not clear from an industry compliance
perspective if any safety improvement has been achieved.[42]
9.36
As noted above the ATSB has no enforcement powers so the extent to which
ATSB investigations enhance aviation safety is limited by the extent to which
any safety recommendations made are actioned. Therefore there is a need for a
closed loop feedback system to ensure they are all implemented in a timely
manner.
9.37
The committee notes the mechanism contained in Section 25A of the TSI
Act which is supposed to ensure that ATSB recommendations are responded to in a
timely manner. That section requires a person, association or agency to provide
a written response to recommendations within 90 days of the report being
published. The response is then published on the ATSB website.[43]
While the front end of the process to receive an initial response to a
recommendation appears to be covered, this does not include a robust tracking
and follow up process.
9.38
The MoU notes that where consideration and implementation of a
recommendation may be protracted, CASA will inform the ATSB of progress at
regular intervals.[44]
The ATSB received its initial response from CASA on 4 February 2002, an update
on 14 November 2002 and then nothing until 2 February 2009 which resulted in
the ATSB assessment of closed – partially accepted.[45]
The committee notes that where the response relegates action to some time in
the future, then years could pass before any timely action is taken. This is evidenced
by the recommendations which lingered for over 10 years and affected this
flight. This timeframe is unacceptable.
9.39
The committee accepts the need for versatility to ensure immediate
action is taken, for example, in cases where safety is threatened. However, the
issue and the action taken should still be transparent. The committee believes
that in order to ensure appropriate tracking, if a safety action is not closed
before a report is issued then a recommendation should be issued. Even where a
safety action has been completed, a report should indicate what the action was,
who was involved and how it was resolved.
Recommendation 18
9.40
The committee recommends that where a safety action has not been
completed before a report being issued that a recommendation should be made. If
it has been completed the report should include details of the action, who was
involved and how it was resolved.
9.41
To ensure actions are addressed in a timely manner the government should
consider setting a time limit to implement or reject recommendations, beyond
which ministerial oversight is required where the agencies concerned must
report to the minister why the recommendation has not been implemented or that,
with ministerial approval, it has been formally rejected.
Recommendation 19
9.42
The committee recommends that the ATSB review its process to track the
implementation of recommendations or safety actions to ensure it is an
effective closed loop system. This should be made public, and provided to the Senate
Regional and Rural Affairs and Transport Committee prior to each Budget
Estimates.
9.43
The committee considers that the ATSB should institute processes to
ensure that there is greater visibility of recommendations that are rejected or
remain unactioned for long periods of time.
Recommendation 20
9.44
The committee recommends that where the consideration and implementation
of an ATSB recommendation may be protracted, the requirement for regular
updates (for example 6 monthly) should be included in the TSI Act.
Recommendation 21
9.45
The committee recommends that the government consider setting a time
limit for agencies to implement or reject recommendations, beyond which ministerial
oversight is required where the agencies concerned must report to the minister why
the recommendation has not been implemented or that, with ministerial approval,
it has been formally rejected.
9.46
The committee considers that these new processes should be applied to
the closure and acceptance of the recommendations regarding the classification
of aeromedical flights and the ability to accurately forecast the weather at
Norfolk Island.
Areas where recommendations are necessary to ensure actions are taken
9.47
The committee is also concerned about several areas which are discussed
below where it believes the evidence has demonstrated that recommendations (or
at the very least the identification of a safety issue) should have been issued
to ensure appropriate action was taken to address issues that affected the
flight and the outcome.
Passing on relevant weather
9.48
Evidence provided to the committee revealed problems obtaining the most
up‑to-date and correct weather information on which to base in-flight
decisions.
9.49
As background, the ATSB advised that in the interests of efficient
management of large areas of contiguous airspace, international agreements have
decided which ATC provides air traffic services in blocks of airspace.[46]
Norfolk Island is an Australian territory but the airspace over it is not. Like
Christmas Island, the airspace is operated by another jurisdiction. In the case
of Norfolk Island it is within the New Zealand flight information region (FIR)
which is managed by the Airways Corporation of New Zealand on behalf of the New
Zealand Government.[47]
However, the flight in question from Samoa passed through airspace managed by
New Zealand[48]
and by Fiji.[49]
Critical weather information not passed on
9.50
The committee received evidence that critical weather information was
not passed on to Capt. James at a point where, had he comprehended the
deteriorating conditions at Norfolk Island, he could have decided to divert. At
803 an amended forecast (TAF) was issued by BoM but was not provided to Capt.
James by Fijian or New Zealand ATC as there was no requirement to do so. The ATSB
report indicates this fact and then focuses on the fact that the crew did not
ask for any updated forecasts.[50]
9.51
The SPECIs issued after the 0800 SPECI and until arrival at Norfolk
Island show the cloud was periodically below the landing minima and that rain
was falling.[51]
Witnesses were concerned that the ASTB made no comment on the duty of the Air
Traffic Service (ATS) to warn of known hazardous conditions.
9.52
Pel-Air submitted that the cause of the ditching was the change of
weather en route and that timely notification of the change in the weather
would have averted the accident. It called for a review of the role of the ATC
to see whether any systemic improvements in this regard could be made.[52]
Usual arrangements when weather conditions
deteriorate en route
9.53
Airservices Australia advised that in Australia when it receives
information that differs from the forecast such as a hazardous weather event
(or SPECI), there is a hazard alert service where the change in circumstances
is proactively notified to all aircraft en route to that destination.[53]
Mr Jason Harfield, Executive General Manager, Air Traffic Control, Airservices
Australia explained what would occur:
What we would do, for example, if an aircraft which had a
terminal area forecast for Sydney was flying between Melbourne and Sydney and
the weather conditions rapidly changed is issue a hazard alert and notify all
aircraft going to that destination of the change in circumstances.[54]
Arrangements for flights to Norfolk
Island
9.54
In the case of the deteriorating weather conditions on Norfolk Island,
these were not proactively conveyed to the pilot by Fijian Air Traffic Control
(ATC) whose airspace the aircraft was in when the updated weather information
became available. The information was not passed on either by New Zealand ATC
which manages the airspace over Norfolk Island.[55]
As indicated, the ATSB report only notes that it was not required to be passed
on.[56]
9.55
Mr Harfield admitted that given what occurred 'that weather information
was critical in the sense that if that bit of information was seen, the outcome
may have been different...Here was a piece of information that should have been
passed to the aircraft which could have prevented this outcome.'[57]
9.56
Surprisingly, when the committee asked whether it had contacted Fijian
ATC or New Zealand ATC to discuss this issue, Airservices Australia confirmed
that three years on from the incident it had not.[58]
When asked why it had not, Airservices stated that it was not aware of the
information contained in the ATSB report until it was published in August 2012.[59]
It was stressed by Airservices Australia that it relies on ATSB reports to
provide information about how the system is working and lessons to be learned.[60]
9.57
Documentation provided to the committee by the ATSB indicated that
Airservices Australia was not included in the DIP process. The committee asked
Airservices Australia to check if ATSB had conveyed any information to it
during the course of its investigation. It responded that it only received a
copy of the final preliminary[61]
and final[62]
reports as part of normal processes.[63]
9.58
Airservices Australia described its normal process to address
recommendations or safety factors raised in ATSB reports. The issue is entered
into its safety action incident reporting tracking, and responsibility for
addressing it is assigned to the relevant area. Airservices Australia also
indicated that it conducts its own investigation and if it identified the need
for a regulation to change it would make a recommendation to CASA.[64]
However, as this incident occurred in a foreign jurisdiction it would not
normally conduct its own investigation and would therefore be heavily reliant
on the ATSB report.[65]
9.59
Ms Margaret Staib, Chief Executive Officer, Airservices Australia,
admitted there 'is room for improvement in managing the cross-boundary areas of
the different jurisdictions, because inevitably it is very difficult to see the
line drawn on a map in the air'.[66]
Airservices Australia stressed that although it can speak about these issues
with its ATC counterparts, this issue is a matter for the Civil Aviation Authority
of New Zealand.[67]
9.60
When asked directly whether there would now be communication with Fiji
and New Zealand to ensure that critical safety information is conveyed to
pilots en route, Ms Staib replied that it will happen. She added that the
first opportunity to discuss the issue would be at the Pacific Forum to be held
before the end of 2012.[68]
However, Airservices Australia admitted in that as at 19 November 2012, it had not
seen the agenda but it would ensure it is raised in the forum by being placed
on the agenda.[69]
In subsequent information, Airservices Australia clarified that the South West
Pacific Safety Forum actually met on 8–9 November 2012 and its next meeting is not
scheduled until May 2013.[70]
Airservices Australia admitted that the issues were not discussed during the
November meeting but will be raised in May 2013.[71]
9.61
It was also pointed out by Mr Aherne that if there is no requirement to
pass on hazardous weather conditions, this contradicts the ICAO Annex 11 Air
Traffic Services Standards.[72]
View of ATSB
9.62
When this issue was discussed with the ATSB, Mr Dolan stressed that he
sees a broader issue which is the en route support provided to flight crews in
terms of assessing their situation, getting access to weather and other related
information. Mr Dolan stressed the provisions of the AIP which states that
principal responsibility is with the pilot to acquire weather-related
information, including forecasts.[73]
Confusingly, Mr Dolan then stated 'there is some provision for air traffic
services to proactively draw attention to the existence of an updated forecast,
normally in the case where aircraft are within an hour of their intended
destination'.[74]
9.63
Mr Dolan concluded that in the view of the ATSB, it did not see anything
that needed to be done to enhance the system.[75]
Committee view
9.64
The committee finds this response by the ATSB disturbing. The ATSB
processes appear to deliberately preclude suggestions that another agency could
have taken action that may potentially save another flight from repeating this
accident.
9.65
To the committee this emphasis on the pilot seeking updates seems
designed to avoid the rather obvious issue of whether the more proactive
provision of information to pilots flying into hazardous conditions could
provide an additional barrier to this incident occurring again. Stressing it is
principally the pilot's responsibility, particularly as the proactive provision
of information about deteriorating weather is a recognised issue which is
addressed in Australia, understates the role of other barriers and ignores
whether flight crews can be better supported by available services.
9.66
The committee is of the view that the provision of deteriorating and
hazardous conditions would have been of assistance to the flight crew and could
have changed the outcome. Australia should take steps to ensure that in future,
relevant information is provided across jurisdictional borders to avoid a
recurrence of this situation.
9.67
TAFs are issued at routine intervals. If an amended TAF (issued on an ad
hoc basis) is not brought to a crew's attention how do they know to ask for it?
The committee accepts the need for crews to proactively seek their own
information at particular points in their flight and is not suggesting the
responsibility for this be abrogated. But surely under such circumstances where
a TAF is amended and it fundamentally affects the safety of an aircraft in
flight, extra assistance in the form of proactive provision of relevant
information would be welcome and should be required.
9.68
The committee finds it worrying that this issue was not raised in the
ATSB report as needing to be addressed and to date the committee has received
no satisfactory explanation from the ATSB.
9.69
The submission from Airservices Australia following its appearance and
answers to questions taken on notice do nothing to assure the committee that
the issue is being proactively addressed. Waiting until May 2013 is nine months
after the publication of the ATSB report and six months after it was raised
with Airservices Australia at the 19 November 2012 hearing. As Airservices
Australia informed the committee that it would speak with its counterparts, the
committee is disconcerted that progress cannot be achieved more quickly. The
committee's concern centres around this situation occurring again and Australia
having done nothing to proactively address it.
9.70
The committee accepts that Airservices Australia was not part of the DIP
process so the first it would have been aware of this issue would have been
when the final ATSB report was issued at the end of August 2012. The committee
also concedes it is by no means clear from the ATSB report that anyone needed
to take action to address this issue. However, there appears to have been some
level of awareness of the issue in Airservices Australia following publication
of the final report which was not acted on until it was raised with Airservices
Australia by the committee. The committee is concerned that had the inquiry not
occurred, current processes mean this issue would never have been highlighted
or addressed. Even now the committee has not received any assurance that it is
being addressed in a timely manner.
9.71
The committee received conflicting information about whether the
requirement to pass on hazardous weather information exists. Given the lack of
clarity on this issue there appears to be two, equally concerning
possibilities. One is that the requirement to pass on this deteriorating weather
information does not exist. The committee is of the view that it should. From
the evidence, the committee remains unclear whose responsibility it would have
been to pass on the information but it is clear that Airservices Australia
needs to address this with Fijian and New Zealand counterparts to ensure that
in future such information is proactively provided.
9.72
The second scenario contemplated by the committee, is that the
requirement does exist but that it did not occur for some reason. Clearly that
would also need to be addressed. The committee heard there is a duty to provide
and initiate provision of known hazards. Section 172.93 of the New Zealand AIP
was also pointed out to the committee which appears to indicate the requirement
to pass on information.[76]
9.73
The committee also notes information in the CASA Special Audit report which
may indicate another possibility that would need to be investigated: 'It is
reported that Nadi weather updates are extremely difficult to obtain as Nadi
ATC only communicate to the RVSM aircraft'.[77]
If this is the case other, aviation operators should be made aware so they can
inform crew. The committee notes that this information also does not appear to
gel with the view of the ATSB that (non-RVSM) aeromedical flights are allowed
to operate in RVSM airspace.[78]
9.74
Airservices Australia, although not directly responsible for the
provision of ATS to the crew, has not proactively tried to address or
communicate to the flight crew the different ATS standards that exist in
different Flight Information Regions.[79]
9.75
The committee recommends that in order to put in place a barrier to such
an event occurring again, Airservices Australia needs to firstly clarify FIS
delivery responsibility for Norfolk Island and whether the requirement to pass
on non-routine weather information exists, and if it does, where that is
stated, whose responsibility it is and why it did not occur on the night in
question.
9.76
If the requirement to pass on the information does not exist,
Airservices Australia should discuss this practice being adopted by New Zealand
and Fijian counterparts. The possibility that non-RVSM aircraft are being
treated differently should also be explored.
Recommendation 22
9.77
The committee recommends that Airservices Australia discuss the safety
case for providing a hazard alert service with Fijian and New Zealand ATC (and
any other relevant jurisdictions) and encourage them to adopt this practice.
Another lost opportunity to pass on
information
9.78
At 0833 there was a conversation between the Unicom[80]
at Norfolk Island and Auckland ATC where the Unicom stated that conditions on
Norfolk Island were deteriorating and asked what time the aircraft was
arriving. Auckland ATC replied the pilot was running a bit late but did not
pass the weather information to the pilot.[81]
Mr Mick Quinn noted that had the Unicom operator been approved as a
meteorological observer he could have contacted the pilot directly instead of
having to contact New Zealand ATC. Mr Quinn highlighted that at that time the
flight crew could have easily diverted to Nadi.[82]
9.79
The committee explored with BoM whether the operator should communicate
directly with the pilot. BoM did not see value in its weather observer
broadcasting directly to the aircraft. BoM informed the committee that the
automatic weather station has an Aerodrome Weather Information Service (AWIS).[83]
9.80
It was later clarified that at Norfolk Island there is no Automated Weather
Information Service (AWIS) radio broadcast. Weather information is broadcast to
aircraft by the airport Unicom operator.[84]
It was also clarified that the information can only be accessed by satellite
phone[85]
which Capt. James did not have. The Unicom operator at Norfolk Island is not an
approved observer recognised by CASA or BoM. The committee heard that in order
for this to occur there would be about two weeks' dedicated observer training.
Authorisation would be valid for two to three years.[86]
9.81
Mr Quinn noted that BoM, ASA and CASA have ceased training the Unicom officers
as approved meteorological observers and argued that Norfolk Island represents
no better case for maintaining trained meteorological observers Unicom
officers.[87]
Had the Unicom operator been approved as a meteorological observer he could
have contacted the aircraft directly at 0833 instead of advising Auckland of
the deteriorating conditions.[88]
Committee view
9.82
The committee notes that the pilot did not have a satellite phone to
hear the broadcast weather observations from the AWS, a situation which has now
been remedied by the operator. The committee believes this action would
constitute a useful learning for the industry and should have been included in
the report.
9.83
This was another lost opportunity to alert the pilot to the
deteriorating conditions and again the information was not passed on which reinforces
the need to address this issue as discussed above.
9.84
The committee understands that CAR 120 states that a pilot may not use
meteorological reports or forecasts provided by a person who has not been
authorised by BoM or approved by CASA.[89]
CASA informed the committee that it has not received any application from the Unicom
operators for approval to provide meteorological reports.[90]
In the committee's view CASA must be aware that this limitation could pose a
risk to operators given the difficulties with accurate forecasting at Norfolk
Island but took no action to mitigate or communicate the risk to industry. The
difficulties with forecasting at Norfolk Island are well known and discussed
further below.
9.85
While appreciating the need for pilots to check weather conditions, Capt.
James clearly was not well supported by the system to achieve a better or more
timely understanding of the deteriorating weather conditions. He was given
incorrect weather details; he did not hear all or did not assimilate the information
contained in the 0800 SPECI and hazardous conditions were not proactively passed
on. The system failures left the retrieval and appreciation of the weather
conditions entirely with the pilot and again he became the last line of
defence. In addition, the difficulty in forecasting weather conditions at
Norfolk Island also played a role as discussed below.
Known difficulties in forecasting weather on Norfolk Island
9.86
Norfolk Island is clearly a difficult location for forecasting weather.
For example it is prone to the incidence of low cloud, and has a history of
problems associated with the accuracy in weather forecasting.[91]
The committee heard from the BoM that about 10 per cent of the time the cloud
will be below the alternate minima for that airport. On the night in question
the cloud base was around 200 feet which is a rare event with the likelihood of
encountering this at less than one per cent.[92]
The BoM submission noted that the probability of encountering unforecast
adverse weather conditions is 2.7 per cent (for cloud base) and 1.3 per cent
for visibility.[93]
9.87
The ATSB also emphasised that the sequence of events leading to the
accident could only have occurred in a very narrow range of circumstances:
Namely, where a flight is aerial work or other general
aviation and the weather on arrival at destination has deteriorated
significantly from that forecast on departure.[94]
9.88
The rarity of the event should not be a reason not to review processes
to see whether further protections can be put in place. Incidents similar to
the accident flight were recognised in an ATSB report 13 years ago.
Previous ATSB recommendation
regarding weather forecasting at Norfolk Island
9.89
This difficulty in forecasting the weather at Norfolk Island was
recognised in the recommendations from an ATSB report 13 years ago on 22
February 2000.[95]
The safety deficiency identified was that:
The meteorological forecasts for Norfolk Island are not
sufficiently reliable on some occasions to prevent pilots having to carry out
unplanned diversions or holding.[96]
9.90
That ATSB report highlighted:
A pilot flying an aircraft that arrives at a destination without
alternate or holding fuel and then finds that the weather is below landing and
alternate minima is potentially in a hazardous situation. The options
available are:
-
to hold until the weather improves; however, the fuel may be
exhausted before the conditions improve sufficiently to enable a safe landing
to be made;
-
to ditch or force-land the aircraft away from the
aerodrome in a area of improved weather conditions, if one exists; or
-
attempt to land in poor weather conditions.
All of these options have an unacceptable level of risk
for public transport operations.[97]
9.91
The recommendation stated:
The Australian Transport Safety Bureau (formerly the Bureau
of Air Safety Investigation) recommends that the Bureau of Meteorology should
review the methods used and resources allocated to forecasting at Norfolk
Island with a view to making the forecasts more reliable.[98]
9.92
The ATSB recommendation appears to deal with the same issues encountered
by the Westwind flight crew and lists a number of examples where aircraft
departed with good weather forecasts, reached points where they were committed
to continue to Norfolk and discovered the weather was very different from the
forecast.
Norfolk Island weather assets
9.93
BoM has a station at Norfolk Island where it has an automatic weather
station (AWS) that has a ceilometer[99]
and a visibility meter.[100]
Observations are transmitted to the Sydney office, to head office in Melbourne,
and then distributed to Airservices Australia and internationally to adjoining FIR
through the Australian Aeronautical Fixed Telecommunications Network (AFTN).[101]
Supplementary input is provided by qualified observers when on duty.[102]
9.94
The committee discussed with BoM what changed as a result of the 2000 ATSB
recommendation. BoM advised that a weather radar was installed in 2003. BoM
further advised:
Other recommendations related to the way in which weather
information was passed to weather forecasters. In 2002, a ceilometer [which measures
cloud base] and visibility meter facility was installed on the island, which
transmits its information automatically and immediately to forecasters. That
facility has largely superseded the need for there to be a call to our
forecasting office from the observers, as was the case before that
instrumentation was available to the forecasters.[103]
9.95
BoM told the committee that there has been no change to the equipment
since 2009. In discussion with the committee, BoM said that perhaps
observations from all over the island could improve the forecast slightly but
the existing observation station is representative of the conditions and
reflects the conditions adequately for forecasting.[104]
9.96
The 2000 ATSB recommendation was recorded as 'Closed – Accepted'.[105]
This appears to be on the basis that BoM is 'actively participating in the
review of fuel requirements for flights to remote islands being undertaken by
CASA'.[106]
Mr Quinn pointed out that at the time of the accident the fuel requirements for
flights to remote islands in aerial work passenger-carrying operations had not
changed.[107]
9.97
Witnesses questioned the accuracy of BoM forecasts at the time of the
flight stating that the 0437 TAF was significantly different to the four SPECIs
and METARs issued during the flight. In addition the 0803 amended TAF (not
received by the crew and which did not forecast that the weather would
deteriorate below the landing minima) did not resemble the subsequent METARs or
SPECIs.[108]
On this issue the committee heard that as pilots are not forecasters of weather,
they should not be held to a higher standard of accountability than BoM:
According to John McCormick it should have been obvious to
the PIC that the weather at Norfolk Island was deteriorating such that at the
expected time of landing the weather would have been below the landing minima
(preventing a landing from being made) then surely it should have been obvious
to the forecasting office. Why did it take them approximately 115 minutes to
issue a TAF that reflected that the weather would deteriorate below landing
minima? The BoM information dissemination processes should have been examined
closely by the ATSB.[109]
Ensuring awareness of conditions by
crew
9.98
AIPA offered the view that the operator is generally best placed to
conduct the research and ensure crews are aware of the peculiarities of weather
in specific locations where it is problematic.[110]
9.99
The committee heard that the disclosure of forecast reliability for all
aerodromes may be of value to pilots in attempting to determine a safe fuel
load or operators trying to develop a safe fuel policy. The committee was
informed that the ATSB should have made recommendations as to how forecast
reliability information could be best communicated to operators to allow them
to manage any risk that may result from that unreliability.[111]
Committee view
9.100
The committee recognises that it is the responsibility of the pilot to
seek weather updates and that, apart from the 0830 update, Capt. James did so.
CASA and the ATSB believe it should have been obvious to the flight crew that
the weather was deteriorating, but from reviewing the forecasts and reports it
seems that even the forecasting office was experiencing difficulty. Between
0800 and 0925, depending on what time an update was requested, conditions were
fluctuating between being below the alternate minima, above the alternate
minima and below the landing minima. At no time did the forecasts indicate that
the conditions would be below the landing minima.[112]
Clearly weather at Norfolk Island is difficult to forecast even for the
professionals.
9.101
The committee notes that the forecast available to the flight crew on
departing Samoa reported scattered cloud at 2000 feet and no issues but when they
arrived it was overcast with cloud at around 200 feet – complete cloud cover, a
radical difference from the forecast.
9.102
The committee notes that the conditions encountered by the flight crew were
particularly rare but that the ATSB report from 2000 indicates that encountering
unforecast adverse weather conditions is not unusual at Norfolk Island. In
addition to this higher incidence of encountering unforecast adverse weather
conditions, the lack of nearby aerodromes present crews with a very different
set of circumstances from most aerodromes in eastern Australia where there are
other aerodromes fairly close by. Further, given the ATSB can articulate the
narrow range of circumstances that occurred on the night of the ditching, the
committee believes this is even more reason to looks at the system to see what
additional assistance can be provided under those circumstances. The rarity of
the occurrence and the fact that 'the existing safety arrangements covered all
other cases...'[113]
is of little comfort to those affected and any flight crew which may face those
circumstances in the future. One of the roles of the ATSB is to improve transport
safety by identifying factors that contribute to occurrences or that might
affect future ones.
9.103
Given the known and continuing difficulties with forecasting the weather
on Norfolk Island, the committee wants to ensure that all feasible steps to
improve weather forecasting have been undertaken and any barriers to passing on
relevant weather have been addressed. Aircraft carrying more fuel is one way to
attempt to address this issue and the committee notes the changes in the
Pel-Air fuel policy and that CASA agreed action to review in part the fuel and
alternate requirements for operations to remote islands. However, the committee
believes it is timely for the relevant agencies to review whether any equipment
or other changes at Norfolk Island would be of assistance in improving weather
forecasting. The review should revisit the issue of whether the Unicom operator
should be an approved meteorological observer, in part due to their local
knowledge.
Recommendation 23
9.104
The committee recommends that the relevant agencies review whether any
equipment or other changes can be made to improve the weather forecasting at
Norfolk Island. The review would include whether the Unicom operator should be
an approved meteorological observer.
9.105
The committee heard that Norfolk Island is prone to incidence of low
cloud and considers that for a person who has never experienced it, there may
be no information (in training manuals for example) to bring this variability
to their attention. The committee heard from BoM that current information on Norfolk
Island is in the ICAO standard format and there is no annotation to TAFs or
SPECIs to indicate that while the information is valid it could, at Norfolk
Island, vary considerably without notice. The committee believes that for those
who have not experienced the variability, it would be helpful to have this
information available. The committee notes that the fact that it is in the ICAO
standard format does not prevent Australia from working with ICAO to change
that if that would be the most helpful way of ensuring the information is
available.
Recommendation 24
9.106
The committee recommends that the relevant agencies investigate
appropriate methods to ensure that information about the incidence of, and
variable weather conditions at, Norfolk Island is available to assist flight crews
and operators managing risk that may result from unforseen weather events.
9.107
The committee notes that the key AIP document used by aircrew to
understand the airport where they are planning to land is the En Route
Supplement Australia (ERSA). The Norfolk Island entry in the ERSA
meteorological information section only identifies the existence of the AWIS
and TAF CAT A. There is no note or caution that forecasts are unreliable and
conditions can change rapidly.[114]
Recommendation 25
9.108
The committee recommends that the Aeronautical Information Package (AIP)
En Route Supplement Australia (ERSA) is updated to reflect the need for caution
with regard to Norfolk Island forecasts where the actual conditions can change
rapidly and vary from forecasts.
9.109
The committee notes that where relevant the recommendations above
relating to Norfolk Island should also be applied to other remote destinations
such as Christmas, Cocos and Lord Howe Islands.
Other improvements
9.110
Other improvements that were suggested for Norfolk Island include a Global
Navigation Satellite System (GNSS) approach would allow a lower minima, had
such an approach been published.[115]
The committee notes a change made at Norfolk Island since the ditching which
was not mentioned to the committee but which may have had an effect on the
outcome. Documentation provided under the Order to Produce Documents from CASA
indicates that a satellite assisted approach (RNP/RNAV [required navigation
performance] approach) was pending approval at the time of the accident. This technology
allows a more precise approach and would have allowed the pilot to descend
lower than the landing minima available at the time in order to achieve
visibility of the runway. It seems the aircraft had the required avionics and
the pilot was licensed/certified to fly RNP/RNAV approaches. In the
documentation CASA's attention was being drawn to the delay in publishing the
new plates and being asked whether the process could be expedited to enhance
safety.[116]
Had this been in place at the time of the accident the outcome may have been
different. The committee notes that since the accident, this has been implemented
by Airservices Australia for Norfolk Island in June (runway 29) and August 2012
(runway 11).[117]
Conclusion
9.111
The committee wishes to assure itself that organisations contributing to
Australian aviation have a proactive culture that seeks every opportunity to
enhance air safety. The committee was disappointed that some key organisations
that gave public evidence, acknowledged the existence of various problems. However,
because it was not their direct responsibility, these organisations had done
nothing to bring issues to the attention of those who could take action, and in
the absence of this inquiry may never have done so.
9.112
This silo mentality has allowed issues to persist for the three years
that the ATSB report took to produce and beyond. This is clearly unacceptable.
The committee, and more importantly the travelling public expect that in the
interests of enhancing air safety, that an issue will be drawn to the attention
of the relevant organisation when it becomes apparent. If it affects the safety
of the travelling public, our aviation safety organisations have the
responsibility to pursue it with the responsible jurisdictions in a timely
manner. In addition, if an organisation becomes aware of an issue which is not
within its powers or rules they should proactively draw it to the attention of
relevant areas so appropriate actions can be taken.
9.113
The committee was not reassured by the responses from Airservices
Australia and found them confusing. Airservices Australia reported 'constantly
having those discussions with them [neighbouring air navigation service
providers] to try to improve the integrity of the system.'[118]
Yet Airservices Australia decided to wait until a regular forum instead of
proactively bringing the issue to the attention of its counterparts.[119]
Airservices Australia also assumed that the ATSB report would have been
provided to New Zealand and Fiji[120]
and that the New Zealand ATC would be doing its own review. However Airservices
Australia admitted that it had not spoken with its counterparts on the issue.[121]
9.114
The committee finds it odd for Airservices Australia to assume that New Zealand
is conducting its own investigation. If Airservices Australia was unaware of
the issue until the ATSB report was published and there was no recommendation
or safety action on the issue, then why should New Zealand ATC have more
awareness if the issue has not been brought to its attention? The committee
certainly hopes this is the case but recognises that hope or assumptions are not
valid mechanisms for ensuring such safety issues are addressed.
9.115
The committee is also concerned about the lack of clear processes in the
absence of recommendations. If there is no mechanism for a foreign jurisdiction
to be aware of the issues then we cannot expect them to act. In addition, even
if the committee accepts that Airservices Australia knew nothing about the
issue until August 2012 when the ATSB report was published, the committee is
concerned that no timely communication or action has been taken since that time.
The committee has no confidence that without this inquiry this issue would have
made it onto the agenda for the next South West Pacific Safety Forum or have
been addressed at all.
9.116
Documentation provided to the committee by the ATSB indicates that as
part of the DIP process the report was not provided to Airservices Australia
but it was provided to the Fijian Civil Aviation Authority and the New Zealand
Transport Accident Investigation Commission. Given the lack of detail in the
report around this issue, that neither organisation had any comment to make and
that it was sent to the New Zealand Accident Investigation Commission and not
the Civil Aviation Authority, it seems unlikely and understandable that no
action in this area has been taken by these jurisdictions.
9.117
The lack of urgency shown by Airservices Australia is both disappointing
and remarkable. Given the significance of this issue, the ATSB appears to have
provided no information to Airservices Australia during the course of its
investigation so Airservices Australia could commence discussions with the
relevant jurisdictions. It is even more remarkable that there has been no
information or recommendation in the ATSB report around this issue. The
committee considers this to be a serious omission from the report which needs
to be addressed.
9.118
The committee’s greatest concern is that in the three years that it took
to produce the ATSB report and the lack of urgent action since, another
incident of the same nature could occur again.
9.119
As for the requirement to provide deteriorating weather information
itself, the committee notes that this has been identified as an issue which is
addressed in Australia. Therefore the committee finds it difficult to
comprehend why there would be no recommendation in the ATSB report that it
would be an enhancement to safety for a neighbouring service provider to
proactively provide the equivalent of a hazard alert. The committee believes
that negotiating the provision of a proactive hazard alert approach with the
relevant jurisdictions would enhance aviation safety for all using that
airspace and provide another barrier or defence to such an incident occurring
again.
9.120
Whatever else occurred, if the flight crew had been made proactively
aware about the deteriorating weather conditions they may have made a different
decision. If the ATSB report had contained a recommendation around this issue
which said this action could be a barrier to a future accident and that it
should be put in place, then the organisations involved would have known to
take action. Without that recommendation, it is conjecture whether the issue
would have been addressed. The committee is of the view that without this
inquiry to highlight the reliance on such recommendations to ensure appropriate
action is taken, it is likely that it would not.
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