List of Recommendations
Recommendation 1
3.68 The committee recommends that the ATSB
retrieve VH-NGA flight data recorders without further delay.
Recommendation 2
4.41 The committee recommends that the minister, in
issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013,
make it clear that safety in aviation operations involving passengers (fare paying
or those with no control over the flight they are on, e.g. air ambulance) is to
be accorded equal priority irrespective of flight classification.
Recommendation 3
4.43 The committee recommends that the ATSB move
away from its current approach of forecasting the probability of future events
and focus on the analysis of factors which allowed the accident under
investigation to occur. This would enable the industry to identify, assess and
implement lessons relevant to their own operations.
Recommendation 4
4.69 The committee recommends that the ATSB be
required to document investigative avenues that were explored and then
discarded, providing detailed explanations as to why.
Recommendation 5
4.78 The committee recommends that the training
offered by the ATSB across all investigator skills sets be benchmarked against
other agencies by an independent body by, for example, inviting the NTSB or
commissioning an industry body to conduct such a benchmarking exercise.
Recommendation 6
4.79 The committee recommends that, as far as
available resources allow, ATSB investigators be given access to training
provided by the agency's international counterparts. Where this does not occur,
resultant gaps in training/competence must be advised to the minister and the
Parliament.
Recommendation 7
4.87 The committee recommends that the Transport
Safety Investigation Act 2003 be amended to require that the Chief
Commissioner of the ATSB be able to demonstrate extensive aviation safety
expertise and experience as a prerequisite for the selection process.
Recommendation 8
4.101 The committee recommends that an expert
aviation safety panel be established to ensure quality control of ATSB
investigation and reporting processes along the lines set out by the committee.
Recommendation 9
4.103 The committee recommends that the government
develop a process by which the ATSB can request access to supplementary funding
via the minister.
Recommendation 10
6.41 The committee recommends that the
investigation be re-opened by the ATSB with a focus on organisational,
oversight and broader systemic issues.
Recommendation 11
6.52 The committee recommends that CASA processes
in relation to matters highlighted by this investigation be reviewed. This
could involve an evaluation benchmarked against a credible peer (such as FAA or
CAA) of regulation and audits with respect to: non-RPT passenger carrying
operations; approach to audits; and training and standardisation of FOI across
regional offices.
Recommendation 12
6.55 The committee recommends that CASA, in
consultation with an Emergency Medical Services industry representative group
(eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue
providers) consider the merit, form and standards of a new category of
operations for Emergency Medical Services. The minister should require CASA to
approve the industry plan unless there is a clear safety case not to. Scope for
industry to assist as part of an audit team should also be investigated where
standardisation is an issue. This should be completed within 12 months and the
outcome reported publicly.
Recommendation 13
6.58 The committee recommends that a short inquiry
be conducted by the Senate Standing Committee on Rural and Regional Affairs and
Transport into the current status of aviation regulatory reform to assess the
direction, progress and resources expended to date to ensure greater visibility
of the processes.
Recommendation 14
7.15 The committee recommends that the ATSB-CASA
Memorandum of Understanding be re-drafted to remove any ambiguity in relation
to information that should be shared between the agencies in relation to
aviation accident investigations, to require CASA to:
- advise
the ATSB of the initiation of any action, audit or review as a result of an
accident which the ATSB is investigating.
- provide
the ATSB with the relevant review report as soon as it is available.
Recommendation 15
7.16 The committee recommends that all meetings
between the ATSB and CASA, whether formal or informal, where particulars of a
given investigation are being discussed be appropriately minuted.
Recommendation 16
8.35 The committee recommends that, where relevant,
the ATSB include thorough human factors analysis and discussion in future
investigation reports. Where human factors are not considered relevant, the
ATSB should include a statement explaining why.
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.
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.
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.
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.
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.
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.
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.
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.
Recommendation 26
10.35 The committee recommends that in relation to
mandatory and confidential reporting, the default position should be that no
identifying details should be provided or disclosed. However, if there is a
clear risk to safety then the ATSB, CASA and industry representatives should
develop a process that contains appropriate checks and balances.
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