Chapter 3
The ATSB investigation and methodology
Background
3.1
The Australian Transport Safety Bureau (ATSB) produced a report on the
ditching of VH-NGA Westwind II, operated by Pel-Air, following a lengthy
investigation.[1]
The report has generated much debate and attracted considerable criticism.
3.2
In order to assess the ATSB investigation report, its conclusions and
criticism of both, the committee sought a great deal of evidence on how investigation
reports should look.
3.3
This chapter looks at the investigation model used by the ATSB, and what
in the committee's view the ATSB report should have covered, with a particular
focus on the requirements under Annex 13 of the International Civil Aviation
Organisation's (ICAO) Chicago Convention and the ATSB's own procedures, as
outlined in the agency's submission.
3.4
The chapter also looks at issues around the agency's decision to not
retrieve VH-NGA's flight data recorder, as well as the inordinate amount of
time taken to produce the investigation report.
3.5
Finally, this chapter explores the reasons the ATSB report took almost
three years to complete.
Accident investigation analysis model
3.6
Investigation analysis models are usually based on the widely-used 'Reason'
model of accident causation. The application of the model extends beyond the
aviation sector. The Reason model has become an industry standard and includes
a broad examination of potential organisational deficiencies, holding that
explanations for accidents which focus on individual performance alone are
inadequate. Essentially, the model considers the complex interaction between
individual and latent organisational factors, which, when aligned in a
particular way, allow an accident to occur. In effect, it highlights the system
an individual works within.
3.7
The ATSB informed the committee that the Reason model of accident
causation consists of five levels of safety factors. These are:
- Occurrence events
- Individual actions
- Local conditions
- Risk controls (in this instance, Civil Aviation Safety Authority
[CASA] regulatory oversight)
- Organisational influences (in this instance, the operator,
Pel-Air)
3.8
According to the model, defences against accidents act as a series of
barriers, often illustrated by consecutive slices of Swiss cheese. Each hole in
each slice—and holes are of varying sizes and may change over time—represents a
weakness in a part of the overall system. The system fails when holes—that is,
weaknesses—momentarily align, allowing an accident to occur.
3.9
The committee was provided with the following figure[2]
depicting how the Reason model works:
Figure 1—How the Reason
model works
3.10
The ATSB report found that individual action, that is, not factors to do
with the operator or regulator, caused the accident. The report identified only
three contributing safety factors, and all three were concerned with individual
action:
-
The pilot in command did not plan the flight in accordance with
the existing regulatory and operator requirements, precluding a full
understanding and management of the potential hazards affecting the flight.
-
The flight crew did not source the most recent Norfolk Island
Airport forecast, or seek and apply other relevant weather and other
information at the most relevant stage of the flight to fully inform their
decision of whether to continue the flight to the island, or to divert to
another destination.
-
The flight crew's delayed awareness of the deteriorating weather
at Norfolk Island combined with incomplete flight planning to influence the
decision to continue to the island, rather than divert to a suitable alternate.[3]
3.11
The ATSB did not identify any wider systemic issues that affected its
conclusions. It is for this reason that the ATSB's report has drawn criticism, as
it appears to determine responsibility without analysing context.
3.12
Mr Mick Quinn, an aviation safety consultant, offered the committee a
flow chart[4]
explaining diminishing culpability, developed by Professor James Reason:
Figure 2—Diminished culpability
3.13
Examining the large volume of evidence received about the investigation,
the committee noted an apparent discrepancy between the findings of the ATSB
report and the agency's own submission, which stated:
The most important safety factors to identify are those that
occur at the risk control and organisational influence levels. These are the
levels where changes can be made which can have a meaningful influence on
safety. Safety factors which exist at these levels are safety issues.[5]
3.14
Despite the widespread use of the Reason model, the ATSB told the
committee that its investigation analysis model, although based on the Reason
model, 'does not attempt to describe all of the complexities involved in the
development of an accident.'[6]
The components of the ATSB model are depicted in the figure[7]
below:
Figure 3—The ATSB investigation analysis model
3.15
However, given that the principal function of an investigation report is
to reduce future risk by exposing how an accident was able to occur, the
committee believes that a best practice report should describe the
complexities involved.
3.16
In simplified terms which best explain the context of this particular
accident, three separate defences should have been in place to prevent or
reduce the likelihood of the Norfolk Island accident: the flight crew, the
operator (Pel-Air) and the regulatory environment (CASA).[8]
Compliance with ICAO guidelines/structure
3.17
The committee is aware that Annex 13 of the International Civil Aviation
Organization's (ICAO) Chicago Convention, to which Australia is a signatory,
places certain requirements on the ATSB and CASA.[9]
This means that ATSB reports should, in theory, comply with these requirements.
3.18
The annex sets out rules for the notification, investigation and
reporting of an accident, who should conduct the accident investigation and
how, which parties can be involved and their rights, as well as how results of
the investigation should be reported. Accident investigations conducted by member
states are required to:
-
gather, record and analyse all available information on a
particular accident or incident;
-
issue safety recommendations where appropriate;
-
determine the causes of the accident if possible; and
-
produce a final report.[10]
3.19
The investigation authority, in this instance the ATSB:
...shall have independence in the conduct of the investigation
and have unrestricted authority over its conduct, consistent with the
provisions of this Annex.[11]
3.20
The annex stipulates that final reports should be released as soon as
possible in the interest of accident prevention, preferably within 12 months.
If reports cannot be produced within 12 months, an interim report is to be
released on each anniversary of the accident.[12]
3.21
Once produced, the final report is required to analyse factual
information gathered and list findings and causes established over the course
of the investigation. This list is required to include 'both the immediate and
the deeper systemic causes' of the accident.[13]
3.22
The annex also requires states to re-open an investigation should new
and significant evidence become available.[14]
3.23
The Australian and International Pilots Association (AIPA) reinforced
the need for analysis to focus on systemic issues in order to help stakeholders
draw meaningful conclusions, make relevant recommendations and propose any
required safety action:
...[A]ccidents and incidents should be seen as organisational, but
preferably systemic, rather than individual events. In this context, that
system includes not only the groups listed above [individuals] but also the
regulators, the clients and even government departments. There should be no
sign that any organisation is “touched lightly” by an investigation as a
consequence of perceived power in interested party consultation, particularly
at the apparent expense of an individual.[15]
3.24
AIPA was not of the view that ATSB analysis in this instance helped
produce the desired outcome. Asking 'Has the system improved as the result of
this investigation?' AIPA suggested the answer is no, or not much. AIPA also
asked:
Was this an opportunity missed to examine more broadly the
system that placed the flight crew on that aircraft in the belief that they
were adequately qualified and competent to achieve the task in whatever
circumstances may arise?[16]
3.25
This view was held by other submitters as well, who made the point that
the lack of systemic issue analysis in the ATSB report stands in stark contrast
to the focus placed on individual error.[17]
3.26
The committee notes the widely held view that the ATSB has failed to
discharge its responsibilities under ICAO guidelines. Mr Bryan Aherne, an
independent aviation accident investigator and safety risk adviser to the
aviation industry, analysed the requirements and informed the committee that
the ATSB's report does not contain an analysis of organisational and regulatory
issues:
...I have itemised the ICAO annex 13 format, which CASA and the
ATSB have signed up to, and the format [of investigation reports] can be
different but the content cannot be different... So I have detailed from ICAO's
aviation accident manual the types of things that are required to be in the
report which are not in this report, and it is completely devoid of
organisational issues and regulatory issues. It is almost as if the flight crew
perished. There is no explanation of why this thing happened. I find it quite
incredible.[18]
3.27
The committee now turns to a significant deficiency identified in the
ATSB's report – the absence of systemic issue analysis.
How the ATSB report falls short
3.28
The committee heard that the ATSB's report represents a low point in the
agency's standard of reporting.[19]
It is not a report the ATSB Chief Commissioner himself expressed a great deal
of pride in when questioned by the committee:
Senator EDWARDS: Chair, since we have started, there has been
mea culpa after mea culpa after mea culpa in this thing. Now you are hearing
evidence for the first time of what is supposed to be a forensic investigation.
I have heard that this report would be a joke in the international standing—if
other reviewers were to have reviewed this. I think that the evidence that
Senator Xenophon and Senator Fawcett are drawing out would suggest that. We
haven't even got to the black box yet. Are you proud of this report?
Mr Dolan: I certainly would not hold this report as a
benchmark. I am still satisfied that the key elements—
Senator EDWARDS: Three years in the making. Mea culpa after
mea culpa. Are you proud of this report?
Mr Dolan: No, I am not proud of this report.[20]
3.29
The committee notes that Mr Dolan was satisfied that the key elements of
the report were in place; however, this view was not shared by most other
witnesses and submitters. By not dealing with organisational, regulatory and
human factor issues, witnesses contended the report fails to meet the standard
the aviation community and industry expects to see. It fails against ICAO
requirements and the ATSB's own procedures, both of which are discussed in
Chapter 4 of this report. One witness stated:
The ATSB public report released on 30 August 2012 is
factually incorrect and contains flawed analysis. On reading the first draft [released
for DIP comment, dated 26 March 2012], I was of the opinion that the problems
with the investigation were due to incompetence, but on seeing the second draft
[released for DIP comment, dated 16 July 2012] and subsequent final report I
have a different opinion. In light of the CASA special audit now in the public
arena, I believe that the ATSB report is partly incompetence but I am now of
the opinion that it contains deliberate and intentional omission of
safety-critical facts and evidence which would substantially change the
findings and analysis. Any aviation safety professional who reads the drafts
and the final report alongside the now public special audit can only form the
same reasonable conclusions. I believe the committee should determine whether
there has in fact been an attempt to breach the TSI Act 2003.[21]
3.30
Similarly, Mr Quinn found the ATSB's report to be seriously flawed and biased.[22]
In commenting on the report's analysis section, Mr Quinn stated:
Human factors analysis—there is none in this report.
Organisational aspects—there basically are none in this report. Aspects
regarding crash survivability and such things as life jackets, as we have
discussed, are not provided in the report.
The analysis section itself is flawed. The analysis section
actually has facts in it not analysis, and it is so brief that—the way accident
investigation goes is that your analysis section is basically your proof. That
is your argument that you are making, so what is in the analysis needs to be
borne out in the factual information, findings, conclusions and
recommendations.[23]
3.31
These views were put to the ATSB and rejected multiple times. In
evidence given before the committee at public hearings, the ATSB asserted that
its accident investigation did in fact look at systemic issues, including the
operator and regulatory environment involved:
[W]e as an organisation were trying to look at this on a
systemic level rather than an individual detail level. We looked at the overall
components of the current system to deal with the risks that go with operation
to remote islands and the particular case were we were dealing with which was
the situation where the weather forecast on departure was for weather suitable
for landing at the destination and that changed en route.[24]
3.32
The committee, however, could not see any evidence of this in the ATSB
report.
3.33
When asked by the committee whether, given the evidence of deficiencies
with both Pel-Air's operations (the CASA Special Audit) and CASA's oversight of
those operations (the Chambers Report), it would be logical to conclude that
these factors should have received greater attention in the ATSB's report, Mr
Dolan answered:
...The methodology that we have designed for our
investigations, which draws, among other things, on the accident causation
model of Professor Reason, is essentially an inductive basis of reasoning. We
start with the facts of a particular event, to the extent we can reasonably
establish them, and then, from those, build possible hypotheses, further test
them and so on. So we are building from facts to a bigger picture and seeing
what we can assemble there with what certainty...
From our process, we would start with the facts, as we
understand them, of the occurrence. We would take account of the layers in the
Reason model that get, in the end, to organisational factors but start with
individual actions, and therefore, work up—as appropriate, based on the facts
we have available to us—towards, potentially, that organisational level. As a
general rule, although it is useful to understand context of how a regulator is
doing his job and a range of other things, we do not start with the alternative
proposition that there is something wrong at the organisational level and we
are trying to find evidence to prove that. That is some context in which I am
answering the question.[25]
3.34
This response from Mr Dolan only served to reinforce the committee's
concern that, by starting with a set of facts which did not include all
available information, the ATSB investigation could not be anything but flawed.
This model would appear to be biased towards establishing contributing factors
at the individual level to the potential exclusion of organisational level
issues. A more impartial process would see each level—individual,
organisational and regulatory—considered in each individual investigation.
3.35
The committee notes Mr Dolan's assertion that what is contained in the
final report may not reflect the full scope of the preceding investigation. In
this vein, when asked by the committee why the ATSB took such a conservative
approach to the range of issues canvassed in its final report, Mr Dolan stated:
...there was a range of lines of inquiry that we went down.
We satisfied ourselves that there was not a safety issue involved in it. Among
the massive documentation we have provided to you, there is a range of lines of
inquiry that clearly we went down. We did not reflect that process in our
report and on reflection that is not ideal...[26]
3.36
The committee also notes however, that in continuing the above statement
Mr Dolan in effect argued that systemic issues surrounding the Norfolk
Island accident, although examined, did not in the ATSB's view warrant
inclusion in its report:
On some of the things you are concerned about [the lack of
systemic issues in the report], our view is we did take a look at them and
formed the view that they were not directly relevant to the issues we needed to
address in the report.[27]
3.37
In light of evidence contained in the CASA Special Audit and the
Chambers Report (both discussed below) the committee does not share this view.
Committee view
3.38
On the basis of evidence received and the committee's own assessment of
the ATSB report on the Norfolk Island accident, the committee has formed the
view that the investigation report does not provide sufficient information
about the system within which the flight crew operated. The ATSB's almost
non-existent analysis of the organisational and regulatory environment does not
provide a balanced report, nor does it appear to comply with the requirements
if ICAO Annex 13. Ultimately, the report does not meet the ATSB's own written
standards, nor does it help the industry learn from this accident, which is a
fundamental and vital aspect of ATSB investigation reports.
3.39
Because of the unbalanced nature of the ATSB report, the only conclusion
that a reader could plausibly reach is that the accident in question was caused
by pilot error. In turn, this appears to imply that the suspension of that
particular pilot's licences by CASA was the only action necessary to enhance
safety and reduce future risk.
3.40
On the basis of evidence presented, however, the committee does not
accept this analysis or conclusion. Decisions made and actions taken by the
crew are certainly important and are often the last line of defence in terms of
aviation safety. This instance was no exception, and the committee is aware of
errors that may have been made by the pilot. However, all flight crews clearly
operate in circumstances significantly structured and influenced by the
regulatory and operational environment. As put by the pilot in command on board
Pel-Air's VH-NGA:
As the pilot in command, I wish to make it clear that on that
night I was not operating by myself in a vacuum. I was licenced by CASA,
trained by structures that CASA created and worked for a company [Pel-Air]
using procedures CASA had approved, and yet CASA found I was the problem.[28]
3.41
This view is not unique to a minority of submitters or the committee.
The ATSB's report into this accident was controversial from the moment it was
publicly released. The committee is reminded of the ATSB's own statement:
The quality of a safety investigation's analysis plays a
critical role in determining whether the investigation results are accepted and
whether it has been successful in enhancing safety.[29]
3.42
There are reasons why this investigation and the resulting report have
attracted so much criticism from submitters. Having spent over seven months
listening to and reviewing arguments put forth by critics of the ATSB's report,
as well as the evidence of the ATSB and CASA, the committee is confident that
in general this criticism is supported by evidence and sound logic.
The CASA special audit
3.43
In the aftermath of the VH-NGA accident, CASA initiated a special audit
of Pel-Air. The audit identified serious deficiencies with the operator and also
raised concerns about CASA's oversight. The ATSB only requested the document
from CASA in July 2012,[30]
one month before its investigation report was published. The ATSB was not of
the view that information about operational and oversight deficiencies
contained in the audit should alter its own report. The audit is discussed
later in this report.
The Chambers Report
3.44
Among a large volume of material provided to the committee by CASA
following an order for the production of documents, the committee came across
an internal CASA report titled 'Oversight Deficiencies – Pel-Air and Beyond'.
The document was commissioned by CASA following the Norfolk Island accident,
completed and handed to senior CASA management on 1 August 2010, and is known
as the Chambers Report.[31]
3.45
The Chambers Report centred on the effectiveness of CASA's oversight of
Pel-Air, and considered the effectiveness of Pel-Air's oversight of its line
pilots. In essence, it looked at organisational and surveillance factors which
may have played a part in the Norfolk Island accident.
3.46
The report unequivocally concluded that indicators existed which 'could
have identified that the Pel-Air Westwind operation was at an elevated risk and
warranted more frequent and intensive surveillance and intervention
strategies.'[32]
In summary the report continued:
It was also apparent that the data systems, training,
surveillance tools, resources and inspector capability showed varying degrees
of inadequacy and contributed to Bankstown Operations and CASA's inability to
fully understand the operator's risk exposure and consequently to intervene to
ensure the operator reduced the risk appropriately.
The Oversight review has identified the need for improvement
in Surveillance methodology; Inspector recruitment, training, standardisation
and assessment; and Oversight Information management. The present level of
Inspector resourcing allocated to front line surveillance requires review as
the indicators are that current resources may not be adequate for the task.[33]
3.47
In other words, Pel-Air was lacking, CASA's oversight of Pel-Air was
lacking, and the accident occurred in an environment of serious aviation safety
deficiencies. In the committee's view, the CASA Special Audit and the Chambers
Report are evidence that there were systemic issues at play.
3.48
Presented with this information, the ATSB remained firm in its position
and defence of its Norfolk Island investigation report:
...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 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.[34]
Committee view
3.49
The committee was and remains deeply concerned by this response of the
ATSB Chief Commissioner. The ATSB report contains not the merest hint of
oversight deficiencies, deficiencies which in the committee's view must have increased
the risks to aviation safety. That the ATSB would maintain its position despite
evidence of serious operational, oversight and regulatory deficiencies is
extremely concerning.
3.50
The committee can only conclude that, in the absence of analysis of
systemic issues involved in the Norfolk Island accident, this report
contributes little if anything to the enhancement of aviation safety in
Australia. As a result it fails to comply with its own purpose and function.
3.51
Furthermore, the committee has no confidence that the systemic issues
raised in the CASA Special Audit, the Chambers report and elsewhere, have been
adequately addressed since the 2009 accident. If any changes have been made to
the regulatory environment within which this accident took place, the catalyst
for such changes was certainly not the ATSB's report.
3.52
The CASA special audit, the Chambers Report and CASA's decision to
withhold the later from the ATSB, as well as why the ATSB chose to scope
systemic issues out of its investigation are matters discussed in greater depth
later in this report.
Retrieval of the flight data and cockpit voice recorders
3.53
In its submission the ATSB informed the committee that 'work commenced
to examine the capability and need to recover the aircraft's cockpit voice
(CVR) and flight data recorders (FDR)' after an initial interview of the
captain on 23 November 2009.[35]
Retrieval of the recorders, the committee notes, is an important opportunity
for safety learning for the aviation sector. From evidence provided, the
committee understands that retrieval of the recorders would be particularly
useful in this instance, as there may not be another example of a night
ditching where all passengers survived.[36]
Recorded data is less subjective than witness accounts.
3.54
The committee understands that the ATSB has certain responsibilities,
set out in ICAO Annex 13, when it comes to retrieval of aircraft involved in
accidents. It is an assumption throughout Annex 13 that, where a FDR exists,
the accident investigation body will prioritise its retrieval:
The aftermath of a major accident is a demanding time for any
State’s investigation authority. One of the immediate items requiring a
decision is where to have the flight recorders read out and analysed. It is
essential that the flight recorders be read out as early as possible after an
accident.[37]
3.55
The committee approached the ATSB on this particular point, asking Mr Dolan
whether he was comfortable that the agency had complied with the requirements
of the annex in choosing not to recover the VH-NGA FDR because of the
associated cost. The committee received the following response:
That was why I drew your attention to that paragraph that I
just read [paragraph 5.4 of ICAO Annex 13]. With the decision I made in
relation to the value as opposed to the cost of recovering the recorders, I was
viewing it in the framework of 'where feasible.' I consider cost as opposed to benefit
to be relevant to the question of feasibility.[38]
3.56
During the course of the committee's hearing on 28 February 2013, an
issue emerged relating to the wording of paragraph 5.4. Mr Dolan, explaining
that he was reading from the current version of the paragraph in question,
challenged the committee's reading of the annex, according to which an
investigative body would be required to gather, record and analyse all
available information on an accident or incident. This would include the flight
data recorder.
3.57
Mr Dolan asserted that the copy of the annex in his possession, being
more current and dated 18 October 2010, contained slightly different wording.
This version does not say that investigations 'shall', but rather 'shall
normally', gather, record and analyse all available information.[39]
3.58
However, although the version of the document Mr Dolan relied upon
before the committee to support his decision not to retrieve the VH-NGA FDR may
have been more current, it was not the version in force at the time of the accident
or its immediate aftermath, when such decisions were being made.
3.59
Furthermore, the ATSB had no disagreement with the committee's reading
of paragraph 5.7 of the annex, which clearly sets out a state investigation
body's responsibilities in this regard:
Effective use shall be made of flight recorders in the
investigation of an accident or an incident. The State conducting the
investigation shall arrange for the read-out of the flight recorders
without delay.[40]
3.60
Despite this, the Chief Commissioner maintained that, according to his
reading of the paragraph, the ATSB was not required to retrieve VH-NGA's FDR:
What I read that [paragraph 5.7] in the light of, in the
structure of this document [Annex 13], is that 5.4 is a general paragraph
setting the context with the others, and so we have the question of whether to
retrieve them in the first place—had we retrieved them, we would agree:
effective use shall be made, and we have to arrange for the read-out, without
delay. As I say, the decision I made was in that general context of
feasibility.[41]
3.61
The ATSB position remained that the relevant paragraph of Annex 13
provided the agency 'the necessary discretion...in its conduct of the
investigation.'[42]
3.62
The committee does not accept this argument. 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.
3.63
This is not the only example of a FDR which has been under water for
some time being retrieved and useful data being produced. Furthermore, the ATSB
appears to be of the view that the data is not worth the cost of retrieval as
information could be obtained from the flight crew, both of whom survived the
accident.
Committee view
3.64
The committee finds the ATSB's refusal to retrieve the FDR incongruous
and questionable. Furthermore, the committee takes a dim view of the ATSB's
reliance on a version of ICAO Annex 13 that only came into force in late 2010,
nearly a year after the accident, to justify this decision. Mr Dolan's evidence
in this regard is questionable and has seriously eroded his standing as a
witness before the committee. Flight data recorders are routinely recovered
around the world despite the existence of surviving crew. They provide
objective records of how events transpired, and allow speech specialists and
psychologists to determine stress levels and what was going on in the cockpit
at the time.[43]
This could offer valuable lessons for the whole aviation industry, not just
about why an accident occurred, but, in this case, how such a successful
ditching was executed under extremely difficult circumstances.
3.65
The committee is of the view that the ATSB is taking a very loose interpretation
of its obligations under ICAO Annex 13. Furthermore, the committee has evidence
indicating that by early 2010 two lines had been attached to VH-NGA which were
strong enough to raise the wreckage. This evidence calls into question whether the
ATSB's argument concerning cost or associated occupational health and safety
concerns was valid, and reflects the fact that the ATSB was not overly
concerned to robustly examine options and costs.[44]
3.66
Having received in camera evidence on the likelihood of VH-NGA's
flight data recorder yielding useful information about the accident despite more
than three years passing since the event, the committee supports calls for the
recorder to be retrieved.
3.67
The fact is, the primary consumer of ATSB investigation reports is the
aviation industry. There is much to be learned about what led to this accident,
and how injuries were minimised upon impact.
Recommendation 1
3.68
The committee recommends that the ATSB retrieve VH-NGA flight data
recorders without further delay.
Time taken to produce the ATSB report
3.69
The ATSB's statement of intent, available online, includes an
undertaking to conduct investigations in a timely manner and 'aim to issue
final reports on investigations within one year from commencement.'[45]
3.70
The aspirational goal certainly did not translate into reality in this
instance. Instead, the ATSB's report on the ditching of VH-NGA took nearly
three years to complete. The committee is not aware of any suggestions that
this was a reasonable, or indeed helpful, timeframe within which to produce a
report meant to allow the industry to learn lessons from this accident.
3.71
On the contrary, witnesses called the three year timeframe unreasonable
and described it as being 'outside the performance expectations set by the ATSB
and other international agencies.'[46]
3.72
ATSB Chief Commissioner Dolan admitted that the time taken to produce
the report was unsatisfactory:
I should say up front
that there are two areas where we think we could have done better with this
investigation and report. The first and obvious one is that it took us far too
long by anyone's standards, including our own, to get to a completion of the
investigation. There are reasons for that, which I would be happy to discuss,
but they do not excuse the three-year time frame for the report.[47]
3.73
Mr Dolan's explanation for the time taken to produce the report
essentially revolved around resource allocation and prioritisation:
When, nearly 3½ years
ago, I joined the newly independent ATSB as chief commissioner, we had over 100
aviation investigations on hand, including four that we classified as level
2—so substantial investigations requiring major and continuing use of our
resources. We were averaging about 18 months for the completion of
investigations, with some serious outliers in that. We had more work on hand
than we knew how to deal with, and we would normally expect in any given year
to get one of those level 2 investigations. So we had a lot more work than we
were used to. That led to delays in a range of reports and, as new
investigations came in, the shifting of resources to different priorities as
they arose. It is clear that, in managing that allocation of resources to
always-shifting priorities, we did not give enough attention to getting to an
expeditious conclusion of this Norfolk Island report. However, that is the
context in which that happened.[48]
3.74
The committee understands that strategic guidance from the minister
leads the ATSB to prioritise investigations into what are referred to as
'fare-paying passenger operations'.[49]
These generally exclude the type of flight VH‑NGA was undertaking at the
time of the accident, which is categorised as aerial work. The Australian and
International Pilots Association (AIPA) suggested that the non-fatal nature of
this accident suggests that its investigation was not accorded a high level of
priority.[50]
3.75
Like AIPA, the committee understands that the ATSB, like most
organisations, has to prioritise its workload.
3.76
When the committee asked whether the ATSB had considered outsourcing any
of its work, or insourcing extra capacity to expedite the production of
reports, Mr Dolan replied in the negative:
Our resources are
largely tied up in maintaining our existing investigative capability, who are
permanent staff of the organisation. We have a longstanding view that in almost
all circumstances it is better to have, if possible, the range of expertise
available to us on a permanent basis and therefore immediately available than
to rely on potentially risky external outsourcers.[51]
3.77
The committee confirmed with Mr Dolan that this was the case even when
the ATSB budget was underspent and its workload was clearly excessive:
Senator FAWCETT: I
am not talking about normal [ATSB] operations. I am talking about a situation
where you have a budget underspend and a clear excess of work. Was it [outsourcing
or insourcing] even considered? That is all I am asking.
Mr Dolan: In that
small underspend, no, we did not consider it.[52]
Committee view
3.78
The committee does not believe that an adequate explanation for the
delay has been provided.
3.79
Given that the ATSB could not, or certainly should not, have known that it
was only going to identify two relatively minor safety issues at the onset of
its three-year investigation, the delay itself had the potential to risk
lives by not alerting the industry to the causes of this accident in a timely
fashion.
3.80
The committee considers the fact that it took the ATSB close to three
years to produce its investigation report following the November 2009 ditching
of VH-NGA unreasonable. The committee also believes that the ATSB made a
significant oversight by not considering external assistance despite a budget
surplus of $0.3 million in 2009-10.[53]
3.81
Furthermore, the quality and complexity of the final report once it was
produced—as will be discussed in later chapters of this report—certainly would
not appear to readily justify a three-year timeframe. This being the case, the
committee is firmly of the view that the stated aim of producing reports within
one year of an incident or accident is attainable and should be met in all but
the most extraordinary and justifiable of circumstances. During the course of
its investigation, if it becomes apparent to the ATSB that it will not meet its
one year timeframe, the ATSB should release an interim report, as required by
ICAO, which would include a public timing update to ensure that the aviation
industry is kept informed of progress and expected timing.
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