The ATSB has announced that it will refer Lessbrook Pty Ltd to the Director of Public Prosecutions for its failure over several years to report aviation safety occurrences to the bureau as required by legislation. Lessbrook Pty Ltd operates under the name Transair and was the operator of the aircraft in which two pilots and 13 passengers lost their lives on 7 May 2005. Despite the accident, it is only in recent weeks that Lessbrook has provided the Australian Transport Safety Bureau with evidence which our analysis has shown includes 25 safety incidents which should have been reported immediately or within 72 hours depending on their severity. The unreported occurrences include 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident. They include a gear failure on departure from Bamaga, a cabin pressurisation warning near Cairns, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and associated flight issues from Gunnedah to Sydney. Under the Transport Safety Investigation Act 2003 (TSI Act) and Regulations such IRMs must be reported immediately by responsible persons (eg the airline operator) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (Section 18 of the TSI Act). Failure to report the more routine matters or to make a written report of IRMs carries a maximum penalty of 60 penalty units, a very steep fine.
While in accordance with international requirements and domestic law, ATSB investigations do not seek to assign blame or liability, a serious breach of the TSI Act with respect to the investigations or reporting requires action to deter people from failing to comply with its safety objectives.
The failure to report these occurrences, which were reported by relevant pilots to the operator, is indicative of a poor safety culture and poor safety system within the operator. However, the reports are a separate safety issue compared with the fatal accident. (ATSB)