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ATSB and CASA criticised by Australian Senate Committee
2 June 2013
Fuselage of the Westwind jet off Norfolk Island (photo: ATSB)

Fuselage of the Westwind jet off Norfolk Island (photo: ATSB)

An Australian Senate Committee inquiry criticised the Australian aviation regulator CASA as well as Australian Transport Safety Bureau (ATSB) on their role in a 2009 accident investigation.

The Senate Committee on Aviation accident investigations was initiated in the wake of an accident involving the ditching of a medical evacuation IAI Westwind jet in November 2009.
The airplane was en route from Apia, Samoa to Norfolk Island in the Pacific Ocean. Headwind was greater than expected and the weather conditions at Norfolk Island deteriorated. The crew had increasing concerns about their fuel reserves but did not divert to an alternate airport. Following four missed approaches to Norfolk Airport in poor weather, the pilot ditched the plane close to the shore. All six on board were rescued.
ATSB concluded that the pilot of the accident flight amongst others “did not plan the flight in accordance with the existing regulatory and operator requirements”.

An episode of the Australian current affairs tv programme Four Corners indicated that there were inconsistencies between the ATSB investigation report and a Special Audit from the Civil Aviation Safety Authority into the operator of the medevac jet.
In September 2012, Independent Senator for South Australia, Nick Xenophon, successfully called for the establishment of a Senate inquiry. The committee’s objective was to find out why the pilot became the last line of defence and to maximise the safety outcomes of future ATSB and Civil Aviation Safety Authority (CASA) investigations in the interests of the travelling public.

Many submitters and witnesses in the inquiry asserted that the ATSB’s report was not balanced and included scant coverage of contributing systemic factors such as organisational and regulatory issues, human factors and survivability aspects.
The Committee stated that CASA failed to provide the ATSB with critical audit documents regarding the operator of the airplane. These documents “demonstrated CASA’s failure to properly oversee the Pel-Air operations,” according to the Committee.
Parts of the ATSB investigation process lacked transparency, objectivity and due process. The committee finds that the ATSB’s subjective investigative processes were driven in part by ministerial guidance prioritising high capacity public transport operations over other types of aviation transport.

The inquiry has made 26 recommendations, including redrafting the information sharing agreement between CASA and the ATSB, and re-opening the Pel Air inquiry.