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Wednesday, 7 December 1983
Page: 3380


Mr SPENDER —by leave-An examination of the report of the Bureau of Air Safety leaves one with a deep sense of unease, doubts as to its adequacy and as to the willingness of those who compiled it to sheet home responsibility and concern at the findings and the unwillingness, so it seems, to make findings on vital issues. The Minister for Aviation (Mr Beazley) in his statement effectively quoted from finding 4.11, which states:

No evidence was found of any negligence, failure to accept responsibility or knowing lack of co-operation on the part of any person engaged in the SAR-

That is, search and air rescue-

action.

Finding 4.14, the last finding, which appears on the same page, reads:

Only one person was sighted in the water. Had the available resources been employed in a more effective manner, his rescue may have been successful.

It is difficult on the face of things to reconcile those two findings but a bare statement of the chronology of events shows that on the day in question, 17 July , when the temperature of the waters of Bass Strait was 12 or 13 degrees Celsius and when a person's chance of survival in those waters was marginal after 1.5 hours, a mayday call was heard. Emergency procedures were immediately initiated and some 59 minutes later a survivor was sighted in a life jacket. He was monitored, he was watched, and the last sighting was at 1713 hours, some two hours 20 minutes later.

There are two main phases in the operation-first, the provision of support and, secondly, attempts to rescue. The support provisions centred mainly about proposals to drop a life raft, which required a plane specially fitted for that purpose and an experienced dropmaster. Three planes were chosen. The first plane , it turned out, was quite unsuitable for the purposes for which it was chosen. The second plane did not complete the mission it started upon because, after modifications, the pilot determined that he was not happy to fly the aircraft with the door off, which was necessary for the purposes of dropping a life raft. The third plane was also unsuitable for the purposes for which it was required. It was not known that either the first plane or the third plane was unsuitable- reasons are given, but time does not permit one to go into them-but the decisions taken were critical decisions. There was no way in which two of the planes could be used for the purposes for which they were intended at the time.

What were the other options? The other option referred to in relation to the rescue of the survivor was the use of helicopters. This option was examined and one sees that for that purpose, apparently-it appears to be quite clear- helicopters were overlooked and in the course of the attempt to recover the survivor of the plane there was misunderstanding as to the whereabouts of one of the helicopters which was sought to be used. The report states:

Appendix IV contains an analysis of possible rescue missions for a number of helicopters in the southern Victorian area, including those above--

certain helicopters are mentioned in the report--

compared with the actual flights-

those which took place. It continues:

although there is no certainty that the projected missions would in practice have been flown as shown, it gives a useful comparison of alternative actions and indicates the timely use of one of the Longford helicopters-

that is, helicopters from Longford--

might have resulted in successful rescue action.

The decision to not check the availability of rescue helicopters other than-

Reference is made to certain rescue helicopters which were checked upon--

. . . is considered to have been an error of judgement.

That was indeed a very major error of judgment. When one looks at Appendix IV it becomes apparent that timely use of existing helicopters in southern Victoria with capacities to winch down somebody to assist the survivor who had been sighted may have resulted in the person being saved. It is not good enough simply to say that this was an error of judgment, nor is it good enough to seek to explain what took place on the basis that those concerned were under pressure , as the report states. Of course those who are concerned in exercises of this kind are under very great pressure, but that is not a sufficient answer. In support of the finding that there was no negligence the report states in finding 4.12:

The deficiencies in performance which occurred were the result of working under pressure.

That is the purpose for which these exercises, these operations, are established . One cannot be very happy with a departmental report which identifies performance deficiencies, systems deficiencies, errors in judgment and failure to pursue options, and which concludes that notwithstanding these matters there was no negligence. I am not in a position to assert that there was negligence, and I know, of course, that all those concerned would have done their utmost, but one can only be left with the most severe concern, the most deep unease, as to the procedures which were followed-their sufficiency and the way in which they were implemented in this case.

As I have said, there are grave questions of system deficiencies and questions of fundamental errors in performance which may have caused this man's life to be lost-fatal errors. Explanations are given which, quite frankly, are sometimes speculative and sometimes do not amount to more than the expression of possible reasons why certain courses of conduct were followed. That is not good enough. Bearing in mind that we are dealing with Bass Strait, the most dangerous area of water in the southern part of Australia, which is overflown every day, and bearing in mind the short survival time for anyone who is lost in those waters in the middle of winter, as any yachtsman will tell us, I propose first of all that there should be a full board of accident inquiry into this matter. I propose that the committee to which the Minister referred in his statement and which he has established should sit in public so that the public has a capacity to judge the efficiency of the procedures as they are implemented and, generally speaking, the efficiencies of search and air rescue procedures in this country, particularly those which relate to Bass Strait. It is not simply a question of two lives being lost, sad enough though that is; the question is: Could a life have been saved and if the same thing happens again what will be the result?