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Wednesday, 29 May 2013
Page: 4492


Ms LEY (Farrer) (18:00): I am pleased to speak for the Appropriations Bill in the parliament today and to reflect on the budgetary position and also my role in this parliament as the member for Farrer and with portfolio responsibilities in the opposition for child care, employment participation and training, and registered training organisations. I also want to mention that I am the chair of this parliament's friends of aviation group, a group that I along with others in this place were instrumental in setting up recently. This group is co-chaired by the member for Chifley and our aim is to recognise and highlight issues critical to the aviation sector in Australia. I believe this sector has been overlooked to a very large degree and that there is a large group of pilots, air operators, maintenance organisations and people who interact with the aviation sector that is feeling quite lost and alone under this government's policies. I would like to think that a recent Senate report highlights to this government a clear failing. I draw your attention, Deputy Speaker, to the Senate report by the Rural and Regional Affairs and Transport Reference Committee, Aviation accident investigations, chaired by my colleague, Bill Heffernan, Senator for New South Wales with an impressive line-up of senators.

Many people will be familiar with the circumstances of a particular accident over Norfolk Island involving Pel-Air and the subsequent ditching of that aircraft, the extraordinary survival of the pilot and all the passengers. One would almost say by skill and luck rather than perhaps judgement and an understanding of systemic procedures. What the committee did in—not re-investigating the accident, because the investigation of air accidents should most appropriately be done by the appropriate bodies, the ATSB and CASA—investigating the processes that were gone through in order to come up with the recommendations which, it is fair to say, largely blamed pilot error for the accident. If I can capture their thoughts, the Senate committee did not wish to let the pilot off the hook, so to speak, because to fly in the dark over a great expanse of ocean without an awful lot of fuel on board is probably something that does deserve a degree of condemnation. What surprised me, the committee and many in the sector is that in coming up with its conclusions ATSB simply did not look into systemic failures of the air operator and the reasons that led to the accident that, if you like, are separate from the actions of the pilot.

I want to draw a little bit from the executive summary of the Senate report because it makes the point very well:

The committee accepts that the pilot in command made errors on the night, and this inquiry was not an attempt to vindicate him. [But the] overriding 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. This report does so by asking:

why errors were made;

why, given that a pilot works within a system, the flight crew became the last line of defence;

what deficiencies existed in the system, with regard to the operator (Pel-Air) and the regulator (CASA), which were not explored as fully as they could have been by the ATSB; and

whether the travelling public can have confidence in ATSB processes… .

The findings of the ATSB's investigation report are the starting point in untangling and addressing these questions. The ATSB's firm position is that the ditching was a one-off event due predominantly to the actions of the pilot and the agency [with its continual defence of that stance is quite extraordinary]. … Over the course of this inquiry the ATSB repeatedly deflected suggestions that significant deficiencies with both the operator (identified in the CASA Special Audit of Pel-Air), and CASA's oversight of Pel-Air, (identified in the Chambers Report), contributed to the accident.

The committee believes that ATSB processes have become deficient for reasons that they continued to detail. They then asked whether CASA exerted undue influence on those processes because CASA failed to provide the ATSB with critical documents which were absolutely relevant to the circumstances of this operator and, therefore, the circumstances of the crash. Why was that? The committee was surprised by the agencies near-exclusive focus on the actions of the pilot and its lack of analysis of the detail of factors that would assist the wider aviation industry.

It has been a long time since anyone in aviation has considered that the final few moments of, in the worst case, a fatal or near-fatal crash should be confined to an analysis of the flight itself. People know I had a career in aviation before entering this place. Every air-crash investigation that you read—and many of us take an interest in these things and watch the relevant programs—will always take great note of the system that resulted in the final few minutes. In tertiary study across the world, you can study human factors in aviation accidents. There is a whole body of organisational and management theory that looks at systems and why they fail. It is extraordinary that our ATSB did not look at those systems.

The committee was understandably very troubled by allegations that agencies, whose role it is to protect and enhance aviation safety, are acting in ways which could compromise that safety. It resolved to take appropriate action to investigate the allegations. I do commend the full report to the public because it is an excellent piece of work. I thank the Senators for doing it, but it should not stop here. The responsibility now rests with this minister to undertake to assure members of the public that our premier investigator is properly resourced, able to do its job, and capable and competent.

After a consultation conversation I had with a previous air accident and incident investigator in my electorate, I have become more and more concerned about ATSB—not just in the context of this particular incident. I should remind members that we are, in terms of our accident investigative capabilities, subject to audits by ICAO, the International Civil Aviation Organization. In 2004, ICAO audited the ATSB and essentially gave it a very good report. It was doing its job well. But its capabilities from 2004 to now appear to have been comprehensively trashed. So what is going on?

The Senate report said that the committee heard that ATSB's report represents a low point in the agency's standard of reporting. Something has happened between 2004 and now and, ATSB being answerable to the minister for transport, the Minister needs to address this is a matter of urgency.

It is always about quality. Whatever we examine in this place is about quality. The quality of reports published by the ATSB is of great concern. My constituent who, as I said, is an air incident and accident investigator, drew my attention to a report which was issued in 2013, some six months after the relevant event. It was about a transport plane which experienced a significant wind change during take-off. It was a Boeing 737 at Perth on 4 December 2012.

The report simply said it took a long time to say the incident serves as a reminder to pilots that significant wind changes can occur during take-off, can be difficult to predict and can occur in the absence of thunderstorm activity. The wind conditions at each end of a runway may differ significantly so that headwind conditions can exist at one end and tailwind conditions at the other. Although it did not exist in this case, it is important for the available windsocks before take-off as the final opportunity to detect wind changes before the take-off begins. Even for people who do not have a commercial flying licence as I do, that must sound quite simplistic and indeed it is. We are talking about an experienced airline flight crew here and the ATSB is reminding them to look at the windsocks before take-off.

The wind change occurred after the take-off commenced and onboard wind shear predictive reactive warning provided no warnings. We know it does not provide warnings if the speed of the aircraft is above 100 knots. We therefore know the speed of the aircraft was above 100 knots. We are told that wind shear can occur in the absence of thunderstorm activity by the ATSB, when the actual circumstances of the accident was there was not a thunderstorm. Well, there was one about 20 nautical miles away. It is very much teaching your grandmother to suck eggs to take six months to produce a report about something that is fairly self-evident.

I do not want to have a go at the ATSB about this report but, if they are struggling with resources, what on earth are they doing taking six months to write this piece of nonsense that adds absolutely nothing to the body of air safety understanding or intelligence in this country? Everybody involved in aviation is struggling at the moment with the operations of the regulator and questions have been raised informally and formally in this parliament for the last 11 years that I have been a member here. This government does not seem to be getting to anything close to a resolution.

We need to have an approach with the regulator that is about quality assurance. It is not about massive restructures or hiring or firing. It is about something as simple as assuring quality because the relationships with the regulator should be characterised by openness and a willingness to listen, especially where recent and relevant industry experience is lacking in the regulator. The regulator cannot know everything about everything that is going on every day but they simply do not consult.

Many of us were invited to a recent industry crisis meeting in south-east Queensland which highlighted deep concerns of the industry about its own future under the current system and the inability of CASA to respond to genuine concerns and questions in any meaningful way that does not involve attempted intimidation of the victims. The attendees at the meeting were really just expressing their concerns. Many of the symptoms of unaccountability and the lack of focus on the real safety issues were brought to the floor and were treated with contempt. That in itself is of huge concern.

I commend the organisations that have struggled through this period and hope that there are brighter times ahead for them, in particular, the Regional Aviation Association of Australia. I met recently with the Aerial Agricultural Association of Australia. They have sensible, responsible common-sense ideas about a new approach to quality assurance in CASA. They really do deserve examination by this minister and this government. We do not have to make statements about changing the culture but, if you establish a quality control system within the regulator, you charge that regulator with consulting, discussing and really listening and with some serious deadlines. The time that it takes to manage business is extraordinary and also the level of intimidation of control that it exercises over what are essentially small businesses trying to make a buck and do the right thing, often in regional Australia where it is very difficult to do that in aviation.

I wanted to spend most of this time talking about an issue that I do not have much time to talk about in this place but which nevertheless is extremely important to me. I endorse the remarks of others about the shocking state of this budget under this government, the shocking state of government debt, the fact that Mr Swan has had to max out the credit card to $300 billion, not indicating that he needs that the debt will reach that amount but if he has maxed out the credit card to that, then clearly it might. That in itself is of huge concern.

We know that if we are fortunate enough, work hard enough on our election in the middle of September, there is an enormous amount of work to do in order to: to pay off debt, to restore the hope, reward and opportunity that we know my constituents in my electorate in rural New South Wales are absolutely hanging out for. Across a wider national sector, the portfolios that I represent this parliament are also desperate for change and looking forward to a new focus and brighter times ahead.