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Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010

CHAIR —Welcome. I remind senators that the Senate has resolved that an officer of the department of the Commonwealth or of a state shall not be asked to give opinions on matters of policy and shall be given reasonable opportunity to refer questions asked of the officer to superior officers or to a minister. This resolution prohibits only questions asking for opinions on matters of policy and does not preclude questions asking for explanations of policies or factual questions about when and how policies were adopted. Officers of the department are also reminded that any claim that it would be contrary to the public interest to answer a question must be made by a minister and shall be accompanied by a statement setting out the basis of the claim. If you would like to make an opening statement, we would be delighted.

Mr Dolan —With your indulgence, I have some brief comments to open. I would like to remind the committee of the status of the ATSB, which is independent under the Transport Safety Investigation Act. The act really places two functions on us, one of which is to improve transport safety and the other is to cooperate with others who have a role to play there. We are also specifically prevented from allocating blame, for providing a means of determining liability or from assisting in court proceedings, so we are very much in the framework of no blame, as it is generally characterised.

We are generally seen as focusing on the investigation of safety occurrences and communicating the results, but we also have a very significant role to play in managing the mandatory and voluntary confidential reporting systems. Because we have the no-blame status, we are reasonably confident that there is a free flow of information under those schemes, although we are always happy to learn ways of making it even better.

As we said in our submission, which largely speaks for itself, at this stage we do not have any evidence of a systemic problem in relation to accident and incident reporting, although we are always happy to learn and recognise that there is room for improvement. We believe in relation to the Transport Safety Investigation Amendment Incident Reports Bill that the proposed offence to influence someone with respect to their reporting responsibilities is largely, if not fully, addressed by the current provisions of the Commonwealth criminal code and we have some reservations—

Senator XENOPHON —It that largely addressed or not addressed by the current criminal code?

Mr Dolan —Largely addressed and maybe completely addressed. There are one or two very minor areas. We have some concerns in its current form about the immunity provisions of the bill. It is not because we have a view against appropriate immunity, it is just the extent of it we think might require some further consideration within a just culture framework. In our view, we are very much in favour of providing specific protection against disciplinary action in relation to people who comply with their reporting responsibilities. We also believe that our existing confidential reporting system offers an additional mechanism for ensuring that safety information is not suppressed for fear of the consequences, and perhaps we need to put more effort into publicising that scheme to give it its full effect. We look forward to assisting the committee and to seeing the results of its work. Thank you.

Senator O’BRIEN —How would you define ‘disciplinary action’?

Mr Dolan —Any intervention that would interfere with the normal operations of the individual involved. The reason this is a potentially difficult area is that there are some events or actions which, if notified, if someone with a safety responsibility becomes aware of them, they are probably required to do something to rectify the situation. That may involve taking a pilot off line for retraining and various other things. How you negotiate that area is where our concern largely lies. If that is seen as a disciplinary intervention rather than an appropriate step to maintain safety, there is a potential difficulty with how things were constructed. It is the two sides of a just culture arrangement that we are talking about here.

Senator O’BRIEN —Would disciplinary action include an assessment of the person whose life had just been made more difficult? It may mean suspension, dismissal or matters such as that. But there are more subtle ways of displaying displeasure, are there not?

Mr Dolan —There are. I think this is part of the challenge in this area. To create criminal law and penalties in relation to certain activity, when it is at that level of subtlety, will be very hard to establish a case and to take enforcement action. You need to have regard to a range of other potential mechanisms, including the role of the Civil Aviation Safety Authority, in relation to the safety management systems of operators and at least an implied just culture responsibility for the operator with the appropriate scrutiny of that, a capacity to assess the culture, to assess the internal reporting systems for their openness, responsiveness and so on. There needs to be a coherent view as to how all of those elements fit together.

Senator O’BRIEN —Do you currently have a system whereby pilots can, for example, make reports about accidents or incidents anonymously?

Mr Dolan —We tend to discourage confidential and, therefore, protected reporting in those areas where there is a legal responsibility to report the incident. It is open to people to report under our confidential scheme, but it does not remove their duty to meet their mandatory responsibilities and notify us of the event. I recognise that there is a potential tension in that arrangement.

CHAIR —If a person were probably going to get the sack if they reported it, so they did not do it through their obligation but did it confidentially, that would say that there is something wrong with the system, would it not?

Mr Dolan —It would.

CHAIR —I have one right here.

Mr Dolan —That is the sort of information that made available to us, de-identified or whatever, would help us to do our job better. As I said, we do not have any evidence of a systemic problem. We are open to receiving evidence of a systemic problem, but what we do not have at the moment is something that we could act on in that area.

Senator O’BRIEN —Where you have an obligation to report, you are satisfied that the legal protections are sufficient to protect someone who fulfils their obligation from consequences from their employing airline, for example?

Mr Dolan —As I tried to say in my opening remarks, we think it would be helpful to make it clear—if we can construct it properly—that we should find a way of preventing any adverse consequences from someone meeting their mandated reporting requirements. My reservation is not about that element of the proposal. It is about how we find a way of identifying and allowing operators to appropriately deal with insufficiencies and so on in the way people are operating within the system of safety.

Senator O’BRIEN —You would have heard Mr Petteford, who gave some evidence about multicrew factor training or however he described it, and I believe there is at least one ATSB report that refers to some deficiencies in that area. What can you tell us about that—Lockhart River?

Mr Dolan —Lockhart River is before my time so to some extent I may have to rely on Mr Hornby. As you are probably more aware than I am, the report on the Lockhart River has a whole series of dimensions, one of which was the relative inexperience of one crew member and certainly our assumption that that had a significant effect on his relationship with the pilot in command. That responsibility gradient is always a potential risk in those sorts of multicrew operations and finding ways of dealing with that are important.

Senator O’BRIEN —Mr Petteford talked about the training on the observance of standard operating procedures and multicrew issues. Is it reasonable to apply that commentary to the assumptions about the Lockhart situation and say that a better trained first officer would have been better equipped to handle that circumstance?

Mr Dolan —I think there is no doubt about that. Indeed, one of the key pieces lacking in the training was in the GPS approach and the second officer’s capacity to support the pilot in managing that. It is almost self-evident in that case.

Senator O’BRIEN —Thank you.

Senator XENOPHON —I would like to go to the issue of resources in terms of the ATSB. There have been a few ATSB reports lately. I am really impressed by the way they are set out and the very comprehensive way that they are put together. For instance, on the go-around event on 21 July 2007, you finally got some information filtered through to you; you are obviously familiar with that report?

Mr Dolan —Yes.

Senator XENOPHON —We will make it clear that with the management of Jetstar there was no deliberate attempt to conceal information. I think those matters have been addressed by Jetstar and Qantas, so I accept that fully. But it is the case that you contacted the operator as a result of media reports; is that right?

Mr Dolan —That is correct.

Senator XENOPHON —You contacted them on 11 September 2007. Unless I am reading this wrong, the publication date was 24 February 2010.

Mr Dolan —Yes. That became public I think on 1 March 2010.

Senator XENOPHON —That is quite a time lag. It is not a criticism of the ATSB. Is that reflective of resources or any other factors?

Mr Dolan —We would always love to have more resources, but what we have is what we have.

Senator XENOPHON —Have you been affected by the efficiency dividend?

Mr Dolan —Everyone is affected.

Senator XENOPHON —No. Are you subject to the efficiency dividend?

Mr Dolan —We are subject to the efficiency dividend, yes. The reason I hesitated is that there were unusual circumstances at the time through most of the period that we were producing that report. We classify the sorts of investigations we do essentially by the level of intensity of the work. In a normal year we would expect to have one level 2 investigation—a large, extensive and time consuming—

Senator XENOPHON —Just for the record, though, how many levels of investigations are there?

Mr Dolan —Five.

Senator XENOPHON —Five is—

Mr Dolan —No. 1 is the what we hope never happens, which is the major aircraft accident with multiple fatalities. No. 2 is a comprehensive investigation requiring a large team, probably for 18 months if not two years.

Senator XENOPHON —That does not involve any injuries, though, does it?

Mr Dolan —Often they do, and fatalities. Lockhart River was a level 2.

Senator XENOPHON —So, level 1 is for a main liner carrier. Level 2 is for a regional carrier?

Mr Dolan —Yes. And there is a range of different ones. Level 3 is a large investigation, but one that we aim to complete these days within the year. Level 4 is comparatively short form. Level 5 is essentially put the data into a structured format. The point of that is that in any given year we would expect maybe one level 2. At the time we were dealing with this we had four level 2 investigations on the books. So, there was a genuine challenge in managing the resources of the organisation.

Senator XENOPHON —What was this one? Was this a level 4 or a level 3?

Mr Dolan —Level 3, I think we classified it as. It started off as what we call—

Senator XENOPHON —It started off as a level 5, did it not?

Mr Dolan —It started off as a level 5, just data entry, yes, because that was the information we had available to us at the time.

Senator XENOPHON —So, Jetstar and the Qantas Group have said that they have changed their procedures in place. Is there scope then more generally to change processes in terms of dealing with this whole issue of ensuring that the relevant facts are reported to you? Because it seems, at first instance, the crew on that aircraft—on that flight—did not provide adequate information to the operator, and there is an argument that should the operator have more thoroughly investigated it—for instance, looking at the flight data recorder; I do not think that was looked at initially—

Mr Dolan —Jetstar, reasonably quickly—because they got evidence that there had been triggering of the EGPWS—did investigate and did look at the data recorders. They were more or less looking at the incident. I am not sure whether they looked at the recorders. From our point of view, there were two key points of breakdown in that process. The first—I think if you read the report—what the pilot has reported, I think, was their understanding of the significance of what had happened. If you read what happened in those 30 or 40 seconds, where the aircraft approached rather close to the ground than anyone would ever wish, the pilots were less than fully aware of the situation.

Senator XENOPHON —Can we just go back to that, because I had the benefit, thanks to the Qantas Group—along with some of my colleagues—of their flight simulators, which is a terrific facility. My understanding of the A320 flight is that the EGPWS alert went off. In other words, that is quite a—

Mr Dolan —Twice.

Senator XENOPHON —Twice. And that is not just a light flashing, it actually is an audible warning, is it not?

Mr Dolan —An audible warning, correct.

Senator XENOPHON —Meaning that you are getting too close to the ground?

Mr Dolan —Yes.

Senator XENOPHON —So, how could the crew not know that? Apparently it is pretty loud and clear as a warning, is it not?

Mr Dolan —I will go with what is in the report and draw attention to the fact that each pilot—each member of the crew—recalled one instance of the EGPWS being triggered. Both of them were remembering one of them, but there were in fact two. They were working at a high level of intensity, because the aircraft was still in landing mode rather than go-around mode and was not responding in the way they expected. So, there was a whole range of human factors issues in play in those seconds that were happening, and so what the pilots were aware of and recalled and what they reported, I think, is actually within the parameters of what was happening.

CHAIR —Perhaps it was a matter of their getting used to the plane flying itself and not being used to intervening in the flying of the plane?

Mr Dolan —As we pointed out in the report—and this is quite a complicated one—one of the key things was a change to the actual standard operating procedures that meant one of the key checks, ‘What flight mode is this aircraft in?’ was deferred. Since there were all these other warning signals and so on going off, there was never a point at which the crew made that check. This is a classic example of a range of factors coming to bear on a single situation creating a high intensity of work for the crew, meaning that their attention is potentially divided among a range of things.

Senator XENOPHON —Sorry, I did not mean to interrupt you, Mr Dolan.

Mr Dolan —No, that is fine.

Senator XENOPHON —That the crew on that flight thought there was a ground proximity warning going off once, when in fact it went twice, was that because the two proximity warnings went off very close to each other, with only a very small gap or not?

Mr Dolan —Not a particularly small gap.

Senator XENOPHON —What was the gap?

Mr Dolan —I would have to—

Senator XENOPHON —It was a number of seconds?

Mr Dolan —A number of seconds, yes. When you experienced the simulator, I am not sure whether you experienced it in—

Senator XENOPHON —I did not try and fly it. I thought that—

Mr Dolan —normal circumstances.

CHAIR —Those that did did not cover themselves in glory.

Mr Dolan —I recall your reference to that the other night, yes.

Senator XENOPHON —My son says I have trouble driving a car, so I thought I would not fly a plane.

Mr Dolan —The point that I am trying to make, perhaps not as clearly as I should, is there was a hell of a lot going on in that comparatively short period, a very high intensity of work, a range of different inputs of various forms that the pilots had to deal with, and in a framework where they had a view as to one circumstance about what mode, how the aircraft was operating, when in fact it was in another. So, that is the cluster of things that is happening. What is going on in someone’s head is they are dealing with decision making, absorbing information and so on, in those circumstances, and what they recall afterwards is what is in play here. So, I think the crew reported in good faith. The report was passed on and its exact words were passed on to the operator, and as passed direct to us was that it was a go-around with some minor handling problems. That was the way it was reported. We looked at that and thought this is not something that requires our closer investigation.

The second breakdown in the system—as I think was explained to you this morning—was that at the point where Jetstar became aware that the circumstance was much more serious and undertook their investigation, they did not tell us that things had changed. But we have had discussions with them and we are confident that that will not recur, that there is a clear understanding that when an occurrence changes we will be notified.

Senator XENOPHON —You mentioned about a year ago that the proposed CASR part 142 would define the responsibilities of the training provider and their relationship with the AOC holder. It seems to have taken quite a long time for that part 142 to come into force. Do you know how close it is to actually coming into effect?

Mr Dolan —I would be relying on my memory, which is not always as reliable as it should be. My understanding is that if it has not gone out at the notice of proposed rule making stage it will be shortly there, but I am sure CASA should be able later on to give you some information on that. We have been drawing attention—this is not the first time—to the need for clarity in this area.

Senator XENOPHON —Let us move on. I have a number of questions, and I want to try and get through them, for my colleagues. You express your reservations—and I am very grateful—and the details as to why you have reservations about the amendment side.

Mr Dolan —I am happy to discuss that.

Senator XENOPHON —I genuinely found that very useful. But there is scope, though, to improve the current system of both immunity provisions, is there not? Also, is there scope to deal with issues of either providing a framework in terms of reporting of incidents so that there is not any suggestion of interference or at least making it clear that there ought not to be any? I am not talking about any particular airline. You have made clear where you see the amendments as being defective, but if you have any suggestions as to how you think it would be workable to enhance and improve the current systems in place, particularly in relation to immunity for pilots, I would welcome that. Perhaps you might want to take that on notice.

Mr Dolan —If you have a little time, maybe I can at least give you our view of what we think is at issue. I think one of the challenges we have is that we tend to look at the various components of what should be an integrated system in isolation. The two key components for us are the mandatory system of reporting, which is meant to give us adequate information about what is going on in the system to know what we should be looking at in terms of investigation and also, as a secondary benefit, it provides CASA with a systemic view of what is going on without giving them the capacity to use it for enforcement against individuals. The second element of this is the confidential reporting scheme, which should give all people operating within the industry the capacity to inform us about safety issues and give them the protection of anonymity. Those are all meant to be part of a coherent view of what is going on. The mandatory system places its initial responsibility on individuals in the system to notify the ATSB of occurrences. We say that responsibility can be discharged if you can reasonably assure yourself that someone else will report what is reportable, and that is to allow for an operator to be the point of reporting for all their employees.

Senator XENOPHON —But there needs to be some guarantee that it will be reported.

Mr Dolan —That is correct.

Senator XENOPHON —Yes.

Mr Dolan —So there is a question around that relationship essentially between employees and the operator and how that might influence what is available to us. There is a second question, which is not so much one for this committee, which is the small end of town individual operators and so on and about how reliable the reporting is on things like wire strikes and so on in agricultural activities and so on. We are working on that with industry. The extra element that we tried to draw out in our report is the recent mandated responsibility for larger operators to have comprehensive safety management systems in place and auditable by CASA. One element of that is the internal notification and reporting systems and the internal review and investigation capability of an operator, which is meant to be done within a framework essentially according to just culture principles. One of the key elements in this is the capacity for the regulator—for CASA—to have regard to how that is operating, to make judgments about whether this is an internal reporting system that has the most likelihood of having information come to the surface. One of the tests of that is the application of just culture principles within the operator. If we have confidence that that is working, then we are confident that pilots will be telling their own internal system and that internal system will inform us.

Senator XENOPHON —What sort of training do you think an operator’s safety investigator should have? Should there be minimum mandated standards for an operator’s internal safety investigator?

Mr Dolan —We would prefer that the internal investigators have familiarity with the sorts of approaches and methodologies we use. In a number of cases they are and in a number of cases they are former employees of the ATSB. We are continually offering opportunities—

Senator XENOPHON —Should that preference be set in stone or should there be some minimum standards?

Mr Dolan —I suspect some attention needs to be given to the appropriate standards for that. I have to say I have not turned my mind directly to that particular question.

Senator XENOPHON —Take that on notice, because we will be putting some questions on notice to others. I would be very grateful if you could give some attention as to what you think would be a reasonable minimum standard.

Mr Dolan —It is probably a matter I would, with your indulgence, discuss with CASA as well, given that they are the ones that have a—

Senator XENOPHON —Obviously you have a key role. Moving on, we have received submissions—and I have had discussions with a number of pilots—suggesting that many pilots are fearful or hesitant of full reporting due to the perception that operators may act against them. Is not the fact that I am getting that feedback, and I think some of my colleagues are getting that feedback, an indicator that those pilots feel that the existing regime of protection is inadequate or ought to be improved?

Mr Dolan —I would very much say so. The thing that concerns me is that no-one has thought to make use of our confidential reporting system to draw that to our attention. I would have thought that is a safety issue that we would have an interest in. I would encourage anyone—

Senator XENOPHON —Sure. But sometimes if an incident is reported, even confidentially, the only two people that would know what occurred would be those in the cockpit generally, and so there is a 50 per cent chance of knowing who is who. How do you deal with that?

Mr Dolan —My point was not about the specifics but about this general concern that the cultures of some operators may not be lending themselves to appropriate disclosure and reporting. We see that in itself as being a safety issue rather than the specific instances. If we had something to work with there, we could make further investigations as to what is going on.

Senator XENOPHON —From the ATSB’s point of view, how do you think CASA might detect an SMS that hides real information? Your key to doing your job is getting that information. How do you do it? And also, I have to mention the Joe Eakins incident. Thankfully, Mr Eakins is back with Jeststar, and that is terrific, and on confidential terms, as I understand. But there was a concern there about whether you speak out and whether there is a problem. I know it has been resolved and that is good, but how do you deal with those sorts of issues?

Mr Dolan —That was one, I would have to say, where I limited myself to observing the public reporting and discussion.

Senator XENOPHON —I do not want your comment on that, but I am saying that is indicative in terms of some concern.

Mr Dolan —Yes, and there is a genuine question as to how we get around this. I think there is some work that still needs to be done. If we are saying this would be all operating under those generically called just culture principles, then we have not done as much work as we should in defining what that looks like.

Senator XENOPHON —Perhaps again you could take that one on notice. Finally, is it the case that you censor—and I do not say censor in a pejorative sense—or you omit incident dates to remove the reporter identity before you pass on that information to CASA?

Mr Dolan —We remove any personal information in terms of the Privacy Act. We are trying to remove all the information that would directly identify an individual or relates to an individual.

Senator XENOPHON —Which would include a date on some occasions?

Mr Dolan —No. We remove as much information as possible, but in order to know about the incident CASA has to receive the relevant information.

Senator XENOPHON —And, finally, is that a procedural choice or a legislative requirement?

Mr Dolan —No, it is not a legislative requirement, but to work within the safety system where CASA needs access to that information they do need to know about incident reports.

Senator XENOPHON —Should it be legally clear, though, Mr Hornby? In other words, should it be made clearer that there is privacy, and that anonymity is protected?

Mr Hornby —That is what we have been trying to do through some consultation with the transport safety investigation regs over the last three or four months. We are trying to make it clearer to the industry about how the scheme actually works. Some of the questions that are arising here are about how we actually let people know when exactly they get immunity.

Senator XENOPHON —Do you mind taking that on notice as well as those other issues that I have raised? That would be terrific. Thank you.

CHAIR —Thank you very much. I would like to send a cheerio call to Mr Dodson, who is also offended by the Irish bomb maker remarks. There you go. Senator McGauran, do you come from a long line of Irish bomb makers?

Senator McGAURAN —Irish, Chair. Yes. Happy to be Irish, but not bomb makers.

CHAIR —Life would be buggered without humour. As to the incident in Melbourne—how many seconds from a disaster was that? Was it 38 feet?

Mr Dolan —Thirty-eight feet to the fuselage of the aircraft and, if you allow for the undercarriage, even less than that.

Senator NASH —How high is this ceiling?

CHAIR —So, it was very close?

Mr Dolan —Close to contact, yes.

CHAIR —All human endeavour has some failure, none more than myself as demonstrated by today’s Irish bomb-maker comment. What alerted them? How did they figure—

Mr Dolan —As we laid out in our report, essentially the pilots took a range of steps to deal with the fact that the aircraft was not handling and responding in the way they would have expected, when they put the thrust levers forward into the go-around mode. There was a period where they were trying essentially in a range of ways to establish why the aircraft was not responding as intended, and their intention was primarily and understandably on that, which led to this point where they were much closer to the ground than—

CHAIR —So, human override took over?

Mr Dolan —The key thing for us in this is in fact the interaction between human beings and aircraft systems and what was going on there, and that is—

CHAIR —We will not get into that. So, as a consequence of that, has there been an instruction put out—and it is so long ago they used to get these things come through—to all pilots as to what happened?

Mr Dolan —We circulated our report reasonably widely. We have drawn attention to it in a range of areas. We still say that the key thing that brought together this constellation of potential risk factors was the change to operating procedures. The one that said rather than No. 2 step, ‘Check what flight mode the aircraft is operating in’, made it, I think, step 7, from recollection. If it had been No. 2 there would have been a fairly early realisation of what was actually going on, an easier rectification of it; everything would have happened fine.

CHAIR —But a lot of people do not read reports. You could send it out in a one-pager so that it landed with each pilot, but you do not do that?

Mr Dolan —It is a case-by-case decision for the organisation. We certainly have a focus where we can on extracting the key safety issues and communicating them to pilot groups, to operators, to others, including to passengers in some cases, when we are talking about seatbelts and the handling of oxygen masks and so on. In this case, actually finding something that is a message for all pilots is quite difficult. As I say, the key thing is in fact a procedural question that related to the particular operator and circumstances, and so a generic message about that was not going to be of much help to the pilots at all.

CHAIR —I guess there must be a way of emphasising that this was a near thing and it was, as you say, the interaction between the machine and the man. That coughing blood cigarette/cancer thing is pretty effective. There must be a way to get this message out.

Mr Dolan —We are always looking for them, as I tried to explain a little the other evening. But sometimes it is very hard to take a quite particular set of circumstances and generalise.

CHAIR —I was given information about a plane that is flying. I have to go and look at it. We get lots of mail, and people say they do not want to lose their jobs. It said that an airliner was in landing mode and it was under the threshold for gear down, and it did not have its gear down, and the right-hand seat said to the left-hand seat, ‘You haven’t got your gear down’, and the left-hand seat said, ‘Oh, well, get it down’, and the right-hand seat said, ‘No, we’re right. We’ll go around and go full power.’ Should you know about that?

Mr Dolan —The way you have described it sounds like one that I do know about and we are currently investigating.

CHAIR —There you go. Pleased to see you are on the job.

Mr Dolan —I can think of two or three in comparable territory. If you want to give me more information. I can certainly give you—

CHAIR —One of the things that distressed one of the people involved in that was that because of the tension that created, perhaps someone should have gone off the next leg and let someone else fly the final leg to wherever it was. I do not want to identify them.

[3.01 pm]