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Rural Affairs and Transport References Committee
31/03/2011
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 a 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 a superior officer 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 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 for the claim.

We have just had some questions about stick-shake events in the QantasLink range of planes. Could you give us a run-through of your perspective on what precautions are being taken and what may need to happen to satisfy yourselves that there is a cure to this?

Mr Dolan —We are currently undertaking an investigation into a recent stick-shaker event involving a Dash 8 aircraft. Until we have completed that, there are some areas that we will not be able to give you a definitive answer on.

CHAIR —Fair enough.

Mr Dolan —That said, for the comparatively small number of safety relevant stick-shaker events, the area that we are most interested in, which was reflected in the report that we put out on the 26 December 2008 incident, goes to appropriate training and management in the cockpit to prevent the stick-shaker happening in the first place—the incipient stall coming into place. From what we have seen, steps are being taken within QantasLink to deal with that. We will make further inquires as we conduct our current investigation.

Senator XENOPHON —Again, this is only one pilot, but I was stopped at an airport by a QantasLink captain who spoke to me about the stick-shaker incidents. His opinion, for what it is worth, is that the difference between the Dash 8s and the Q400s is such that there needs to be some additional training. His feeling—which he said was shared by some of his colleagues—was that there may have been some more differential training between the Dash 8s and the Q400s in terms of dealing with stick-shaker incidents, because the aircraft are slightly different. I think Captain Davey from QantasLink set that out. Is that a factor that the ATSB would be looking at?

Mr Dolan —The incidents we are most interested in relate to the 300 series rather than the 400.

Senator XENOPHON —Yes, but the difference between the training on the Dash 8s—

Mr Dolan —I understand the point you are making. I am making the point that we have focused on the incidents that have occurred in 300s because they are the ones that have come to our attention. But I will be happy to ensure that our investigation looks at that issue of any potential risk that comes from the different arrangements in the 300 and 400 series aircraft.

Senator XENOPHON —So that is one of the things you are looking at in terms of levels of training?

Mr Dolan —We are looking at the risk factors that lead to these situations and might have a potential influence on how they are handled when a stick shaker actually occurs.

Senator XENOPHON —Do you go back to the manufacturer Bombardier in relation to this?

Mr Dolan —We have not seen anything at this stage that leads us to the view that there is a manufacturing design or mechanical problem.

Senator XENOPHON —Let me make this clear: I was not implying that in any way. As I understand it, Bombardier have liaised with QantasLink and other airlines. I am not suggesting a design fault at all, but I am asking whether issues of training and related issues might be beneficial in dealing with these incidents?

Mr Dolan —I am sorry if I seem to be avoiding a definitive answer, but it is because we have something in process. What we normally do with our investigations is to establish what we see as the relevant safety issues and then look into who is best placed to help deal with that identified issue, which may include Bombardier and what it does in standard operating procedures that operators of the aircraft take into account and embed in their training approaches.

Senator XENOPHON —Sure, and that was the context in which I wanted to ask it.

CHAIR —Senator O’Brien, do you have stick shake questions?

Senator O’BRIEN —I thought we dealt with that, unless there is more information that ATSB have that they can give us about the stick shaker matter since they last gave evidence?

Mr Dolan —No, nothing to add.

CHAIR —Is the Australian Transport Safety Bureau aware of similar events globally? Qantas have told us it is not peculiar to our mob, it is peculiar globally. This would indicate a trick in flying the plane, surely?

Mr Dolan —We are not aware of anything, Senator. Given an apparent pattern, it is clearly a question that can reasonably be asked. Different countries have different standards for reporting, so whether there would be a comprehensive answer is an interesting question. We can certainly, in the course of the investigation, acquire some additional information on that.

CHAIR —Given that the regular pattern activity both at high speed and the less regular low-speed air safety risk, is this something that you are confident, with the regulations and training that are available now, will be satisfactorily addressed?

Mr Dolan —From our point of view at this stage, and this goes to our examination of the material we have available to us about stick shakers generically as well as in the Dash 8 fleet, high-speed incidents—the ones in cruise, the ones on descent—fall within normal parameters. There is not anything we have seen in those that would say anything needs to be done. Turbulence and suchlike are part of normal operations and will have a propensity to have a short-term trigger of a stick shaker or similar things in aircraft. So our interest is particularly in the area of stabilised approach of stick shakers, particularly in approach to land.

CHAIR —Could I move, with the required sensitivity, to another area: could you take us through the various levels of notices that are issued to airlines that finishes up with the—what were we told this morning?

Mr Dolan —I could help you with what we do in our investigations. There is a set of things that our colleagues in the Civil Aviation Safety Authority do in their audits and what response to those they expect from operators. What we do is identify safety issues through our investigations. Depending on the severity of the safety issue, we will draw attention to an issue that we suggest could be dealt with but which we do not consider particularly significant. If it is a significant issue, we will issue either an advisory notice or, if necessary, a formal recommendation. A formal recommendation brings with it a responsibility, on whoever we give the recommendation, to respond within 90 days as to what they are going to do about our recommendation.

CHAIR —So is that the foundation stone of a show-cause notice?

Mr Dolan —No, a show-cause notice is CASA looking at compliance with the Civil Aviation Act, the regulations and orders, and asking someone to essentially give evidence or more information about why action should not be taken against them because there is a prima facie breach of their responsibilities under the act.

Senator XENOPHON —And that action could involve immediate remedial action or what?

Mr Dolan —Show-cause notices, as I understand them and I am outside my formal responsibilities here, are the regulator indicating that it intends to take the most severe possible action—that is, removing a permission to operate.

CHAIR —Are these things that have happened in the past? Is it on an irregular basis? Is it a very irregular event to be given a show-cause, to the best of your knowledge?

Mr Dolan —To the best of my knowledge, it is a comparatively rare event. It normally comes out of either an egregious breach of responsibilities or an ongoing pattern of failure to comply that leads to serious safety concerns.

Senator XENOPHON —‘Egregious’ is not a word you use lightly, I take it?

Mr Dolan —No, I thought about using it and I think it is the correct one.

CHAIR —To work up the case for a show-cause, would the Australian Transport Safety Bureau have input into the case?

Mr Dolan —No, explicitly not. For the benefit of the committee, perhaps it is worth explaining how the Civil Aviation Safety Authority and the ATSB work together. The Transport Safety Investigation Act explicitly prevents us from allocating blame, from supporting any finding of liability on the part of someone in the system or from supporting any court based action against anyone operating in the system. So the material we have explicitly cannot be used, essentially, for regulatory purposes except in the picture of information we have that discloses trends that may tell the regulator where to look.

CHAIR —So if there was a show-cause notice issued in an event would you be consulted?

Mr Dolan —No. We would probably be advised because quite often those sorts of matters relate to things that we are also investigating.

CHAIR —Thank you for those answers, Mr Dolan. Senator O’Brien now has some questions.

Senator O’BRIEN —I understand that we have been told that ATSB are now investigating a Jetstar event on a flight out of Darwin, impacted by a local thunderstorm event. Suggestions have been made in these proceedings about ‘difficulty to climb’ and those sorts of matters.

Mr Dolan —Yes. It was a matter that we originally we did not initiate an investigation on because we did not think it was outside the parameters of normal operations—however serious it may have felt to those involved—but, following our discussion last time, we indicated that we would take a look at it. We are still completing that investigation. We have the information from flight data recorders and other sources. We will interview the pilots to get a clear understanding of not just—

Senator O’BRIEN —So there was no interview of pilots before?

Mr Dolan —No, because the information we had to us was that, while it was a significant event—there was a windshear and it substantially affected the climbing capability of the aircraft—it was within the normal parameters. That is what we are trying to establish by—

Senator O’BRIEN —What does ‘within the normal parameters’ mean?

—There is provision within the operating procedures for an aircraft to deal with windshear on take-off. A set of procedures are put into place if an aircraft encounters windshear at that crucial stage of flight. Our understanding in the initial stages was that it fitted within those operating procedures. There was a substantial reduction in the climbing capability of the aircraft for a period of time, but the aircraft always had positive climb—that was our initial understanding of the event. We are confirming whether or not that was the case and we hope to conclude that investigation within the next week or so.

Senator O’BRIEN —I am given to understand that a normal rate of climb would be about 2,000 feet a minute.

—Between 2,000 and 2,500.

Senator O’BRIEN —This was climbing at less than 10 per cent of that capacity. Is that normal acceptable parameters?

—My understanding—from what we have available to us— is that it would have been at approximately 25 per cent, so there was a significant diminution of the climbing capability of the aircraft.

Senator O’BRIEN —So you say 25 per cent. If it was at around 10 per cent or less of the capacity, how would that categorise that event?

Mr Dolan —Clearly there is a point where—I am not quite sure—this is a matter of degree and always will be. At the moment we are looking at trying to establish what is reasonably manageable—that is, what would be safe operations in these challenging conditions and the extent to which there remains a risk that a really significant windshear could lead to either no rate of climb, or perhaps a drop, remains a potential hazard. That is part of the context in which we are looking at the details of this particular one. The information we have at this stage is that, while there was a significant degradation in the climbing capability of the aircraft for a period, it was within what one would reasonably expect were one of these windshear events to occur. It is an ‘extreme event’—it would have had fairly extreme consequences on the aircraft—but it is the sort of thing that the normal procedures envisage and that crews are trained for.

Senator O’BRIEN —How do you categorise events like that? If it is within the normal parameters, then there is not an investigation?

Mr Dolan —We would, in those circumstances, depending on how our initial assessment of the information went, deal with it as what we call a factual investigation, where we would record in detail and confirm the facts of the event and publish that. We would use that in future as one of a potential series of trend information, so we could come back to it in due course if we saw there was another. We would essentially position it so that it was there for us to refer back to on the basis of establishing a pattern of event. If we, on a risk assessment, considered it to be more serious as an individual event than that, then we would do a full-blown investigation. We are always making decisions based on initial reports as to likely significance, whether we should gather further information, investigate and so on.

Senator O’BRIEN —I am wondering in a case like this, where there is substantial effect on aircraft, whether you might proceed down the path of investigating the available weather information present in the tower and on the flight deck of the aircraft, in terms of whether better could be done with the information that was available and whether the information that should have been or would be available was available for or used by persons in either of those locations at this time, and making some finding as to advisability of flight in certain circumstances.

Mr Dolan —What I can say at this point is part of our inquiry is to establish the situation in relation to weather forecasting and availability, and particularly the question of overhead thunderstorms, as was the case in this event. So available weather information and what that might mean in terms of risk factor is something we are looking at.

Senator O’BRIEN —But in the first instance that is not something that you would have done?

Mr Dolan —In the first instance we received the report, which we have satisfied ourselves was the report lodged by the pilot and passed on to us by the operator, that positioned this as an event which, although significantly uncomfortable, was within normal parameters. So it was a reportable event, but not one that was saying, ‘Something really, really bad happened here.’ That was the initial point. If there had been a different sort of report from the operator then we would have given it a different level of attention.

Senator O’BRIEN —Where does ATSB get its expertise in these fields? Do you have staff who are experienced high-capacity pilots et cetera?

Mr Dolan —One of our challenges in staffing is retaining pilots with high-capacity jet experience. We cannot quite pay the same rates as they can expect in operational roles, but we do have several staff members with high-capacity jet experience. We also have air traffic controllers, including those with military air traffic control experience, and we have the set of information that would let us make an informed decision about the circumstances at Darwin.

CHAIR —That begs the question, and you may not want to answer this: do you have capacity constraints? In other words, do you need more capacity? Is there any change in the workload of ATSB? Are there more incidents or fewer incidents? Have you got adequate staff to look down every rabbit warren, as it were, or would it be helpful if you had more staff and more budget?

Mr Dolan —I would never say no to more staff or more budget.

CHAIR —But is it justified by incident increases?

Mr Dolan —Over the last few years there has been a substantial increase in the level of activity in the aviation sector. The level in terms of the number of occurrence reports we receive and those that we classify as having a safety element to them has not changed very much over the last few years. So we are looking at essentially the same number of things that we would have the potential to investigate. The picture is distorted because when the organisation started in its independent status it had a substantial overhang of older investigations, so we had a backlog, if you like, and a fair amount of our resources have been devoted to clearing that backlog. We have almost completed that; there are a few very old reports that will shortly come out that will conclude that process.

Having done that, we are looking at the best way of taking what will always be limited resources and allocating them to the points where the most significant safety benefit is likely to accrue from investigation. It means we will occasionally look at an interesting rabbit burrow and say, ‘From the perspective of learning something to the benefit of safety, we will not go down that one. If I had more resources, then I might take a different view.’ There is always going to be a balance between available resources and things we look at.

Senator XENOPHON —Mr Dolan, thank you for coming back. I think this is the third time for this inquiry, but I appreciate it and the committee does too. I want to go back to the issue of resources and also experience. How many ATSB staff would have experience in high-capacity, regular public transport operations?

Mr Dolan —I would have to confirm that number, but we have three or four at the moment.

Senator XENOPHON —How recent would that experience be?

Mr Dolan —It would be somewhat dated now, although we attempt to give our people some experience at least in the ground-school side of modern aircraft operations. I try to keep them up to the bar but recognise that we cannot maintain them to the actual operational level required to fly these aircraft.

Senator XENOPHON —You could take that on notice. I will go back to the windshear incident involving the Jetstar plane, but Senator Heffernan asked you some questions about the issue of show-cause notices. I was not picking up on the word ‘egregious’—it is a strong word to use. I think you said that, to get a show-cause notice, there could be an egregious lack of compliance. How would you define it from your understanding?

Mr Dolan —I am hesitant to go too much further on this because it is not my responsibility. What I was trying to say is this: the end game of a show-cause notice is to show cause why a permission to do things within the aviation system should not be taken away from you. That is what a show-cause notice is about. That can be driven by either a one-off but highly significant issue or an ongoing series of failures to comply with the provisions of the system. If it were a one-off—that is the basis upon which I was using the word ‘egregious’. It would have to stand out in a quite negative way, which is my understanding of ‘egregious’.

Senator XENOPHON —This committee needs to make certain recommendations and presumably will be at least looking at the interaction between CASA and the ATSB, in terms of levels of cooperation. I am not saying that you are not cooperating with each other, but in a statutory sense. You have indicated that you regard a show-cause notice as something very serious. For the benefit of Hansard, you are acknowledging that is the case?

Mr Dolan —Yes. Obviously different permissions have different consequences within the system and a show-cause notice to a major operator is a bit different to a show-cause notice to a pilot operating a single aircraft somewhere. In that context, I would certainly say that was the case.

Senator XENOPHON —Currently, if a show-cause notice is issued by CASA—because that is not your statutory function—are you made aware of it being issued in a formal sense and in an informal sense? What are the protocols?

—In a formal sense, there is no explicit provision for exchange of that information. On a more informal basis, there are several circumstances where CASA as a regulator may be looking at a particular operator and we may be investigating a particular event. The two things, while being independent and with us maintaining a no-blame role so that they can not interfere with each other, we try and inform each other within the limitations of our legislation about what is going on. This really has to be done on a case-by-case basis. We do not want to interfere with legal responsibilities, but it is helpful for me to understand the cases we are investigating where regulatory action is imminent.

Senator XENOPHON —So, if a show cause notice is issued by CASA, it is not unreasonable, from your point of view, for the ATSB to at least be aware of that and then you can weigh up the relevance of that show cause notice in the context of anything that ATSB may or may not be investigating?

Mr Dolan —It is potentially relevant for a number of reasons, one of which is that it will have, if you like, a chilling effect on our capacity to interview those involved. Even though they recognise that we have a responsibility to protect any information that is given to us, if they are in parallel under regulatory attention, that may place some limits on the amount of corporation we are likely to get from individuals.

Senator XENOPHON —I have two other issues. I might need a moment to speak to my office about one of them because I have received some information on which we may or may not need to go in camera to put to the ATSB; it is in relation to someone who has expressed some concerns, not about the ATSB but about a particular operation. I just want to go to the windshear incident that Senator O’Brien referred to. I am trying to establish what the triggers are for a high-level investigation. I appreciate that the ATSB is now looking at that incident at a higher level but, initially, the ATSB made a decision not to investigate further on the basis of information provided; is that a fair summary?

Mr Dolan —Correct.

Senator XENOPHON —Did that information consist of a report from the pilot?

Mr Dolan —A report from the operator which, we understand, was pretty much a verbatim report of the pilot.

Senator XENOPHON —That report obviously would have indicated that there was a windshear incident, but did it also indicate the rate of climb?

Mr Dolan —As I recall, although I will have to confirm this, the initial report did not go to rate of climb, but we made inquiries of the operator as to rate of climb.

Senator XENOPHON —Were those inquiries on the basis of looking at the flight data recorder?

Mr Dolan —On the basis of asking the operator what they had in terms of the flight data recorder.

Senator XENOPHON —Given that you are now investigating this, are you able to comment further? Can you advise whether you were notified as to the rate of climb at that time?

Mr Dolan —At the time of the initial report?

Senator XENOPHON —Yes.

Mr Dolan —As I say, my recollection is no, but I will confirm whether that is the case. I would prefer to take the question on notice to be absolutely sure.

Senator XENOPHON —I understand that. Further to the line of questioning on this by Senator Heffernan and Senator O’Brien, if the normal rate of climb for an A320 is 2,000 to 2 ½ thousand feet per minute and if the rate of climb were about 10 per cent of that, from your point of view would that raise concerns for a more robust investigation?

Mr Dolan —It would take us to that point where we would be seeking further information to establish significance. This is somewhat hypothetical. The number as we understand it was somewhat higher than the one you are quoting, and we will make that public in whatever we do in terms of our current investigation. There will always be a question as to what the trigger point is for an investigation. Even if we had much more generous resources than we currently have, there will always be a set of things that we will look at and say, ‘We will record that in our occurrence database but we won’t actually formally investigate it.’

Senator XENOPHON —It is just that the trigger for the investigation was, I think, when Captain Woodward, who is in the gallery today, said that he raised concerns about it. Was that the trigger for a further investigation, that you were given more information that came to light?

Mr Dolan —The trigger was in this forum. We heard information that cast a different light on the occurrence from that which was available to us. So we are establishing more clearly the facts through examining the flight data recorder and other information, through interviewing the pilots and so on.

Senator XENOPHON —I emphasise that this is not a criticism of the ATSB. I am just trying to work out the protocols and whether the requirements for information provided to you are adequate for the ATSB to be able to do its job properly.

Mr Dolan —At this stage, we remain confident that the information provided to us by operators, which is essentially based on internal reporting systems, is reliable. The reason that we wanted to take a closer look at this was that we heard in this place a view of the events that was at odds with what had been reported to us, so we are establishing to the best of our ability what the facts are.

Senator XENOPHON —So does that mean that it would be appropriate in any future windshear incidents to try to establish to what extent the rate of climb was compromised as part of the incident as to the level of investigation that the ATSB would carry out?

Mr Dolan —Yes, but perhaps I should be clear. In our decision to investigate, we made inquiries as to the rate of climb and formed a view based on that information. As I say, we received a different view of it in this forum and that is why we want—

Senator XENOPHON —Okay. I will not belabour this point because I do want to go in camera in a moment. When you received information on the rate of climb, was that verified by flight data recorder information, or was it on the basis of representations made to you?

Mr Dolan —It was on the basis of the operator’s advice to us of the information they had established through their examination of, I think, the quick access recorder of the aircraft. So, yes, we did rely on that information.

Senator XENOPHON —Which would give you rates of climb?

Mr Dolan —Yes.

CHAIR —Would those records still exist, or do they have a termination period?

Mr Dolan —There is a period past which the material is overwritten, but this was well within those parameters so we had the information.

CHAIR —So if you want to go back and have a look for yourself, would you be able to?

Mr Dolan —Yes, we are.

Senator XENOPHON —Mr Dolan, is it fair to say that you are now looking at this matter and that there will be a report prepared in relation to it? Has it got to the stage where there will be some formal report?

Mr Dolan —There will be some formal publication of what we have discovered as a result of our investigations.

Senator XENOPHON —And, who knows? This committee may want to ask some more questions on that.

CHAIR —Before we go in camera, I would like to ask a question about fatigue. This may not be in your bailiwick. On trains we took a long time to get firemen off railway engines that did not have a fire. They are single crewed now, and one of the safety devices for a train driver is that he has to push a button every minute or two or the train will pull up. One of the scary things to come to terms with in fatigue is if someone at the wheel goes to sleep, and if there were two people and both of them went to sleep it would be a pretty scary experience if anyone knew about it, and it would be hard to prove. As an extra precaution, given all the information we have received about the capacity of the human body to tolerate different fatigue levels and loads, could there be a device in the pilots cabin, referring it back to the cabin crew, that would send a warning if they did not push it every so often? So, if the alarm went off, you would know that everyone has gone to sleep.

Mr Dolan —There is an addressing of balance there, Senator. It is not an intervention that I would necessarily see as ideal in that flight crew are normally being asked to do a whole range of things—

CHAIR —I understand that.

Mr Dolan —With the level of work they are required to do this might just end up being an additional distraction rather than an additional defence against fatigue in the system.

CHAIR —But if there were the slightest evidence of an event where pilots may have snoozed off, would that cause you to rethink?

Mr Dolan —What I can say is that when we do our investigations we are always alert to the risks of fatigue, and we go to considerable efforts to establish by a range of mechanisms whether we think fatigue might have been a relevant consideration. We are not at the point where we have an evidence set that would lead us to the view that there is a problem with nodding off that would lead us to make a recommendation about it.

CHAIR —I understand. I advise the gallery that we want to clear the room for perhaps 10 minutes so that the hearing can go in camera. We will proceed with these hearings in camera.

Evidence was then taken in camera but later resumed in public—

Proceedings suspended from 12.10 pm to 12.21 pm

Mr Dolan —I have a very quick comment, Chair. It is just a clarification of the discussion we were having about the relationship between CASA and the ATSB in terms of sharing information at various levels, including potential action that CASA might or might not be taking. The bit that I did not draw clearly and would be happy to provide to the committee is that we have a memorandum of understanding with the Civil Aviation Safety Authority. It is a public document that explains how that information-sharing relationship is managed. That might help to put some of that information in context and I am happy to supply it to the committee, if that is helpful.

CHAIR —I thank the ATSB for your evidence today.

[12.23 pm]