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Rural and Regional Affairs and Transport References Committee
Aviation accident investigations

DOLAN, Mr Martin, Chief Commissioner, Australian Transport Safety Bureau

SANGSTON, Mr Ian, General Manager, Aviation Safety Investigations, Australian Transport Safety Bureau

WALSH, Mr Julian, General Manager, Strategic Capability, Australian Transport Safety Bureau


CHAIR: I now welcome another part of the family—the ATSB and their group of dedicated people. I welcome representatives from the Australian Transport Safety Bureau. I remind senators that the Senate has resolved that an officer of the Commonwealth or of a state shall not be asked to give opinions on matters of policy and should 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. It does not preclude questions asking for explanations of policies or factual questions about how and when policies were developed. 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 should be accompanied by a statement setting out the basis of the claim. The ATSB has lodged submission 2 with the committee. Do you want to make any amendments or alterations to that?

Mr Dolan : No. We have also lodged several supplementary submissions with the committee, but we are satisfied with those submissions as well.

CHAIR: Would you like to make a brief opening statement?

Mr Dolan : I would, with your indulgence. Thank you, Mr Chair and senators, for the additional opportunity to discuss our investigation into the ditching of the Westwind VH-NGA off Norfolk Island on 18 November 2009. At the earlier hearing, I curtailed my opening remarks in the interests of time. In the light of submissions that have been made and evidence that has been given to the committee, there are some points, however, that I would now like to make on behalf of the ATSB.

The ATSB has been set up by law to improve transport safety principally by investigating transport accidents and other occurrences and by identifying factors that have contributed to occurrences or that might affect future transport safety—that is, asking whether there are there risks that need to be treated—and communicating those factors by stating them clearly so they can be addressed and, where necessary, making recommendations and issuing safety advisory notices.

We issue recommendations when we are not satisfied that sufficient action has been taken to address identified safety factors. Our test is essentially whether we think all reasonably practicable steps have been taken to reduce the identified risk. As the committee knows, we are specifically prohibited from apportioning blame, from providing the means to determine liability and from assisting in court proceedings. We are required, as you were discussing with Professor McMillan, to protect information acquired or produced in the course of an investigation. We are also required to act in a manner consistent with Australia's international obligations, including under the Chicago convention.

We undertook the investigation of the Norfolk Island accident and published an investigation report under those functions and conditions. A number of claims have been made about the inaccuracy of the investigation report or about omissions in the report. As I indicated, we have provided a range of submissions to the committee addressing the points raised. The latest was yesterday, addressing some assertions that had been made about the fuel planning and management of the accident flight. The ATSB remains satisfied that there is no material error of fact in the report. We have also satisfied ourselves that, at this stage, no significant new information has been brought to light that requires a formal reopening of the investigation. I would like to make it clear that the ATSB stands by its report.

The sequence of events leading to the Norfolk Island accident could only have happened in a very narrow range of circumstances: namely, where a flight is aerial work or other general aviation and the weather on arrival at destination has deteriorated significantly from that forecast on departure. These weather conditions at Norfolk Island occur one or two times a year. It did, unfortunately, occur in the case of this accident. The existing safety arrangements covered all other cases, all normal passenger flights and general aviation flights where the bad weather was already forecast before departure. While having regard to the prohibition on apportioning blame, it is necessary also to point out that the risk presented by the unforecasted deterioration in Norfolk Island weather was exacerbated, in this case, by inadequate flight planning, carriage of less fuel than required for what had been planned and poor monitoring and management of the flight itself. We do not consider that the conduct of the flight met the existing standards in those areas. We raise this as relevant, because it directly effects how we assess the effectiveness of existing risk controls.

Having considered all the circumstances of the accident, the ATSB concluded that there were two safety factors likely to affect future safety. They were two areas where more could be done to reduce the risk associated with some other flights in the future. They related to the guidance available on fuel planning and the use of weather information en route and the operators' procedures for managing risks presented by unforecast weather deterioration.

We considered that the principal source of action on the first issue was CASA and for the second was Pel-Air. Both CASA and Pel-Air informed us of the action that they had taken or that they had proposed in response to the identified issues.

The ATSB assessed the action taken or proposed and concluded that it did, or would, address the identified safety risks. For that reason we did not consider it necessary to make a safety recommendation in relation to those issues. Because some of the CASA action is not complete, we will keep the safety issue open and monitor its implementation until we are satisfied that all action is finalised. I am happy to clarify any issues arising from this statement or from the submissions we have made to the committee, and to answer any questions.

Senator NASH: You were just saying then that you had no need to make any recommendations because CASA and Pel-Air had told you what they had done to address the issues. When was that?

Mr Dolan : It was in the course of finalising the reports. Part of the directly involved parties' process, sending a draft report out with identified safety issues in it is to seek information from those parties as to what action they have taken, or propose to take, in response. Our aim is that by the time the report is complete we have good information about action that is taken or proposed and can satisfy ourselves as to whether further action needs to be recommended. So it is an integral part of the way we run our process.

Senator NASH: It is almost as if you have said, 'Here are the issues,' and CASA and Pel-Air have come back and told you what they have done and then you do not make a decision about whether you need to make any recommendations until that point in time—is that correct?

Mr Dolan : That is correct.

Senator NASH: Has it always been the case?

Mr Dolan : I would have to check with colleagues. It certainly has not always been the case; it has been the case for my entire tenure of 3½ years in the organisation and its predated my arrival by a year or two—Mr Walsh?

Mr Walsh : Yes, I think for that specific approach it has been about four years.

Senator NASH: All right. Why would ATSB not make recommendations earlier on so that other parties knew exactly what would be required of them to address the issues?

Mr Dolan : The mechanism we have arrived at, which seems to work well, is one that looks to identify the shape of issues as early as possible and to get them sufficiently clear so that the relevant party can start proactively doing something about them before the investigation is even complete.

Senator NASH: I take your point, but it does not really answer the question. Why would you not make recommendations earlier on given that you are the ATSB? If there is no specific recommendation there, aren't any parties really stabbing in the dark a bit to see if they are going to get their response right? Why would you not do it early on? You are the ATSB, you know what needs to be done to rectify things when you see a situation, regardless of what that might be. I am just struggling as to why you would not say to parties, 'This is what you need to do to rectify the situation.'

Mr Dolan : There are two points, Senator. Where necessary we will make recommendations in the course of an investigation, as we did in the case of Qantas Flight 32, the uncontained engine failure. We made a very explicit recommendation to Rolls-Royce in terms of the return to service of those engines. So it is not that we do not do it, it is that we need to be clear on the significance of the matter we are dealing with and get it clear before we make a recommendation.

The second point is that the assumption has been for a considerable period of time—and I and my fellow commissioners have satisfied ourselves that we are comfortable with this—that while the ATSB is well-equipped to specify what the problem is that needs to be addressed—what is the risk that apparently has not been adequately managed—we do not always know the right way of addressing it. Those closer to controlling the event have a better chance of specifying the necessary action, and that can be an iterative process.

Senator NASH: So in this instance, can you just remind me of the length of time before the issuing of the draft report—from the time the accident happened to when the draft report was issued?

Mr Dolan : I cannot remember exactly.

Senator NASH: A ballpark figure—roughly.

Mr Sangston : The draft report was sometime around 23 March this year.

Mr Dolan : About 2½ years.

CHAIR: About 2½ years, I think I recall.

Senator NASH: One of my concerns is that the draft report took that long to be produced. If, as you are saying, the parties respond to the draft report and then come to you with how they have addressed the issue, how did they have any idea in that 2½ years of what they were supposed to do to address the issues, if they did not have a draft report?

Mr Dolan : The provisional view we formed quite early on was that the key set of things at issue here was the en route management of the flight—the decision making in relation to weather and management of fuel that led to a situation where there was not a possibility of landing at Norfolk Island and insufficient fuel to go anywhere else. This was, in fact, a more significant issue than what might have happened with preflight planning and those sorts of things. At a very early stage, we drew these very clearly and explicitly to the attention of the Civil Aviation Safety Authority. Because we take a prudent view of these things, we very strongly stated what we saw as provisionally the risk that was involved here—the risk that the guidance about en route management of these flights was not adequate.

Senator NASH: You made a judgement call that it was those things that you have just referred to, but what concerns me is that chances are that pilot is not going to get in a plane and do that again. One of the bigger issues that has emerged, surely, is this fault line in the provision of information from New Zealand. That is a set of circumstances that, at any period of time, could happen again, obviously with a resultant, potential, dire, catastrophic consequence. You identified early those pilot issues as being the most important. Isn't that rather presumptive given that this other issue has virtually been completely overlooked?

Mr Dolan : I would differ with you on the question of the overlooking of that issue. We took the current provisions of the AIP and the current arrangements for the provision of weather information by air traffic services. Those provisions in the AIP clearly say, 'Principal responsibility is with the pilot to acquire weather related information, including forecasts.' There is some provision for air traffic services to proactively draw attention to the existence of an updated forecast, normally in the case where aircraft are within an hour of their intended destination.

Senator NASH: We had Airservices Australia in here only two days ago, admitting that the provision of weather information from New Zealand was an issue that they are now going to address through the Pacific forum, which they were not going to do until it was raised through this forum. But you are saying it is not an issue. So they are saying it is an issue and that they are going to address it, but you are telling us today that you do not see that it is an issue.

Mr Dolan : We see a broader issue, which is: what is the support that is provided to flight crews en route in terms of assessing their situation, getting access to weather and other related information, applying that to the management of their fuel and so on? This is in a context where we saw in the AIP something that very clearly said that it is the responsibility of pilots to obtain information necessary to make operational decisions and that pilots will not automatically receive routine TAF information showing deteriorating weather conditions if they are en route to a location. That was the status quo with Airservices, with New Zealand and, as we understand, with Fiji.

Senator NASH: That is extraordinary.

CHAIR: Can I just ask some basic wooden-headed questions? I have a wooden head. This is Australia's landmass—Norfolk Island. It is part of our sovereignty?

Mr Dolan : That is my understanding.

CHAIR: So why don't we control our own airspace? It is our airspace.

Mr Dolan : It is not a matter that I am an expert on, but I understand in the interests of efficient management of large areas of contiguous airspace that there have been international agreements about who provides air traffic services in which block of airspace. Norfolk Island sits inconveniently, if you like, in the middle of an airspace that is essentially the responsibility of New Zealand.

CHAIR: Are you saying that the airspace over our landmass is not our airspace?

Mr Dolan : The airspace over Norfolk Island is controlled by the air traffic service of New Zealand.

Senator NASH: Why?

Mr Dolan : Because of that agreement about efficient management of the airspace.

CHAIR: Anyhow, it is closest. We will just get that down.

Senator THORP: It is a bit like Berlin in the middle of East Germany.

CHAIR: As Senator Nash has pointed out, we were told by Airservices of the urgency of what went wrong, and you would agree that the nonrelay of the weather from the New Zealand bureau to our plane in their airspace, approaching our landmass, did not happen. From a perspective of air transport safety, we were told by Airservices, 'but he could have actually tuned in to a repeater service that would give him the weather'—an automatic repeater out of Norfolk Island. Are you familiar with that?

Mr Dolan : I am familiar with the capacity to phone the automatic service on Norfolk Island. I am not—

CHAIR: Can you call it up though, or have you got to phone it?

Mr Dolan : I am not sure.

CHAIR: So it is not a UHF or VHF?

Mr Dolan : My colleagues tell me that they understand that it is a matter of phoning it rather than calling it up on the radio.

CHAIR: So you would have to use a satellite phone, I guess?

Mr Dolan : Correct, Senator.

CHAIR: Do we know if there was a satellite phone on the plane? Just as there is a requirement to have a fire extinguisher, should there be a requirement to have a satellite phone? Otherwise you cannot get the weather.

Mr Dolan : Could I perhaps put some context to this, just so we can understand what is going on from an ATSB perspective. I would respectively disagree with you on the question of what New Zealand might or might not have provided. The basic information that is required—

CHAIR: Just before you do that—and I respectively appreciate your answer—we have got the phone so you could phone in. I just want to get the mechanics right before we go on. Is it the bureau of meteorology or an aviation authority in New Zealand that provides the information?

Mr Dolan : The information from the automated weather service on Norfolk Island goes to the Bureau of Meteorology in Australia and then is pushed to a range of relevant providers, including the New Zealand air services provider and, I believe, the Fiji air services provider. Indeed, it must be, because they gave some SPECI and other information that drew on that automatic—

CHAIR: So it is an air services provider that provides the weather information. Do they transfer that with VHF or HF?

Mr Dolan : HF in the airspace we are talking about. That is my understanding.

CHAIR: Could you provide us with the frequency of that HF and the distance of the signal? As you would probably be aware, HF, depending on your frequency, can be very unreliable.

Mr Dolan : Yes, it can vary, depending on the time of day, among other things.

CHAIR: I am an HF person.

Mr Dolan : The automated weather service provides regular updates and also provides updates if there is a significant variation in the reported conditions via a METAR or a SPECI. That information is automatically transmitted to the ATS providers and they are required to provide it to the crew, which is the SPECIs that we talk about and other things in our report.

CHAIR: Just pausing there, a person is legally obliged to provide that updated information from the auto into Australia over to there. Is there a fixed instrument in the plane to receive that information or do they have to turn it on to receive it?

Mr Dolan : The communication is on a specified high-frequency arrangement, which gets changed. I think there is a sequence of them to go through if you are not getting adequate reception. But the basic communication is a high-frequency communication with the air traffic control centre responsible for the airspace.

CHAIR: On one frequency or several?

Mr Dolan : I believe it is available on several.

Mr Sangston : There are a number of frequencies available.

CHAIR: That will pick it up?

Mr Sangston : Generally what crews will do, in my experience, is start at the lower numbers at the beginning of the day, and as the day progresses you would get into the higher numbers of frequencies.

CHAIR: And the distance?

Mr Sangston : It is to do with propagation and so on, and that is about the level.

CHAIR: As part of the flight plan, this young pilot would have known the frequencies and had the radio to tune into those frequencies, and as part of his flight—like you switch from air traffic control if you are flying into Sydney from Wagga to somewhere else—

Mr Dolan : Yes, exactly that. That is what we would expect.

CHAIR: he would have had to tune in and have the radio on and be able to receive?

Mr Dolan : Yes, and there are several cases where we have got confirmation that SPECI information was transmitted and received by—

Senator STERLE: And received—

Mr Dolan : And received.

Senator STERLE: by the pilot?

Mr Dolan : By the pilot.

Senator STERLE: That the weather was deteriorating?

Mr Dolan : It was confirmed by the flight crew that they received this information.

Senator STERLE: Can you provide that to the committee?

Mr Dolan : It is in our report.

Senator XENOPHON: There is some dispute about what was received at what time, isn't there?

Mr Dolan : There is no dispute in the information we put in our draft report as factual information and provided to the flight crew and others involved. They agreed with the information as we specified it in our report.

Senator STERLE: I cannot hear you, sorry, Mr Dolan.

Mr Dolan : I am sorry.

Senator STERLE: Sorry, what did you say then?

Mr Dolan : I am a naturally quietly spoken person. I apologise.

Senator STERLE: That is because you are not married to—

CHAIR: He is well behaved and quietly spoken!

Mr Dolan : I am sorry; I got taken a little off track. In our report, which was based, among other things, on interviews with the flight crew, we specified those times when SPECI and METAR information was transmitted to the aircraft, received by the crew and acknowledged by the crew as having been received.

Senator STERLE: Can you tell us—I know that it is in the report—how many times that information was passed on and received and over what period of time?

Mr Dolan : If you have the report with you—

Senator STERLE: I left it in my other bag.

Mr Dolan : The problem—

Senator XENOPHON: Chair, this is directly supplementary to Senator Sterle's line of questioning in terms of who understood what. My understanding is that it was denied by both the pilot in command and the first officer. It was denied in the re-enactment by both pilots that they actually heard the cloud level. I understand that there was a video re-enactment of that. I am not sure if the committee has received that? I am advised that we have it, but I have not had a chance to see it. My understanding—which is directly relevant to what Senator Sterle has asked—is that the pilots were quite shocked. They said that they did not hear it, and there was a look of surprise on their faces when faced with that information.

Mr Dolan : True.

Senator XENOPHON: You say that is true?

Mr Dolan : We say that in our report. What we say in our report, which I think is consistent with the facts, is that SPECI observation at that point was received but not assimilated by the flight crew. There is an acknowledgement by the flight crew of receipt of the information, and indeed a thank you to air traffic control for the information having been provided.

Senator XENOPHON: Did they mishear the information? Is that still in contention?

Mr Dolan : No, we would agree with what the crew told us, which is that at that point—just after 0800 UTC—the information had been transmitted and the information had been received and acknowledged, but the crew did not understand the significance of the information that they had received.

CHAIR: Did they then get an 8.30 update which they assimilated?

Mr Dolan : The next SPECI was transmitted sometime after 0900 UTC.

Senator XENOPHON: There is a fundamental issue here. You are quite correct in saying that the crew acknowledged the information they received, but the question in contention is what information they think they received, because of the nature of the high frequency—the HF—and Fijian air traffic control, as I understand it, not providing a recording. We do not really know the quality of what they heard, because, even if the cockpit voice recorder were retrieved, it would not have been within that two-hour loop—is that correct?

Mr Dolan : That is correct.

Senator XENOPHON: Let's just be clinical about this. They acknowledged receipt of information, but what they heard could have been subject to the vagaries of HF.

Senator THORP: If I may interject here, I think I might be able to shine some light on this.

Senator XENOPHON: Please do.

Senator THORP: If I understand you correctly—and I have a bit of sailing experience and I think the same thing applies when you get weather forecasts over radio—you can hear a weather report that says the wind has shifted to whatever direction and it has gone to this particular height. You receive that information but you may not necessarily twig in your head that that is really serious. It is not that you have not heard what has been said; it is that you have not interpreted it correctly. That is what I think you were trying to say, rather than that something was said and the person misheard it. They have heard it and they have acknowledged it but they perhaps failed to recognise—

Mr Dolan : That is what we intended by the expression 'received but not assimilated'. They did not understand the consequences of the information received.

Senator XENOPHON: Senator Thorp is quite right in what she said, but is there another potential scenario? We do not know, because there is no recording of what was actually heard by them by virtue of the two-hour loop, and it was not recovered—correct?

Mr Dolan : That is correct.

Senator XENOPHON: In other words, the recording of what was transmitted at the point of transmission does not necessarily mean it is what they actually heard. I am just asking that you consider that as a potential scenario.

Mr Dolan : I can certainly consider it as a scenario. The thing that weighs against it in my mind is the explicit acknowledgement of the receipt of the information.

Senator XENOPHON: I want to be fair here. They explicitly acknowledged the information, but because of the vagaries of HF, which can be distorted—is that right?

Mr Dolan : Yes, it can.

Senator XENOPHON: Right. How do you explain the fact that when there is a video, as I understand it, of the pilot in command and the first officer they both expressed surprise when the recording was played back to them? It would obviously have been a clear recording because it would have come out of Fiji air traffic control. I am just trying to clarify that.

Mr Dolan : Out of Auckland, in fact.

CHAIR: Can I just attempt to assist the committee. Do I understand correctly that Fiji said that the cloud was at 6,000 feet and should have said 600?

Mr Dolan : There are two things. There was a request, first of all, for weather at Norfolk Island when Fijian air traffic control did specify the wrong cloud height.

Senator NASH: What time was that?

Mr Dolan : That was just before the transmission of the SPECI.

Senator NASH: When you say 'just before', how far before?

Mr Dolan : About 30 seconds before.

Senator STERLE: So it was cleared up straightaway. There was a mistake and false information and then it was cleared up.

Mr Dolan : There was incorrect information. Immediately thereafter there was transmission which, as Senator Xenophon has said, may have—

CHAIR: From New Zealand or from Fiji?

Mr Dolan : From Fiji.

Senator XENOPHON: I apologise. Is it possible that it was actually recorded by New Zealand's quite large receiver?

Mr Dolan : It was, at Auckland.

Senator XENOPHON: That is right, but the crew's relatively puny aerial does not hear it the same as the New Zealand recording. It would not be the same recording quality, would it? That is pretty axiomatic, isn't it?

Mr Dolan : I would only say two things. There is a lot of detail here. My understanding is in the Westwind it would not be a reasonable description of the aerials to say they are relatively puny. They are in fact quite reliable HF aerials. Certainly the transmission both to and from the aircraft that was recorded by Auckland does not appear to show any distortion. I recognise it may have been different in the cockpit.

CHAIR: Just to get it into my block, the Fiji air traffic called up whatever the flight is and said the cloud was at 6,000 feet?

Mr Dolan : As we say in the report—

CHAIR: Who was it 30 seconds later who said, 'Oops—600'?

Mr Dolan : No, sorry. With respect, it was not 'Oops!' The error in the METAR, the routine weather report that was transmitted that gave the wrong cloud height, was overtaken by the SPECI.

Senator STERLE: What does that mean?

Mr Dolan : Sorry, Senator. There is a routine report that is transmitted on a regular basis, the METAR—

CHAIR: No, no, I am chairing. Direct yourself to my head. Fiji transmits the wrong altitude—correct?

Mr Dolan : Could I perhaps read from the report?


Senator NASH: Chair, please, this is really important. Could Mr Dolan read the two transmissions into the Hansard so that we have the first one and then the second one in the Hansard?

CHAIR: No, before you do that: how was the Fiji transmission to the aircraft, whatever it said, transmitted—by HF, by telephone, by carrier pigeon? How did the plane get the message from Fiji?

Mr Dolan : By HF radio transmission.

CHAIR: On the same frequency that New Zealand was tuned into?

Mr Dolan : It would have been one of the frequencies that New Zealand was tuned into, yes.

CHAIR: And the correction some seconds later was transmitted to the plane from where by who?

Mr Dolan : From Fiji by HF radio.

CHAIR: On the same frequency?

Mr Dolan : On the same frequency by the same controller. The only point I would make, Senator, is that this was not a correction. The inaccurate cloud height information from the METAR was not corrected. What happened was that an updated report, a SPECI, was then transmitted a short time later.

Senator NASH: Is it possible to read both of those into the Hansard for us?

Mr Dolan : It is appendix A to the report. Would you like me to just read the report?

CHAIR: No, it will take two hours.

Senator NASH: How long is it?

Mr Dolan : It is a page in the report.

Senator NASH: All right, we will note that. In the second, as you say, it was not a correction; it was a second report. At any stage, did the second report refer to the first report as having been incorrect?

Mr Dolan : No.

Senator NASH: Therefore the pilot, in listening to a report almost immediately after the first one, had no way to be alerted to the fact that there was a significant difference in the height of the cloud. I am just saying that because, if I am driving along and I hear a weather report on the radio and then I hear another one a minute later, I am going to assume that they are almost exactly the same because of the shortness of time. Just come with me for a second here. Given the couple of minutes—I think you said—between the two, why would the pilot assume that there was an extraordinarily significant difference in the second report when there was nothing in that that would alert him to the fact that it was in any way, shape or form catastrophically different to the first one? I say that, going back to your earlier comments that your understanding is that the pilot received it—absolutely, in some way, shape or form. We are not sure of the quality, because of the HF that the chair refers to. But surely you would have to take into account that there would be nothing in the pilot's brain that would trigger the catastrophic difference between those two, given that they were so close in time and the second report did not refer to the fact that the first one was incorrect?

Mr Dolan : There is probably one point to be made there. To take your road parallel, the equivalent would be if the second report you received said 'urgent weather update', because, in transmitting the second report, the air traffic controller contacted the aircraft and then said:

… this the latest weather for Norfolk … SPECI … I say again special weather Norfolk at 0800 Zulu …

SPECI means that there has been a significant shift in the weather conditions at the reporting site. That is what SPECI means, and, 'SPECI, I say again SPECI,' is the message that went through.

Senator STERLE: And then the pilot said 'thank you' or 'roger'?

Mr Dolan : It was:

Thank you nadi … much appreciated november golf alpha

Senator XENOPHON: There is an issue of who heard what. How many times did the pilot in command or the first officer say 'say again'? Can I suggest to you that it was said on number of occasions in the transcript?

Mr Dolan : According to our transcript it was one time, I think.

Senator XENOPHON: I think it was several times to Fiji.

Mr Dolan : Are we talking about these two specific transmissions?

Senator XENOPHON: No, I am saying that in the transcript that you have, in terms of the communications with Fiji, the pilot actually said on several occasions 'say again'. If a pilot says 'say again', does that indicate to you perhaps a lack of clarity or some communications problem? We are assuming that Mr James's hearing was reasonable. Assuming that he has relatively normal hearing, if a pilot says on several occasions 'say again', would that tend to indicate some form of communications problem?

Mr Dolan : I only have a partial transcript in front of me, so I am happy to take it on notice.

Senator XENOPHON: Could you take it on notice. Furthermore, if it is shown that there were several occasions when the pilot said 'say again', would that tend to be indicative of some form of communications issue?

Mr Dolan : Yes.

Senator XENOPHON: Is that a yes or a no?

Mr Dolan : Yes, I am happy to take that on notice and get back to you.

Senator XENOPHON: But would you agree that, if someone keeps saying 'say again' to air traffic control, that could indicate some sort of problem?

Mr Dolan : It could indeed.

Senator STERLE: By the same token, if they say 'thank you', they have got it clear.

Senator XENOPHON: But this is 'say again'.

Mr Dolan : We will take it on notice. The point I am making is that, on the transcript that is available to me, the only reference we have to 'say again' is a transmission by the aircraft to Nadi—having completed that first weather update, the METAR—saying:

Ahhh … copy … just say again the issue time for the METAR

So specifically there appears to have been some problem in either understanding or hearing the issue time for the METAR.

Senator STERLE: How long was that before the SPECI?

Mr Dolan : That was at 0802 and eight seconds. The SPECI was at 0802 and 32 seconds, so the SPECI was less than 30 seconds later.

CHAIR: At that stage , it could have diverted to Noumea.

Senator THORP: In that 20-second gap?

Mr Dolan : We, by the reconstruction of the fuel planning and fuel consumption for the flight, are very confident that there could have been a successful diversion at that point and indeed at several other points up until probably about 0930 Zulu.

CHAIR: And Noumea does have ILS.

Mr Dolan : It does.

CHAIR: Norfolk does not.

Senator STERLE: Noumea has what? I did not hear that.

Mr Dolan : An instrument landing system.

CHAIR: An instrument landing system.

Senator STERLE: That clears that up, thanks, Mr Dolan. You were talking about the two safety factors being fuel and weather risk. We have covered the weather risk. In terms of the fuel, do you have the figures that the pilot used on his way to pick up the patient? Where were the fuelling stops when he left Australia to get to—where was the patient, Noumea or Samoa?

Mr Dolan : I am not sure whether we have the fuel. The flight was, as I recall—and Mr Sangston can correct me if I have got it wrong—Sydney, Norfolk Island, Apia, in Western Samoa, to pick up the pilot, and then the return was planned over Norfolk to pick up fuel in Norfolk and then to Melbourne. So on the outward flight there was a landing and a refuelling at Norfolk Island.

Senator STERLE: Do you have the figures for the fuel, how many litres or gallons, that was put on at Norfolk Island to get to Western Samoa?

Mr Dolan : We would have that available but not in the report.

Senator STERLE: I know that there were extra passengers on the way back—I get all that—so I am interested to know whether the pilot, in your view, had enough fuel for the weight that he was carrying as per the weather conditions he was told. I want to clarify: I am of the belief that I heard that you said he could have carried more fuel for the return trip.

Mr Dolan : The report says that there was a capacity to load more fuel in the tip tanks of the aircraft, yes.

Senator STERLE: The fuel usage would be calculated at a certain height that the plane would travel?

Mr Dolan : In the operations manual and the flight manual of the aircraft, there is a range of information and facilities for calculation to work out fuel consumption on climb, on cruise at different levels, at different weights and so on.

Senator STERLE: When you were doing your report, did you look at the height that, say, Airservices would have allowed the plane to travel at and do the fuel calculations?

Mr Dolan : We did a number of fuel calculations. We also looked at the height that the aircraft operated at, both its intended initial cruise height and the one that it was given by air traffic control, after negotiation, to climb to. The planned flight was at 35,000 feet. Air traffic control then said—sorry, I should probably be referring to the report rather than relying on my somewhat ageing memory! On climb to the cruising height of 35,000 feet and then established, air traffic control at a later point said, 'We've got crossing traffic and we would like you to go down to 270'—27,000 feet. The pilot said, 'I would prefer to go to flight level 390,' which is higher, where you consume less fuel because the air is thinner and a range of other things. Air traffic control agreed to that, and there was a climb to that level and cruise at that level, I believe, until descent into Norfolk Island. There are fuel calculations and fuel burns that go with those sorts of movements.

Senator STERLE: Obviously, the pilot had spoken to air traffic control and said, 'This is how many gallons I have on board and this is the reason why I need to fly at a different level than what you first'—or is that all taken into consideration?

Mr Dolan : I am not sure how detailed the pilot was in his request to go up rather than down, but that was the context for the request.

Senator STERLE: But there was no restriction from air traffic control to allow the pilot to change the level that he was on?

Mr Dolan : No. It was agreed to—

Senator STERLE: It was okay. Great. Are you able to provide to us the figures on the fuel that was—

Mr Dolan : Yes.

Senator STERLE: used, topped up or whatever the term is? You fly-boys use all these acronyms; you've got me buggered! But anyway, when he filled up at Norfolk Island—

Mr Dolan : On the way out.

Senator STERLE: and then the fuel coming back—can you compare the weight for us, because everyone is an expert. They all throw things like you have in front of you.

Mr Dolan : We threw that at you, Senator.

Senator STERLE: We need the assistance of the experts—well, everyone is an expert, so there you go—just to make sure—

CHAIR: Mr Dolan, thank you for your patience. I think we took evidence—I would have to go back to the transcript, and I apologise if I have got it wrong—that, when the plane took off to come back to Australia with the patient, the fuel load may not have fitted specifications for that flight, yet, when it attempted its landing at Norfolk, the fuel load was legal. Is that—

Mr Dolan : I am sorry; this is going to be a rather lengthy answer, so please bear with me. To the extent that there was flight planning, the planning was on the basis of a direct flight to Norfolk Island, having no regard to possible diversion for other alternate aerodromes. So, in calculating the fuel necessary for that flight, the requirement was to find where, essentially, the point of no return was, calculate the fuel that would be necessary to get from the point of no return to the intended destination, Norfolk Island, and then do a range of other calculations and then work out a fuel load. By those calculations, we have formed the view that it would have been necessary to fully load—or as close as possible—the aircraft with fuel, use the tip tanks, and that having done so would have met the requirements for that planned flight. The tip tanks were not filled on departure.

CHAIR: If they had been and the same thing had happened, what would have happened?

Mr Dolan : There would have been more fuel above Norfolk Island, and there would have been more fuel at various points—

CHAIR: Would that have got him to Noumea, though, or would it have got him into the sea off Noumea?

Mr Dolan : By our calculations, at about 0930 UTC, there was still sufficient fuel onboard that aircraft for a decision to have been made to divert to La Tontouta, at Noumea.

Senator XENOPHON: Would you mind repeating that?

Mr Dolan : By our calculations it was 0928 UTC, because that is the point at which they said the landing minima were no longer there for Norfolk Island. At that point, by our calculations, the aircraft could have diverted to La Tontouta at Noumea and arrived with the fixed fuel reserve intact on the basis that they would encounter 90-knot head winds.

Senator STERLE: With the fuel that he had on board?

Mr Dolan : That is correct.

Senator EDWARDS: So he ditched when he should not have?

Mr Dolan : Instead of making a decision to divert to La Tontouta, Noumea, the decision was made to attempt to land on the understanding that it was likely the conditions were not quite as bad as reported or there would be the ability to get through.

CHAIR: So when he made his first aborted attempt to land at Norfolk, according to your calculations, if he had said, 'I am out of here. I am going to Noumea—

Mr Dolan : No, that would not have worked. The decision needed to have been made before descent.

Senator XENOPHON: Can I put an alternative scenario to you, Mr Dolan. Going back a step from Senator Sterle's line of questioning, my understanding is that the pilot had full fuel on the way over because the weather required it—that is, on the way from Norfolk Island to Samoa. But if he had full fuel on the way back, he would have had difficulty in climbing to 39,000 feet because of RVSM; is that correct?

Mr Dolan : Not because of RVSM.

CHAIR: What is RVSM?

Senator XENOPHON: It is the acronym for reduced vertical separation minima.

Mr Dolan : To deal with the two points, reduced vertical separation minima is a provision in a range of airspace that lets appropriately equipped aircraft operate there and operate closer to each other than they would otherwise be able to do. The Westwind aircraft was not equipped with that, but aeromedical flights are explicitly allowed to operate in this RVSM airspace.

The difference between 35,000 feet and 39,000 feet, as the senator says, is that with a full fuel load the aircraft could have only climbed to 35,000 feet until it had burnt off a substantial amount of fuel, at which point it could then have gone to 39,000 feet.

Senator XENOPHON: Because you burn more fuel at a lower altitude.

Mr Dolan : That is correct. So it is likely with a full fuel load at the point where air traffic control said, 'We want you to go down,' that that would have been a requirement. And that, as the crew told us on the reconstruction, would have led to their seriously rethinking their options, as you would expect. But that was not the way this played out.

Senator THORP: They went up?

Mr Dolan : They did not get up to 39,000 feet.

Senator THORP: If they had been fully loaded that option probably would not have been there.

Mr Dolan : That is correct.

CHAIR: If they had filled the fuel tanks—and we can all be wise after the event—and they had gone to Norfolk and thought, 'Oh, my God,' would they have had enough fuel to get anywhere?

Mr Dolan : On the assumption that they had made a first attempt to land and then climbed again and got all the way, that would have chewed up a lot of fuel. Our best assessment is that they could have done it with a full fuel load, but they would have eaten into their fixed reserve. They would have had to declare a fuel emergency.

Senator NASH: What is the flying time from Norfolk to Noumea that you have calculated for that fuel use?

Mr Dolan : I am told that it is about an hour and 10 minutes.

Senator THORP: You mentioned earlier that the first draft of your report was about 23 March.

Mr Dolan : Somewhere around there.

Senator THORP: And the final report was in August?

Mr Sangston : I think it was 30 August.

Senator THORP: And there were several iterations in between?

Mr Dolan : There were.

Senator THORP: Did each of those drafts and further iterations contain recommendations?

Mr Dolan : There is not any point that I am familiar with in the process of the report where the report included a recommendation.

Senator THORP: Until?

Mr Dolan : A report at no point that I am aware of has included a recommendation.

Senator STERLE: Mr Sangston, are you aware of any reports, at any of the drafts—

Mr Sangston : No.

Senator THORP: I am just trying to establish—

Mr Dolan : From the initial draft stage, we specified a number of safety factors and some safety issues, but the process is, having identified the safety issues, we then seek information as to what has been done to address them and assess that action and then determine whether it is necessary to make a recommendation—that is, is there something that still needs to be done that is not being done?

Senator XENOPHON: I am thoroughly confused about this, because my understanding—

Senator STERLE: That makes two of us.

Senator THORP: Three.

Senator XENOPHON: Wasn't the pilot in command asked to descend to 27,000 feet at one point, or 28,000 feet?

Mr Dolan : Yes.

Senator XENOPHON: Why was he asked to descend to that point?

Mr Dolan : Because there was crossing traffic.

Senator THORP: So he did not bump into anyone else.

Senator XENOPHON: But that would have made it very difficult for him because he would have burnt up too much fuel at 27,000 feet.

Mr Dolan : Correct.

Senator THORP: Which is why he asked to go up.

Senator XENOPHON: That is why he asked to go up?

Mr Dolan : Yes.

Senator XENOPHON: But, further to Senator Thorp's line of questioning, if he had 100 per cent fuel, he would have had trouble getting up to that.

Mr Dolan : That is correct.

Senator XENOPHON: Given he had passengers—the doctor, the patient and her husband.

Mr Dolan : There would have been a period of about an hour, as I recall—but others can inform me—

Senator XENOPHON: Doesn't New Zealand AIP prohibit flying in the range of 28,000 to 39,000 feet?

Mr Dolan : No.

Senator XENOPHON: What does it prohibit?

Mr Dolan : It says that appropriately equipped aircraft can use RVSM airspace at any time, that other aircraft can use RVSM airspace with four hours notice but may have to be directed from that airspace if it conflicts with other traffic, and that air ambulance work—which was how the New Zealand rules saw this operation and it was defined in their air traffic control system—is immediately allowed into that airspace and allowed to operate in it.

Senator XENOPHON: Could you, on notice, provide us with that specific section of the regulations in respect of that? Is it in the report?

Mr Dolan : No. I believe it is in one of our supplementary submissions, but we will make sure there is a further copy supplied.

Senator XENOPHON: If it is in the supplementary submissions, our very capable secretariat will dig that up. That is fine. I put to you a proposition, Mr Dolan, that the pilot could have diverted to Fiji up until 0845 but, past that point, he was committed to Norfolk Island, and that Noumea was a problem because of the issues with the French aviation authority in terms of equipment, but he did not have the fuel to go to Noumea when he realised, at 0900, that the weather at Norfolk was getting worse.

Mr Dolan : That is where it appears we are in disagreement, because our assessment is, with the fuel that was actually loaded—not the fuel that could have been loaded; the fuel that actually was loaded—at 0900 UTC it would have been entirely possible for the aircraft to divert successfully to New Caledonia and to arrive with the fixed reserve intact.

Senator STERLE: Without declaring an emergency—

Mr Dolan : With no need to declare an emergency.

Senator STERLE: So he had enough fuel on board to be able to divert, that he did not have to ditch.

Mr Dolan : By our calculations.

Senator NASH: You said there was a report at nine o'clock and one just after. They were the ones we were talking about before. Is there a standard period of time that they are issued? Is it every hour? There was not one between eight and nine o'clock, was there? I just want to clarify that. Is there a standard—

Mr Dolan : There is a standard reporting period.

Senator NASH: And what is that?

Mr Dolan : The METAR are updated every half an hour.

Senator NASH: So why was there not one at 8:30 given that the 8:45 one seems to be the timing issue?

Mr Sangston : I cannot confirm whether there was or was not.

Senator NASH: I am sure Mr Dolan told me earlier that there was one at eight but then not till the two at nine o'clock. I want to clarify this before we move on. If I have got you wrong, Mr Dolan, I am sorry but I thought you said earlier there was one at eight and then there were those two on either side of the nine o'clock one or whatever.

Mr Dolan : Yes, but we should understand the difference between routine reports, the METARs, and the SPECIs, which are the reports that say there has been a significant variation.

Senator NASH: I have got that but you were saying those—excuse my layman—should happen at 30-minute intervals. Why was there not one at 8:30?

Mr Dolan : This is what we are checking. We understand there was but we will have to confirm that.

Senator NASH: If you could provide the answer to that one on notice as quickly as you can, that would be great.

Senator STERLE: Mr Dolan, for those of us who are not pilots, I will talk about us truckies. We go down the road and we are taught from the very first time that we step into the cab of a truck to watch our dials, keep an eye on our gauges and if a warning light comes on there is something wrong. Am I right to assume you are telling us that if there is a SPECI that comes over the radio—and this is not like all of a sudden its music radio and I like this song so I will turn it up—pilots are attuned to hear it? If they hear it or they do not hear it, is it their duty straight away to clarify?

Mr Dolan : I would not say it was their duty. I would have thought it would be prudent. This goes to the reasonably identified safety issue to do with the guidelines and information available to support decision-making, weather information and so on in flight. Firstly, the detailed information on what you need to do is not brought together in one place and is not as clear as it should be—so there is one element to your the answer. Secondly, the SPECIs we are talking about are essentially saying that the clouds are still okay at the location for there to be a reasonable likelihood of a safe landing but if you are planning your flight you should have in mind your alternate aerodrome. That is what the SPECIs were saying up until 09:28, at which point it said the clouds are awful; you are not going to get in.

CHAIR: At 09:28, which is all too late?

Mr Dolan : As I said, we do not necessarily share that view.

Senator STERLE: You did not say that at all in your scheduled report. At 9:28 there was enough fuel in your calculations to divert.

Senator NASH: To clarify, did you say 9:45 was the cut-off point? Is that correct?

Mr Dolan : I do not think we took the calculations beyond 09:28 because that seemed to us to be the critical point for a decision.

CHAIR: Do you generally report these incidents in a year?

Mr Dolan : Our target is to complete most investigations within a year.

CHAIR: And what was this one?

Mr Dolan : This one was three years.

CHAIR: Can you tell us why it took three years?

Mr Dolan : There is a range of reasons. At the time this happened, we had a lot of investigations on our hands including several major ones. We had over 100 investigations on hand and of those three were major. There was Papua New Guinea, the Kokoda accident. There was Qantas flight 72, the in-air pitch down that was very complicated and which led to injuries to 100 passengers. There were another two—

CHAIR: In other words, your resources were stretched.

Mr Dolan : Our resources were stretched and we were trying to direct it into a range of priorities. But we did set ourselves a standard of one year for this sort of investigation and we failed to meet it.

CHAIR: There was talk that at a mid-level—whatever that means—there was a view that this was a critical safety incident.

Mr Dolan : At a quite early stage in this—and I would not have said it was mid-level; I believe Mr Sangston signed off the initial letter—we drew the attention of CASA to what, on a provisional basis, we thought—

CHAIR: You thought it was a critical safety issue?

Mr Dolan : We thought it could be a critical safety issue.

CHAIR: The term 'critical safety issue' means that there was an intolerable risk. Is that correct?

Mr Dolan : Yes.

CHAIR: Mr Sangston, you thought there was a reasonable chance it was a critical safety incident?

Mr Sangston : Yes, based on the information we had at the time.

CHAIR: It was an intolerable risk?

Mr Sangston : At the time, based on the information we had.

CHAIR: Yet, through a series of tos and fros, it went down to a minor safety incident, which means it was a broadly acceptable risk. How, in God's name, can you go from intolerable to acceptable? We would like to see the paper trail and the communications which made that happen.

Mr Dolan : If I could start and then perhaps Mr Sangston can—

CHAIR: Is there a paper trail?

Mr Dolan : There is an exchange of correspondence with CASA on this. There is our initial letter and there is—

CHAIR: Can we see the paper trail?

Mr Dolan : Absolutely. It is in the material we have provided. We can select it out and make it available separately.

CHAIR: We have a container load. Could we just have—

Mr Dolan : Our material was on a searchable hard disk. But we will make sure the information is provided.

Senator Sterle interjecting

CHAIR: As Senator Sterle said, we would like the date—to give us some guidance—it went from intolerable to acceptable.

Mr Dolan : We are happy to provide that separately.

CHAIR: Would it be fair to say that it went from intolerable to broadly acceptable after you were counselled by CASA?

Mr Dolan : Having regard, among other things, to information provided to us by CASA, yes.


Mr Dolan : From a personal perspective, I note that this was early in my time in the ATSB.

CHAIR: They put it over you.

Mr Dolan : I would not have assessed, even at that stage, that it was a critical safety issue. I would have through that, prudently, we would have said it was significant. However, what the record shows is that it was identified as a critical safety issue.

Senator STERLE: But in your opinion it was not?

Mr Dolan : By reviewing the material—

CHAIR: You were new on the block. But, Mr Sangston, were you new on the block when you thought it was critical?

Mr Sangston : I had been in the job about six months at the time.

CHAIR: Do you think that maybe, having been counselled by CASA, you would be happy to call it significant—which is the mid-shot?

Mr Sangston : There was no counselling by CASA.

CHAIR: That is a terminology of mine.

Senator XENOPHON: To use another word—after consultation with CASA?

Mr Sangston : As per the documentation, we did have a meeting with CASA and we expressed our understanding, at the time, of a potentially critical safety issue. We talked through it and CASA wrote back to us, I think, just over a month later and gave us their position. That pointed us to some other areas which we then looked at. As we developed our understanding, the level of risk changed.

CHAIR: So is it fair to say that you were wrong—that you could not tell the difference between intolerable and broadly acceptable risk?

Mr Sangston : No, as Mr Dolan said, we take a conservative view initially and—

CHAIR: Fair enough.

Mr Sangston : On the evidence we had, we understood it to be—

CHAIR: Did the evidence change?

Mr Sangston : The evidence and understanding and application—

CHAIR: No, did the evidence change?

Senator STERLE: Was there any new evidence which came to light after—

CHAIR: No, I am doing this. Did the evidence change?

Mr Sangston : We certainly looked more widely at the aeronautical information—

CHAIR: Did the evidence change?

Mr Sangston : In terms of the documentation, yes—our understanding of the evidence.

CHAIR: No, the evidence.

Senator XENOPHON: Not your understanding—the evidence.

Mr Sangston : The evidence was in the publication.

CHAIR: No, my question is: did the evidence change? I am not asking about how you interpreted the evidence. Did the evidence change?

Mr Sangston : No, but our awareness—

CHAIR: Thank you very much. That is all I need to know. Did your interpretation of the evidence change?

Mr Sangston : Our understanding and interpretation of the application of the evidence to this circumstance changed.

CHAIR: If in your discussions CASA thought they were able to get you to say it was broadly acceptable rather than intolerable, does that mean you did not know what your job was? I do not mean that personally, but you have been six months on the job and it is a mystery how a senior officer who is dedicated and fair dinkum—and all Australians who travel rely on the Air Transport Safety Bureau—could review his position from intolerable to broadly acceptable.

Mr Dolan : I will try and add some information to that. As we tried to make clear, there was an initial assessment of the evidence we had available to us, which was essentially about decision-making en route and what informed us and everything else—whether the guidance that was available was reliable. Given that this had been a potential disaster—there were potentially six fatalities in this accident and it was only a fortuitous thing that there were not—we gave a very significant weight to any issue that was associated with this. So we said to CASA: 'This was almost a six fatality accident. Here is what we see at the initial stages to be a problem, and in the context of this accident we think it is significant. Pay attention.' CASA paid serious attention to it and gave us a response, which led us to further lines of inquiry to better understand what was at issue—the safety issue we have identified. We continue to review it and it remains in the report as a safety issue but not at the level of—

CHAIR: In the meantime, with no change to the evidence, you have repositioned yourself from intolerable to broadly acceptable.

Mr Dolan : Correct.

CHAIR: Incidentally the chief pilot from Pel-Air happened to go and work for CASA.

Mr Dolan : So I understand.

Senator NASH: Could you provide that comment from CASA you were just talking about?

Mr Dolan : Yes.

CHAIR: With no change in the evidence, what convinced you that what you thought was intolerable was broadly acceptable?

Mr Dolan : You can see where we ended up in the report. We still said there was a safety issue. We said the safety issue went to what the AIP and other information said about what the pilot should do in circumstances where the weather deteriorates over the course of the flight. We weigh that up in our normal procedures at the investigation to say: 'What is the likelihood of a recurrence and what is the consequence of a recurrence of this?' We reviewed the issue in that light, which is in accordance with our procedures.

CHAIR: Anyhow, I understand that you may be in a difficult position with some of this. We were told the other day by Airservices and their perfect bureaucrat who gave the evidence—a beautiful job he did—that they were going to raise at the next Pacific Forum the vagaries of the transmission of the weather through New Zealand into this airspace. Is there a legal obligation on New Zealand to transmit that weather into that airspace? I understand there is not.

Mr Dolan : My understanding is that the situation in New Zealand very closely parallels the situation in Australia. The situation in Australia, as in the summary put out by Airservices, is that pilots are responsible for obtaining information necessary to make operational decisions and will not automatically receive routine TAF information showing deteriorating weather conditions if they are en route to a location. That is the position of both Australia, as published, and, as we understand it, New Zealand.

CHAIR: So if I am flying from Mount Isa to Sydney and it all turns to custard, it is not Sydney's obligation to tell me it has all turned to custard?

Mr Dolan : If you are within an hour of Sydney then the fact of the availability of an amended TAF is information that should be provided to you.

CHAIR: Let us say I am on my way to Norfolk Island—I am an hour and a half out from New Zealand's controlled airspace over Australia's land space—and the weather has turned to custard and New Zealand knows it has turned to custard. Are they legally obliged to tell me?

Mr Dolan : In your 'turn to custard' situation there is a level of responsibility. The situation was that there was an updated forecast at the time that this flight was approximately three hours out and in Fijian airspace. By the time they were in New Zealand airspace that was the extant forecast. So, from the point of view of New Zealand, they have a forecast—an extant forecast, not a new forecast—and there is no requirement to deal with it. If there had been an updated forecast then they would have made that known.

CHAIR: But I understood the weather deteriorated. I understand the difficulty in all of this, but I further understand that New Zealand had information which would have been valuable to the pilot if it had got to him. What want to know is: was New Zealand legally obliged to let the pilot know that he was going to fly into deteriorating weather?

Mr Dolan : I am having trouble answering the question because that does not reflect the actual circumstances.

CHAIR: I am sorry, but I have to call a brief suspension because we have to go to a division in the chamber.

Proceedings suspended from 17:57 to 18:07

CHAIR: Mr Dolan, could you assist the committee by giving us the date on which the decision was taken in the ATSB to downgrade the report from intolerable to broadly acceptable? You can take that on notice if you like.

Mr Dolan : I will take that on notice.

CHAIR: Could you also provide the date of the transfer of the chief pilot of Pel-Air to CASA?

Mr Dolan : We will ask CASA and do what we can.

Senator XENOPHON: It might be simpler to ask CASA directly.

Mr Dolan : I think it might be, but we will do what we can to facilitate. Can I suggest that I ask CASA to provide the information direct to the committee?


Senator XENOPHON: Or the committee could ask CASA directly. Did Unicom tell New Zealand twice about the weather by phone?

Mr Dolan : I will check the report.

Senator XENOPHON: Mr Sangston, while you are looking at that, you said that at the time you had been in this position for six months?

Mr Sangston : The accident was in November, and I think I started in the position in June or July.

Senator XENOPHON: But you have been with the ATSB for how many years?

Mr Sangston : Since 2002.

Senator XENOPHON: And you had a number of senior positions leading up to that?

Mr Sangston : A team manager position and then the general manager position, yes.

Senator XENOPHON: I just wanted to clarify that to clear up any ambiguity that you had only been fresh into the ATSB for six months. Mr Dolan, I know your position; you started fresh in the organisation.

Mr Dolan : I had responsibility for the organisation.

Senator XENOPHON: Perhaps you could take on notice, Mr Sangston, whether UNICOM told New Zealand twice about the weather by phone and whether it was passed on. My understanding is that that information was not passed on. Will you take that on notice, Mr Sangston? I am just trying to speed through a few questions. Secondly, Mr Dolan, have you read the Hansard of evidence by Airservices Australia on Monday, 19 November?

Mr Dolan : I have not read the Hansard. I did watch Airservices given evidence on the day, so I have a recollection of the oral evidence.

Senator XENOPHON: You have a recollection of the issues. Airservices Australia—and they will get back to us on this—have said that they will tell us when they had communications with the ATSB. But, as a matter of course in something like this, did ATSB communicate with Airservices Australia at a stage prior to your report being made public?

Mr Dolan : Not that I am aware of, but we can check the details and see what communication there may have been with Airservices in the course of this.

Senator XENOPHON: But, given what appear to be critical issues, important issues with respect to Airservices Australia and its potential material impact in terms of the outcome that occurred here, wouldn't it have been prudent for the ATSB to communicate with Airservices Australia in respect of these matters? It is a matter that Senator Heffernan was quite alive to on Monday.

Mr Dolan : I am happy to take the question on notice and give you that information.

Senator XENOPHON: From a policy point of view, do you think Airservices Australia would be relevant to contact?

Mr Dolan : From the way we were understanding and reviewing the issues that were in play in this investigation, we took as the starting point the existing regulatory provision that it is the responsibility of flight crews—pilots in command—to seek various sorts of information. We were more interested in what the AIP said than in what provisions may have been in place with air traffic providers to provide information. What we determined was that what is in the AIP and elsewhere in terms of expectations of pilots and how they use information is not as adequate as it could be, and that is why we focused on that area in our report. We did not see this as primarily an air traffic control issue. We saw it as an AIP guidance to pilots issue.

Senator XENOPHON: And you are saying that the AIP was a relevant issue?

Mr Dolan : Yes.

Senator XENOPHON: Can we go to issues of the AIP, and this is something that was raised by Senator Fawcett at the hearing in October. I think Senator Heffernan is well aware of this. There was an email from a senior CASA official on Saturday, 20 March 2010 sent to another senior CASA official about this incident. Are you familiar with that email?

Mr Dolan : I am familiar with the discussion that occurs in this committee about that email.

Senator XENOPHON: Perhaps I could read it: 'I am happy with the path you are taking. My point is—and you are addressing it—that, as a result of reliance on the AIP, which has no head of power and contains much that we need to revisit anyway, there is one group of pilots that have one view, which leads to a mandatory diversion, and another group with the opposite view. Putting aside the practicalities, both groups believe they are legally correct.'

The second paragraph reads:

If we find ourselves in an AAT or a court, we once again could look a bit foolish if we, the regulator, find ourselves in a position where we have to say that there are two conflicting views, one of which has to be wrong, and we have done nothing to rectify that over the years—very untidy.

Does that refresh your memory in relation to that?

Mr Dolan : I can remember the discussion and listening to that discussion in front of this committee.

Senator XENOPHON: Do you see that as significant?

Mr Dolan : I see that as an issue that is taken up in the safety factor and safety issue we identified. The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

CHAIR: You wrote, as I understand it—we have the correspondence—to CASA and said that that you think this is a critical incident which is an intolerable risk.

Mr Dolan : Yes.

CHAIR: In the meantime, this discussion took place internally with CASA.

Mr Dolan : Yes.

CHAIR: After this discussion took place in CASA, they wrote back to you and said, 'We don't think this is an intolerable risk.'

Mr Dolan : Yes.


Senator STERLE: Following on from there, it is appearing to anyone listening out there that the officers at the table were not capable of making a decision. People listening out there may have just tuned in.

CHAIR: To correct you: the evidence upon which they based the intolerable risk has not changed.

Senator STERLE: Okay. But now, to give the officers a chance, because I would like to know—

CHAIR: No, I am not putting these blokes under the gun.

Senator STERLE: But you are not putting them on a pedestal saying that they are absolutely fantastic.

CHAIR: No, I am. You do not have to be very smart to work out what happened.

Senator STERLE: In all fairness, there are some assumptions around. If that is not the case, what made you change your mind to shift from 'intolerable risk'?

CHAIR: We will get the correspondence.

Senator STERLE: The officers may be able to tell us.

Senator XENOPHON: I just want to—

Senator STERLE: I think it is critical that we know.

Senator XENOPHON: I do not want to interrupt Senator Sterle; I just want to get the answer—

Senator NASH: Do you mind? Senator Sterle, finish your question.

Senator STERLE: What changed, Mr Dolan?

Mr Dolan : At the initial stage, as I say in my assessment, we were probably over the top in saying it was critical. But, be that as it may, that is what we said. The process of investigation is to establish clearly, based on the evidence and its analysis, what the issues are. This remained an issue that was a subject of the investigation, and, as we clarify those issues and understand them—put them in draft reports and in final reports—and understand what action has been taken in response, we shift our assessment of what the residual or underlying risk is. There is a process in terms of how we do investigations that reassesses, over time, the significance of an issue and how we view it. That is essentially what happened in this case, and we have ended up with the safety issue as it stands in the report now.

CHAIR: I just wanted to go somewhere now—

Senator NASH: I would like to ask a question on notice.

CHAIR: Go on.

Senator NASH: Thank you for that, Mr Dolan. But you did not really answer Senator Sterle's question. Can you take on notice for us: given, as Senator Heffernan has so clearly pointed out, that the evidence did not change, what specifically changed your view that the risk had changed from intolerable to acceptable?

Mr Dolan : The only comment I would make, and I am happy to provide details on that, is: while the evidence we relied on initially did not change, we did acquire additional evidence and we were assessing and analysing the evidence.

Senator STERLE: Which was not stated earlier.

Senator NASH: Could you also include what the additional evidence was?

Mr Dolan : Yes.

Senator STERLE: That has shone a light on it for me. Thank you.

CHAIR: So that the person standing at the back of the room there has an independent view of all this—

Senator XENOPHON: Chair, can I just follow on directly—

CHAIR: I was about to do what you are doing. On the 'boys, we'd better get our act together because we have a difference of opinion' email—

Senator XENOPHON: It goes further than that. It actually talks about potential legal liability.

CHAIR: I am going to come to that. So this is the person who directs all this and you are going to give us the date on which the chief pilot of Pel-Air was found to be involved in an incident somewhere between an intolerable risk and a broadly acceptable risk. I will be interested to see what happened during this repositioning with this internal email here of 20 March at 15.50. Any normal person—I am not saying I am normal—who transferred across as the chief pilot to the policeman's side of it would not have had to say anything. Just having a cup of tea and winking and nodding, you can communicate. You do not have to leave a paper trail.

This organisation, CASA, and the boss have the audacity to send out an internal memo which says, 'Do not be dismayed by our vocal but largely uninformed minority of critics.' You may not be described as a critic but you did say, 'This is an intolerable proposition,' and they said, 'Beg your pardon—we don't think it is.' So that could make you a critic of CASA. The email continues: 'They are symptomatic of other ills in society. I prefer "facts" when engaged in discussions'—I presume when you have discussions you deal with facts—'not hearsay and tautological rubbish.' This is out there on the edge of the ice-skating rink, in my view. I think that sort of an internal memo could be quite intimidatory of witnesses and people with whom they are dealing, including you. If that is the mindset of the boss, I think that is what I would call bullying in the gathering of evidence.

Senator STERLE: Chair, I think that is drawing a long bow. It is a bit of a stretch there. You have something from our private meeting this morning and I do not think it is fair to throw that at the officers from the ATSB.

CHAIR: The facts are the facts.

Senator XENOPHON: On what you have just said, Chair, and on what Senator Sterle said, maybe we can draw a shorter bow. You have heard the comments attributed to Director McCormick. Is that the sort of attitude you take to this inquiry?

Mr Dolan : I am here because I understand that I and my organisation are accountable to the parliament and I am happy to provide any information and support I can to the committee so they can understand what we did.

Senator XENOPHON: Could you imagine sending an internal memo or a newsletter to your staff in similar terms?

CHAIR: I do not think you have to answer that.

Senator XENOPHON: No, you do not have to.

Mr Dolan : The only thing I think I can usefully say, and I have no wish to make any commentary on the Civil Aviation Safety Authority, is that my staff are very interested in what this committee is doing. They have asked me and I have said we will provide all the information necessary and we will help the process of the committee.

CHAIR: We are greatly appreciative of it.

Senator XENOPHON: Yes. Like the chair, I genuinely appreciate the attitude you have taken.

Senator STERLE: While we are having a love-in, can we tick along? We are running out of time.

Senator XENOPHON: Yes, we can. Thanks for the reality check. Let's go back to this email between two senior officials of CASA of 20 March 2010 where issues of legal liability were raised. You have two different points of view that seem to be split fifty-fifty amongst the flight operations inspectors. Were you aware of that particular email at the time you prepared your report?

Mr Dolan : No.

Senator XENOPHON: Do you consider it to contain material information?

Mr Dolan : We consider it to contain the same information that we got through our own inquiries of various pilots as to what they would have done in this sort of circumstance. It was considerably varied, which is why we are saying there is an issue here.

Senator XENOPHON: Let's be quite forensic and specific about this. This particular email is essentially saying that 50 per cent of CASA's flying inspectorate are split on the available guidance. Isn't it reasonable to assume that the substitution test says that the pilot in this accident was not alone in his decision making? Do you agree with that?

Mr Dolan : Yes. There are a range of—

Senator XENOPHON: But were you aware that there was such a massive split, in CASA's own flying inspectorate, over what the appropriate thing to do was—whether there should be mandatory diversion or not?

Mr Dolan : No.

Senator XENOPHON: You consider that significant?

Mr Dolan : What we understand is that a range of pilots—when we put this scenario to them—had different views about what they would do.

Senator XENOPHON: When did you become aware of that split?

Mr Dolan : Which split? The general one?

Senator XENOPHON: The very split we are talking about—between mandatory diversion and another group with the opposite view—as referred to in the email.

Mr Dolan : I am sorry?

Senator XENOPHON: The email says there is one group of pilots with one view—a mandatory diversion—and another group with the opposite view. The opposite view is, presumably, to continue powering along to Norfolk Island. We are not talking about general pilots and we are not talking about students; we are talking about CASA's flying inspectorate. Were you aware that CASA's flying inspectorate had such a split view on this?

Mr Dolan : No, but what we were aware of, as we say in our report, is that the guidance increased the risk of inconsistent in-flight management and decisions to divert. We are aware that this is an issue and we are saying that it requires clarification.

CHAIR: To assist the committee: in the investigations you made independently of CASA—the pilots you put the scenario to, who were not CASA pilots, were split too?

Mr Dolan : It was mostly ATPL students, I believe, who are very familiar with—

Senator XENOPHON: Hang on. We are talking about ATPL students but not the CASA inspectorate?

Mr Dolan : No, we did not see a need to talk to the CASA inspectorate on this particular issue.

Senator XENOPHON: I meant the CASA flying inspectorate.

Mr Dolan : We were trying to understand how the pilot community in general viewed the existing guidance in relation to acquisition and use of on-flight information, including weather information, to make decisions to manage the flight and, potentially, to divert.

CHAIR: But your information was collected from trainee pilots?

Mr Dolan : There was at least one exercise to do that. We also talked to pilots in our organisation and did various other things. We had some internal debates. What was clear was that there were different interpretations of the available guidance and that this was an issue which needed to be dealt with.

Senator NASH: Why would you not go to the CASA flying inspectorate?

Mr Dolan : We went to CASA to obtain CASA's view. We would normally leave it to CASA to work out, among themselves, what the CASA view is.

Senator NASH: CASA did not provide you with the information Senator Xenophon has been referring to—that email?

Mr Dolan : No. They provided us with a response to the safety issue and we paid due regard to that response in determining how to take it forward.

Senator XENOPHON: I think this is absolutely critical. That email, to find which we had to dig and sift through the many thousands of documents, sends alarm bells because it says things like: 'We might find ourselves in AAT or a court. We will look a bit foolish if we as a regulator find ourselves in a position where we say there are two conflicting views, one of which has to be wrong and we have done nothing to rectify that over the years. Very untidy.' You interviewed ATPL students—is that right?

Mr Sangston : Yes, and a number of other pilots in the industry.

Senator XENOPHON: How many?

Mr Sangston : I think there were a total of eight. We also examined the operations manuals of a number of operators to see what guidance—

Senator XENOPHON: Is that included in your final report?

Mr Sangston : Yes.

Senator XENOPHON: Including the background analysis and the interviews?

Mr Sangston : Not specifically interview by interview.

Senator XENOPHON: Perhaps you could provide that for the interviews which were undertaken. That might be useful to give the background you had before you reached that conclusion.

Mr Dolan : This is not—

Senator XENOPHON: We do not need to know the names of the students.

Mr Dolan : My only comment would be that this is at the heart of the restricted information provisions in our act. So we would want that information to be treated confidentially by the committee.

Senator XENOPHON: If we do not know who it is—if it does not identify the pilots and it shows divergent views—how is that restricted information?

Mr Dolan : It is acquired in the course of our investigation and it comes under—

CHAIR: We can take it in camera.

Senator XENOPHON: You agree that ATPL students would not have the same level of expertise as CASA FOIs?

Mr Dolan : The reason we picked ATPL students is that these are the people who would have just been through the training to learn how to make these sorts of decisions. So we had a fresh group who had a sense of what was at issue. What was clear was that there were differing views about what should be done in the circumstance. We backed that up with interviews of others.

Senator XENOPHON: What do you make of the fact that an email on Saturday, 20 March 2010, said, 'If we find ourselves in the AAT or a court, we could look a bit foolish,'—or words to that effect? Do you read anything into the fact that the AAT hearing for Dominic James was first set down for 23 March 2010?

Mr Dolan : I am not sure that is something I can usefully comment on. It does not go to my function or to what I am trying to explain to this committee.

Senator XENOPHON: Given that this material, this email of 20 March between two CASA officials, was not provided to you in the course of your investigation, my first question is: do you consider that it would have been helpful to the ATSB's investigation to be aware of both the content of and background to that email?

Mr Dolan : I do not believe it would have added anything to what we already knew, which is that there is a serious division of views on what the current guidance says and that therefore there is a problem. It would have reinforced it, but we already knew there was a problem.

Senator XENOPHON: The fact that one is CASA FOIs and the other is students—you do not put any additional weight on CASA FOIs?

Mr Dolan : I would certainly take account of the views of CASA FOIs. What I am saying—clearly enough, I hope—is that what the CASA FOIs appear to be disputing is the very thing that we know other pilots were disputing.

Senator XENOPHON: CASA has said, in relation to the AIP with respect to this, that they intend—emphasis on the word 'intend'—to change it in 2014. Given what has occurred, do you consider that time frame to be reasonable?

Mr Dolan : This goes to my opening remarks in which I pointed out that the problem we are dealing with here relates to a very particular circumstance, a rare circumstance, where a weather forecast turns out not to be reliable—

Senator XENOPHON: Not so rare on Norfolk Island, though. We heard from the Bureau of Meteorology on Monday that it is not so rare—2.7 per cent of the time, isn't it, in terms of accuracy?

Mr Dolan : No, my understanding is that it is somewhere between 0.6 and 0.8 per cent—six or eight in a thousand. That is why I said one or two a year. We have done our own review of a range of material about reliability of forecasts on Norfolk Island. The circumstances are comparatively rare and only apply to general aviation flights. Any passenger-carrying charter or RPT flights are, in those circumstances, required to plan for fuel to get to destination—Norfolk Island—and, from there, to an alternate. While we think it is useful to clarify the AIP, the key step which has been taken is the one which says that passenger-carrying aircraft, particularly aeromedical ones, will be required to plan for fuel to the destination and from there to an alternate. That means that these sorts of difficult decisions—about how much weather information is needed and how to make decisions to divert and so on—get taken off the table.

Senator XENOPHON: Going to the issue of when it was changed from a critical safety issue to a minor safety issue—at what date did you receive communications or representations from CASA saying, 'We do not think it is a critical safety issue'? Was it after this email of 20 March 2010 I have referred to?

Mr Dolan : We will provide the correspondence and you can check that.

Senator XENOPHON: I will be keen to pursue that.

CHAIR: We will be putting some questions on notice. You may contribute to that, Senator Xenophon. The committee would be interested to know exactly when the ATSB requested the CASA special audit and when ATSB actually received the document.

Mr Dolan : We can provide that information.

Senator EDWARDS: Your opening statement was full of conviction and you said you firmly stand behind your report. It was vastly different from your previous evidence in which you said on two occasions that you were not proud of the report.

Mr Dolan : I only recall saying that once, but I did say that.

Senator EDWARDS: What has changed? Why are you now standing behind a report you are not proud of? You have muscled up since we saw you last.

CHAIR: That is his interpretation!

Mr Dolan : Senator, if my recollection is correct, it was your question as to whether we were proud of the report. What I should have said by way of context is that we are not proud of how long it took us to complete this report. The second thing is that, at the time we were previously before the committee, there was a range of assertions, evidence and other things directly challenging a whole range of dimensions of our report that we had not had the opportunity to fully consider and test against the information we had to respond to. So if we seemed a little tentative it was because there were a lot of apparently unanswered questions still on the table. We have spent a lot of effort in analysing all the information and responding to it. I and my fellow commissioners have reviewed the material and that is why we can say with confidence that we stand by our report.

Senator EDWARDS: Since our last hearing, have you had meetings within your division as to how you would change things so that this never happens again?

Mr Dolan : For almost all my time in the organisation, as Mr Sangston and Mr Walsh can tell you, I have been very insistent that we substantially improve the timeliness of our reports. It has been a point of criticism. What I have said is that, for most reports, we aim to complete them in less than a year, and, in most circumstances, we are hitting that target. It comes and goes depending on how much work we have on hand. And we will continue to do that. We are currently building a whole range of investigation management tools to make it easier to manage them as defined projects and set clear scopes, clear resourcing and clear time frames for completion so that we can manage resources better. We are putting a whole range of things in place to continue to manage that challenge.

Senator EDWARDS: Are you prepared to share with the committee those recommendations or memos about how you would like to change the culture of the way in which you operate? Is there anything out there formally?

Mr Dolan : I can show you how, over time, we have set much tighter targets for the completion of our reports. I can show you the things that—

Senator EDWARDS: No, I mean specifically in the last month.

Mr Dolan : I am trying to think. Other than reminding staff—

Senator EDWARDS: No worries; take it on notice.

Mr Dolan : I will take it on notice. I do not think we have done anything specific, other than having a discussion at the executive level about what we have learnt from this. What I said to the staff is that one of the things we have learnt from this is that timeliness remains a very important thing for our organisation.

CHAIR: Mr Walsh, you have got out of this rather lightly. You are the strategic capability general manager. Airservices said they are going to raise the New Zealand reporting arrangements at the Pacific Forum in six months time. I do not know how often they have Pacific forums but, if someone I knew was on the plane, I would have raised it a bloody lot earlier. They think there is some need for improvement in the way the weather is reported in that particular airspace. Do you think the ATSB has the strategic capability to do something about that?

Mr Walsh : That might be a misunderstanding as to my role as general manager strategic capability. It is about providing capacity within the organisation to do its task. My role is actually looking after the notifications and confidential reporting function; aviation research; and technical analysis, which is engineering evaluations and recorded analysis—flight data recorders and those types of things.

CHAIR: Wouldn't that involve making sure planes get the weather?

Mr Walsh : That is an investigation matter that is part of the investigation process.

CHAIR: I still have not got in my head an answer about the legal responsibility of people in New Zealand to let people flying into Norfolk Island know about the weather.

Mr Dolan : We have got information on that from New Zealand and from Australia. I think we need to have discussions with our colleagues in Airservices to understand better what seems to be a slightly different view on our part about what is required than what they believe is the case. Once we have got that, we will have a better view as to how much we will be urging them to raise matters of concern.

CHAIR: If we went in camera now, would you tell us what you think?

Mr Dolan : I do not think it makes any difference whether I say it in camera.

CHAIR: So can you tell us here what you think the difference is?

Mr Dolan : As I said earlier—and I am happy to table this document—that is part of a pilot brief called Safety Net on the Airservices website.

CHAIR: On pilot responsibilities.

Mr Dolan : It is on pilot responsibilities for obtaining information in flight. It sets out something that is pretty much consistent with what is in the AIP and we believe is broadly consistent with what is in New Zealand.

Senator XENOPHON: I want to go to the request for a CASA special audit. That was only requested by the ATSB on 4 July this year?

Mr Dolan : That sounds about right, yes.

Senator XENOPHON: Were you aware that there was a special audit?

Mr Dolan : Yes.

Senator XENOPHON: Prior to 4 July?

Mr Dolan : Yes.

Senator XENOPHON: For roughly what time period were you aware of that special audit?

Mr Dolan : Because we have regular meetings with CASA to talk about various information, we would have been aware of it at the time they kicked it off.

Senator XENOPHON: And you did not think it was relevant for the purposes of your report to obtain a copy of that special audit?

Mr Dolan : Our focus was the en route side of this—

Senator XENOPHON: No, your brief is much wider than that.

Mr Dolan : I know, but we scoped our investigation in that way. We did not see that there was direct significance in the regulatory exercises that CASA was undertaking in relation to the pilot or in relation to the—

Senator XENOPHON: How would you know without seeing the special audit report what its significance would be?

Mr Dolan : We were trying to understand might need changing in the existing rule set that CASA regulates. CASA was giving force to its responsibilities requiring that the existing rule set is complied with—and that is the difference between us as an investigator and CASA as the regulator. So we do not see that it was directly relevant.

Senator XENOPHON: But how did you would know whether it was or wasn't directly relevant if you had not seen the special audit report?

Mr Dolan : We see our job as a different job from CASA's. The special audit was in relation to CASA's views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.

Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB's final report?

Mr Dolan : That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason's model, would be viewed as violation; and that is principally the responsibility of the regulator.

CHAIR: In your last report to us in recent days, you acknowledged that there are several points of that special report to take note of. Is that correct?

Mr Dolan : That special audit had highlighted several of the same issues that we had already determined in our investigation.

Senator XENOPHON: Isn't the ATSB supposed to be looking at CASA in its investigation. Isn't it part of your job to look at the regulator? Yes or no?

Mr Dolan : I am sorry but it is not a yes or no answer. It depends on the context of an individual investigation.

Senator XENOPHON: So you could potentially be looking at CASA in terms of its regulations and the way it regulates?

Mr Dolan : Yes.

Senator XENOPHON: On 19 October 2012 the ATSB annexed a submission of the ATSB, aware that the final report included the special audit's findings. Isn't that impossible in the sense that the 28 March 2012 draft has the exact material you are quoting word for word, when you said you received a special audit in July this year? I am confused about time frames as to what you actually relied on at what time. There seems to be inconsistency with the annex A submission in terms of time frames.

Mr Dolan : I am not sure I understand your question.

Senator XENOPHON: I am not sure I have explained it very well. In the 19 October annex, your final report has included the special audit findings/considerations. You have made reference to the special audit in your final report, is that right?

Mr Dolan : Yes, that is correct.

Senator XENOPHON: But in terms of the earlier drafts of this report there seem to be identical conclusions. So your report has not in fact changed in any way as a result of CASA's special audit?

Mr Dolan : That is correct.

Senator XENOPHON: Okay. I hope that clears it up.

CHAIR: Thank you very much. We are once again most grateful to the ATSB for your evidence and your dedication.

Committee adjourned at 18:47