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Rural and Regional Affairs and Transport References Committee
Aviation accident investigations

STAIB, Ms Margaret, Chief Executive Officer, Airservices Australia

HARFIELD, Mr Jason, Executive General Manager, Air Traffic Control, Airservices Australia

HOBSON, Mr Peter, Acting Manager, Network Management Services, Airservices Australia

Committee met at 10:07.

CHAIR ( Senator Heffernan ): I declare open this public hearing of the Senate Rural and Regional Affairs and Transport References Committee. The committee is hearing evidence on its inquiry into aviation accident investigations and I welcome you all here today. This is a public hearing and a Hansard transcript of proceedings is being made. Before the committee starts taking evidence, I remind all witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee and such action may be treated by the Senate as a contempt. It is also a contempt to give false or misleading evidence to a committee.

The committee prefers all evidence to be given in public, but under the Senate's resolution witnesses have the right to request to be heard in private session. It is important that witnesses give the committee notice if they intend to ask to give evidence in camera. If a witness objects to answering a question, the witness should state the ground upon which the objection is taken and the committee will determine whether it will insist on an answer, having regard to the ground which is claimed. If the committee determines to insist on an answer, a witness may request that the answer be given in camera. Such a request may, of course, be made at any other time.

Finally, on behalf of the committee I would like to thank all those who have sent representatives here today for their cooperation with this inquiry. I welcome representatives of Airservices Australia and the brilliant new boss straight from the Pentagon. I remind senators that the Senate has resolved that an officer of a department of the Commonwealth or of a state cannot be asked to give opinions on matters of policy and shall be given reasonable opportunity to refer questions asked of the officer to superior officers or to a minister. This resolution prohibits only questions asking for opinions on matters of policy. It does not preclude questions asking for explanations of policies or factual questions about how and when policies were adopted. Officers are also reminded that any claim it would be contrary to the public interest to answer a question must be made by a minister and shall be accompanied by a statement setting out the basis for the claim.

If you would like to make an opening statement, you may.

Ms Staib : I do not intend to make an opening statement. Thank you.

Senator XENOPHON: What are the hazardous weather procedures for domestic flights in the context of amended TAFs and SPECIs? In other words, how are pilots conducting domestic flights notified of changes in meteorological conditions?

Mr Hobson : A pilot of an aircraft can expect a service from the unit managing where the hazardous weather might occur.

Senator XENOPHON: On the ground, you mean?

Mr Hobson : Yes.

Senator XENOPHON: In this case, Norfolk Island?

Mr Hobson : Norfolk Island is within the New Zealand flight information region.

Senator XENOPHON: So it would have to be information coming out of New Zealand. Is that right?

Mr Hobson : Yes.

Senator XENOPHON: So we would have to rely on the New Zealanders to tell us what is happening on Norfolk Island?

Mr Hobson : No. The New Zealanders are responsible for their airspace. They know what they need to do and they would receive weather information from the Bureau of Meteorology.

Senator XENOPHON: How is that conveyed to the pilot?

Mr Hobson : If he is in flight, by radio.


Senator XENOPHON: Yes, HF. Say New Zealand is aware of deteriorating weather conditions on Norfolk Island. Then what happens? It would then go to Airservices Australia, and then where?

Mr Hobson : No. The unit in communication with the aeroplane would provide that service.

Senator XENOPHON: So it would come out of New Zealand.

Mr Hobson : Yes.

Senator XENOPHON: What are the differences for international flights in Australian managed airspace? In other words, are the procedures for notifying pilots in flight of changes in meteorological conditions identical for domestic and international flights?

Mr Hobson : I am not aware of any differences there.

Senator XENOPHON: Could you take it on notice if there are any differences? How are flights to external territories treated by Airservices? Are they treated as domestic or international? How would you classify Norfolk Island?

Mr Hobson : The flight from Samoa to Norfolk Island is what we are looking at, yes?

Senator XENOPHON: Yes.

Mr Hobson : That flight did not enter Australian airspace at all.

Senator XENOPHON: But it did enter Australian airspace at some point, didn't it?

Mr Hobson : No.

Senator XENOPHON: Is there a zone around Norfolk Island that would classify it as Australian airspace?

Mr Hobson : It is an Australian territory, but the airspace is not Australian. It is exactly the same, in fact, for Cocos Island or Christmas Island—I am not quite sure which. One of them is in Jakarta's airspace. So there are two airports in Australia that are in Australian territories and where there are Australian citizens but where the airspace overlying them is operated by another jurisdiction.

Senator XENOPHON: Can you explain that? I am just trying to get the context here. What are our international obligations in regard to the sharing of hazardous weather information with other air traffic service organisations?

Mr Harfield : We have a monitoring system where the Bureau of Meteorology obviously monitors a number of locations around Australia and within the jurisdiction of the airspace that we manage. When we get information provided that is of a differing nature from the forecast, such as a hazardous weather event or the SPECI information that you mentioned previously, that information is then sent to the control positions. It is then relayed to the particular aircraft based on certain parameters where the weather has changed. We call that a hazard alerting service. What we would do, for example, if an aircraft which had a terminal area forecast for Sydney was flying between Melbourne and Sydney and the weather conditions rapidly changed is issue a hazard alert and notify all aircraft going to that destination of the change in circumstances.

Senator XENOPHON: Did that happen in Norfolk Island? Did they deter any traffic?

Mr Harfield : We are unaware because the flight went through different jurisdictions and was in New Zealand airspace.

CHAIR: So that is a fundamental flaw, is it? The evidence we received was that there was a deterioration report on the weather into Norfolk Island, which was not conveyed to the pilot by New Zealand. Is there nothing we can do about it, just tough tits?

Mr Harfield : We were aware of the leg of this particular flight obviously from Sydney to Norfolk Island and also on the return Norfolk Island-to-Sydney leg, which is where there aircraft would transfer to Australian airspace and air traffic control would be managed. The flight between Samoa and Norfolk Island was in another jurisdiction, so we were not aware of what was going on.

CHAIR: For future planning, so we do not have a repeat, have you been in touch with New Zealand bureau of met to get an understanding of what went wrong?

Mr Harfield : No.

CHAIR: Shouldn't you have? Would it not be in your best interest to know if the weather was deteriorating in one incident, which ended up in the sea? If it was evident that New Zealand knew the weather was deteriorating and the pilot did not have that update, wouldn't you be interested to know? Would you not think: shit, we better not let this happen again?

Mr Harfield : Yes and that is why we rely on things like the ATSB reports—to give us that information on how the system was working. If the aircraft did not ditch, we were not aware of that flight, we were not managing that flight, we were not dealing with that flight and so therefore—

CHAIR: Yes, but you would be interested.

Mr Harfield : Correct, we would be interested in the lessons learnt from the incident and we would rely on the ATSB report for that.

Senator XENOPHON: On page 7 of the ATSB report it states:

Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew

Does that not seem to be an unsafe practice in that it is tantamount to the withholding of critical safety information that might otherwise prevent a flight from continuing into a dangerous situation, which occurred here?

Mr Harfield : Yes. However, they are the rules for Fijian air traffic control as instructed by Fiji and international agreement. Within the Australian airspace that we manage, we are required to pass that information on to the flight. Those are rules of Fiji air traffic control.

Senator XENOPHON: But we are talking about an aircraft heading into Australian territory though, are we not?

Mr Harfield : It was going to Norfolk Island, yes, but Norfolk Island is managed by New Zealand air traffic control.

Senator FAWCETT: So it is not Australian airspace?

Mr Harfield : It is not Australian airspace.

Senator XENOPHON: Are you saying because it is managed by New Zealand, there is nothing you can do about it?

Mr Harfield : I am not saying there is nothing we can do about it. We can talk to our New Zealand colleagues about—

Senator XENOPHON: Have you spoken to your New Zealand colleagues about the Pel-Air ditching?

Mr Harfield : No, we have not.

Senator XENOPHON: It has been three years and one day since the ditching.

Senator STERLE: I am interested too. You did say, Mr Harfield, that you would do that if there was a recommendation from ATSB? Would you say that?

Mr Harfield : I think we need to put a couple of things into context. You have CASA, which is the air safety regulator that provides the rules and procedures we abide by. We are there air traffic service provider. We provide services based on the rules and regulations that are set by CASA, so we apply the rules as set. When another air traffic service provider has a particular issue, we have discussions with that service provider about the issues that we see. We are surrounded by 11 different flight information regions. We are in constant contact with our neighbouring air navigation service providers. At the end of the day, we can talk about those particular issues but they also work under the jurisdiction of their safety regulator and apply the rules that their safety regulator deems. The fact is, this would be a matter for the civil aviation authority of New Zealand.

Senator FAWCETT: A string of those comments point to the fact that if there were a recommendation coming out of an accident report it would be an enhancement to safety for a neighbouring service provider to proactively push an equivalent of a hazard alert. Then you would act on behalf of the government to talk with your peer, but that would need to come from a recommendation that CASA picked up, which was then put as a requirement. Does that all lead to the fact that ATSB reports should, in fact, have recommendations? If there were no recommendation, where would you take your action from?

Mr Harfield : From our perspective, as an air navigation service provider, we do not just rely on an ATSB report. If we see any particular safety issue we have regular meetings and discussions with our neighbouring air navigation service providers, talking about the number of safety issues that come to our attention. It may not necessarily be in an ATSB report. We are constantly having those discussions with them to try to improve the integrity of the system.

Senator FAWCETT: How long has it been since this accident.

Mr Harfield : 2,00—

Senator XENOPHON: 2,097 days.

Senator FAWCETT: How many meetings have you had with your New Zealand counterparts since this accident?

Mr Harfield : We probably would have them twice a year, but this particular issue is something where we did not know the intent of what was being passed to that particular flight—because it is New Zealand air traffic control with the Pel-Air aircraft. It is the same with Fiji air traffic control with the Pel-Air aircraft. Not until the ATSB report was released were we aware that there could have been a deficiency with the passage of weather. It is something that we would normally discuss. New Zealand air traffic control would be doing their own particular review. I want to make sure it is understood where our role is, reference the rules and procedures of a foreign jurisdiction.

Senator FAWCETT: I accept that. The intent of this committee is to make sure that we have the most proactive approach to enhancing air safety. It means that occasionally we expect people to lean across the boundaries of their organisation and say, 'We see something that needs to occur' and if it is not within your current powers or within the rules, the expectation of a reasonable person is that it will be flagged so that this place, which makes rules, can take appropriate action. We would welcome discussion around what proactive steps Airservices has or can take as opposed to saying, 'That is the regulator's problem.' So forgive us if we appear a little tetchy on this, but we are hearing a lot of 'That is someone else's responsibility.'

Mr Harfield : Let me add to that. That is not actually what I am saying. All I am saying is that the head of power for certain rule changes sits with the relevant regulator. That is the point I am trying to make. When it comes to discussing aviation safety, I will use an example of our northern neighbours, Papua New Guinea and Indonesia. We are in regular contact with them on a six-monthly basis. We are either travelling up there or they are travelling down here. We are going through all the incidents that we have recorded between the two particular areas and trying to work to make the system a better and safer one. That is regardless of the regulators. We are reaching across the boundary. The fact that we have not reached across the boundary, per se, to address this particular issue is a different matter.

CHAIR: I think rather than having to accuse you of 'Don't ask; don't tell' we will go back to Senator Xenophon. Like the US army.

Senator XENOPHON: Mr Harfield, further to Senator Fawcett's very pertinent line of questioning, you are all over the shop on this. One minute you tell us that you have a role to reach across to other agencies, but nothing has happened here after 1,097 days since the Pel-Air incident. While the chair was out of the room you agreed that it is an unsafe practice in that Nadi ATC was not required by any international agreement to proactively provide the O8O3 amended Norfolk Island tap to the flight crew. You agree that it is unsafe, yet what meetings, discussions or proactive steps—as Senator Fawcett has mentioned—have you taken to deal with this unsafe practice?

Mr Harfield : First of all, I did not say that it was an unsafe practice. I have said that we have a different procedure in Australia where we actually pass—

Senator XENOPHON: Do you agree that it is withholding critical safety information?

Mr Harfield : What I—

Senator XENOPHON: I think you did.

Mr Harfield : No, what I am saying is—

CHAIR: If you do not mind, I am chairing this.

Senator STERLE: Give him a chance. He has been asked a question and you have jumped on him. You should give him a chance to bloody answer it.

CHAIR: No. The point that Senator Xenophon is trying to make is that, in this case, there is a fault line in the transfer of information from New Zealand. We are not saying that you are the cause of the fault line, but do you not think that the present arrangements are a bit bizarre?

Mr Harfield : First of all—

CHAIR: We are not blaming you for the—

Mr Harfield : No, I understand. I just want to make sure that I am clear in what I am saying. The fact is that it was Fijian air traffic control that did not pass on the amended weather information, not New Zealand air traffic control. On the basis of what happened in the accident, that weather information was critical in the sense that if that bit of information was seen, the outcome may have been different. I am reluctant to say that the procedure is unsafe because I do not have the broader information on what is going on. Here was a piece of information that should have been passed to the aircraft which could have prevented this outcome.

Senator XENOPHON: If we could step back a bit. You have conceded that was a critical piece of information. What steps have been taken to liaise with, communicate with or have discussions with Fijian air traffic control since the ditching of that flight three years and one day ago?

Mr Harfield : None so far from Airservices Australia's perspective.

Senator XENOPHON: Do you think that is a satisfactory response?

Mr Harfield : At this particular stage, I do. We did not investigate this accident and we were not privy to the information associated with this accident until the ATSB report came out. In other words, I know that there has been a lengthy time since the accident happened, but we were not privy to the information contained in the report until the report was published.

Senator XENOPHON: Can I just confirm: were you given drafts of the report in relation to this? Were you kept informed of developments? Are you kept informed when an accident is being investigated?

Mr Harfield : I am unaware of whether we got the draft reports, because we are not necessarily interested parties.

Senator XENOPHON: Can you please take on notice that we are interested parties. Ms Staib, I appreciate you have just stepped into this position, and congratulations on your new role. Do you have concerns about the fact that your organisation has not appeared to have taken any active or proactive steps—as Senator Fawcett has referred to it—in relation to this incident? We know the aircraft ditched. We knew this very early on from early investigations. I would assume that there would be information being conveyed from ATSB to Airservices Australia, and—if you take that on notice—I would find it extraordinary if ATSB was not sending information. I am quite shocked that even since the report came out in August there has been no communication with Fijian air traffic control. It has been three months. Leaving aside what occurred earlier, is this something that Airservices Australia will now follow up with Fijian air traffic control?

Ms Staib : The first thing I would say is that I am not concerned about how Airservices has dealt with this particular matter. The whole point is—

CHAIR: Is that because it is not in your jurisdiction?

Ms Staib : It is because we have followed our area of responsibility.

CHAIR: That is right. Exactly. It is not in your jurisdiction to have what does not worry you?

Ms Staib : Not in the way that this particular incident was handled. What it has brought out in my mind—appearing here before you—is that there is room for improvement in managing the cross-boundary areas of the different jurisdictions, because inevitably it is very difficult to see the line drawn on a map in the air.

CHAIR: Surely, in normal human workings, this is—with your permission Senator Xenophon—a fundamental flaw in that the weather was not conveyed in New Zealand airspace by the Bureau of Meteorology in New Zealand. Everyone knows that. The guy—even if you were the most mediocre pilot, like I used to be—would know to divert to somewhere like Noumea with ILS. That did not happen, because he did not get the information, and the outcome was catastrophic, to say the least. Surely, it is not one of those things where, like Senator Fawcett said: 'Don't look over the boundary. You mightn't like what you see.' For God's sake, why wouldn't you have been up CASA and up ATSB and up everyone else, like I intend to be, over this? It is obviously a flaw and obviously bureaucracies tend to protect themselves and put up a shell—'Don't ask, don't tell. That wasn't our responsibility' and 'Don't look over the fence.' For God's sake, what is going on?

Senator STERLE: Chair, Ms Staib is not saying that.

Ms Staib : Perhaps I can reiterate—

CHAIR: Back to you, Senator Xenophon.

Senator STERLE: Hang on—you have said something, Chair: you assume Ms Staib said, 'Don't look; don't ask,' but she did not say that. I think we need to get that correct.

CHAIR: That is my interpretation of it.

Senator STERLE: That is right, but you said it was Ms Staib, so she has the opportunity to, once again, reinforce that she did not say that. She acknowledged that.

Ms Staib : Certainly, Chair, I do not subscribe to: 'Don't ask; don't tell.' There is an opportunity here to learn from this incident. As the service providers, we can work with our colleagues in near jurisdictions and, indeed, across the world to understand if there is better practice in dealing with the handoff points across jurisdictions.

CHAIR: Welcome to your first hearing, by the way.

Ms Staib : Thank you.

CHAIR: I would split someone's head open over that, in a philosophical sense. Back to you, Senator Xenophon.

Senator XENOPHON: I realise that I have had more than a fair go. I would like to put some question on notice in a second. I want to spell them out, just so that it is clear what is on the agenda. Ms Staib, as the new CEO of Airservices Australia, given what you know now, given what we know from the ATSB report, given what occurred three years and one day ago, will there now be communications between Australia and Fiji air traffic control and New Zealand air traffic control so that this sort of critical safety information can be conveyed to pilots en route? Will that now happen or will you be considering whether it happens or not?

Ms Staib : It will happen. The first opportunity to discuss the issue is at the Pacific forum, where many of the players that we have talked about will be—

Senator XENOPHON: When is the Pacific forum?

Mr Harfield : Coming up before the end of the year.

CHAIR: Three years after the event.

Senator XENOPHON: Are you seriously suggesting that we have to wait for a forum and that you cannot pick up the phone and say, 'This has happened. This is something I want to bring to your attention'? You are not seriously suggesting that we need to wait for a forum that happens every year or every two or three years?

Ms Staib : No, I am not seriously suggesting that. I am just saying that is an opportunity that presents itself.

Senator XENOPHON: Why can't the opportunity present itself before that forum to say that this is a critical issue?

Ms Staib : That particular opportunity is coming up in a couple of weeks.

Senator XENOPHON: So it will not be before the forum?

CHAIR: With great respect, I would have been on the bloody phone the next day. This happened three years ago.

Mr Harfield : As I said, I understand that the accident happened three years ago. However, the ATSB report has only just come out in the last few months. Up until that particular time—

CHAIR: You abided by the bureaucratic rules around it. Like this committee, we do not play politics here; we just deal with the facts—bugger the politics—and that is what you ought to be doing.

Mr Harfield : The fact is that we have a Pacific safety forum that comes up where you get all these people from the various jurisdictions. We are not just dealing with Fiji by itself; we are dealing with New Zealand. We go through an agenda of all the issues that have popped up over that time and discuss them as a group rather than individually.

CHAIR: So, in the meantime, if it happens again, that is too bad? What a joke. You are a joke. Back to you, Senator Xenophon.

Senator STERLE: Colleagues, I understand the frustration and I am experiencing it too. But, with the greatest respect, yelling at the officers from the department is not called for. Chair, I think Senator Xenophon, rather than putting the question on notice, should put his questions to the officers now while we have the opportunity.

Senator XENOPHON: Just to reiterate without labouring the issue, could you please provide us details, including copies of documents, of whatever information you had about this particular incident, the dates at which you knew what was happening, et cetera? I think there would be a fair-minded approach and an objective approach. Many in the community would say that, at the moment, you were aware that there was an issue with air traffic control in Fiji and there should have been a proactive approach taken. So I think there is a real issue there. I can tell you what my view will be, ultimately, when this committee reports: I am very concerned about that. I would urge you, Ms Staib, as a new CEO, not to wait until the forum but to actually take some steps before that, because we are very lucky that there was not a loss of life on that aircraft. Does Airservices maintain tape records of high-frequency radio traffic on its allocated frequencies? Can you tell me whether that is the case or do you want to take that on notice?

Mr Harfield : Can you just say that again, Senator?

Senator XENOPHON: Does Airservices maintain tape records of high-frequency radio traffic on its allocated frequencies?

Mr Harfield : We are required to record all our traffic, regardless of the frequency.

Senator XENOPHON: Are all air traffic service organisations required to keep similar records, such as those out of Nadi?

Mr Harfield : We have to take that on notice.

Senator XENOPHON: Please do, and regarding New Zealand as well. Regarding the Australian Aeronautical Information Publication, is the text provided to Airservices by CASA or do you control all of the editorial resources?

Mr Harfield : I will hand that to Mr Hobson to answer that particular question.

Mr Hobson : Regarding the content of the AIP, in terms of the text and the language used, in the main the author is CASA and Airservices is the publisher.

Senator XENOPHON: So you have to rely on what CASA provides to you?

Mr Hobson : That is correct.

Senator XENOPHON: Who is responsible for ensuring that material, which requires some sort of mandatory action, is properly based on a legal instrument and with an appropriate head of power?

Mr Hobson : The author, CASA.

Senator XENOPHON: In the particular case of AIP ENR 73, Alternate Aerodromes, is there one or more legal instruments that establish those requirements?

Mr Hobson : On notice, please.

Senator XENOPHON: It seems likely that the briefing officer was aware that the pilot's flight planning from Samoa was not based on all the relevant information. Has Airservices issued any instructions or information to staff accepting flight plans with regard to a potential duty of care if they become aware that the flight plan submitted is based on out-of-date or superseded information? Is there any vetting of flight plans carried out?

Mr Hobson : I might take that one on notice as well. I can give you a partial answer.

Senator XENOPHON: You can see the significance of this in the context of the sequence of events?

Mr Hobson : Sure I can, yes.

Senator XENOPHON: I am happy for you to take it on notice. I just want a considered answer to that because I think it is a key issue.

Mr Hobson : Yes.

Senator XENOPHON: Ms Staib, is there any likelihood that Fiji air traffic control, the Fijian counterparts, will be contacted prior to the forum in relation to this incident?

Ms Staib : Yes, Senator.

Senator XENOPHON: Thank you.

CHAIR: This is probably an unfair question: has Airservices Australia struck any incidence of a control tower giving clearance to land and then going to lunch?

Ms Staib : Chair, could you say that again?

CHAIR: Where an air traffic controller, anywhere on the planet, has said to incoming air traffic control, 'You're clear to land; I'm going to lunch now,' long before the plane got there?

Mr Harfield : I am not aware of any incident like that, Senator.

CHAIR: You are in for some surprises.

Senator NASH: Can we go back to this issue of the provision of the information from New Zealand? What date is the Pacific forum?

Mr Harfield : Let's take it on notice. I think it is in the second week of December, but I will advise.

Senator NASH: Okay. Fingers crossed that it does not happen, but if there were another incident of the same nature between now and a few weeks away, whose responsibility would it be that this issue had not been dealt with immediately? I am just trying to ascertain: if there were another accident and it had been, as it has been, identified that there is this fault line issue—as you said, Ms Staib, it could be addressed better in our planning and that will be done at the Pacific forum—whose responsibility is it when that has not been addressed?

Ms Staib : It seems to me—and, as you will appreciate, I am still learning—that in the first instance the New Zealand regulator would have to step in. What I am saying here is that there is an opportunity for us to work in a better community practice, and that is a good thing. But we all have our specific roles to play.

Senator NASH: I understand that. I take the point that you work within the framework that you have. I take that point completely. But what has been identified is this anomaly.

Ms Staib : Yes.

Senator NASH: I take your point that New Zealand would be responsible, but they are not required to provide this information. That is my whole point. I am trying to understand who is responsible if there is another accident before this issue is addressed—as hopefully it will be.

CHAIR: Whose head do we cut off, in other words?

Senator NASH: Somebody would have to take responsibility for the fact that this issue, having been identified, was not addressed urgently. Who would be responsible for it not having been addressed urgently?

Mr Harfield : The fact that this information is now available—and I am assuming that the ATSB report would have been given to the Civil Aviation Authority of New Zealand as well as to the regulator in Fiji—and because of their rule set or their regulations, if they have not taken action on it and something occurs then the responsibility would be with that particular jurisdiction. The point I am trying to make is that we do not own the rule set and cannot change the rule set of a foreign jurisdiction.

Senator NASH: We are not blaming you; we are trying to find a resolution. What we need from you and others who appear before us is to get all the pieces of the jigsaw puzzle so that we can put them into a picture. We are not blaming you—that is fine. We understand the rules that you work under. What we are trying to do is to figure out how to resolve it. That is where we are hitting the wall. You attended the Pacific forum. When was the decision made that you should talk to your counterparts from New Zealand and Fiji at the Pacific forum?

Mr Harfield : The Pacific forum is a regular—

Senator NASH: I know it is.

Mr Harfield : It is a regular thing. When those of us with responsibilities and areas of control in the South Pacific come together, we work through the various safety—

Senator NASH: I understand all that. When did you make the decision to raise this issue with Fiji and New Zealand at the Pacific forum? Was it this morning? Was it last week? Was it a month ago? When did you make the decision?

CHAIR: Was it six months ago? Three years ago?

Mr Harfield : Regarding the decision to put that on the agenda, without knowing what is already on the agenda, after this discussion here we will ensure that it is on the agenda.

CHAIR: So it is not on the agenda.

Mr Harfield : But there is a level of assumption that all instances—

Senator NASH: That is fine. I am just trying to ascertain information. So I am correct in saying that because of the discussion this morning at this hearing you have now decided to take this issue to the Pacific forum. Is that correct?

Mr Harfield : We will ensure that it raised at the Pacific forum.

Senator NASH: Okay, so it was not on the agenda before now. If we were not having this particular inquiry, what would have triggered the decision to collectively with your counterparts examine this issue of the fault line and the fact that there is an anomaly? Would it not have happened? What I am trying to get at is this: if we had not asked you these questions this morning—if we had not been discussing it here this morning at this inquiry—would you have raised this at the Pacific forum as an issue.

Ms Staib : My expectation is that that is why we have those sorts of forums: so that we can share lessons learned from incidents that occur.

Senator NASH: Okay. Then why wasn't it already on the agenda?

Ms Staib : I cannot answer that, because I have not seen the agenda.

Senator NASH: What?

Mr Harfield : The fact is that we do not have the agenda in front of us, so we do not know the detail.

Senator NASH: So you get an agenda and then figure out if you are going to add something?

Mr Harfield : No. The agenda is set by—

Senator NASH: No, hang on; Ms Staib just said that she has not seen the agenda.

Mr Harfield : the various coordinators that we have. For example, the manager of upper airspace, who is the manager of the airspace that abuts Fiji and New Zealand, is the representative of Air Services Australia who goes along to the forum. They set the agenda. I do not have the agenda in front of me.

Senator NASH: So do you have any opportunity to have input into the agenda from Airservices?

Mr Harfield : Yes, Airservices has—

Senator NASH: Okay. Airservices does. So who within Airservices would have responsibility for placing this issue on the agenda for the Pacific forum?

Mr Harfield : Our representative at the forum.

Senator NASH: And who is that?

Mr Harfield : It is the manager of upper airspace for Westwind.

Senator NASH: Okay. So why didn't they put this on the agenda before? Why has it taken this committee inquiry to get this on the agenda?

Mr Harfield : We will take that on notice. I am not saying that it was not already on the agenda. We are unaware whether or not it is on the agenda, and we have said that we will ensure that it is. It could already be on the agenda. I am just unaware.

Senator NASH: I find it extraordinary that you do not know whether or not this issue is on the agenda for the Pacific forum. That is extraordinary.

CHAIR: With respect, if your mum or dad or one of your kids was in the plane, I bet it would have been. I have one question. How many Pacific forums have we had since the accident?

Mr Harfield : We would have to take that on notice.

CHAIR: You are a perfect bureaucrat. Senator Fawcett.

Senator FAWCETT: I have some questions about some of the points in the report. RVSM airspace was the subject of considerable contention for several witnesses. Have you had any correspondence from your regional counterparts about Australian aircraft seeking to transit through RVSM airspace on a regular basis when they are not certified for RVSM?

Mr Harfield : We get that on a fairly regular basis, because there are aircraft that are not RVSM approved. The way that RVSM airspace is constructed in the Australian jurisdiction is that we will allow aircraft, on an as-is basis, to operate in there if they are not approved, but in high density type environments they will be asked to go below the RVSM airspace. But aircraft going through that are not RVSM approved is a relatively regular occurrence.

Senator FAWCETT: Okay. Do you ever pass on to the operators of the aircraft concerns that have been raised with you by regional counterparts?

Mr Harfield : Yes, we do. We pass that on.

Senator FAWCETT: Could you take on notice whether you passed on to Pel-Air the concerns about their Westwind aircraft.

Mr Harfield : Yes.

Senator FAWCETT: Because the context of that is clearly that the pilot felt some pressure not to intrude into RVSM airspace and felt that he had made that point clear. I am just interested to know what has come back through the official channels. The pilot also talked about Noumea and whether or not the aircraft was cleared to operate into or out of Noumea. Do you get involved in discussions at all with regional authorities about whether aircraft are cleared, or is that purely between the operator and the relevant authority?

Mr Harfield : The relevant authority. We do not get involved.

Senator FAWCETT: Sure. Flying that kind of route through your automated weather briefing system, NAIPS, I would expect normally to get the grid point winds as the detailed breakdown of winds across the gradient. For a phone briefing, would the phone operator normally give the relevant winds for the planned flying level or would they not give those upper-level winds in a phone briefing?

Mr Hobson : The pilot-briefing officer would respond to the information requested by the pilot.

Senator FAWCETT: Okay. Mr Harfield, your opening comment was that, if there were recommendations by the ATSB, you would look to take action. Does it surprise you that ATSB reports no longer appear to have recommendations about things that might trigger situations like the incident we have been talking about for the last five minutes? It is a simple concept. You would have a report that said: 'Here's an issue. We recommend that the Australian government contact its counterparts to see what can be done.' Does it surprise you that there is not a recommendation in there?

Mr Harfield : Maybe it is because of the way we review reports, but I was unaware that they are no longer making recommendations as such in ATSB reports. When any ATSB report comes in, we look at the relevant safety factors that have come out of that particular report and then we crosscheck whether we have already done something about it from an air traffic perspective or whether there may be a gap in our investigative process. We track everything that comes out of an ATSB report on safety factors or where there were previously recommendations and track them through to resolve them. I am not sure why I did not pick it up, but I was not aware that they were no longer making recommendations in reports.

Senator FAWCETT: In your internal tracking system, do you have a committee or something that meets every six months or every year and reviews each of those items that have been flagged?

Mr Harfield : No. The review is done on a much quicker cycle than that. When there is a safety factor raised or a recommendation from an ATSB report we put that into what we call our safety action incident reporting tracking, and those particular recommendations are then assigned responsibility to the various areas. For example, an air traffic control related recommendation will be assigned to me and I will take responsibility for it and then put in the process of addressing that. Then there are milestones and I am held to account on meeting those particular milestones.

CHAIR: You receive recommendations from ATSB even though ATSB allegedly does not make recommendations. Do you then make recommendations or is that—

Mr Harfield : No. There are two processes that go on. Say, for example, we have a particular incident that the ATSB is investigating, we investigate ourselves literally straight away because we want to check the integrity of the system. We would do our own investigation. That would have recommendations for safety improvement actions associated with it that we will take action on when the ATSB report finally comes out. We obviously crosscheck to make sure that what we have done has identified any gaps and then we will take further action as required. So we do not make any recommendations. Being in charge of the operation, I receive the recommendations and have accountability for actioning them.

Senator FAWCETT: Who are you accountable to to carry out those actions?

Mr Harfield : The chief executive officer and the board.

Senator FAWCETT: Is that a formalised process?

Mr Harfield : Yes. It is reported on monthly, and tracking goes to not only the chief executive but also our board safety committee at each of their meetings.

Senator FAWCETT: So if you had a job offer you could not refuse and somebody else came into your role there would be a process whereby all the—

Mr Harfield : Correct. It is not personality driven, as such. It is role specific. That system is there—and the reporting against it—to ensure that action is taken.

Senator FAWCETT: You have highlighted a couple of times, and I completely understand, that you implement regulations that are made by CASA in many instances. If in your review of an incident you believe that there should be a change in the regulation so that you can implement it differently, do you make a recommendation to CASA that they look at that?

Mr Harfield : Yes, we do. We advise CASA and say, 'We picked up this particular risk associated with an incident. These are the actions that we have taken to mitigate that particular risk, but from a systemic point of view we would look at changing the regulations or the standards that underpin the regulations. We think that needs to be addressed to ensure that there is a systemic fix being made.'

Senator FAWCETT: Do you have a similar tracking system within Airservices to say, 'We have made five or however many recommendations to track if, when and how they are either closed out or still open'?

Mr Harfield : We would be able to advise which recommendations have come up and that we have passed on to, for example, CASA for further work and where that would be at.

Senator FAWCETT: So if we asked you to take on notice how many such recommendations over the last five or 10 years you have made to CASA and how many have been actioned and closed out, you should be able to come back and tell us that?

Mr Harfield : That is correct.

Senator FAWCETT: Could you do that, please.

Mr Harfield : Yes.

Senator XENOPHON: You were saying, Mr Harfield, that you rely on what the ATSB says in its recommendations insofar as it relates to Airservices Australia. Is that a relevant—

Mr Harfield : Yes, in the sense that we have usually done our own investigation and we look at it to see whether it supports the findings that we found in our recommendation and whether there are any gaps.

Senator XENOPHON: I might be guided by Senator Fawcett on this if I have got this wrong, but my understanding of the ATSB report into this particular accident is that there was not much said at all about air traffic control, was there?

Mr Harfield : That is correct.

Senator XENOPHON: So, in the absence of the ATSB making recommendations about air traffic control issues, where does that leave you?

Mr Harfield : In this particular case, because this happened in a foreign jurisdiction, we would not necessarily be doing our own investigation into it.

CHAIR: The perfect mushroom!

Mr Harfield : As a result of that, we are very heavily reliant on the ATSB report, because that is our prime source of information as to whether there would be an issue, so therefore—

Senator XENOPHON: I just want to tease this out. Were there or are there any discussions between the ATSB and Airservices Australia in relation to this incident?

Mr Harfield : There would have been. We will have to take it on notice as to what they particularly were about.

Senator XENOPHON: Could you please provide—I take it I have the committee's support—details of memoranda, emails, correspondence, anything produced in writing, even records of phone conversations, with respect to those discussions in respect of this incident? In terms of Airservices Australia's role, Ms Staib—and I appreciate you have only just stepped into this role; how long has it been?

Ms Staib : Just one month.

CHAIR: By the way, we also appreciate that Airservices has been in some sort of disarray for a good while over the various problems you have had with credit cards.

Senator XENOPHON: And, if I could put it on the record, it is noted and I think we all welcome that Mr Houston is chair of Airservices Australia. I think that is a unanimously welcome appointment by the government. What role do you see for Airservices Australia to champion the change to the more proactive procedure that Senator Fawcett has quite rightly pointed out? Does it have a role? It seems to me right now that, unless the ATSB raises the red flag, there does not seem to be much of a role for Airservices Australia. Do you think that is an appropriate response?

Ms Staib : As we have discussed previously, in dealing with that incident there were various regulators involved, various service providers involved. But let us talk moving forward, because that is what I think you are asking me. In terms of looking forward, how do we look at these incidents? I see a role where we would work and talk to the other service providers in the region—and indeed, as I said before, globally—where we can learn lessons, understand what is going on. As I said before, when you have jurisdictions that abut each other, we need to be having open dialogue to make sure that we understand the roles everybody has to play and where we can work together to improve the system.

Senator XENOPHON: In terms of that open dialogue, could you provide as a matter of some urgency to the committee once you have had that dialogue with Fijian air traffic control, and indeed any communication you have with New Zealand, because I think it may well be relevant to the deliberations of this committee. Thank you.

CHAIR: Mr Harfield, is it?

Mr Harfield : Correct.

CHAIR: The world's perfect bureaucrat. Congratulations. Have you read the ATSB report?

Mr Harfield : Most of it, yes.

CHAIR: Mr Hobson, have you read it?

Senator XENOPHON: Sorry; Chair. Mr Harfield, you say you have read most of it. Which parts haven't you read?

Mr Harfield : I have read it. I mean 'most of it' in the sense of flicking through it and picking up various bits and pieces.

CHAIR: So you have had a flick?

Mr Harfield : Yes.

Mr Hobson : I have read it.

CHAIR: In detail?

Mr Hobson : Yes.

CHAIR: Does it not mention New Zealand's catastrophic unreported weather change? Does it not raise that?

Mr Hobson : I do not recall a comment on the New Zealand service provider.

CHAIR: Isn't that then a catastrophic flaw in the report? For God's sake, it is the key to why this may have happened and it is not even in the report! And that lets you off the hook.

Mr Hobson : Airservices responds to questions from the ATSB for information. We are not the authors of the report.

CHAIR: Senator Fawcett says I am a bit too far out there. I will go to Senator Nash and then to Senator Fawcett.

Senator NASH: I have some further questions that I will probably put on notice given the time. My question is following on from that and the ATSB report not having any reference to the New Zealand traffic control lack of provision. I asked you before, Mr Harfield, if, in the interim between now and when the Pacific forum takes place, there is another incident, who would have responsibility. You said New Zealand would because the ATSB report had been circulated so, then, if they did not act on that they would then be responsible, which made perfect sense to me. But now we find out there is actually no reference to New Zealand lack of provision of the information by the traffic control in the ATSB report. So how can they act on something that is not in that report?

Mr Hobson : My recollection is that the report talks about the responsibility of the pilot in command.

Senator NASH: Yes, but my point is that you, when I asked who would be responsible if an accident were to happen in the interim before this is addressed, answered that New Zealand would. But they have no information in that report to act upon. So how can that be correct?

Mr Hobson : That may well be the case.

Senator NASH: Mr Harfield, further to the answer you gave me before?

Mr Harfield : The question that I was asked before was, 'Who would be responsible if something happened again?' As I was saying, if the ATSB report has been passed to the New Zealand civil aviation authority and they, taking that up, have identified there is an issue then it is their regulation and their change.

Senator NASH: That is my point. There is no issue in their report for them to identify. That is my exact point.

Mr Harfield : Then there is no mechanism for the foreign jurisdiction to be aware there is an—

CHAIR: So you are the bunnies and the ATSB have, 'Do not ask, do not tell.' Senator Fawcett?

Mr Harfield : Say that again, Senator?

CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question. Senator Fawcett?

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.

We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?

Mr Harfield : That is a correct assumption.

Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?

Mr Harfield : That is a fair assumption.

Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?

Mr Harfield : In this case I do not recall and I do not think that they did. However, in other instances where things have occurred they have come to us to ask for assistance—for example, with some incidents that have happened in Indonesia.

CHAIR: But no-one cared about the prang off Norfolk Island?

Mr Harfield : That is not correct, Senator; I just do not recall the ATSB coming to us to ask us for assistance in this particular jurisdiction.

CHAIR: How long have you been at Airservices?

Mr Harfield : Nearly 25 years.

CHAIR: I think you need a change of career.

Senator FAWCETT: Can I clarify that if ATSB did come to you in the same way they came to CASA and said, 'Here is something that potentially could be a barrier to a future accident,' that would be a sufficient trigger for you to then take that on corporately and see what action you could take with your regional partners?

Ms Staib : Absolutely.

Senator FAWCETT: That is what we are trying to look at here—we are trying to ascertain what are the things that we can drive into the relationships between departments to make sure that we wrap up the system safety to the best extent possible.

CHAIR: So you will let us know how many Pacific Forums there have been since the crash where this has not even been thought about. Have you been to those Pacific Forums in the meantime?

Mr Harfield : Not personally.

CHAIR: Who goes?

Mr Harfield : The person that reports to me in charge of the airspace that abuts those areas.

CHAIR: Who is that.

Mr Harfield : It is my Manager, Upper Airspace Services.

CHAIR: What is their name?

Mr Harfield : Mr Doug Scott.

CHAIR: He still works for Airservices?

Mr Harfield : Yes, he works with me.

CHAIR: We would be delighted to have him come here and give evidence, Ms Staib, if you would permit that—if you do not, we will subpoena him.

Ms Staib : I do not think you will need to do that.

CHAIR: I am disgusted. Thank you very much for your evidence.

Senator FAWCETT: Chair, whilst you may feel that I do not think that represents the view of the committee. I recognise that there are some failures in the system and we need to work on that—

CHAIR: Can I clarify that I am disgusted not by the officers but by the system that allows this to happen. We are in no way blaming you. I think you are the bunnies.

Senator XENOPHON: Can we get the time line on Hansard for the email trail of communications between Airservices Australia and ATSB in relation to this incident, and indeed if the regulator, CASA, was involved as well, about this incident—any correspondence, communications, notes, memoranda and whatever. How long would that take to dig up?

Mr Harfield : We will do it as soon as practicable.

Senator XENOPHON: I would appreciate that.