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

Mr Dolan, do you wish to make an opening statement?

Mr Dolan : Given the time, just a brief opening statement?

CHAIR: Yes. The last one tried to talk us out of it.

Mr Dolan : I know I will not succeed in that, Senator! I just want to make four points that relate to the material that we have provided to the committee and perhaps help to understand a bit of context. A safety investigation is intended to understand what happened that led to an accident or other safety occurrence. The focusing question for the ATSB is whether the existing arrangements for the management of safety risk are adequate. To the extent to which they are not, we specify the inadequacy as what we call a safety issue. We assess its significance, and that is reflected in our report.

As we said in our submission to the committee, we have a comprehensive methodology for doing this. That methodology takes as its starting point, its base, the principles of human factors that were initially enunciated by Professor Reason and have been built on by a range of others. So, rather than seeing human factors as a separate issue in our investigations, we have integrated them into our overall processes.

By law, in shorthand, our investigations are required to be 'no blame'. That means we are not in a position of being able to apportion blame to any parties involved in an accident or occurrence, and we are not able to support any finding of liability. That being an explicit legislative provision, we take that seriously. It sometimes constrains the material we can put into a report.

CHAIR interjecting—

Mr Dolan : To some extent it would reflect that, but it has a range of other implications as well. In addition, there are provisions in the act which reflect the intent of annex 13 of the Chicago convention, which effectively say that there is a range of information acquired in the course of an investigation which should be protected and should only be released in the form of a report to the extent that it is necessary to understand that report and its analysis.

We drew to the attention of the committee that a range of the documents that the committee asked for were restricted information in those terms, and we asked—and you agreed, and we are grateful for it—that you would treat that information as confidential. It is possible that in the course of our discussions we may get to the point where you are asking us to comment on the details of a piece of restricted information, and at that point I would be requesting to the committee that we potentially deal with that in camera. But to expedite matters, perhaps, if there are a sequence of those, we could leave them rather than going in and out of camera.


Mr Dolan : Other than that, I have been carefully looking at the various submissions that have been made available to us in the course of this and listening to the evidence that has been given today. As a learning organisation, we continue to reflect on whether we could have done things better. It would appear to me that, rather than wait for you to draw it from me in questioning, I should say up front that there are two areas where we think we could have done better with this investigation and report. The first and obvious one is that it took us far too long by anyone's standards, including our own, to get to a completion of the investigation. There are reasons for that, which I would be happy to discuss, but they do not excuse the three-year time frame for the report.

Secondly—which has become clearer to me as I have listened to today's discussions—in balancing the requirements of restricted information only to include in the report that information that supports analysis and conclusions, we did not give enough prominence, and in some cases did not even include in the report, a range of lines of inquiry that we considered and assessed were not relevant to our investigation. So the report only gives a partial picture of the sorts of issues that have been before this committee. Again, I am happy to talk about those lines of inquiry and answer any questions on them. I am in the hands of the committee.

Senator FAWCETT: The first obvious question is: why did it take three years?

Mr Dolan : When, nearly 3½ years ago, I joined the newly independent ATSB as chief commissioner, we had over 100 aviation investigations on hand, including four that we classified as level 2—so substantial investigations requiring major and continuing use of our resources. We were averaging about 18 months for the completion of investigations, with some serious outliers in that. We had more work on hand than we knew how to deal with, and we would normally expect in any given year to get one of those level 2 investigations. So we had a lot more work than we were used to. That led to delays in a range of reports and, as new investigations came in, the shifting of resources to different priorities as they arose. It is clear that, in managing that allocation of resources to always-shifting priorities, we did not give enough attention to getting to an expeditious conclusion of this Norfolk Island report. However, that is the context in which that happened.

Senator FAWCETT: Did you have an underspend in your budget this year, last year or the year before?

Mr Dolan : There have only been three complete financial years now. In the first year—in the first of my years of stewardship of the organisation—we had a slight underspend. In the last two years we have had slight overspends, but always within less than one per cent of our allocated budget.

Senator FAWCETT: You have not considered outsourcing any of the work or insourcing extra capacity to expedite the production of reports?

Mr Dolan : Our resources are largely tied up in maintaining our existing investigative capability, who are permanent staff of the organisation. We have a longstanding view that in almost all circumstances it is better to have, if possible, the range of expertise available to us on a permanent basis and therefore immediately available than to rely on potentially risky external outsourcers.

Senator FAWCETT: I am not talking about normal operations. I am talking about a situation where you have a budget underspend and a clear excess of work. Was it even considered? That is all I am asking.

Mr Dolan : In that small underspend, no, we did not consider it.

Senator FAWCETT: Having heard the evidence today, you have undoubtedly heard that there is a very strong view of the fact that there are systemic regulatory and human factors issues that many witnesses do not feel were explored at all or adequately. I hear your comment that human factors are integral to the report, but certainly the impression I have had from a lot of witnesses is that that has not been drawn out as a specific issue or even potentially a contributor to what appears to be very much a focus on the violation by an individual as opposed to what may have led to the circumstance. Can I take you back to, for example, your own organisation's recommendations over a decade ago that things like Norfolk Island should have a specific fuel policy developed by CASA. It is the fact that your organisation made such a recommendation, and yet here we are a decade later and it has not been implemented, and now we have lost a hull but thankfully no lives. Does it not even cross the organisation's mind that that sort of thing might be a factor?

Mr Dolan : It is probably worth a small point of clarification. As best we understand it, and we have checked our records, the recommendation that relates to the previous Norfolk Island investigation related to passenger transport operations, and CASA did in fact change their regulations to change the fuel and other requirements for passenger operations to Norfolk Island. So that recommendation was in fact addressed by the Civil Aviation Safety Authority. But it did not address the question of operations classified as air work.

Senator FAWCETT: You do not think it was worth mentioning in the report that that discussion has been held previously but no action has been forthcoming?

Mr Dolan : The recommendation that we were originally talking about, as I understand it, related to passenger transport. We had satisfied ourselves as an organisation in terms of that recommendation action—

Senator FAWCETT: No, I am now going to the other recommendation you were talking about, which is about making EMS a charter as opposed to air work. You do not think that was relevant?

Mr Dolan : There has been continuing debate following our Newman investigation as to the range of air work operations that carry other individuals, some of whom are employees of organisations and so on. While the recommendation of a particular investigation was focused more on mining and similar operations, there is an ongoing question as to balance. For ambulance and similar works in emergency situations the understanding was that the necessity for urgent action led to a situation where you required more flexibility. In the course of pointing out, as we did in the findings of our investigation, that there were problems with the overall guidance and so on for fuel management, we draw attention to something that we saw as a positive step, which was CASA's work to consider the classification of ambulance and similar operations and effectively impose the charter standard on them.

Senator FAWCETT: That is still a prospective view of something that might happen, as opposed to identifying the fact that this was an issue discussed nearly a decade ago upon which no concrete action has been taken. Surely that is relevant to an EMS flight under the air work category that has almost cost us a number of lives?

Mr Dolan : As I said, we were looking at the overall system as it operated in this case for this flight to Norfolk Island and the broader context. This involved the limited but still significant number of cases where departure to a remote island destination was at a time when the forecast was good and en route the forecast became bad, of which there are somewhere between six and eight instances in 1,000; that is the risk context for this. We looked at the overall framework. The difficulty we have in this case is that we looked at the existing arrangements that were in place and considered compliance—the issue of error and violation—at early stages and the extent to which they actually contributed to the situation. Given the weighting that it appeared necessary to give to less than perfect planning, the likelihood that insufficient fuel was loaded than was required by the existing standards for whatever the weather was at the time and so on, it is about finding the balance in terms of our methodology to say it is very hard to take it all the way up the organisational tree. We have a methodology that effectively starts from the facts and tries to assemble the facts into issues and then assess them appropriately. In that process we did not get to the point where the classification of operations issue became sufficiently prominent that we thought it required attention in the final investigation report.

Senator FAWCETT: It was 2.3 on the error. I am not going to go over all the discussions we have had because I understand you have been listening to it. So you will understanding my contention that errors do not tend to occur overnight. People tend to drift towards errors, particularly where there is not a robust checking and training system and proficiency checks. Why was that not covered at all, given that you had visibility of a special audit that indicated there were very real deficiencies in those areas in the organisation?

Mr Dolan : This goes to my comment that there were a range of lines of inquiry which were reflected in the report if only to say that we considered and appropriately dismissed them. We are satisfied, having viewed the training, and the check and training records in relation to the pilot, that there was no indication of any drift, which makes it even more puzzling as to the—

Senator FAWCETT: Would it be a more accurate thing to say that there was no record in most cases?

Mr Dolan : Mr Sangston might be able to provide detail on that but my understanding is that we do have records. Some of them are more yes/no, check-type records, but there are a set of records that indicate that proficiency did not appear to be a problem or a trend in terms of the pilots involved. Is there anything you would like to add, Mr Sangston, on that?

Mr Sangston : Not particularly, apart from to observe that we make comment in the report that the proficiency reports were not commenting on everything that was covered in the proficiency checks. But that aside, I have nothing to add.

Senator FAWCETT: The observation going through some of the drafts to the final report seems to indicate that there has been a shift within ATSB's position from one of recognising a number of systemic issues to one that says, 'The company complied with everything they had to, legally, and the fault rests with the pilot.' Why did that shift occur?

Mr Dolan : The significant shift is on the issue of en route decision-making and the support and guidance that is available for en route decision-making. In the initial stages, as we were still gathering the facts of the event and trying to understand what had happened, we went to the Civil Aviation Safety Authority and said, 'We think we have something that looks like a critical issue.' We do that in a proactive way even before we have finally come to an assessment of significance. So we err on the side of caution.

Our assessment at that point, based on what we knew at that point, was: there is something seriously problematic here that the regulator should take a look at. And we had an interchange, some of which I think CASA has already discussed with you. That was the key systemic issue at the early stages. We were trying to understand the rest of it and applying, progressively, our methodology. What we tend to do is have a series of review steps—peer review, managerial review, and finally review by myself and my fellow commissioners, of reports at various stages. The question is: having identified a safety issue such as the en route guidance and planning, how do we do a risk assess—that is in the material we have given to the committee—of this issue we have identified?

Having done that risk assessment, likelihood and consequence, we form a view as to how serious the issue is in our eyes. So we start off with, as I said, a very conservative view. If it looks serious we treat it as serious until we verify it. But on the way through, as we checked and reviewed the position according to our methodology, progressively we were less convinced in our framework that this was as significant an issue as we first thought.

Senator FAWCETT: Did CASA reveal or disclose to you the fact that their FOI population was split 50-50 over that exact issue that was initially identified as a critical safety issue.

Mr Dolan : I do not recall that. It was certainly not brought to my attention. Are you aware, Mr Sangston, of anything else?

Mr Sangston : No, I was not aware. I saw what was said by the previous interviewees but I was not aware of that.

Senator FAWCETT: So it was presented to you as a fairly black and white issue that the training, the existing legislative basis, and things like AIPs should have been sufficient guidance for any pilot to make the appropriate decision, and that was why it was downgraded.

Mr Dolan : That was one of the relevant considerations, yes.

Senator FAWCETT: With the process you are describing whereby you use a process, and risk and consequence and all the good tables I have seen in your submission, do you consider balancing that against the cost of action? I will take for example the New Zealand flight information service where, in Australia, if there is a deteriorating weather situation they have an obligation to update the pilot and alert them to the fact that something is occurring, or the Unicom operator who was not legally allowed to use the HF radio to talk. But if either of them had said, 'The situation is getting worse,' as Unicom did to the New Zealand FIS who chose not to pass it on, surely, even including that kind of thing, there should be a recommendation that the Australian government should talk to the New Zealand government and ask for cooperation for safety reasons. Even if it is only for one in 1,000 flights and your probability of occurrence is very low, given the cost of action is also very low, why does your process exclude consideration of something that to the common man in the street seems like common sense? Why are we not seeing logical, reasonable recommendations coming out of ATSB reports to an address in this case two things, either of which probably would have prevented the accident?

Mr Dolan : There are two things there and I will go to the question of recommendations before I get to the specifics of your question. The ATSB at the point where it became independent of the Department of Infrastructure and Transport also got a shift in its powers in relation to the making of recommendations which raised the ante with recommendations and their significance. There is a legal requirement to respond to each of the recommendations we make. In recognition of that we set up the system of identifying safety issues that said there needs to be a critical or a significant safety issue before we will explicitly use that power to make a recommendation and require a response, and we would generally limits recommendations to those sorts of things. What you are talking about we would in our normal framework, given what you said about likelihood and consequence, deal with as a safety issue without going to recommendation. That is the context: it is still there but your question remains.

The answer is we assessed the facts of the information made available in the course of the flight, the number of opportunities to receive information and to absorb it. We said that that did not seem to indicate that there needed to be any change to the system. That is a matter that others based on those facts could form different views on, but the view we formed was we did not see anything that needed to be done to enhance that system.

Senator FAWCETT: With all due respect, to have a process that deliberately closes the door to suggestions that another agency, if they wished to say they would respond to that recommendation by saying no but if they chose to say yes may have saved this flight and may potentially save another flight, I suggest is process that is extremely poorly misplaced and prioritised.

Mr Dolan : I accept you can suggest that to me. As I said, we as an organisation were trying to look at this on a systemic level rather than an individual detail level. We looked at the overall components of the current system to deal with the risks that go with operation to remote islands and the particular case we were dealing with which was the situation where the weather forecast on departure was for weather suitable for landing at the destination and that changed en route. That seemed to us the key issue. There was also an issue about what happened in pre-flight planning and so on, but for us as we say in our report the key issue was, having left, how to deal with the situation where things change in flight. What we tend to do in identifying safety issues is rather than specifying a precise solution to the issue we try and draw the issue to the attention of those who are best placed to do something about it and for them to take steps to deal with it.

We could certainly have a discussion about this, but it is the methodology we currently use. Rather saying precisely there is a problem explicitly with the issue of the proactive provision of weather information by air traffic control, we focused on the general framework to support information, the seeking of information and the provision of information, and decision-making en route. We left it as a general issue rather than coming up with a precise set of answers and making those a requirement. That is the way we normally do the business: we try to leave it to the organisation best positioned—in this case, the Civil Aviation Safety Authority principally—to decide how best to deal with the issue and to tell us what is being done to address the issue, which is the safety action part of our report.

Senator FAWCETT: Mr Dolan, I think you have probably heard a number of the witnesses this morning indicate that in their view ATSB in the past has taken a far more proactive approach to identifying issues and being prepared to make a recommendation. The general consensus from witnesses has been that that is a far more value-adding document. With a technical issue, for example an A330 off the North West Shelf with a software glitch that causes the aircraft to plunge, in terms of probabilities it was very remote that that would never happen again. But there was a report, recommendations and the OEM put a fleet-wide alert out to look at a software reload or whatever. If that approach is taken on something that almost led to the loss of an aircraft, here we have the loss of an aircraft. Why did you take such a conservative approach as opposed to saying any information, any opportunity to preclude a further incident by including all of the regulatory and systemic issues in terms of the organisation, their training, they check-in training, the lack of control, the lack of standardisation around fuel planning—all the things that led to this occurrence—should be canvassed in the report? I have heard your process, but putting the process aside, is the process wise when after three years we end up with a report that deals quite narrowly with one element of the things that led to this incident?

Mr Dolan : As I said earlier in my general reflection on what I have been hearing through the submissions and today, there are two elements to this. The first is that there was a range of lines of inquiry that we went down. We satisfied ourselves that there was not a safety issue involved in it. Among the massive documentation we have provided to you, there is a range of lines of inquiry that clearly we went down. We did not reflect that process in our report and on reflection that is not ideal. That is the first issue. On some of the things you are concerned about, our view is we did take a look at them and formed the view that they were not directly relevant to the issues we needed to address in the report.

Senator FAWCETT: When you say 'we', who is we? I assume you have a drafter and a reviewer.

Mr Dolan : Yes, there is an investigator in charge with a team.

Senator FAWCETT: Who was that in this case?

Mr Dolan : That was Mr Michael Watson who was investigator in charge. He has a manager.

Senator FAWCETT: Who is?

Mr Dolan : Who is Mr Ian Brackenshire. There is our general manager, Mr Sangston. There is also a process for peer review of drafts. I am trying to remember who the peer was in this case; Ms Samantha Moran.

Senator FAWCETT: Can you just describe to me which level get involved. My understanding is that there were two or three drafts that were sent to interested parties. Is it peer reviewed and sent to interested parties? Does it go through to Mr Sangston or to you? Who authorises that release?

Mr Dolan : The release of a draft report to interested parties for their comment as to factual accuracy and any other comments they wish to make, depending on the report, is a matter for the general manager or for me and my fellow commissioners.

Senator FAWCETT: In this case who was it?

Mr Dolan : In this case it was Mr Sangston who authorised its release, with the authority of the commission, but the commission at that stage, while it read the draft report, did not authorise its release.

Senator FAWCETT: Did it provide any informal feedback?

Mr Dolan : It provided some informal indication as to the drafting but nothing as to content at that stage—so the language of the report and its readability. Normally there is a single round of directly interested party process, the comments come back, the investigator in charge reviews them and we actually have a specific component of our overall investigation support system to support that. Each comment is taken, read in context and then explicitly put into our system, with a response which is then either reflected in our final report or not.

Senator FAWCETT: To date, this all sounds like a big happy family. Was there any dissent or difference of opinion between any of those levels of review or drafting?

Mr Dolan : There were certainly differences of view and indeed vigorous debates at times, which is what I would expect from the organisation. I would be worried if we were too quickly forming a consensus on an investigation. So there were points all the way through where there were disagreements in the organisation that had to be resolved. Indeed, there was one point in the finalisation of the report where the commission, having reviewed the material, was not satisfied that a certain assertion was sufficiently backed up by evidence. So there are a whole range of innovations all the way through, to try and get the best quality—

Senator FAWCETT: Do any of the commissioners have a background or qualification in aviation accident investigation?

Mr Dolan : I do not believe any of the three commissioners are qualified in aviation accident investigation. I have a reasonably significant background in aviation safety—air security and various other things—and a broader background in safety, including work health and safety and the systems approach to that. The other two commissioners have backgrounds in marine safety and rail safety.

Senator XENOPHON: Chair, with Senator Fawcett's indulgence, could I get a clarification of what you just said, Mr Dolan, in terms of who authorised what. You are saying that the drafts of the report were authorised by Mr Sangston? Just give me the sequence of events.

Mr Dolan : The draft report that was circulated to interested parties for their comment was released under the authority which Mr Sangston holds—under Mr Sangston's authority.

Senator XENOPHON: But effectively it is his delegated authority from you.

Mr Dolan : Yes.

Senator XENOPHON: So you had not seen that report?

Mr Dolan : I saw that report at the time it was sent as a draft to directly interested parties for their consideration.

Senator XENOPHON: So it was reviewed by the commission or it was not reviewed by the commission?

Mr Dolan : It was not reviewed at that stage by the commission.

Senator XENOPHON: Please clear this up for me, because at page 42 of your submission, in the third last paragraph, it says:

Based on the nature and scope of the draft Norfolk Island investigation report, it was not reviewed by the Commission and the General Manager approved its release to the directly involved parties (DIP) for comment on its factual accuracy on 26 March 2012. Comments were requested from DIPs by 23 April 2012.

Is that a little different from what you have just told me?

Mr Dolan : I do not believe so. Certainly the intent was to say that the report was released with Mr Sangston's delegated authority and was not considered by the commission.

Senator XENOPHON: But didn't you say that the commission reviews things? Don't you, as the commissioner, review a report of this nature before it goes out to directly interested parties?

Mr Dolan : We review some reports before they go out to directly interested parties and with others we are satisfied that, at the draft stage, it can be authorised by the relevant general manager.

Senator XENOPHON: So in this case, you did not review it?

Mr Dolan : That is, before it was sent to interested parties. That is correct.

Senator FAWCETT: You did not see it formally or informally before it went out?

Mr Dolan : I am trying to recall.

Senator XENOPHON: What do you define as 'review'? Do you define it as seeing something before it goes out?

Mr Dolan : That is what I am trying to recall. Mr Sangston may be able to help me. I cannot recall receiving an informal copy of the report at the draft stage—

Senator XENOPHON: Hang on—

Mr Dolan : My recollection is that it was simultaneous with the release.

Senator XENOPHON: Please correct me if I am wrong, but didn't you say that it was an authorised release by Mr Sangston and not authorised or not reviewed by you?

Mr Dolan : Mr Sangston has the authority on his own behalf, essentially delegated by the commission, to circulate a draft reports under section 26 of the Transport Safety Investigation Act—

Senator XENOPHON: Sure, and therefore it is an authorised release?

Mr Dolan : It was an authorised release. Yes, Senator.

Senator XENOPHON: But it was not reviewed by you?

Mr Dolan : It was not reviewed by me before release.

Senator XENOPHON: But was it seen by you before release?

Mr Dolan : I do not recall seeing it before release.

Senator XENOPHON: Would you normally recall seeing a report of this nature before release? What would your normal practice be?

Mr Dolan : My normal practice would be: if the report is at the draft stage to be authorised for release by the commission, the commission will see it before it is released; if the decision were made, as it was made in this case—and there is some discretion with our general managers—on the part of the general manager to release it, they are authorised to do so. I had informal discussions at various times about the progress of the report and when it was coming out, but I do not recall ever formally reviewing the report with my fellow commissioners until it was back from the directly interested party stage.

Senator FAWCETT: Mr Sangston, did you feel as though you received any feedback that shaped or influenced the report from the commissioners before you authorised its release?

Mr Sangston : My recollection is that Mr Dolan did not do a formal commission type review but read the report some time around the same time that I approved it to go to directly involved parties. I cannot categorically say whether it was before or after—

Senator FAWCETT: I guess the critical question is: do you feel as though that resulted in any feedback, formal or informal, that shaped the report that went out?

Mr Sangston : The draft report?

Senator FAWCETT: Yes.

Mr Sangston : No.

Senator FAWCETT: Some of the witnesses today talked about the fact that they believe that this report represents a low point in ATSB's standard of reporting. Within your review process and the robust debate that went on, did any of that debate go to the heart of the issue of how this complies or measures up against the international standard that people expect to see, dealing with the whole range of organisational, regulatory and human factor issues? Did anyone push for that and was it contested by the people who obviously won?

Mr Dolan : Up to the point you are talking about, Mr Sangston, as we have been discussing, was much more closely involved in that process than I was. He may wish to add detail. Our general view—and, as I say, we attempt to be a learning organisation, so we clearly need to review this in light of the response to this report—is that, if we are satisfied that the investigation has proceeded in accordance with our methodology and the report has been drafted in accordance with our standards for writing reports, they are the benchmarks that we set for ourselves. They are meant to reflect international requirements under the annex 13 provisions of the Transport Safety Investigation Act and what we understand to be better practice. Rather than looking externally, we tend to look more towards our own standards for this. I am not sure whether Mr Sangston could add more to that.

Mr Sangston : I do not think so.

Senator XENOPHON: Annex 13 is the benchmark by which accident reports ought to be prepared. Is that correct?

Mr Dolan : Annex 13 sets some recommended format for reports, which—

Senator XENOPHON: It is not just about format; it is also about substance—the content of a report—isn't it?

Mr Dolan : In terms of content, headings and some guidance as to what goes under those headings, yes.

Senator XENOPHON: I will not labour the point, but it goes on to the objective of the investigation, the notification, the responsibility of the state of occurrence, organisation conduct of the investigation, the issue of the flight recorders, accidents and incidents, informing aviation security authorities, nondisclosure of records and the reopening of an investigation. It goes into more than just format—it is quite substantive, isn't it?

Mr Dolan : Perhaps I misunderstood your question. I thought your question related to the report. The provisions you are referring to, which are very much at the heart of annex 13, reflect some explicit requirements for the investigation process. Chapter 6—

Senator XENOPHON: Have you complied with those? Do you reckon this report complies with ICAO annex 13, the international benchmark for such reports?

Mr Dolan : In terms of the way we have viewed annex 13 and the way our procedures and internal standards draw on annex 13 in the light of the Transport Safety Investigation Act, our view was that yes, it did meet those requirements.

Senator XENOPHON: On what basis? Can you tell me by looking at ICAO annex 13 and the requirements in ICAO annex 13 how you say the Norfolk report prepared by the ATSB in any way remotely adheres to the principles set out in annex 13? You can take it on notice. You might want to consider it. Maybe I am completely wrong, but my reading of it is—are we reading completely different documents?

Mr Dolan : This is why I tried to draw distinction between the question of the report and the broader question of the investigation. The report—as in, the document that is produced at the end of the investigation—is essentially chapter 6 of annex 13, which recommends in the format of the final report that an appendix be used, but it may be adapted to the circumstances of the accident or incident. Chapter 6 of annex 13 is the one that relates to the final report of an investigation.

Senator XENOPHON: But before you get to the final report there is a whole range of things that need to be done, a whole range of protocols suggested.

Mr Dolan : There is a whole range of protocols in relation to the conduct of the investigation.

Senator XENOPHON: And do you reckon you have satisfied those protocols?

Mr Dolan : By my best assessment at this stage, yes.

Senator XENOPHON: Let us go back to another issue. In the ATSB submission you present your investigation model. In the build-up to that model you talk about the ATSB approach to safety factor analysis as a superior approach because:

It better enables the search for potential safety issues, particularly those more remote from an occurrence. The enhanced searching will result in more safety issues being identified and communicated to relevant organisations to enhance safety.

It has a greater potential for providing a richer or more detailed description of the factors involved in the development of an occurrence …

Then, on page 13, following the diagram of the model, you explicitly state:

The most important safety factors to identify are those that occur at the risk control and organisational influence levels. These are the levels where changes can be made which can have a meaningful influence on safety.

Do you believe this report meets the ideals you have set out in your submission to this inquiry?

Mr Dolan : We made what we considered every reasonable effort to get from individual action in this case towards those higher level controls—

Senator XENOPHON: How do you reconcile the ideals set out in your submission with the fact that the CASA special audit does not make it into your report? There is no mention of it. Serious organisational issues with respect to Pel-Air do not make it into your report—how can that be?

Mr Dolan : We do not explicitly refer to the CASA audit report in our investigation report. We provided the committee, which probably has not had a chance to consider it yet, with our assessment —

Senator XENOPHON: Sorry, have you not had a chance to consider the CASA special audit?

Mr Dolan : No, we have reviewed it carefully, and we have reviewed it carefully in the light of our report.

There were a range of factors that were highlighted in the CASA special audit that we believed we had already addressed, particularly in the factual basis of our report.

Senator XENOPHON: But why didn't you mention the CASA special audit in your report? It goes to systemic issues, it goes to organisational issues, it identified a number of deficiencies in relation to Pel-Air's operations, yet not one mention of it is made in the ATSB report about an incident involving a Pel-Air aircraft.

CHAIR: The other thing being that the person who was the chief pilot at the time, who would have been responsible for—what do they call the policy? The audit report criticised Pel-Air's—what is the word I'm looking for, Senator Fawcett?

Senator XENOPHON: Chair, can I just follow up another issue, because I know we are running out of time. There is something that concerns me that was raised by AIPA in their evidence. I am not sure if you heard AIPA's evidence today.

Mr Dolan : I did, Senator.

Senator XENOPHON: And I do not think they have any axes to grind; it looks like they understand as pilots about making reports to the ATSB about any incidents, so there is that just culture and the like. Now, in a recent consultation document on the enhanced mandatory reporting proposal, you, or ATSB, said:

Presently, CASA receives a summary of each occurrence with only a little more detail than in the Weekly Summaries posted on the ATSB’s website.

I put it to you, Mr Dolan, that that statement is deliberately misleading or at least grossly misleading. Do you agree with that proposition?

Mr Dolan : No, I do not.

Senator XENOPHON: Well, I am told that CASA actually gets the verbatim report with only the reporter's name redacted but still all the details of the aircraft and the time of the incident.

Mr Dolan : That is certainly not my understanding. Mr Walsh is responsible for the system—

Senator XENOPHON: I have seen a document that seems to contradict what you have just put.

Mr Dolan : Would you like to comment, Mr Walsh?

Mr Walsh : We certainly provide CASA with a daily report on all occurrences that the ATSB has received. We remove any overt personal information that identifies any individual from those—

Senator XENOPHON: You include the aircraft, though, don't you?

Mr Walsh : Yes, we do include that.

Senator XENOPHON: So, through identifying the aircraft, you can identify the pilot, can't you?

Mr Walsh : Yes, you can and—

Senator XENOPHON: Hang on. So, Mr Dolan, given Mr Walsh's answer, when the ATSB says, 'Presently, CASA receives a summary of each occurrence with only a little more detail than in the weekly summaries posted on the ATSB's website,' that is actually grossly misleading because you can identify the pilot involved because you identify the aircraft. And the AIPA pilots, two very competent men who are well regarded in aviation circles, had no idea of that.

Mr Walsh : We have just completed some face-to-face consultation as part of the consultation package that you have talked about. During that process, we flew around the country and spoke to many operators—all the major airlines, a lot of the regional airlines and the like—and we also met with representatives, as I understand it, from AIPA. During those conversations, we made it quite clear what we provide to CASA currently. Obviously, the reaction by industry to the proposal in that consultation package has been very strong. We are trying to work with CASA at the moment to—

Senator XENOPHON: Mr Walsh, I apologise, but I am running out of time. I need to ask you, ATSB, and Mr Dolan in particular: what protection is currently provided to a reporter under the existing mandatory reporting scheme, given the ease with which CASA can establish the redacted information; and have we actually already embarked on a regulatory assault on the reporter's privilege against self-incrimination? We have; isn't that the case?

Mr Dolan : The notification system is in parallel with our investigation system and not part of it. It is a mandatory system that is designed—

CHAIR: Did that note you just got help?

Mr Dolan : No, Senator. On the specific question, the system is designed to provide safety information not just to the ATSB but to the broader system. It is designed to minimise the risk that it will be used by the regulator to identify and take action against individuals.

Senator XENOPHON: Mr Dolan, we are running out of time.

Mr Dolan : We are having a discussion at the moment in terms of a proposal to change the system.

Senator XENOPHON: No, the system has already changed, hasn't it? In a recent consultation document, you said:

Presently, CASA receives a summary of each occurrence with only a little more detail than in the Weekly Summaries posted on the ATSB’s website.

Given what Mr Walsh has said, that is actually grossly misleading, because CASA can identify the pilot because you can identify the aircraft. Do you agree with that proposition, Mr Dolan?

Mr Dolan : I still stand by it, but I can understand—

Senator XENOPHON: How can you stand by it? It is patently misleading. It is false. How can you stand by a misleading statement? How can you say that there is only a little more detail in the weekly summaries posted on the ATSB website, which guarantees anonymity, when in fact the information that you provide to CASA can pinpoint the pilot? How can you stand by that?

CHAIR: The easiest way out might be to say it might be a bit of a balls-up and say, 'Yes, we've cocked it.'

Mr Walsh : I think the point is that the ATSB, as I think Mr Dolan said, only plays one part in the safety system, and we do not have any responsibility for the management of risk in the aviation industry. That is something that is much more aligned with CASA. For CASA to be able to perform its functions, it must have access to occurrence information, and information that is de-identified to the extent that it does not become usable would not be helpful.

Senator FAWCETT: Speaking of defences and things that are important, I just want to come back again to content in the report. The last line of defence for these people when they exited the aircraft was life jackets and life rafts. The procedures in place for the life raft involved placing it by a door. Most crash loads are expected to be in excess of 20G. Clearly placing it by a door is not going to work. Hence it disappeared somewhere in the aircraft in the dark. Life jackets did not work properly, which has potentially caused somebody a lifetime of disability, not to mention all the other mental issues. This sort of equipment and these sorts of procedures are probably fleet-wide through similar operations around the nation. Why was that not even covered and not even mentioned in the report?

Senator XENOPHON: And the lights did not work on the life jackets.

Senator FAWCETT: Lights; whistles that did not have a long enough lanyard to blow. It would almost be laughable if it were not so serious.

Mr Dolan : Mr Sangston may wish to add more.

Senator FAWCETT: Mr Dolan, you have regaled us very proudly with the process that you used to date and your tables weighing risk, probability and outcomes. Why weren't the life jackets and life rafts even mentioned given the potential to affect so many people?

Mr Dolan : As I understand it having reviewed the various materials, we did examine the question of life jackets—on reflection, perhaps not at the level of detail we should. With the life rafts, I do not recall that there was any examination in detail. In terms of the survivability aspect of the report, it is certainly not comprehensive. So that would be my response, and that was the framework on which I wish Mr Sangston to comment.

Senator XENOPHON: The only reason this has not gone to the coroner's court is that Dominic James happened to have a waterproof torch that somebody on land at Norfolk Island happened to see. Otherwise we would have been looking at six dead people. Would you agree with that?

Mr Dolan : The lights on the life jackets were still operating when they were picked up; they were seen by the rescue vessel. But the issue of the light was in fact related to the fact that Norfolk Island rescue thought that the aircraft had ditched in a different place to the one where it actually was.

So there are two separate issues here. One is the question of the torch, and that relates to a misunderstanding about the location of the ditching. The second is the detectability of the lights on the lifejackets, when a search is occurring in the correct area.

CHAIR: [inaudible]

Mr Dolan : They are not designed to be seen at a long distance. They are designed to be seen—

CHAIR: But could it be possible that they are underwater, especially if you are hanging onto someone who does not have a lifejacket.

Mr Dolan : It is possible.

CHAIR: Three lifejackets for six people—

Mr Dolan : It is possible.

CHAIR: While you are at it have you issued an order to lengthen the string on the whistles?

Mr Dolan : It is not an issue that was brought to our attention in our investigation. There are some details that—

CHAIR: We still have the short string, so when the next one goes down: 'Can I have a lend of your whistle?' Is that what is going to happen. You guys know about it so why haven't you done something about it?

Mr Sangston : That was not brought to light during our investigation about the length of the strings to the whistles.

Senator NASH: Now that it has been, what are you going to do about it?

Mr Dolan : We will re-examine that part of the report. In light of the evidence that has now been brought to our attention, and that was not brought to our attention during the investigation or in the factual review of the reports—

Senator EDWARDS: Isn't it your job to find out these things and interview these people? We have been here for a day and we found this out.

CHAIR: It begs the question, if you did not find out in the investigation it probably means that you did not ask the right questions. Surely to God—the people who told us that were so distressed at the time that if you would have asked them they would have told you. Did you ask them?

Mr Sangston : A number of interviews were carried out. I am not aware that this issue came up as a result of those interviews.

CHAIR: With the people who were in the water?

Mr Sangston : I understand that that is the case.

CHAIR: Not 'understand': yes or no?

Mr Sangston : I would have to check it and get back to you.

CHAIR: So you may not have interviewed the people who were actually in the water?

Mr Sangston : I cannot imagine that being the case, because as—

CHAIR: Nothing would surprise.

Senator EDWARDS: You do not know whether or not you interviewed the people who miraculously survived this crash?

Mr Sangston : We did, I was going to say, because we described how each of the individuals were, fortunately, able to extricate themselves from the aircraft.

Senator NASH: So at no stage did you ask them, 'Did the prescribed safety procedures work?' You are the Australian Transport Safety Bureau and at no stage did you ask the prescribed safety requirements work?

Mr Sangston : I do not know precisely what was asked in the interview.

CHAIR: Could we have a record of the interviews?

Mr Dolan : We can draw it to your attention. It should be amongst the material we have already supplied. We will find it for you.

Senator NASH: Wouldn't that be the first thing you would do? We all spend half our lives on planes and we are getting the safety procedure drilled into us every time we get on a plane. Surely, as the ATSB, the first thing you would ask would be: did the process work properly?

Senator EDWARDS: Was the lifejacket under your seat?

CHAIR: I always check?

Senator STERLE: I—

Senator NASH: Sorry, Senator Sterle, I just want an answer.

CHAIR: Here comes the 'no'.

Mr Dolan : It is an attempt to establish a matter of fact, Senator. The focus of the investigation, from a comparatively early stage, was on what led up to the accident. If there is a fair criticism here it is that we did not quite get the balance right. We were focused more on why it came to that event rather than what happened afterwards. That is what I am hearing and I think there is substance to it. With the wisdom of hindsight, it might not have been quite the right balance in terms of how we reviewed processes.

CHAIR: I do not think there is much wrong with the investigation of what led to it—in great detail.

Senator EDWARDS: Chair, since we have started, there has been mea culpa after mea culpa after mea culpa in this thing. Now you are hearing evidence for the first time of what is supposed to be a forensic investigation. I have heard that this report would be a joke in the international standing—if other reviewers were to have reviewed this. I think that the evidence that Senator Xenophon and Senator Fawcett are drawing out would suggest that. We haven't even got to the black box yet. Are you proud of this report?

Mr Dolan : I certainly would not hold this report as a benchmark. I am still satisfied that the key elements—

Senator EDWARDS: Three years in the making. Mea culpa after mea culpa. Are you proud of this report?

Mr Dolan : No, I am not proud of this report.

Senator EDWARDS: Senator Fawcett has questioned you about what the outcome is of it: forget the people, forget who you nailed, forget who was responsible—what did we learn, and where does it go from here? We have not heard that. He has asked you twice. Where do your recommendations go? In fact, you do not make many recommendations a year, do you? Two last year?

Mr Dolan : I think that would be right.

Senator EDWARDS: I am a fair bloke. I do not live in the airline world like many people on this committee. But this is not reasonable for you. I have one last thing to ask before I hand over to my more learned friends. I am holding up a folder and the yellow papers in there are confidential evidence received by this committee—there is a majority percentage of the information in this folder. We are trying to get that on the public record. But in the context of there being nearly a ream of confidential information that you have not seen—email trails and things like that from people who have been involved—did you or your officers have any formal or informal ongoing involvement with CASA officials in and about the formation of this report? Remember, I have all of this information I have indicated.

Mr Dolan : I recognise that and I do not think that would change my answer at all. In the broad, in terms both of our memorandum of understanding with CASA and of our operational relationships, given that we both have roles in the safety system, we have ongoing interactions with CASA. We have six-monthly meetings with CASA formally with an agenda to work through issues of common interest and how they are working—

Senator EDWARDS: Specifically about this inquiry.

Mr Dolan : All I am aware of in relation to this inquiry is the discussion that took place in relation to that initially identified critical safety issue, and how that was played through. There was some discussion from time to time about the progress of the investigation, as part of our normal contact with CASA—and update. And a directly—

Senator EDWARDS: Were they critical of you and the time you were taking?

Mr Dolan : And a directly interested party stage. They asked from time to time about progress. But Mr Sangston may be aware of other interactions that I am not aware of.

Mr Sangston : In addition to those, I at times have an administrative type interaction with a gentleman of the Accident Liaison and Investigation Unit in CASA. But that is on an formal administrative basis only, so it was not specific to the progress of this investigation—

Senator EDWARDS: At any time did any of those people direct you as to what your line of inquiry should be or who you should be targeting for interviews and outcomes.

Mr Sangston : No.

Senator EDWARDS: Suggest?

Mr Sangston : No.

Senator FAWCETT: Going back in part to the issues Senator Xenophon was pursuing about the information that is passed on to CASA, given that the general aviation community to date has not been aware, broadly, of that level of disclosure of enough information that CASA knows the name of the pilot, now that they are aware of what is going on, do you anticipate that that may lead to a drop-off in the number of people who are reporting incidents?

Mr Dolan : We have certainly had that risk drawn to our attention as part of our consultation about potential new arrangements. We have paid serious attention to that, and in the light of those comments we are reviewing the proposal we put out for consultation. The existing reporting form makes it clear that information that is reported to us through the current system will be shared with CASA, so it is not operating in a vacuum. I think it is a fair comment that not everyone who is notifying us would be aware of all the details of how that information is shared. And, yes, there is a risk that that will lead over time to some reduction in the extent and the detail of the reporting we receive.

CHAIR: Mr Dolan, who made the decision not to recover the black box?

Mr Dolan : I did, Senator.

CHAIR: We may go into camera on that. You know I have never sent an email in my life, and it is quite evident every day why you should not. There is an email here from a senior CASA official to senior CASA officers in which they talk about this matter. They get to you in this email: 'The ATSB are apparently'—this is the division of opinion which we got out of them this morning—'inclined to a mandated solution for a range of in-flight decision-making issues and are likely to press that line. Clearly, you may be heading to a difference of opinion here.' Are you?

Mr Dolan : As I was discussing earlier, we specified what we saw at the early stages of the investigation as a potentially critical issue. We drew it to the attention of CASA, and CASA considered it and responded that, having had regard to what we had drawn to their attention, they preferred an outcome which addressed the issue through training and procedural information rather than a regulatory mandate.

CHAIR: They say of course in an earlier one on 20 March that this is very untidy for them. Forget that.

Mr Dolan : I do not doubt—

CHAIR: You worry about their untidiness. You look after your own patch. They go on in that same email that they may be heading to a difference of opinion. Then they go on to say; 'This is not the end of the world. It may be that a meeting with ATSB to discuss the issues or clear the air will at least provide a position from which we can respectfully disagree and not have a public scrap.' Did you have that meeting?

Mr Dolan : I did not have that meeting.

CHAIR: Did any of your officers have that meeting?

Mr Dolan : Mr Sangston, did any of your people have the meeting with CASA?

CHAIR: I will go back: this is the division of opinion in CASA, which they say is a very untidy look—and God knows what the legal implications were and I am sure the lawyer who was here today would not either. They then go on to say: 'Clearly, we were heading to a difference of opinion here'—that is between ATSB and CASA. They then say: 'While that is not the end of the world, it may be that a meeting with ATSB to discuss the issue to clear the air or at least provide a position which we can respectfully disagree and not have a public scrap.' Did you have a meeting?

Mr Sangston : We had an initial meeting, and I think the letter is on the Four Corners website about that meeting.

CHAIR: But did you have a meeting and discuss the problem of that particular division of ideas: mandatory versus whatever?

Mr Sangston : There was a second meeting whereby we met with a gentleman, John Grima, in CASA and we discussed the proposal again. If you peruse the letter that initially went to CASA, you will see that from our standpoint there was no proposal or intent to mandate any resolution. Indeed, the way we identify our safety issues is to identify the safety issue and then the owner, if you like—which in this case was CASA—would develop the response to the safety issue.

CHAIR: But you had a meeting with them to discuss their difference of position between yours and theirs.

Mr Sangston : We had an initial meeting to discuss the safety issue as I have just described and then there was a second meeting to discuss what CASA understood was the—

CHAIR: The tidying up meeting so that they did not have a public scrap with you: 'Hang on! We'd better'—that is what they are saying here.

Mr Sangston : I was not at that meeting, Senator, but I have got the letter back from CASA in which they outlined a lot of the in-place regulatory and other guidance in terms of the safety issue, but there was no—

CHAIR: They identified to you that they had a clear division of opinion within CASA?

Mr Sangston : No.

CHAIR: Because, obviously, speak no evil, hear no evil: we didn't talk. So to the best of your knowledge, they did not talk.

Mr Sangston : That did not come up in that meeting, no.

CHAIR: Or the other one that you were not at.

Mr Sangston : Not from what I understand.

CHAIR: So can you take that on notice and refer to us any email trail around that issue?

Mr Dolan : I will just elaborate on that so we understand the context we are talking about. We identified for CASA a safety issue and indicated our view at the early stage that there were no regulations or public guidance for application by flight crews when making in-flight weather related decisions. That was the issue we had on the table, and you can track that through to a safety issue in our final report. Having done our risk assessment, including the safety action that was already in place or proposed, we formed a different view by the end of the process as to its continuing significance.

CHAIR: So the special audit that CASA conducted on the issue in which they found a lot of problems—50-odd—the chief pilot at the time, who now works for CASA, would have been at the head of the pecking tree on a whole range of things within Pel-Air. Given he was the chief pilot, he would have been responsible for a lot of the decisions that led to the criticisms of the systems within Pel-Air, yet he has transferred to the judges' side of the bench, joining the bloke who did the investigation at Bankstown as a comrade. They share morning coffee and a glass of wine. Do you think that is a bit bizarre?

Mr Dolan : It is not a matter that I think I am required to have an opinion on.

CHAIR: No, you are not. I just thought you might take the bait.

Mr Dolan : I regrettably—

CHAIR: decline the invitation.

Senator XENOPHON: I have an issue to raise that relates to the recovery of the cockpit voice recorder. I am conscious of the fact that these documents were provided to us in camera. Without me referring too much to the documents, are you happy to discuss openly the issue of the recovery of the cockpit voice recorder or would you prefer to go in camera?

Mr Dolan : I would not have any concerns about discussing that in public.

Senator XENOPHON: There is a briefing note on points for consideration in relation to ATSB recovery of aircraft flight recorders for the Westwind aircraft, VH-NGA—and it goes through various things. It talks about an overview of flight crew, recovery options, issues, risks, decision points, the costs and the benefits. It talks about the ATSB's reputation of being seen as acting seriously when appropriate and fulfilling its share of the commitment associated with the considerable costs of installing and maintaining black boxes. It said 'present indications show a likelihood of strong safety measures in both normal and abnormal flight conditions based on existing data'. Then it talked about the benefits and costs, risks and ATSB's reputation for being relevant on risks. It says, 'Next year's budget was reduced because of this year's underspend. We cannot assess the accuracy of the pilot's perceptions.' Following the EMT, it advised the approved deployment of the investigation team in Norfolk Island to conduct a search for the aircraft using a ping locator. They also approved funding of up to $20,000 to recover the recorders and were open to discussions on further expenditure if required. So there clearly was a detailed discussion. The conclusion early on seemed to be to recover the cockpit voice recorder, but it was not recovered. We are all mystified—or I am. I think my colleagues are also mystified as to why we did not recover it.

Mr Dolan : At the initial stages, we understood the aircraft was in comparatively shallow water and that access to the recorders would be reasonably achievable by a diver or other mechanisms without too much difficulty. That brief was to convince me to make the necessary allocation of resources to retrieve the flight data recorder and the cockpit voice recorder. Upon investigation, it became clear that the depth at which the aircraft was in the water, its location at a remote island, Norfolk Island, and the work health and safety standards applying to diving to those depths meant that there would have been a substantial cost of recovery.

The requirement was effectively that there be a decompression chamber, none of which was available on Norfolk Island, for the full time of the retrieval because of the depth at which the divers would be operating. When we got a reasonable and first approximation assessment of that, in the knowledge that, from our point of view, the key information we had about flight decision making would not have been recorded on the cockpit voice recorder which only had a two-hour time on it—

Senator XENOPHON: That is that 08:00 weather detail thing?

Mr Dolan : The crash was nearly at 10:30 and there is only two hours on the cockpit voice recorder. So we did a benefit-cost analysis of recovery and formed the view that the costs substantially outweighed the benefits.

Senator XENOPHON: So let us not labour the point. That was an earlier assessment and subsequent assessment said that it was going to cost a lot more?

Mr Dolan : Correct.

CHAIR: Even though someone offered to do it for $500.

Senator EDWARDS: Is that right?


Senator XENOPHON: But it would not have been on, on health and safety. Chair, to be fair to the ATSB, there is no way—

Mr Dolan : I would be unable to countenance that in terms of my responsibility.

CHAIR: As for your occupational health and safety background I am not allowed to climb up on my bloody bulk tanker, which I have been climbing on for 40 years, to put a hose in the top of it because it is not safe to climb up the side on a ladder on a fuel tank.

Mr Dolan : Falls from heights are a substantial cause of injury—

CHAIR: Yes, mate, but I have been doing it for 50 years and everyone else has been doing it. But there you go. All right and okay and we are grateful for your evidence.

Senator STERLE: Chair, I've got some.

CHAIR: Sorry, Senator.

Senator STERLE: I will do them quickly. I apologise as I was out of the room earlier. In terms of the report, Mr Dolan, I am gobsmacked that Pel-Air have walked out of this clean. Is it normal to have an aviation accident in a report by the ATSB without having recommendations?

Mr Dolan : The majority of our reports these days have at best a small number of recommendations, if any. As I was explaining earlier, it is the difference between identifying a safety issue and turning it into a recommendation. The question of anyone getting off lightly or not is in fact not something that we are in a position to turn our minds to, given the explicit forbidding of us apportioning blame, and so that is always a balancing act we are doing. We want to understand how the system operated and what things needed to be done—which in our view was principally in terms of the management of in-flight information and decision making—and work out where best a recommendation or at least a finding as to a safety issue in that area could be addressed, which would involve the Civil Aviation Safety Authority.

Senator STERLE: Yes, and very quickly, where we have an incident like this and people walk away to tell the story there is obviously something we would all learn from, wouldn't there be?

Mr Dolan : Yes.

CHAIR: So if you are the pilot and the aircraft may not be suitable for the flight because of loading and separation requirements and all those? There is an argument this whatever-it-was plane may not have been the right sort of plane for that particular job given the particular circumstances it may have risked and did risk. So if you are the young pilot and the chief pilot says, 'Get on your way, son,' and you know that you are going out there to rescue someone that will die if you do not do it—and you are the pilot and the nurse is sitting there—and you get to wherever it is and the bloody shades would not work and you did not get a sleep as room maintenance came in -'God, struth I'm tired but I've got to save this person's life'— there are other considerations besides your own, aren't there? Sometimes they make a special effort like Simpson on the donkey and yet a plain black-letter-law custodian like CASA or someone actually says, 'Oh, no, they broke the law. It's all their fault.' The reason Canberra got burnt, Mr Dolan—and this is well off the page and you know me, that I get off the page occasionally—is the bloody firefighters were not allowed to go into the Brindabellas because someone declared it was an occupational health and safety issue to go in and put the damn fire out, so they let it run. Crazy! Anyhow, that is well off the page. Is there anything further you would like to add?

Mr Dolan : I am just trying to make sure. I thought I heard a question in what you were saying before the reference to the bushfires.

CHAIR: There seems to be a disproportionate amount of blame going on here. The chief pilot is purer than the driven snow—and you can make out that argument.

He is responsible for the systems because he is at the head of the tree that CASA criticised in 40 instances. He now works for CASA. I have been in charge of bushfires and sometimes you do not go to bed for a couple of days and you do not even think about it because you are fired up to put the fire out. This pilot surely deserves some compassionate consideration given that it was a lifesaving mission. It is a bit like going over the top and fixing the bayonet kind of thing. How did we get tail gunners in World War II if they did not have the guts to do it? You can be black-letter with occupational health and safety—you have to have so much rest et cetera—but there has to be some consideration of what is going on in the person's mind, as Senator Fawcett said, and none of that consideration is in the report. You have not given any consideration to the human aspects of this.

Mr Dolan : The basic assumption in relation to the aircraft was its performance both with the full fuel load and the partial fuel load—that was known at various cruising heights and so on and that was in the various manuals and other activity for the aircraft—

CHAIR: Was the aircraft suitable for that task as it turned out?

Mr Dolan : Transferring a patient from Western Samoa to Melbourne was the task. The planning of that task is one of—

CHAIR: Given the ultimate expediency and actuarial assumption on the downside—things going wrong, a big headwind and all the rest of it—was the plane capable of doing it against the worst of conditions?

Mr Dolan : Was that plane capable of getting across the Pacific—

CHAIR: With a full fuel load and an overweight passenger load with the patient and the equipment was it the wrong plane? That is the question that really needs to be answered.

Mr Dolan : We were looking at the various ways you can get from Samoa to Melbourne and, in the particular case of a decision to use Norfolk Island, whether the aircraft had the capacity within the standards to get there and what was happening. It was always going to be something marginal on fuel. There is a planning question. There is a fuel management question.

CHAIR: So maybe it was not the wrong plane. We really have to go to the next witness. We would be delighted to have you back at another time. We look forward to that. Thank you very much.

Mr Dolan : Thank you.

Evidence was then taken in camera—

Committee adjourned at 18:29