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Rural and Regional Affairs and Transport Legislation Committee
23/05/2012
Estimates
INFRASTRUCTURE AND TRANSPORT PORTFOLIO
Australian Transport Safety Bureau

Australian Transport Safety Bureau

[14:34]

CHAIR: I now welcome the Australian Transport Safety Bureau.

Senator WILLIAMS: From 1 January next year ATSB will take on an expanded role as Australia's no-blame rail and maritime safety investigator. You currently receive approximately 9,000 accident or incident occurrences per year, and that is expected to increase to up to 25,000 per annum. Are those expectations around the mark, do you think? Do you expect to get around 25,000 once you take up that extra role?

Mr Dolan : We are still in discussions with the existing rail regulator as to the level of occurrence notifications we are likely to receive. They fall into two categories—those that are immediately reportable, which is accidents or serious incidents, and then a whole range of other occurrences that are of safety relevance. We should know in the next month or two the scale of what we are dealing with. But the vast bulk of them will be managed initially by the new national safety regulator. We are still sorting out the likelihood—and it will not be in place by January next year—that we will be the marine investigator.

Senator WILLIAMS: You say it will not be in place by January next year?

Mr Dolan : It has not yet been agreed by governments.

Senator WILLIAMS: Surely, if you take on the role of rail and maritime safety investigator, you will have more workload. There will be more incidents.

Mr Dolan : More incidents and more accidents to investigate, yes.

Senator WILLIAMS: Your budget increases to $25.8 million next financial year, $26.4 million the following financial year and then it drops back to $24.7 million. Where will the additional money be spent?

Mr Dolan : The additional money will be spent principally in the expanded business we will be undertaking in rail. That is the increase. The decrease in the final year largely reflects a reduction in external income in relation to overseas cooperation and some effect of the efficiency dividend that has been applied to the organisation.

Senator WILLIAMS: Will you have more staff?

Mr Dolan : Yes. It is slightly complicated in that, as well as having directly employed staff for our rail investigations, we have also entered into agreements with the existing state based investigative organisations in New South Wales and Victoria to provide us with investigative capability.

Senator WILLIAMS: You will have more staff, and what will their role be, in a nutshell?

Mr Dolan : Essentially in rail.

Senator FAWCETT: Mr Dolan, I do not know if you were listening in the back room when Airservices was in here.

Mr Dolan : I was trying to pay attention, yes.

Senator FAWCETT: Very good. Obviously, your reports played a role in triggering some of the interest of this committee in Airservices Australia. Could you comment on whether you have any residual concerns about the level of manning, training or oversight by CASA of Airservices in terms of the air traffic services they provide?

Mr Dolan : There is nothing available to us at this stage that would lead me to the view that there is a critical safety concern. We are in the course of undertaking a range of investigations into individual occurrences, each of which has the potential to illustrate broader systemic issues. They will be sequentially completed in the course of this year. We are also bringing together a more research based investigation which will take the trend analysis of data and the findings of a range of investigations and see if there is a systemic issue that can be disclosed by joining that information together. At this stage we have not seen anything that we would classify as a critical safety issue that needs to be addressed immediately.

Senator FAWCETT: Would it be your expectation that, if you made recommendations or observations in a report—very clear observations or recommendations—they would be acted on?

Mr Dolan : Certainly if we make a recommendation our full expectation is that it is acted on. There is a requirement if we make a recommendation that the body that we make the recommendation to will, at a minimum, respond to us and we will publish their response. We cannot compel anyone to actually do anything, so we have to rely on the rigor of our own analysis and the accuracy of our observations.

Senator FAWCETT: Do you have any form of audit beyond requiring the subject body to respond to your recommendations to actually assure yourselves of implementation, or is that where you leave it—at their response?

Mr Dolan : No. We keep tracking all the safety issues we have identified until we are satisfied that necessary action has been taken.

Senator FAWCETT: In any of your reports looking at Airservices and the supply of air traffic services, was manning a concern, in terms of levels of manning available to them?

Mr Dolan : There is no report, at least back to 2007, that related directly to staffing issues in Airservices. The findings we have made in relation to Airservices since 2007 have focused either on specific elements of training or on some procedural matters. That is where the two key focuses seem to have been to this point. We still have work in train to make sure we are not missing something.

Senator FAWCETT: Could you give us a quick summary of where the concerns lay with training?

Mr Dolan : There is a very specific one which related to our investigation of a breakdown of separation, which was that there was inadequate training of air traffic controllers in handling—as in recovering from—loss of separation assurance. As a result of that significant safety issue being identified in the report, Airservices agreed to take the necessary action to train and retrain in that area. We are satisfied that the action is adequate to meet the issue.

Senator FAWCETT: Does that also point to a lack of robustness either in their auditing of competencies during the recruitment of previously trained controllers transferring from another organisation—which I believe was the one that you were referring to—or in tracking the competence or the competencies achieved by their initial trainees?

Mr Dolan : We have not seen anything. Every time we identify a factor as contributing to a particular occurrence, we subject it to a risk assessment. That is where we get the categories like 'significant' or 'critical'. If there is an untreated risk that we think requires significant attention, it is 'critical' or 'significant'. We have not seen anything in that area that goes to the broader question of checking and competency standards. One of the difficulties of a role like ours is that you are sometimes working on partial information, which is why we have undertaken that broader study, to make sure we are picking up any trends that may be there.

Senator FAWCETT: I am very heartened to hear about the role that you said you play in following up on issues. I congratulate you on, for example, the report that you issued on single-engine failures and reduced power situations after take-off and exploring that whole issue. Going back to previous estimates, I asked about the number of examples of aircraft that had these sorts of failures. I noticed there was a figure of around 21 that had been highlighted in a short time frame. Your report goes to a much larger number. Can I confirm that they are only talking about GA aircraft and that if RAA aircraft were included that would be a larger number?

Mr Dolan : I need to confirm that with Mr Walsh but my understanding is that we were focused on VH registered aircraft. So the number of 242 partial power loss on take-off events over a 10-year period relates to single-engine aircraft with VH registration.

Senator FAWCETT: In terms of your tracking of safety issues and monitoring developments, your report goes to the heart of the fact that, following a partial power loss or a complete engine failure, the pilot essentially has three options, which is to do a forced landing outside the airfield, on the airfield but not on the runway, or on the runway if they are very skilful or have the appropriate height et cetera.

Two of those situations require that clear space be available. Are you concerned by the encroachment of residential and non-aviation facilities, whether that be Bella Vista at Caloundra, the old folks home that has just been approved at Evans Head, or things like the Toll building at Bankstown in the undershoot of the approach to the helipad? Do you have concerns from a safety perspective, given that your excellent report highlights the need for survivability for the pilot to be able to conduct a forced landing in and around the vicinity of the aerodrome, that this encroachment of non-aviation related infrastructure is actually elevating the risk, given the relatively high occurrence of those power loss situations?

Mr Dolan : The short answer is that, in accordance with the risk analysis that we undertake, I am not at the point where I share the concern, or not to the extent that you clearly do. The number is, say, 242 occurrences over a 10-year period, which is 24 a year—

Senator FAWCETT: For GA. If you include RAA—

Mr Dolan : for single-engine GA. I would have to confirm the figures on that, but it is something like 1.6 million movements each year. Once we look at the likelihood as well as the consequence in our risk assessment, we do not see this as a significant safety issue.

Senator XENOPHON: Mr Dolan, according to the current budget papers the ATSB intends to meet a new KPI in relation to time lines for investigations. How does the ATSB intend to meet that, given its new additional responsibilities?

Mr Dolan : We have been given additional resources to undertake our new responsibilities. We are also reviewing carefully our processes for managing investigations as projects to make sure that we are making the most effective use of our investigation resources.

Senator XENOPHON: Following on from that, the ATSB conducts a no-blame aviation safety investigation. Is that a fair summary?

Mr Dolan : In shorthand, yes.

Senator XENOPHON: That is a shorthand way of saying it. I understand the motivation is to get people to report freely and to provide appropriate protection to people who report to further critical safety. Does that sum it up fairly?

Mr Dolan : The additional point is that, although we rarely use it, we have quite significant powers to compel people to give us information and an equally powerful responsibility to protect it.

Senator XENOPHON: But it is still under the umbrella of this no-blame approach?

Mr Dolan : Absolutely.

Senator XENOPHON: It has been suggested to me that, with the ATSB's pursuit of no-blame results in reports, on the one hand they are delayed by seeking high levels of consensus amongst interested parties and, on the other hand, they could potentially end up lacking human factors reporting as to risk, rendering the reports almost as historical records rather than safety enhancement tools. Could you comment on that? Is the amount of time spent on consulting interested parties detracting from the timeliness of publishing reports? I know there are some tensions here in terms of due process and fairly helping people. I have tried to set out what the concern is.

Mr Dolan : I hear two elements to your question, so I will take them sequentially. The key process of consultation is done at the point where we have a draft report. So we have examined all the facts, we have done our analysis and we have formed provisional views. We circulate a draft report under the protection of our act—so not to be released—to what we call directly involved parties. If it is domestic, we expect any comments within a month and we emphasise that we are principally seeking any corrections of factual inaccuracies in our report. We are also seeking, where we have identified a safety issue, information on any action that the relevant party may have taken in response to the identified issue. The focus is on getting something done in response to our findings. That process normally takes a month plus another week or two to make sure that the relevant concerns that may have been raised with us are integrated into the final report. I do not see it as a major constraint on our timeliness.

Senator XENOPHON: You do not think it constrains you in terms of providing more depth in human factors analysis?

Mr Dolan : That was the second part, as I was saying, of the question. There is the specific timeliness thing, an appropriate level of review to make sure that the rigour and the factual accuracy of our reports is in place, which I think is important, and it also goes to procedural fairness. Although we are a no-blame organisation, people can read our reports as pointing the finger, even though we do not intend them to. So there are no surprises for those involved.

The second point is that I am startled that there is a belief out there that we do not have human factors at the core of what we do. Our entire investigation and analytical model is based on fundamental principles of human factors—understanding human error, understanding how to minimise it, accepting that you can never remove it, and looking therefore at how you capture errors and make sure they are dealt with in the system. I am not sure, in addition to that, how much I can say.

Senator XENOPHON: I will possibly put some questions on notice about Airservices Australia. In relation to that issue of human factors, it was not a criticism; I am just saying that was a concern that has been expressed to me by those in aviation. I am thinking of the Air France 447 investigation, which of course the ATSB has nothing to do with—that terrible loss of life over the Atlantic.

Mr Dolan : We are watching it with interest.

Senator XENOPHON: No doubt you are looking at it with interest. You correctly emphasised factual information. With Air France 447, I think there is still a final report down the track?

Mr Dolan : The report is due for release next month, as I understand it, from Mr Troadec of the BEA.

Senator XENOPHON: That whole investigation seems to be looking at human factors. It seems increasingly clear that the 'what' does not so much clarify the 'why'. To what extent will the 447 investigation influence the way that air safety investigators around the world conduct their work, or is it just an instance of human error?

Mr Dolan : I suppose this might help you in explaining my puzzlement. I have had conversations from time to time with my French counterpart, Mr Troadec. I would totally agree with you that some of the key issues in Air France 447 relate to human factors—understanding why some of the various actions that were clear from the flight data recorder and the cockpit voice recorder, once retrieved, happened. The reason I remain puzzled is that the 'why' is at the heart of what we are trying to do. We normally get the 'what' in the initial occurrence report. The time we take is to try to understand the 'why' and whether anything needs to be done as a result of us having determined the 'why'.

Senator XENOPHON: That helps to clarify it. Obviously we are all awaiting with interest the 447 report.

Senator LUDLAM: I have a couple of questions on derailments on the Central Australia railway line. I understand this is something that the ATSB has had a fair bit to do with in the last two years or so. You investigated a derailment on the central line on Thursday, 25 November 2010. Your report indicates that issues were identified and brought to the attention of the company, by which we mean the company that has a 50-year lease on that track. I have had a quick look at the photos on your site. It looked like a very long train that had been double stacked with mostly empty containers, so it was relatively light. When the wind hit it, it pushed it over and trashed the train. Can you tell us what has been done to monitor what has happened since your agency identified and brought it to the attention of the company?

Mr Foley : The incident you are referring to occurred at Cadney Park. It was the last in a string of these investigations that we have looked at. We have had three where there were double stacked containers, empty, loaded on wagons which have actually been blown over in a thunderstorm. In terms of Cadney Park, the operators are certainly now much more aware of the mechanism, if you like, for these sorts of derailments. It was something of a first. We identified it. We did some wind tunnel testing with the first of these that we investigated.

Senator LUDLAM: When was that first one?

Mr Foley : From memory, the first one was at Loongana. Once again, it was in the Nullarbor and it was a blow-over derailment as a result of a thunderstorm. What occurs is that there is a downburst of air. The train enters, they get a sudden shift of air from one side of the train to the other, and it actually blows the wagon or lifts the wagon off the tracks. We did some wind tunnel testing and ascertained what the derailment mechanism was. People then started to believe us. There was a fair bit of disbelief prior to that time. Operators are now looking at the way they load the containers to make sure that they have a low centre of gravity, and they are bringing to the attention of their train drivers the fact that there are things they can do to minimise the risk of derailment in those circumstances, like slow the train.

Senator LUDLAM: I do not know if you have this with you or on your website. Could you provide us with the dates and places of the three events that you referred to?

Mr Foley : By all means.

Senator LUDLAM: Was the one that I am raising now the second in the series of three or the last?

Mr Foley : I cannot tell you off the top of my head. I will have to go back and have a look at our records. We have now had three very similar sorts of derailments.

Senator LUDLAM: So it is not the track so much; the first one across the Nullarbor presumably was on the tracks?

Mr Foley : No. It is related to the dynamics of the actual roll vehicle itself.

Senator LUDLAM: Has the operator, particularly in the instance of the Central Australian railway line, heeded the advice of the regulator? What can they do apart from loading the trains up?

Mr Foley : As I said, there are things that they can do in terms of informing their drivers of the risk when they do get into these sorts of circumstances. If they experience or see a thunderstorm ahead when they are driving, they can slow the train, which will minimise the risk of a derailment. That sort of education process has gone on as a result of this. There have also been some procedural changes as a result of this. We have brought it to the attention of some of the international players. We presented a paper at the last International Rail Safety Conference on this theme, so we are making industry aware that there is a risk.

Senator LUDLAM: Who is responsible for maintaining weather reporting or weather stations along those lines?

Mr Foley : The Bureau of Meteorology has the majority of the weather stations along the line. There are large sections where there are no automatic weather stations or weather stations. The Australian Rail Track Corporation, I understand, also has a couple of weather monitoring stations on that line. Once again, it is a very long piece of track. These events tend to be very localised.

Senator LUDLAM: It is not something that the rail company or the haulage company could see coming over the horizon and warn their drivers not to run their trains into?

Mr Foley : No. I think the best defence that the Bureau of Meteorology has is probably weather radar. Obviously there is no weather radar in some of these places.

Senator LUDLAM: There was another derailment on the same line, I guess from a different cause because this one was fully loaded. On 27 December 2011, this time north of Katherine, an OZ Minerals shipment of copper concentrate got chucked into the Edith River. The entry on the side indicates that it was Cyclone Grant that caused that derailment. Could you give us an update on that investigation?

Mr Foley : We released an interim or preliminary factual report on that about a month after the occurrence. It was at Edith River. The circumstances were basically that there was a lot of rain in the catchment area and it washed away the embankment in the approaches to the rail bridge. The previous train safely negotiated the bridge as the river level was still relatively low. The train that derailed actually negotiated it some hours later and derailed as a result of water that had overtopped and washed away the embankments on the bridge. That report at this stage is not finalised. At the moment it is out for comment from interested parties. We anticipate that it is probably about two months away from being published.

Senator LUDLAM: That will be a public document, won't it?

Mr Foley : Yes, it will.

Senator LUDLAM: Unlike the kind of downdraft conditions or however you described it a moment ago that would push an empty train over, which are localised and probably move fairly quickly, you can see cyclones coming a fair way off. Should the operator have done anything differently rather than just ploughing the train into that situation?

Mr Foley : I do not want to pre-empt the final report; it is not public and we are still in the process. Essentially every operator has a series of mechanisms in place to manage those sorts of risks. As part of that investigation we had a close look at the mechanisms that this particular operator had. Indeed the final report examines what procedures were in place and potentially what may have been improved at that time.

Senator LUDLAM: What kind of containers was the copper concentrate in and how much of that concentrate ended up spilling into the river?

Mr Foley : Once again, the numbers are in our preliminary report. It was about 1,200 tonnes, from memory, of copper concentrate. The containers that it was in at the time were canvas covered containers. The shipper of the minerals, which was Oz Minerals, I believe, had a dispensation to operate that type of container until, from memory, 31 December. The derailment, as you know, occurred on 27 December. The rules have now changed for the carriage of copper concentrate. It must be in a fully enclosed container.

Senator LUDLAM: So the whole 1,200 tonnes went over the side, in other words. If it had been in a steel drum perhaps they would have lost a lot less?

Mr Foley : Potentially, yes. It is hard to speculate. The steel drums, they fill a fair way up. The drums may have ruptured too, which would have released the copper concentrate.

Senator LUDLAM: As of December they are not able to ship in a canvas topped container?

Mr Foley : The rules have changed. Whether or not the relevant authority has issued a further dispensation for carriage of copper concentrate in the containers they were using at the time, I do not know.

Senator LUDLAM: Once there has been an accident you are then responsible for working out why and how to prevent a future one. Do you have any further involvement in the clean-up?

Mr Foley : No. We have no further involvement.

Senator LUDLAM: We learn from what has occurred but now look toward what might happen in the future. What are you doing or are you likely to do to safeguard against similar incidents involving, for example, manganese coming out of the Bootu Creek Mine, which will transit up that same line, or the approximately 2,000 tonnes of radioactive copper concentrate that will be coming up that line every day if BHP gets its way at Roxby?

Mr Foley : We have no role in respect of regulating the carriage of those products. That is left to the appropriate state based authorities. Our role is in the event of an accident. We have a look at what may have been better, which may have limited, if you like, the consequences—in this case, the derailment at Edith River. We have a look at those things in the context of a safety investigation. We have no role in regulating or potentially administering, if you like, the carriage of dangerous goods

Senator LUDLAM: I am not trying to split hairs here. You have an interesting case study of a shipment of copper concentrate that fortunately was not radioactive that went into the drink last year. You will learn things and the company will learn things from the incident reporting and the analysis that you do. Do you then have any role in making sure that the regulators do end up getting to see that report, and will it make recommendations about prevention?

Mr Foley : We do not recommend in that way. We identify a safety issue and we allow people to, if you like, provide their own fix. We identify it. We say, 'This is an issue; go away and have a think about it.' In terms of the regulator for that particular shipment, yes, they are an interested party or an involved party. So they will get a copy of the draft report. We have been having an ongoing dialogue with them in the course of the investigation as well. They are aware of the issues, and anything we identify in the course of the investigation they will be made aware of

Mr Dolan : Excuse me, can I add something for context there? As I was saying in answer to, I think, Senator Xenophon, when we have identified a safety issue we subject it to a risk assessment. We look at future likelihood, future consequence of these sorts of events, to give it a weighting in terms of the significance of the issue. The sorts of examples you have cited are the sorts of things that will help us understand how you give a risk rating to the issue that is involved in this particular event.

Senator LUDLAM: Presumably you do not have to wait for an accident to occur before you can do that kind of analysis, though?

Mr Dolan : That is correct. We have to do the analysis based on the facts and other information available to us and make sure it is reliable. The final report is where that will all come together.

Senator LUDLAM: Even though the latter one I am talking about, Edith River, occurred in the Northern Territory—and the company will be responsible for shifting something in the order of three-quarters of a million tonnes of radioactive copper concentrate over that same bridge, over that same watershed, every year—will you be advising South Australian regulators of what you have learned as a consequence of the Edith River spill?

Mr Foley : They will get a copy of our draft and final reports. If there is a recommendation to be made we will make it at that time. We will identify any safety issues within that report.

Senator LUDLAM: I am still not altogether clear about the degree to which you can be pre-emptive or highlight issues you might have noticed. For example, and I am not trying to pull you into a hypothetical here, the shipment that went over the side at Edith River was not radioactive copper concentrate. What can you tell us about if it had been, or what can you tell regulators, or what can you tell the company?

Mr Foley : Obviously the standards of carriage for radioactive materials are quite different to the standards of carriage for the copper concentrate that was being carried. We would examine, if you like, the mechanism and derailment, the consequences of the derailment in that context. If we saw that there was a clear safety issue as a result of the method of containment or the way in which the product was being carried, then we would make some observations and potentially examine a range of safety issues.

Mr Dolan : If it would give you additional comfort, and I hope it does, the other thing we do, where appropriate, having completed an investigation and a report, is determine whether there are any other broader safety measures that we think should be promulgated. We do not just focus on what is relevant to the circumstance of an individual case. If there is a broader message we will make sure that is promulgated, and that is part of the way we approach our business.

Senator LUDLAM: If I ask you about the Roxby shipment of uranium concentrates coming all the way from Wiluna in WA, which is an awfully long transport corridor, because they are hypothetical and they have not happened, do you get to get in front of that? You hold a pretty important store of knowledge and learning about these kinds of accidents.

Mr Dolan : It is speculative at two levels; so I am not sure there is much we can usefully say at this point. It is speculative because we have not completed our investigation for Edith River, and it is speculative because it is for a different type of transport operation and it is not clear to me at this point the extent to which there is a connection, as Mr Foley said. The standards for transport of radioactive material are different to the standards for transport of concentrate.

Senator LUDLAM: What I do not want to happen is to be having this conversation with you gentlemen, who do hold the database and the knowledge, in the aftermath of a spill and you have depopulated and had to evacuate an area like the Edith River watershed and everything downstream of it, and then be asking you, 'What the hell happened? Could this have been avoided?' I do not want to hear you guys say, 'If we had six months to do some preparatory work and been invited to contribute we could have prevented this occurring at all.' Do you see where I am getting to? We do not just need your expertise in retrospect.

Mr Dolan : I understand that. There is a limit to what is available to us, given that our whole job is to look in retrospect and then try to project for the future. We can only draw the lessons from what we have direct evidence of, from our investigations, and then try to say, 'Here is a future safety message.' If we have a safety message and we need to draw the attention of other regulators to assessing the risk and dealing with consequences, we will do that.

Senator LUDLAM: My final question—I guess it is in a similar vein—is on road rather than rail. You might have seen reporting earlier in the press about Toro's proposal to truck uranium concentrates from Wiluna in Western Australia through Central Australia and export them out of either Adelaide or Darwin. Have you assessed the long transport routes arising from yellowcake shipments from Western Australian uranium mines?

Mr Dolan : We have no legislative authority in road transport.

Senator LUDLAM: If the minister asked you to do that, you could do that?

Mr Dolan : No. At this stage the legislation limits us to aviation, rail and marine.

Senator LUDLAM: Not road?

Mr Dolan : Not road.

Senator LUDLAM: Thanks.

CHAIR: Thank you, Senator Ludlam. Senator Fawcett and then Senator Xenophon.

Mr Dolan : Excuse me, could I provide some additional information? I said to Senator Fawcett that the 242 numbers for partial power loss accidents did not include recreational aviation aircrafts. I am advised by my people that it does in fact include those, not just VH reg but also all the RA Aus Fleet.

CHAIR: Thank you, Mr Dolan. Senator Fawcett.

Senator FAWCETT: When there is an aircraft accident and there is a fatality and the coroner becomes involved, can you describe the relationship between ATSB and the coroner?

Mr Dolan : The legislation, the Transport Safety Investigation Act, requires us to cooperate with coronial processes. Therefore, coroners have, if you like, a special relationship with us. There is a range of information and support that we are required to give to coroners that we do not give to other legal processes. We try, as far as possible, to ensure that our reports are reliable and comprehensive and therefore can be used by coroners to form their views, which are largely no blame and in parallel with what we are trying to establish.

We recognise that there are areas where coroners will investigate and we do not. We are trying to deal with that carefully. We do that mostly by making sure we are in close contact with the police who are working with the coroner so that there is clarity from the beginning as to whether we are going to be playing to any significant extent. We are always happy to explain our reports to coronial processes. In addition, we have been offering accident fundamentals training, the basics of how we approach our job, to a range of police officers across the jurisdictions who are likely to be assisting coroners in carrying out their duties.

Senator FAWCETT: Do coroners ever face the situation where they have to choose between your advice and that of another aviation expert?

Mr Dolan : Quite often. It used to be more common than I think I have noticed in the last year or two that alternative views were put to coroners—

Senator FAWCETT: Who would those other stakeholders be?

Mr Dolan : Our experience has been that counsel assisting, in trying to do a comprehensive job in support of a coroner, sought other lines of information and brought it to bear in the process. Other parties, all of whom have their own interests in a coronial process, often find it necessary to test a range of alternative hypotheses. Sometimes the weight comes down to a different place than we placed it. That is just part of the relationship. If there is a coronial finding that is inconsistent with what we found or more information comes to light in the course of an inquest that is relevant to our investigation, we will reopen the investigation and make sure that is properly weighed up in our processes.

Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

CHAIR: Senator Xenophon, did you want one very quick one?

Senator XENOPHON: I will try to make it a very quick one. I keep getting complaints from those who are in safety-sensitive positions in aviation about fatigue issues and that the fatigue issues seem invariably to accompany reports of an oppressive workplace culture, most recently in terms of air traffic controllers. How does the ATSB deal with the particular issues of fatigue management and the performance consequences of workplace culture, given the subjectivity inherent in those concepts? Do you see a role in ATSB monitoring the performance of the fatigue management systems or do you see it as a purely regulatory function? Do you think that the regulatory agencies are doing enough about fatigue risk management? I am happy for you to take it on notice.

Mr Dolan : With your indulgence, I can answer it quite quickly.

CHAIR: Yes, get to the point.

Mr Dolan : Fatigue, when it is detected as a contributing factor in any investigation we undertake, we will look to fatigue management systems to see whether they can be improved to better manage the risk of fatigue in the system. I do not have any evidence in front of me that would allow me to give you an additional comment on the adequacy of regulatory oversight. We have not seen anything that would say it is inadequate.

Senator XENOPHON: Thank you.

CHAIR: I thank officers from the Australian Safety Bureau.