Plane crash review: Are Australia's aviation bureaucrats endangering lives?

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Norfolk Island crash pilot Dominic James (screen shot via

Aviation would be safer if the regulators realised pilots aren't suicidal and acted as partners rather traffic cops, says pilot Dr Norm Sanders.

THREE GOVERNMENT BODIES are tasked with keeping Australian aviation safe: CASA (Civil Aviation Safety Authority), ATSB (Air Transport Safety Bureau) and Airservices

CASA deals with regulations and pilot qualifications, the ATSB investigates crashes, and Air Services operates the radio facilities to control air traffic.

Of the three, Airservices has the best reputation among Australian pilots. Airservices operates within a strict regulatory framework, but the safety of pilots and passengers is foremost and getting planes back safely on the runway takes priority over the multitude of rules.

CASA is just the opposite. Rules are paramount. Pilots trust Airservices but universally hold CASA in low esteem.

I flew for years as a commercial pilot and flight instructor in the U.S. before coming to Australia. I had two in-flight emergencies in that time — one involving an engine fire, which required an emergency landing at busy Santa Monica Airport, near LA. Once safely on the ground, there were smiles and congratulations from the firemen and the airport manager. No recriminations.

I found a completely different attitude in Australia. Ask pilots in this country if they would declare an emergency in a dangerous situation and many would say, “Only if a wing had just fallen off". They are all fearful of the punitive action CASA would take.

Some time ago in Tasmania, a pilot took off from Strahan on the West Coast. He got lost and asked for assistance from Launceston Flight Service. They had no radar and could not give him his position. The pilot managed to find his way back to the field and took off for Hobart in better weather a few days later. When he contacted Hobart Tower, he was told to tie his plane down securely and wait in the area. The bureaucrats had decided to take away his licence — for getting lost and admitting it! The message here? Don't ask for help.

That things haven't changed much over the years is shown by the recent Aviation Safety Regulation Review into CASA and the ATSB.

The final report found

'A significant disconnect between the Industry and CASA, which, if left unchecked, could put both the safety and reputation of the industry at risk.' 

The report, also known as the Forsyth Report, made 37 recommendations for reform. (About half have been implemented so far.) The Review Panel found that CASA’s hard-line attitude has distanced it from the industry — contrary to the approach taken by many leading aviation regulators around the world.

In the U.S., the FAA (Federal Aviation Administration) has a much better reputation. The FAA is charged with the promotion and regulation of aviation. CASA sees its role as the creation and enforcement of laws.

An inquiry was instituted by former Senator Nick Xenophon after the Norfolk Island Crash of a CareFlight medical evacuation aircraft on the night of 18 November 2009. Dominic James was piloting a two-engine jet owned by a firm called Pel-Air. His copilot was Zoe Cupit. A Melbourne woman was on a stretcher, being tended by a flying doctor and a nurse. The woman's husband was also on board. The flight had originated at Samoa and was heading for Australia, planning to stop at Norfolk Island for fuel. 

The weather reports for Norfolk Island were good on departure, but a storm moved in while the plane was in the air. Air traffic services in Nadi and Auckland did not radio the flight crew all the revised information that should have been provided so that the pilot could head for an alternative airport. 

There was torrential rain at Norfolk Island that night and the clouds were down to the surface. James made four attempts to land but couldn't see the runway. Fuel was running out and James had to try to ditch at sea, which he considered to be a better option than crashing on land. It was dark and raining so heavily that he couldn't see the direction of the swell in order to land parallel to the wave tops. The plane hit hard, but everybody miraculously got out of the aircraft and into the water. James had a small pocket flashlight which he pointed at the shore. A fireman saw the light and alerted the rescue crew. All survived the crash, but some were injured.

Businessman and aviator Dick Smith described James’ actions as

“ ... an incredibly talented feat. Being able to get that plane down at night and all the passengers out alive was great.” 

James was hailed as a hero, like Sully Sullenberger who landed on the Hudson. 

But the bureaucracy didn't agree. CASA downgraded Jame's licence. The ATSB stated that he did not put the aircraft down at optimal speed and failed to report his intended landing position on the radio. (Pilots have a saying: "Aviate, Navigate, Communicate". Jame's priority was to make a successful landing. He was too busy to “communicate.”)

A subsequent Senate Inquiry found that the ATSB accident report was “deeply flawed” and unfairly blamed the pilot wholly for the accident. They recommended the report be redone. The Inquiry also found evidence of collusion between agencies and that the heads of both agencies gave evidence that “wasn't credible”.

The second ATSB report was released last week, almost eight years to the day after the accident. In the 531 page report, the ATSB investigators are again critical of Mr James, but also raise concerns about inadequacies with the country's aviation regulations and the risk-control measures of Pel-Air — a subsidiary of NSW airline Regional Express, which was operating the air-ambulance flight.   

Senator Nick Xenophon said the process remained a “deeply flawed and conflicted”. The pilot, Dominic James, commented that the ATSB did not “want to rock the boat” when it came to criticising the system and the aviation bureaucracy.

James said:

"They have lost their nerve — they are not courageous. They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result. If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a Senate Inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

Another common criticism of the ATSB is the length of time taken to publish findings of crash investigations.

Dick Smith ascribes it to a "toxic culture" in the ATSB:

According to Smith, a former chairman of CASA, it all goes to a toxic culture in the ATSB, which he describes as secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals.

(The same could be said of CASA.)

These individuals include relatives of those killed in air accidents who understandably want closure. Environmentalist John Davis was killed in a helicopter crash in November 2015. The ATSB promised his wife, Felicity, a report in a year, but it is now two years since the crash and she still has heard nothing.

With regard to CASA, the Aviation Safety Regulation Review noted:

'Foreign regulators adopt a performance based system with a focus on a "just culture", and an approach that places more trust in the operators to carry out their activities in compliance with the applicable regulatory scheme. The regulator monitors and takes appropriate action on any breaches of that system. In comparison, many in the industry would argue CASA’s approach requires the operator to proactively prove that they have not done anything wrong. The proponents of a performance based regulatory system argue that it supports a more open discourse between the regulator and the industry, leading to better safety outcomes.'

CASA has to realise that pilots aren't suicidal. We have a vested interest in our own survival and that of our passengers. We WANT to do the right thing. Aviation would be much safer if we could consider CASA as a partner rather than a traffic cop. Then maybe we wouldn't be afraid to declare emergencies. 

Dr Norm Sanders is a former Tasmanian MP and Australian Federal Senator. He is also a qualified commercial pilot and flight Instructor.

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