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Canada’s TSB publishes critical review of ATSB

written by WOFA | December 2, 2014

VH-NGA, which ditched off Norfolk Island. (Paul Sadler)
Pel-Air Westwind VH-NGA, which ditched off Norfolk Island. (Paul Sadler)

Investigators at the Australian Transport Safety Bureau (ATSB) did not follow proper process and had poor oversight during an investigation into the ditching of a Pel-Air Westwind aircraft off the coast of Norfolk Island in 2009, a report says.

The conclusions are found in the Transportation Safety Board of Canada (TSB) review of the ATSB which was released on Tuesday.

In the report, the TSB said its review of how the ATSB investigated the crash of the Pel-Air aircraft, registration VH-NGA, “revealed lapses in the application of the ATSB methodology with respect to the collection of factual information, and a lack of an iterative approach to analysis”.

“The review also identified potential shortcomings in ATSB processes, whereby errors and flawed analysis stemming from the poor application of existing processes were not mitigated,” the TSB said.

The ATSB requested the TSB conduct the review after the commission was heavily criticised for its report on the Pel-Air accident off Norfolk Island, where the Westwind corporate jet conducting an aeromedical flight from Apia, Samoa to Melbourne, crashed after running out of fuel.

All six passengers and crew on board survived the crash and were rescued.

The ATSB report into the incident cited errors by the flightcrew and found the pilot in command of the aircraft Dominic James did not plan the flight in accordance with regulatory and operator requirements.


However, the ATSB investigation was the subject of a scathing assessment by a Senate committee which found, among other things, that the Civil Aviation Safety Authority (CASA) withheld a number of documents critical of Pel-Air. A Four Corners investigation also highlighted serious flaws in the way the investigation was conducted.

“The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected,” the TSB said.

The TSB review said the ATSB collected “insufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general”.

“Poor data collection also hampered the analysis of specific safety issues, particularly fuel management, company and regulatory oversight, and fatigue,” the TSB said.

The TSB made 14 recommendations relating to improved investigation methodologies and processes, improving oversight and governance of investigations and managing communications challenges more effectively.

On a positive note, the TSB found the ATSB’s methodologies “met or exceeded the intent and spirit of those prescribed” in the International Civil Aviation Organisation (ICAO) convention on international civil aviation.

ATSB chief commissioner Martin Dolan said his office was carefully and methodically working through the review’s findings.

“While I’m pleased to see that the ATSB mostly met or exceeded international investigative standards, there is clearly room for improvement,” Dolan said in a statement.

The ATSB said it would provide a detailed, formal response to the review in early 2015.

The full report can be found on the TSB website.

Canada’s TSB publishes critical review of ATSB Comment

  • GMS


    Very selective reporting, more worthy of a tabloid. Take the negative 20 per cent and omit (until the end) the positive, about how ATSB manages most of its processes well.

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