Footnotes

Executive Summary

[1]        This strong reputation was earned by the ATSB's predecessor, the Bureau of Air Safety Investigation (BASI), in particular in terms of accident reporting and its 'no-blame' approach.

Chapter 1 - Introduction

[1]        See correspondence between the committee and the ATSB regarding request for documents, received 3 October 2012, available at http://aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=rrat_ctte/pel_air_2012/submissions.htm (accessed 9 April 2013).

Chapter 2 - Background

[1]        Australian Transport Safety Bureau (ATSB), Submission 2, p. 4.

[2]        Transport Safety Investigation Act 2003, subsection 12AA(1).

[3]        ATSB, Submission 2, p. 4.

[4]        See www.atsb.gov.au/media/1371655/mou_atsb-casa.pdf (accessed 3 April 2013).

[5]        Transport Safety Investigation Act 2003, section 12AD.

[6]        See www.icao.int/Pages/icao-in-brief.aspx (accessed 19 March 2013).

[7]        ATSB, Submission 2, p. 4.

[8]        Subsections 13(1) and (3), TSI Act.

[9]        ATSB, Submission 2, p. 43. The advanced release of reports to DIPs is separate from an earlier stage of the report drafting process, where DIPs are given the opportunity to comment on any perceived factual inaccuracies, as outlined in Chapter 4 of this report.

[10]      ATSB, Submission 2, p. 43.

[11]      See Mr Gary Currall, Submission 9; Mr Mick Quinn, Submission 11, p. 18; Mr Bryan Aherne, Submission 10.

[12]      ATSB, Submission 2, p. 42.

[13]      Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), Additional Information 12, received 10 October 2012.

[14]      Civil Aviation Safety Authority (CASA), Submission 1, pp 1–2.

[15]      Civil Aviation Act, subsections 12(1), (1A) and (2).

[16]      CASA, Annual Report 2010-2011, p. 4.

[17]      CASA, see www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_91621 (accessed 22 March 2013). The committee notes that the Department of Infrastructure, Transport, Regional Development and Local Government preceded the Department of Infrastructure and Transport, and the Department of Regional Development, Local Government, Arts and Sport.

[18]      ATSB/CASA Review, Report to the Minister for Infrastructure, Transport, Regional Development and Local Government (the Miller Review), Appendix 1, p. 18.

[19]      Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 22 October 2012, p. 27.

[20]      Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 22 October 2012, p. 27.

[21]      Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 22 October 2012, p. 27. See also www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_91621 (accessed 22 March 2013).

[22]      Memorandum of Understanding between the ATSB and CASA, available at: www.atsb.gov.au/media/1371655/mou_atsb-casa.pdf  (accessed 5 February 2013).

[23]      ATSB/CASA Review, Report to the Minister for Infrastructure, Transport, Regional Development and Local Government (the Miller Review), Appendix 1, p. 82.

[24]      Airservices Australia, Submission 17, p. 2.

[25]      Airservices Australia, Submission 17, p. 2.

[26]      Airservices Australia provides operational documentation which pilots can use to find out about hazards prior to planning or operating into a location. See for example: www.airservicesaustralia.com/aip/current/dap/AeroProcChartsTOC.htm#N and www.airservicesaustralia.com/aip/aip.asp?pg=40&vdate=7-Mar-2013&ver=1 (accessed 19 April 2013).

[27]      Airservices Australia, Submission 17, p. 2.

[28]      Bureau of Meteorology (BoM), Submission 14, p. 1.

[29]      TAFs are statements of meteorological conditions expected for a specific period of time for the airspace within a 5 nautical mile radius of a given aerodrome. See BoM, Submission 14, p. 1.

[30]      BoM, Submission 14, p. 1.

[31]      BoM, Submission 14, p. 1.

[32]      BoM, Submission 14, p. 1.

[33]      Australia's State Aviation Safety Program, April 2012, available at: www.infrastructure.gov.au/aviation/safety/ssp/index.aspx (accessed 1 May 2013).

[34]      Mr Barry Hanstrum, Regional Director NSW/ACT, BoM, Committee Hansard, 19 November 2012, p. 15.

Chapter 3 - The ATSB investigation and methodology

[1]        Ditching – Israel Aircraft Industries Westwind 1124A, VH-NGA, ATSB Transport Safety Report AO-20090072 (ATSB Report), www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-072.aspx.

[2]        Illustration courtesy of Aerosafe Risk Management.

[3]        ATSB Report, p. 43.

[4]        Mr Mick Quinn, Submission 11, p. 22.

[5]        ATSB, Submission 2, p. 13.

[6]        ATSB, Submission 2, p. 12.

[7]        ATSB, Submission 2, p. 13.

[8]        The committee notes that there are other defences, such as maintenance, but no issues were identified with these.

[9]        See Annex 13 of the Chicago Convention, 10^th Edition, July 2010.

[10]      Annex 13 of the Chicago Convention, 5.4.

[11]      Annex 13 of the Chicago Convention, 5.4.

[12]      Annex 13 of the Chicago Convention, 6.5, 6.6.

[13]      Annex 13 of the Chicago Convention, Appendix.

[14]      Annex 13 of the Chicago Convention, 5.13.

[15]      Australian and International Pilots Association (AIPA), Submission 8, p. 7.

[16]      AIPA, Submission 8, p. 19.

[17]      Confidential submissions.

[18]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 9. The committee notes that the ATSB may hold the view that insufficient evidence existed to suggest that organisational and regulatory issues were primary factors leading to the accident.

[19]      This view was put forth by a number of in camera witnesses.

[20]      See discussion between the committee and Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, pp 64–65.

[21]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 8.

[22]      Mr Mick Quinn, Submission 11, p. 1.

[23]      Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 16.

[24]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 57.

[25]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 15 February 2013,          pp 24–25. The ATSB investigation process only allows inclusion of evidence that is linked to a high risk event. As the VH-NGA flight was classified as aerial work, the Pel-Air accident had little chance of being properly assessed. For more on the risk assessment process see Chapter 4.

[26]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 58.

[27]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 58.

[28]      Mr Dominic James, Committee Hansard, 22 October 2012, p. 1.

[29]      ATSB, Submission 2, p. 11.

[30]      The request came only after a lawyer acting on behalf of the VH-NGA pilot-in-command wrote to the ATSB querying why the CASA Special Audit did not feature in the investigation report.

[31]      The Chambers Report, Additional Information number 11. Available at: www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=rrat_ctte/pel_air_2012/submissions.htm.

[32]      The Chambers Report, p. 2.

[33]      The Chambers Report, p. 2.

[34]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 28 February 2013, p. 3.

[35]      ATSB, Submission 2, p. 35. FDRs and CVRs are two different types of recorders used for incident and accident investigation purposes. CVRs are typically used to record audio in the aircraft flight deck, while FDRs record parameters such as altitude and airspeed with respect to time. The committee uses the term FDR to refer to both.

[36]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 12.

[37]      See Committee Hansard, 28 February 2013, p. 9.

[38]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 28 February 2013, p. 9.

[39]      See discussion between Senator David Fawcett and Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 8.

[40]      Paragraph 5.7, ICAO Annex 13, emphasis added.

[41]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 28 February 2013, p. 9.

[42]      ATSB, answer to question on notice 8, 28 February 2013, p. 3.

[43]      Committee Hansard, in camera.

[44]      Confidential document.

[45]      See www.atsb.gov.au/about_atsb/ministers-expectations/statement-of-intent.aspx (accessed 25 March 2013).

[46]      Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 14.

[47]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 54.

[48]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 55.

[49]      Although the ATSB is an independent body, the TSI Act obliges the agency to 'have regard' to strategic guidance from the minister. Prioritising fare-paying passenger operations has been bipartisan policy for some time. See discussion between the committee and Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 4.

[50]      Australian and International Pilots Association, Submission 8, p. 9.

[51]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 55.

[52]      See discussion with Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 55.

[53]      For information on the ATSB's financial performance in 2009-10 see ATSB Annual Report 2009-10, p. 28, available at: www.atsb.gov.au/publications/2010/ar_2009-2010.aspx (accessed 19 April 2013). 

Chapter 4 - The ATSB's accident investigation processes

[1]        The Australian Transport Safety Bureau (ATSB), Submission 2, p. 11.

[2]        For more detail see ATSB, Submission 2, p. 6.

[3]        ATSB, Submission 2, p. 11.

[4]        ATSB, Submission 2, p. 8.

[5]        ATSB, Submission 2, p. 8.

[6]        ATSB, Submission 2, p. 8.

[7]        ATSB, Submission 2, p. 9.

[8]        ATSB, Submission 2, p. 9.

[9]        The matrix the ATSB uses to assess future risk is discussed later in this chapter.

[10]      ATSB, Submission 2, p. 10.

[11]      ATSB, Submission 2, p. 10.

[12]      For more detail see ATSB, Submission 2, p. 31.

[13]      ATSB, Submission 2, p. 32.

[14]      ATSB, Submission 2, p. 32.

[15]      ATSB, Submission 2, p. 31.

[16]      ATSB, Submission 2, p. 33.

[17]      ATSB, Submission 2, p. 34.

[18]      ATSB, Submission 2, p. 34.

[19]      ATSB, Submission 2, p. 7.

[20]      ATSB, Submission 2, p. 7.

[21]      ATSB, Submission 2, p. 19.

[22]      ATSB, Submission 2, p. 41.

[23]      ATSB, Submission 2, p. 20.

[24]      Confidential submission.

[25]      For more detail see ATSB, Submission 2, p. 20.

[26]      ATSB, Submission 2, p. 21.

[27]      ATSB, Submission 2, p. 21.

[28]      ATSB, Submission 2, p. 22.

[29]      ATSB, Submission 2, p. 22.

[30]      ATSB, Submission 2, p. 41.

[31]      The committee came to this conclusion on the basis of the ATSB report and evidence before the committee. See, for example, committee's discussion with Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 15 February 2013, pp 23–24.

[32]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 28 February 2013, p. 8.

[33]      See Minister's Statement of Expectations for 1 July 2011 to 30 June 2013, available at: www.atsb.gov.au/about_atsb/ministers-expectations/ministers-statement-of-expectations.aspx (accessed 19 April 2013).

[34]      ATSB Report, p. 43.

[35]      ATSB Report, p. 33. Had the crew requested information at this point, it may have been too late. When the crew did actually realise how bad the weather was, they had no option to divert.

[36]      It was pointed out that neither the regulations nor the AIP requires a pilot to provide for an alternate based on weather reports. See Mr Bryan Aherne, Submission 10, p. 3. The company operations manual also did not required a diversion in the circumstances. See ATSB report,      p. 31.

[37]      CASA, Answers to questions taken on notice from 22 October 2012 hearing, number 2.

[38]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 21 November 2012, p. 8.

[39]      ATSB report, pp 34-36.

[40]      Confidential submission.

[41]      Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 19.

[42]      Letter from ATSB to CASA, 26 February 2010, additional information, number 2. See also Mr Gary Currall, Submission 9, p. 2.

[43]      CASA, Additional information, number 14.

[44]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 29. CASA also indicated it was reviewing regulation and guidance material related to fuel planning and the identification of alternate aerodromes with a view to seeking appropriate amendments.

[45]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 37.

[46]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 36.

[47]      The ATSB confirmed that CASA had not shared the results or existence of the survey. See Mr Martin Dolan, Committee Hansard, 22 October 2012, p. 57.

[48]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 14.

[49]      CASA, Additional information, number 4; CASA, Answers to questions taken on notice from the 22 October 2012 hearing, number 2.

[50]      CASA, Additional information, number 4.

[51]      Mr John McCormick, Committee Hansard, 22 October 2012, pp 37–38. See also CASA, Answers to questions taken on notice, 22 October 2012 hearing, number 2.

[52]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 14.

[53]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 40.

[54]      Confidential submission.

[55]      Mr Bryan Aherne, Supplementary submission, 8 February 2013, pp 10–11.

[56]      See www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PARTS135, (accessed 16 May 2013).

[57]      Confidential submission.

[58]      Mr Martin Dolan, Committee Hansard, 2 October 2012, p. 67.

[59]      Mr Dolan informed the committee that the investigator in charge of the VH-NGA case did not support this position. See Committee Hansard, 15 February 2013, p. 32.

[60]      Mr Martin Dolan, Committee Hansard, 22 October 2012, pp 56–57.

[61]      Mr Martin Dolan, Committee Hansard, 22 October 2012, pp 56–57.

[62]      ATSB, additional information, number 12; CASA, addition information, number 13.

[63]      ATSB, additional information, number 12.

[64]      CASA, Additional information, number 13.

[65]      Committee Hansard, 15 February 2013, p. 19. CASA minutes from 18 November 2011 indicate that there was potentially an issue with the ATSB and CASA difference of opinion in relation to the safety issue identified. The action was for Mr Farquharson and Mr Boyd to talk to the ATSB to work through the implications of the safety issue identified.

[66]      Mr Martin Dolan and Mr Ian Sangston, Committee Hansard, 15 February 2013, p. 32.

[67]      It was submitted that, given awareness of this division among the professional pilot community, it is difficult to imagine that the safety issue could be downgraded based on consequences. The submitter concludes that the downgrade must have come about by ascribing an extremely low probability to the likelihood that such a gap in the guidance material available to pilots could have a bearing on the accident outcome. Confidential submission.

[68]      Confidential submission.

[69]      Committee Hansard, in camera.

[70]      Confidential submission.

[71]      Confidential submission.

[72]      Confidential submission.

[73]      See www.atsb.gov.au/about_atsb/commissioners.aspx, (accessed 3 April 2013).

[74]      ATSB 2010-2011 Annual Report, p. 3. Available at: www.atsb.gov.au/publications/2011/annual-report-2010-2011.aspx, (accessed 3 April 2013).

[75]      Flight Safety Foundation, Submission 21, p. 1.

[76]      Flight Safety Foundation, Submission 21, p. 2.

[77]      Flight Safety Foundation, Submission 21, p. 2.

[78]      This was not the case a decade ago, when the ATSB recommended a change emergency medical service (EMS) operations are categorised. For more on this see Chapter 9 of this report.

[79]      Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 22 October 2012, p. 55.

Chapter 5 - System failures

[1]        Mr Whyte, AIPA, Committee Hansard, 22 October 2012, p. 23.

[2]        Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 12.

[3]        Mr John McCormick, Committee Hansard, 15 February 2013, p. 21.

[4]        Australian Government, Australia's State Aviation Safety Program, April 2012, p. 6.

[5]        AIPA, Submission 8, p. 19.

[6]        AIPA, Submission 8, p. E2.

[7]        ICAO Annex 13, Ninth edition, App-2.

[8]        Mr John McCormick, Committee Hansard, 22 October 2012, p. 31.

[9]        Mr John McCormick, Committee Hansard, 22 October 2012, p. 33.

[10]      See www.abc.net.au/4corners/stories/2012/08/30/3579404.htm (accessed 4 March 2013)

[11]      Pel-Air Aviation Pty Ltd is a wholly owned subsidiary of Regional Express Pty Ltd (REX).

[12]      CASA Special Audit, 8 January 2010, pp 4–5.

[13]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 9, 10 and 21.

[14]      CASA Special Audit, 8 January 2010, p. 5.

[15]      See www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PC_93397 (accessed 22 March 2013)

[16]      See CASA Special Audit, p. 13.

[17]      Mr Dominic James, Committee Hansard, 22 October 2012, p. 5.

[18]      Mr Bryan Aherne, Submission 10, p. 40.

[19]      Confidential submission.

[20]      ATSB report, p. 43.

[21]      A Request for Corrective Action was issued in relation to CAR 220. CASA Special Audit, p. 13. Note: In 2012 CASA changed Request for Corrective Action (RCA) to Non-Compliance Notice (NCN) to clearly reflect that CASA believes regulations have been breached. See http://www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD:1001:pc=PC_100847 (accessed    19 April 2013).

[22]      ATSB report, p. 25.

[23]      Confidential document. See also CASA Special Audit, p. 12.

[24]      ATSB report, p. 48.

[25]      CASA Special Audit, 8 January 2010, p. 6.

[26]      CASA Special Audit, 8 January 2010, p. 16.

[27]      CASA Special Audit, 8 January 2010, p. 13.

[28]      CASA Special Audit, 8 January 2010, p. 14.

[29]      CASA Special Audit, 8 January 2010, p. 16.

[30]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 10.

[31]      AIPA, Submission 8, p. 10. See also Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 19.

[32]      ATSB report, pp 37–38.

[33]      ATSB report, p. 48.

[34]      Confidential document.

[35]      CASA Special Audit, 8 January 2010, p. 6.

[36]      AIPA, Submission 8, p. 14.

[37]      CASA Special Audit, 8 January 2010, p. 18.

[38]      CASA Special Audit, 8 January 2010, p. 19.

[39]      Mr Bryan Aherne, Submission 10, p. 10, 21; See also AIPA, Submission 8, p. 14.

[40]      AIPA, Submission 8, p. 12.

[41]      ATSB, Supplementary submission, 19 October 2012, p. 1. The ATSB indicated that this oversight was due to a typographical error.

[42]      FAID is a fatigue assessment tool.

[43]      CASA, Additional information, number 19.

[44]      CASA Human Factors Section Special Audit of Pel Air Express Fatigue Risk Management System, 21 December, 2009, p. 3.

[45]      Mr Greg Hood, Committee Hansard, 15 February 2013, p. 5, 10; CASA Supplementary submission, 1 March 2013, p. 3.

[46]      CASA Human Factors Section Special Audit of Pel Air Express Fatigue Risk Management System, 21 December, 2009, p. 6.

[47]      CASA, Additional information, number 15. Note: The ATSB has since questioned the UK analysis. See ATSB, Answers to written question taken on notice from 15 February 2013 hearing, number 4.

[48]      ATSB report, p. 48.

[49]      Mr Bryan Aherne, Supplementary submission, 18 March 2013, comments on question 10.

[50]      ATSB, answers to written questions on notice from 15 February 2013, number 16.

[51]      ATSB, answers to written questions on notice from 15 February 2013, number 16.

[52]      CASA Special Audit, 8 January 2010, p. 7.

[53]      CASA Special Audit, 8 January 2010, p. 42.

[54]      Capt. Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 24.

[55]      First Officer Ian Whyte, Committee Hansard, 22 October 2012, p. 24. See also Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 19.

[56]      Mr Bryan Aherne, Submission 10, p. 26.  See also Mr Mick Quinn, Submission 11, pp 4-5.

[57]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 11. See also Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 18.

[58]      CASA Special Audit, 8 January 2010, p. 7.

[59]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 31.

[60]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 31.

[61]      Mr John McCormick, Committee Hansard, 22 October 3012, p. 40.

[62]      Mr Bryan Aherne, Submission 10, p. 36.

[63]      AIPA, Submission 8, p. 17; See also Mr Gary Currall, Submission 9, p. 2.

[64]      AIPA, Submission 8, p. 17.

[65]      ATSB report, pp 48–49.

[66]      ATSB report, p. 37.

[67]      ATSB, Supplementary Submission, 19 October 2012, Appendix A.

[68]      CASA Special Audit, p. 42.

[69]      ATSB Report, p. 3.

[70]      ATSB report, p. 48.

[71]      For the RVSM (Reduced Vertical Separation Minima) issue see:  AIPA, Submission 8, p. 14; Mr Gary Currall, Submission 9, p. 3; Mr Richard Davies, Submission 12, p. 12; Mr Dominic James, Committee Hansard, 22 October 2012, p. 5, 7; Mr Mick Quinn, Submission 11, p. 31; Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 16; Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 10. See also Mr Bryan Aherne, Submission 10,        pp 28–33; Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 16. See also ATSB, Answers to questions taken on notice from 21 November 2012 hearing, number 4; Mr Bryan Aherne, Supplementary submission, 8 February 2013, p. 7.

[72]      For Noumea issue see: Mr Bryan Aherne, Submission 10, p. 33; Mr Mick Quinn, Submission 11, p. 17; CASA, Supplementary submission, pp 11-12.

[73]      Mr Mick Quinn, Submission 11, p. 8.

[74]      For suitability of aircraft see: Mr Dominic James, Committee Hansard, 22 October 2012, p. 7.

[75]      For role of the chief pilot see: Mr John McCormick, Committee Hansard, 22 October 2012,     pp 33–35; Capt. Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 25; Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 10; Mr John McCormick, Committee Hansard, 22 October 2012, pp 33, 35 and 36. See also Mr Mick Quinn, Submission 11, p. 29.

Chapter 6 - Regulatory issues

[1]        AIPA, Submission 8, p. 17.

[2]        AIPA, Submission 8, p. 26.

[3]        The committee notes that regular surveillance does not provide assurance that the regular audits were effective nor that the standards against which the company was being evaluated were valid. The leads to the recommendation later in the report for industry to be included in the development of standards they should be operating to.

[4]        Mr John McCormick, Committee Hansard, 22 October 2012, p. 31.

[5]        Mr Richard Davies, Submission 12, p. 14.

[6]        Mr John McCormick, Committee Hansard, 15 February 2013, p. 2. See also CASA Supplementary submission, 1 March 2013, p. 4.

[7]        See for example Mr Bryan Aherne, Submission 10, p. 49; and Mr Mick Quinn, Submission 11, p. 5.

[8]        See CASA Supplementary submission. 

[9]        Chambers Report, p. 1.

[10]      Chambers Report, p. 1.

[11]      Chambers Report, p. 5.

[12]      Chambers Report, p. 6.

[13]      Chambers Report, p. 7.

[14]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 8.

[15]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 2; See also CASA Supplementary submission, 1 March 2013, pp 6–7.

[16]      The committee notes the request, dated 22 October 2010, appears quite narrow, asking for:  electronic copies of AOC surveillance, check and training and ops manual files for Pel-Air between 01 January 2004 and 18 November 2009; and the last surveillance check or audit of the fuel planning and management systems in the Pel-Air ops manual.

[17]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 2.

[18]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 2.

[19]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 3.

[20]      Mr Martin Dolan, Committee Hansard, 15 February 2013, p. 23.

[21]      Mr Ian Sangston, Committee Hansard, 15 February 2013, p. 23.

[22]      ATSB, answers to written questions taken on notice from 15 February 2013 hearing, number 3.

[23]      ATSB report, p. 24.

[24]      Mr Martin Dolan, Committee Hansard, 15 February 2013, p. 24.

[25]      ATSB, Answers to questions taken on notice from 15 February 2013 hearing, number 1.

[26]      ATSB, Answers to questions taken on notice from 15 February 2013 hearing, number 1.

[27]      ATSB Submission 2, p. 12.

[28]      Chambers Report, p. 3.

[29]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 2.

[30]      Mr Martin Dolan, Committee Hansard 28 February 2013, p. 2.

[31]      Mr Martin Dolan, Committee Hansard, 28 February 2013, pp 2–3.

[32]      ATSB Submission 2, p. 13.

[33]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 3.

[34]      Chambers Report, p. 6.

[35]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 4.

[36]      ATSB, Submission 2, p. 13.

[37]      Chambers Report, p. 7.

[38]      ATSB Submission 2, p. 13.

[39]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 4.

[40]      Republic of Indonesia, Ministry of Transportation, National Transportation Safety Committee, Aircraft Accident Investigation Report, Dornier 328-100, 6 November 2008.

[41]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 5.

[42]      Mr Martin Dolan, Committee Hansard, 28 February 2013, p. 5.

[43]      ATSB, Additional information, number 12.

[44]      ATSB, 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010'. p. 49.

[45]      See www.austlii.edu.au/au/cases/cth/aat/2011/61.html (accessed 16 April 2013).

[46]      ATSB, 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010'. p. 49.

[47]      ATSB, 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010'. p. iii.

[48]      ATSB, 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010'. p. 53.

[49]      ATSB, 'Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010'. p. 49.

[50]      ATSB Submission 2, p. 21.

[51]      ATSB report, p. 24.

[52]      For example see Helicopter Emergency Medical Services (HEMS) USA industry risk profile, published by the Flight Safety Foundation, developed by Aerosafe Risk Management, April 2009.

[53]      In practice this would mean that if industry and CASA do not agree, the issue would be elevated to the departmental secretary and, if necessary, the minster.

[54]      AMROBA, Submission 15; Confidential submission.

[55]      See www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_92098 ; www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_92107; Steve Creedy, 'Civil Aviation Safety Authority close on reform of rules', The Australian, 4 November 2011. The article notes that the new regulations may not be in place before the end of 2014; Emma Kelly, InFocus, 'Australia closes in on regulatory reform', 19 February 2013. www.flightglobal.com/news/articles/in-focus-australia-closes-in-on-regulatory-reform-382027/; Paul Phelan, 'To hell with the rules', 6 April 2013, Pro Aviation http://proaviation.com.au/?p=639 accessed (19 April 2013).

[56]      AMROBA, Submission 15, p. 1; Civil Aviation Authority of New Zealand, Strategic Direction, October 2011.

Chapter 7 - Communication between CASA and the ATSB

[1]        The Miller Review, p. 30.

[2]        For more detail see chapters 3 and 6 of this report.

[3]        The Chambers Report, internal CASA report titled 'Oversight Deficiencies – Pel-Air and Beyond, additional information 11.

[4]        As discussed in Chapter 4 of this report.

[5]        Paragraph 4.4.6, MoU between the ATSB and CASA.

[6]        See discussion with Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 15 February 2013, p. 2.

[7]        Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 15 February 2013, pp 2–3.

[8]        Mr John McCormick, Director of Aviation Safety, CASA, Committee Hansard, 15 February 2013, p. 2.

[9]        Transport Safety Investigation Act 2003, Subsection 24(1).

[10]      See discussion with Mr Ian Sangston, General Manager, ATSB, and Mr Martin Dolan, Chief Commissioner, ATSB, Committee Hansard, 15 February 2013, p. 23 and pp 25–26.

[11]      ATSB, answer to question on notice 5, 15 February 2013, p. 6.

Chapter 8 - Human factors

[1]        Civil Aviation Safety Authority, A practical guide: Human Factors, available at www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_101005 (accessed 15 April 2013).

[2]        See for example Mr Bryan Aherne, Submission 10, p. 26; Mr Mick Quinn, Submission 11, p. 2; and AIPA, Submission 8, p. 4.

[3]        ATSB, Mr David Adams, A Layman's Introduction to Human Factors in Aircraft Accident and Incident Investigation, June 2006, p. vi.

[4]        ATSB, Mr David Adams, A Layman's Introduction to Human Factors in Aircraft Accident and Incident Investigation, June 2006, p. 20.

[5]        See www.atsb.gov.au/about_atsb/international-recognition.aspx (accessed 29 March 2013).

[6]        Mr Martin Dolan, InFocus Blog, 'Investigating Human Error', 4 December 2012.

[7]        Mr Martin Dolan, Committee Hansard, 2 October 2012, p. 54.

[8]        Mr Bryan Aherne, Submission 10, p. 26.

[9]        AIPA, Submission 8, p. 14.

[10]      Time references are to Coordinated Universal Time (UTC), the primary standard used to regulate clocks and time worldwide.

[11]      Mr Martin Dolan, Committee Hansard, 21 November 2012, pp 11–12.

[12]      Mr Bryan Aherne, Submission 10, p. 42.

[13]      Mr Bryan Aherne, Submission 10, p. 41.

[14]      ATSB Report, pp 6–7.

[15]      Mr Davies, Submission 12, p. 9; and Mr Bryan Aherne, Submission 10, p. 18 indicated that should be 1000 ft, not 1100 ft as indicated in the ATSB report, p. 7. In a supplementary submission dated 19 October 2012, on p. 1, the ATSB acknowledged that the figure on p. 7 of the ATSB report should read 1000 ft and not 1100 ft.

[16]      ATSB report, p. 7.

[17]      ATSB report, pp 7 and 16.

[18]      Pel-Air, Submission 7, p. 3.

[19]      ATSB report, pp 7 and 16.

[20]      Mr Richard Davies, Submission 12, p. 9.

[21]      It should be noted that a SPECI is issued when there has been a significant change to the conditions which could be a deterioration or improvement.

[22]      For example Mr Richard Davies, Submission 12, p. 9; Mr Mick Quinn, Submission 11, p. 6.

[23]      ATSB Report, p. 7.

[24]      ATSB Report, p. 17.

[25]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 9.

[26]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 11.

[27]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 12.

[28]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 13.

[29]      ATSB answer to question on notice from 21 November 2012 hearing, number 1.

[30]      ATSB answer to question taken on notice from 21 November hearing, number 2.

[31]      Mr Bryan Aherne, Supplementary submission, 8 February 2013, p. 21.

[32]      Mr Bryan Aherne, Submission 10, p. 40.

[33]      ATSB Report, p. 15.

[34]      Selective Calling, or SELCAL, is a radio system used to notify flight crew that a radio station wishes to communicate with them.

[35]      Mr Mick Quinn, Submission 11, p. 8. See also Mr Bryan Aherne, Supplementary submission, 8 February 2013, p. 4. The committee notes that many pilots adjust the squelch control to eliminate the white noise until they have to make a call or are expecting a call. However, the committee is unaware of the effectiveness in this instance.

[36]      ATSB re-enactment video.

[37]      It can skip so that an aircraft close to the ATC may miss part of a broadcast but an aircraft much further out will receive it. Clarity can be poor with fading in and out requiring elements of transmissions to be repeated.

[38]      Mr Bryan Aherne, Supplementary submission, 8 February 2013, p. 4.

[39]      ATSB report, p. 14.

[40]      ATSB report, p. 14.

[41]      ATSB report, p. 15.

[42]      Mr Mick Quinn, Submission 11, p. 21; Mr Bryan Aherne, Submission 10, p. 43.

[43]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 47.

[44]      Confidential submission.

[45]      CASA, Fatigue management strategies for aviation workers: A training and development workbook, May 2012, p. 80. See also Bryan Aherne, Supplementary submission, 18 March 2013, comments on question 4.

[46]      CASA, Fatigue management strategies for aviation workers: A training and development workbook, May 2012, pp 80–81.

[47]      Mr Martin Dolan, Committee Hansard, 15 February 2013, p. 28.

[48]      System of Aircrew Fatigue Analysis.

[49]      CASA, Additional information, number 15.

[50]      ATSB, answers to written questions on notice, from 15 February 2013 hearing, number 4.

[51]      Mr Bryan Aherne, Supplementary submission, 18 March 2013, comments on question 4, 15 and 16 and comments on written questions on notice, number 1.

[52]      ATSB, Supplementary submission, 11 November 2012, p. 2; ATSB, answers to written questions taken on notice from 15 February 2013 hearing, number 4; Mr Martin Dolan, Committee Hansardi, 15 February 2013, p. 29.

[53]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 4.

[54]      Confidential submission. Civil Aviation Order 48.0 covers flight time limitations.

[55]      ATSB report, p. 14.

[56]      Confidential submission.

[57]      Mr Bryan Aherne, Supplementary submission, 18 March 2013, comment on number 10.

[58]      Confidential document.

[59]      ATSB, Additional information, number 16.

[60]      ATSB, Additional information, number 17.

[61]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 12.

[62]      As noted in Chapter 3 of this report, this is required by the International Civil Aviation Organisation (ICAO).

[63]      Confidential submission. The committee also heard in camera evidence indicating that the aircraft and cabin structures' crashworthiness, as well as the pilot-in-command's operating technique in executing the ditching, should have been examined.

[64]      Mr Bryan Aherne, Supplementary submission, 8 February 2013, pp 6–7.

[65]      Mr Dominic James, Committee Hansard, 22 October 2012, p. 4.

[66]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 13.

[67]      ATSB report, p. 24.

[68]      ATSB report, p. 20.

[69]      ATSB, Supplementary submission, 11 November 2012, pp 6–7; ATSB, answers to written questions on notice from 15 February 2013 hearing, number 14.

[70]      Mr Bryan Aherne, Supplementary submission, 18 March 2013, comments on question 14.

[71]      Mr Bryan Aherne, Supplementary submission, 18 March 2013, comments on question 14.

[72]      Confidential document. See also Committee Hansard, 15 February 2013, p. 21.

[73]      Mr Martin Dolan, Committee Hansard, 22 October 2012, p. 63.

[74]      Mr Martin Dolan, Mr Ian Sangston, Committee Hansard 22 October 2012, pp 63–64.

[75]      ATSB report, p. 21.

[76]      Mr Dominic James, Committee Hansard, 22 October 2012, pp 3–4.

[77]      Mr Dominic James, Committee Hansard, 22 October 2012, p. 4.

Chapter 9 - Key issues around recommendations and ensuring action

[1]        See for example Mr Mick Quinn, Submission 11, p. 1; and Capt. Geoffrey Klouth, AIPA, Committee Hansard, 22 October 2012, p. 23.

[2]        TSI Act, subparagraph 12AA(1)(d)(ii).

[3]        Available from: www.atsb.gov.au/about_atsb/ministers-expectations/ministers-statement-of-expectations.aspx (accessed 26 March 2013).

[4]        MoU between ATSB and CASA, February 2010, p. 8, paragraph 5.3.1.

[5]        Answers to questions taken on notice from 22 October 2012 hearing, number 10.

[6]        See ATSB, Submission 2, p. 24; ATSB, Supplementary Submission, 11 November 2012, p. 8; Answers to questions taken on notice from 22 October 2012 hearing, number 10; and Answer to question taken on notice from 21 November 2012, number 18.

[7]        ATSB, Answers to questions taken on notice from 22 October 2012 hearing, number 10.

[8]        ATSB Submission 2, p. 24.

[9]        ATSB, Answers to questions taken on notice, 21 November 2012, attachment to the 26 February 2012 ATSB letter to CASA.

[10]      Answers to questions taken on notice from 22 October 2012 hearing, number 10.

[11]      See for example Capt. Geoffrey Klouth, AIPA, Committee Hansard, 22 October 2012, p. 26.

[12]      Capt. Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 24. See also First Officer Ian Whyte, Committee Hansard, 22 October 2012, p. 24.

[13]      AIPA, Submission 8, p. 28

[14]      First Officer Ian Whyte, AIPA Committee Hansard, 22 October 2012, p. 24.

[15]      ATSB, Submission 2, p. 28.

[16]      Mr John McCormick, Committee Hansard, 15 February 2013, p. 21.

[17]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 45.

[18]      Senator David Fawcett, Committee Hansard, 15 February 2013, p. 21; Confidential document.

[19]      Mr Mick Quinn, Submission 11, p. 13.

[20]      Mr Dominic James, Committee Hansard, 22 October 2012, p. 7.

[21]      AIPA, Submission 8, p. 28.

[22]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 11.

[23]      Mr Bryan Aherne, Submission 10, p. 4. Information available from: www.atsb.com.au/publications/recommendations/2001/r20010195.aspx (accessed 13 March 2013). The recommendation asked CASA to consider proposing an increase in the operations' classification, and/or the minimum safety standards required, for organisations that transport their own employees and similar personnel (for example contractors, personnel from related organisations, or prisoners, but not fare-paying passengers) on a regular basis.

[24]      Information available from: www.atsb.com.au/publications/recommendations/2001/r20010195.aspx (accessed 13 March 2013).

[25]      It is proposed that 'Emergency Services Flights' will  cover aerial fire-fighting, law enforcement and search and rescue operations, while 'Medical Services Flights' will cover air ambulance flights, health services flights, and emergency medical services flights. See www.atsb.com.au/publications/recommendations/2001/r20010195.aspx (accessed 13 March 2013)

[26]      Information available from: www.atsb.com.au/publications/recommendations/2001/r20010195.aspx (accessed 13 March 2013).

[27]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 44.

[28]      CASA Supplementary submission, October 2012, p. 7.

[29]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 46.

[30]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 9: and Mr Bryan Aherne, Submission 10, p. 7.

[31]      Mr Bryan Aherne, Committee Hansard, 22 October 2012, p. 9; and Mr Gary Currall, Submission 9, p. 2.

[32]      See also CASA, Supplementary submission, p. 17.

[33]      Mr Mick Quinn, Committee Hansard, 22 October 2012, p. 19.

[34]      RFDS, Submission 20, p. 1.

[35]      AIPA, Submission 8, p. 11.

[36]      Pel-Air, Submission 7, p. 4.

[37]      Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013)

[38]      Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013)

[39]      Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013)

[40]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 46.

[41]      CASA, Answers to questions taken on notice from 22 October 2012 hearing, number 4.

[42]      AIPA, Submission 8, p. 16. See also Mr Dominic James, Committee Hansard, 22 October 2012, p. 1.

[43]      TSI Act, Section 25A.

[44]      MoU, paragraph 5.3.5, p. 9. 

[45]      See www.atsb.com.au/publications/recommendations/2001/r20010195.aspx (accessed 15 April 2013).

[46]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 8.

[47]      Airservices Australia, Submission 17, p. 2.

[48]      Mr Peter Hobson, Airservices Australia, Committee Hansard, 19 November 2012, p 1. See also Airservices Australia, Submission 16, p. 1.

[49]      ATSB Report, pp 5–6. See also Airservices Australia, Submission 17, p. 2.

[50]      ATSB Report, p. 16. The ATSB was unclear whether this was not required by ICAO, the AIP or the Pacific Agreement. The committee asked the ATSB for a copy of the Pacific Agreement to which it replied that it did not have a copy and did not seek one. The committee therefore does not know on what evidence the ATSB claims there was no requirement to pass on the information.

[51]      ATSB Report, p. 57.

[52]      Pel-Air, Submission 7, p. 2.

[53]      Mr Harfield, Committee Hansard, 19 November 2012, p. 2.

[54]      Mr Harfield, Committee Hansard, 19 November 2012, p. 2.

[55]      Witnesses were not clear on exactly who should have passed on the information which is concerning in itself but the point is there is no requirement to do so which needs to be addressed by those managing the airspace.

[56]      ATSB Report, p. 16.

[57]      Mr Harfield, Committee Hansard, 19 November 2012, p. 4.

[58]      Mr Harfield, Committee Hansard, 19 November 2012, p. 5.

[59]      Mr Harfield, Committee Hansard, 19 November 2012, p. 5.

[60]      Mr Harfield, Committee Hansard, 19 November 2012, pp 2–3.

[61]      Advance copy of finalised Preliminary Report provided three weeks before publication.

[62]      A copy of the final report was provided upon publication.

[63]      Airservices Australia, answers to questions taken on notice from 19 November hearing, number 2; Mr Harfield, Committee Hansard, 19 November 2012, p. 4.

[64]      Mr Harfield, Committee Hansard, 19 November 2012, p. 10.

[65]      Mr Harfield, Committee Hansard, 19 November 2012, p. 11.

[66]      Ms Margaret Staib, Committee Hansard, 19 November 2012, p. 5.

[67]      Mr Harfield, Committee Hansard, 19 November 2012, p. 3.

[68]      Ms Margaret Staib, Committee Hansard, 19 November 2012, p. 6.

[69]      Mr Harfield, Committee Hansard, 19 November 2012, p. 8.

[70]      Airservices Australia, Answers to questions taken on notice at 19 November 2012 hearing, number 5.

[71]      Airservices Australia, Answers to questions taken on notice at 19 November 2012 hearing, number 6.

[72]      Mr Bryan Aherne, Supplementary submission 2, 8 February 2013, pp 4–5.

[73]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 8.

[74]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 8.

[75]      Mr Martin Dolan, Committee Hansard, 22 October 2023, p. 57.

[76]      Confidential submission.

[77]      CASA Special Audit, p. 14.

[78]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 16. See also ATSB, Answers to questions taken on notice from 21 November 2012 hearing, number 4.

[79]      Confidential submission.

[80]      Universal communications services are non-ATS radio communications services provided on an MBZ frequency or CTAF to enhance the value of information normally available about a non-controlled aerodrome....General aerodrome weather reports provided by a Unicom operator are to be limited to simple, factual statements about the weather, unless the Unicom operator is authorised by CASA to make meteorological observations. See CASA Manual of Standards, Part 139, section 14.4.

[81]      Mr Bryan Aherne, Submission 10, p. 35.

[82]      Mr Mick Quinn, Submission 11, p. 17. See also Mr Bryan Aherne, Submission 10, p. 35.

[83]      Mr Jackson and Mr Hainsworth, Committee Hansard, 19 November 2012, p. 18.

[84]      BoM, Answers to questions on notice, received 3 May 2013.

[85]      Mr Hainsworth, Committee Hansard, 19 November 2012, p. 18, 21. See also Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 9.

[86]      Mr Gordon Jackson, Head, Aviation and Defence Weather Services, BoM, Committee Hansard, 19 November 2012, p. 18. Note: new procedures and validity period are being finalised.

[87]      Mr Mick Quinn, Submission 11, pp. 6–8.

[88]      Mr Mick Quinn, Submission 11, p. 17.

[89]      CAR 120.

[90]      CASA, Supplementary submission.

[91]      AIPA, Submission 8, p. 14.

[92]      Mr Barry Hanstrum, Regional Director NSW/ACT, Bureau of Meteorology, Committee Hansard, 19 November 2012, p. 15.

[93]      BoM, Submission 14, p. 2.

[94]      Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 6.

[95]      Mr Mick Quinn, Submission 11, p. 13.

[96]      Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013).

[97]      Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013). Emphasis added.

[98]      Recommendation R20000040. Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013).

[99]      Measures the cloud base.

[100]    BoM, Submission 14, p. 3; Note: Range of the radar, if heavy rain, would be in the order of    150 to 200 km in a radius around the island, Mr Hanstrum, Regional Director NSW/ACT, Bureau of Meteorology, Committee Hansard, 19 November 2012, p. 19.

[101]    Mr Barry Hanstrum, 19 November 2012, Committee Hansard, pp 15–16.

[102]    BoM, Submission 14, p. 3.

[103]    Mr Hanstrum, Committee Hansard, 19 November 2012, p. 19.

[104]    Mr Hanstrum, Committee Hansard, 19 November 2012, p. 20.

[105]    Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013).

[106]    Information available from: www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx (accessed 25 January 2013).

[107]    Mr Mick Quinn, Submission 11, p. 15.

[108]    Mr Mick Quinn, Submission 11, pp. 6–8.

[109]    Confidential submission.

[110]    AIPA, Submission 8, p. 14.

[111]    Confidential submission.

[112]    ATSB report, pp 57–59.

[113]    Mr Martin Dolan, Committee Hansard, 21 November 2012, p. 6.

[114]    See AIP, ERSA, Norfolk Island, 7 March 2013.

[115]    Mr Mick Quinn, Submission 11, p.10.

[116]    Confidential document.

[117]    Mr Mick Quinn, Submission 11, p. 10; See AIP, Departure and Approach Procedures (DAP), Aerodrome and Procedure Charts, Norfolk Island.

[118]    Mr Harfield, Committee Hansard, 19 November 2012, p. 3.

[119]    Ms Margaret Staib, Committee Hansard, 19 November 2012, p. 6.

[120]    Mr Harfield, Committee Hansard, 19 November 2012, p. 8.

[121]    Mr Harfield, Committee Hansard, 19 November 2012, p. 4.

Chapter 10 - Changes to mandatory and confidential reporting

[1]        Information available from: www.atsb.gov.au/aviation_newregs.aspx (accessed 19 March 2013)

[2]        ATSB, Enhanced Aviation Mandatory and Confidential Reporting, Consultation paper, p. 3.

[3]        ATSB, Enhanced Aviation Mandatory and Confidential Reporting, Consultation paper, p. 1.

[4]        Information available from: www.atsb.gov.au/aviation_newregs.aspx (accessed 19 March 2013).

[5]        REPCON is a voluntary and confidential reporting scheme which allows any person who has an aviation safety concern to report it to the ATSB confidentially. See www.atsb.gov.au/voluntary/repcon-aviation.aspx (accessed 15 May 2013).

[6]        Information available from: www.atsb.gov.au/aviation_newregs.aspx (accessed 19 March 2013).

[7]        ATSB, Enhanced Aviation Mandatory and Confidential Reporting, Consultation paper, p. 1.

[8]        ATSB, Enhanced Aviation Mandatory and Confidential Reporting, Consultation paper, p. 1.

[9]        AIPA, Submission 8, Appendix 1, Australian Airline Pilots' Association response to ATSB Enhanced Aviation Mandatory and Confidential Reporting, pp [45–46].

[10]      AIPA, Submission 8, p. 29. See also: Captain Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 22.

[11]      First Officer Ian Whyte, Committee Hansard, 22 October 2012, p. 25.

[12]      AIPA, Submission 8, Appendix 1, Australian Airline Pilots' Association response to ATSB Enhanced Aviation Mandatory and Confidential Reporting, p. [46].

[13]      AIPA, Submission 8, Appendix 1, Australian Airline Pilots' Association response to ATSB Enhanced Aviation Mandatory and Confidential Reporting, p. [48].

[14]      AIPA, Submission 8, Appendix 1, Australian Airline Pilots' Association response to ATSB Enhanced Aviation Mandatory and Confidential Reporting, p. [49].

[15]      AIPA, Submission 8, Appendix 2.

[16]      Mr Julian Walsh, Committee Hansard, 22 October 2012, p. 62.

[17]      Captain Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 25.

[18]      APSA, Submission 4, p. 5.

[19]      Captain Geoffrey Klouth, Committee Hansard, 22 October 2012, p. 25.

[20]      First Officer Ian Whyte, Committee Hansard, 22 October 2012, p. 24.

[21]      ATSB, Enhanced Aviation Mandatory and Confidential Reporting, Consultation paper, p. 4.

[22]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 51.

[23]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 51.

[24]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 51.

[25]      Mr John McCormick, Committee Hansard, 22 October 2012, p. 51.

[26]      CASA, Answers to questions taken on notice from 22 October 2012 hearing, number 6.

[27]      ATSB, Consultation paper, p. 2.

[28]      Mr Julian Walsh, Committee Hansard, 22 October 2012, p. 62.

[29]      Mr Julian Walsh, Committee Hansard, 22 October 2012, p. 62.

[30]      Mr Julian Walsh, Committee Hansard, 22 October 2012, p. 62.

[31]      Mr Martin Dolan, Committee Hansard, 22 October 2012, p. 62.

[32]      Mr Julian Walsh, Committee Hansard, 22 October 2012, p. 63.

[33]      Mr Martin Dolan, Committee Hansard, 22 October 2012, p. 65.

[34]      ATSB, Answers to questions taken on notice, 28 February 2013, number 5.

Additional Comments by Senator Nick Xenophon - Who guards the guards themselves?

[1]        Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), Additional Information 12, received 10 October 2012.

[2]        Information available from: www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PARTS135 (accessed 7 May 2013).

[3]        Information available from: www.casa.gov.au/scripts/nc.dll?WCMS:PWA::pc=PARTS136 (accessed 7 May 2013).