Late yesterday the independent air safety investigator, the ATSB released a damning report into an astonishingly unsafe approach to Sydney Airport by a QantasLink turbo-prop at the end of a flight from Moree on Boxing Day 2008.
It missed all the general media outlets, not that the timing mattered given the unwillingness of newspapers to digest and fearlessly report on air safety failings of big advertising airlines in Australia.
But in terms of aviation safety, this was just another episode of Hush, my Country is Sleeping.
There is no effective accountability in air safety reporting in this country, nor in the official policy of never prosecuting big airlines for clear breaches of the law, compared to the regulatory enforcement of such matters in the US and most of Europe.
Earlier this year the ATSB, which does technical investigations that are admired and respected worldwide, released a report that detailed breaches of the law on reporting serious incidents by Jetstar.
Yet the ATSB shut down questioning of its investigation by declaring that it would take no queries about it following a press conference in Canberra, which didn’t even come with a dial-in facility.
There is a conflict inherent in the ATSB charter not to find or apportion blame in its investigations because of the emphasis on improving air safety, and the blunt reality of its descriptions of dangerous or illegal actions.
Surely the correct approach by the media, and the safety enforcer, the Civil Aviation Safety Authority, is to use the factual findings of an ATSB inquiry to pursue recognition of failures in airline standards by the responsible managements of the carrier involved.
In the case of the latest report, a 50-seat QantasLink turbo-prop was flown so badly that it flirted with aerodynamic stall twice in 10 seconds at low altitude because the pilots neglected to adhere to the airline’s operational procedures.
The captain, who was supervising and assisting the first officer who was the pilot doing the actual flying, was disobeyed after he ordered the landing to be aborted and a go-around made. The first officer nearly stalled the Dash 8-300 airliner again, only seconds later by persisting in an unstable and dangerous low-speed flight configuration as the turbo-prop struggled towards the runway.
Qantas is totally responsible for the safety standards of its pilots. However, its submissions to the ATSB and those of CASA before the final report was issued late yesterday were suppressed.
There is in this era of cost cutting, and questionable safety cultures, a need for total transparency in incidents such as this. Only then can he public be confident that the causal factors of such dangerous incidents are occupying the attention of airline managements, and being acted upon.
“The captain, who was supervising and assisting the first officer who was the pilot doing the actual flying, was disobeyed after he ordered the landing to be aborted and a go-around made. The first officer nearly stalled the Dash 8-300 airliner again, only seconds later by persisting in an unstable and dangerous low-speed flight configuration as the turbo-prop struggled towards the runway.”
Obviously the captain had ultimate responsibility in the cockpit, but was any action taken against the first officer? The latter sounds like the sort of cowboy who shouldn’t be allowed anywhere near a load of passengers!
Ben, I haven’t yet read the report. I do know the ATSB can investigate and report on any training inadequacies which may have contributed to an accident or incident. Maybe there should be a requirement for airlines to report back as to follow up action taken pursuant to a report and for this to form part of the public record. The investigations should remain in camera to avoid trial by media and to encourage candour by operating crew and airlines. Candour is of course essential if safety lessons are to be learnt from past mistakes. A punitive regime would lead to silence and secrecy all round.
I have read the report now. Shades of Colgan crash at Buffalo. Deteriorating airspeed not detected. Improper response to stick shaker by PF. Inadequate CRM. Fortunately in this case the crew recovered in time. Maybe the Captain’s long experience saved the day.
The candour element in the investigation of the incident is indeed crucial to the process of discovery and remedy. However it should not then lead to the big Australian airlines being untouchable for breaches of the law, subsequent to an inquiry. Jetstar should have been prosecuted for its failure to notify the ATSB of a reportable incident, in fact, it was only a report in Crikey and in Aviation Business that caused the investigation into the very grave incident to be opened by the ATSB.
Then the ATSB refuses to take questions and gives Jetstar a free pass for what is an offence under the relevant legislation. And the media runs away and hides.
There needs to be a rule of law in this country in respect of compliance with aviation regulations, not a wink and a nod. Enforcing the law, FAA style, will not impede a candid inquiry into an air safety incident. But it may well prevent a disaster.
In the case of Qantaslink, surely the minimum course of action should have been an audit of its flight standards, and a show cause in relation to its AOC if serious deficiencies were uncovered.
At the moment the truth about these issues is suppressed, leading the public into false assumptions in that it doesn’t know what CASA knows, as proved to be the case in the Transair crash at Lockhart River. CASA knew and tolerated an unsafe situation. Fifteen people died.