Australian Transport Safety Bureau Commissioner Chris Manning has said that the final report into the re-opened Norfolk Island ditching investigation had to address issues in the original report earmarked by both the Canadian Transportation Safety Bureau (TSB) review and a senate inquiry.
The resulting 531-page second investigation report was released today.
“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” Manning said. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.
“The ATSB recognises the importance of being able to demonstrate that the re-opened investigation addressed identified areas for improvement with the original investigation. A main focus of the re-opened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”
The final report found 36 safety factors, including 16 safety issues. According to the ATSB, many of these stemmed in part from the amount of information obtained by the re-opened investigation and the depth of analysis
“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Manning. “The ATSB was mindful at all times that the people and organisations involved in this accident have been intently waiting for the results of the reopened investigation and acknowledges the time that it has taken to complete the final report.”
The original report provoked controversy because it seemingly laid blame at the feet of the flight crew. After a senate inquiry resulted in 26 recommendations and the TSB review found that the ATSB had not followed its normal procedures, the ATSB agreed to re-open the investigation, which included recovering the flight data recorder.
According to the ATSB, special measures were taken to distance the re-opened investigation from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, the investigation was conducted by investigators and overseen by managers who had not been involved in the original. ATSB’s current Chief Commissioner, Greg Hood, was also not involved in any part of the investigation because he had been in a senior role at CASA at the time of the accident.
The depth of the report document and the greater scrutiny have failed to impress the pilot involved in the ditching, Dominic James, who says the ATSB has missed an opportunity to make a real improvement to aviation safety by including reams of irrelevant information.
"They've incrementally improved their understanding of what happened," he told Australian Flying, "but given how much attention has been poured into this and what resources were given to them, the fact that they haven't come up with a landmark document that could be given out as a paragon of accident investigation is a total cock-up.
"There's about 200 pages there that should hit the cutting-room floor straight away.They don't help anyone do anything. It's quite simplistic: if I am given the right weather on the night before I leave Samoa, or I get the correct weather handed to me in flight, the accident doesn't happen; it's a weather accident.
"To talk about thing like pressurisation fuel when no de-pressurisation took place is a total red herring. It would be like having a whole expose on my pre-flight technique, but if nothing I did in the pre-flight had an impact on the accident, why go chapter-and-verse about my pre-flight technique?"
The full ATSB statement that accompanied the release of the investigation report is available on the ATSB website.