A Canadian review of the Australian Transport Safety Bureau (ATSB) has criticised the investigation into the 2009 Pel-Air ditching off Norfolk Island.
The report, published by the Transportation Safety Board of Canada (TSB) on 1 December, examined the ATSB's systems and methods, focusing on three investigations in particular: Norfolk Island, a winching accident involving an AW139 helicopter at kangaroo Valley in 2011, and the crash of a Piper Mojave at Canley Vale in 2012.
According to the TSB report, the ATSB did not stick to sound investigation procedures in the Norfolk Island case, and cites the Kangaroo Valley and Canley Vale crashes as examples of good methodology producing "defensible" results.
"The TSB Review of the Norfolk Island investigation 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 published report states.
"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.
"First of all, an early misunderstanding about the responsibilities of the Australian Civil Aviation Safety Authority (CASA) and the ATSB in the investigation was never resolved. This led to the ATSB collecting 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."
Several aspects of theNorfolk Island investigation were singled-out for special mention in the report including:
- Three peer reviews of the draft report identified issues, but nothing was done
- The investigation oversight was ineffective, resulting in problems with insufficient data not being addressed
- There was no process to ensure the ATSB communicated its reponses to comments offered by people directly involved
- A safety issue on guidance to pilots for obtaining weather forecasts was sent to CASA as "critical", but appears as "minor" in the final report.
"The response to the Norfolk Island investigation report clearly demonstrated that it did not address key issues in the way the Australian aviation industry and members of the public expected," the report concluded.
Conversely, the TSB report describes very different outcomes for both the Kangaroo Valley and Canley Vale investigations.
"The review of the Kangaroo Valley and Canley Vale investigations showed that when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the result is more defensible.
"In contrast to Norfolk Island, the Kangaroo Valley and Canley Vale investigations underwent regular critical reviews and used the ATSB analysis tools effectively, which gave rise to well-documented decisions, and revised data collection plans and analyses.
"In the Canley Vale investigation, additional information collected as a direct result of a critical review guided informed decisions with respect to the investigation of regulatory oversight."
Fourteen recommendations for improvement have been presented to the ATSB.
The report also identifies several aspects about ATSB procedures that meet world best-practice standards.
The full report is available on the TSB website.