The senate committee report into the ATSB investigation of the Norfolk Island ditching has made 26 recommendations.
Some of the recommendations have purely administrative value, with others standing to have long-term effects on CASA and the ATSB if they are implemented.
Most primary among those are:
- The ATSB should re-open the accident investigation onto the 2009 Pel-Air ditching
- Immediate steps be taken to recover the flight data recorders
- ATSB investigator skills be benchmarked against an independent body such as the USA's National Transport Safety Board (NTSB)
- The Chief Commissioner of the ATSB have aviation safety expertise
- An expert aviation panel be established to ensure the quality of aviation accident investigations
- The Senate Standing Committee on Rural and Regional Affairs and Transport conduct an inquiry into the aviation regulatory reform program
- The memorandum of understanding between CASA and the ATSB be rewritten to remove ambiguities
- A review of the weather forecasting at Norfolk Island.
Included in the body of the report are some statement damning to both the ATSB and CASA.
"The ATSB's firm position is that the ditching was a one-off event due predominantly to the actions of the pilot and the agency has defended this stance without, in the committee's view, a solid evidentiary base," the report summary contains.
"Over the course of this inquiry the ATSB repeately deflected suggestions that significant deficiencies with both the operator (identified in the CASA Special Audit of Pel-Air) and CASA's oversight of Pel-Air, (identified in the Chambers Report) contributed to the accident.
"The committee takes a different view and believes that ATSB processes have become deficient ... allowing this narrow interpretation of events to occur."
Also noted in the report was that many people who submitted to the inquiry prefered to do so in camera due to fear of retribution from CASA.
"The committee also notes that this reticence to speak in public has been apparent for each inquiry this committee has conducted in this area over several years, and find this deeply worrying.
"There is an obligation on CASA to allay these concerns that retribution could follow speaking out, which appear to be widespread in the aviation industry."
Within the report are also a comparison of the Pel-Air report to the Canley Vale Mojave crash, and the implication that CASA may have breached the Transport Safety Investigations Act
The full report will be available here on the senate website for a short time only.