At 5.25 AM on July 24, 1999, a fatal airplane crash in mountains bordering Naitasiri and Namosi killed all 17 people on board. During the probe into the deadly crash, investigators and families questioned the preparedness of the country's emergency response operations.
The tragic crash of Air Fiji's PC121 brought under intense scrutiny the industry's reporting procedures, highlighting the need for better training and stricter regulations, particularly when it was found that it took at least an hour and a half before air traffic controllers alerted the authorities.
There was also concern about air traffic controllers' failure to immediately raise the alarm when the aircraft failed to make mandatory positional reports. Bureaucratic red tape also caused the delay in airlifting emergency officials to the crash site, doctors arriving at the site of the wreckage some six hours after the plane went down.
As a result, the investigation team from the Australian Transport Safety Bureau made some recommendations — and also below is the response received from Civil Aviation Authority CEO Netava Waqa.
1. The government of Fiji should ensure that the Civil Aviation Authority of Fiji (CAAF) is adequately resourced with well qualified and experienced personnel to:
CAAF response - The CAAF is a government statutory authority which was established in 2000 as part of the Government's Civil Aviation Institutional reform under Public Enterprises Act.
The reform was intended to make civil aviation services more efficient and establish CAAF as the Civil Aviation regulator to focus purely on civil aviation safety oversight. CAAF has its budget reviewed and approved by the government ministry or minister responsible for Civil Aviation yearly after endorsement by the CAAF Board.
As a signatory to the Chicago Convention, part of government's review is to ensure that CAAF is adequately resourced to ensure Fiji among others meets its international obligations particularly in performing its licensing, certification and surveillance responsibilities.
Part of the CAAF budget is an allocation on training and development of staff to maintain core competencies that are required by CAAF to effectively deliver all its regulatory services.
* conduct frequent comprehensive scheduled and unscheduled surveillance audits of all commercial aircraft operators.
CAAF response - The CAAF prepares an annual work plan as part of the budget process and the plan identifies the surveillance audits that are required to be carried out by each inspecting staff during the year for the companies they oversight. Provisions for unscheduled surveillance and Ramp audits are also contained in the plan.
The frequency, scope and depth of the CAAF surveillance programs are driven by the safety information and data that CAAF has in its database about a company and CAAF audit focuses on the reviewing the functionality of key safety systems or process and the company safety performance as required by the Safety Management System (SMS) by ICAO.
Under the SMS standards each company is required to set safety indicators and targets and conduct ongoing hazard identification, risk assessment and remedial actions.
* conduct regular regional operational safety education meetings for line pilots and aircraft maintenance engineers. These meetings should target current safety concerns, such as adherence to standard operating procedures and crew resource management practices.
CAAF response - CAAF conducts Air Operator Certificate (AOC) holders and Service Providers meeting every month to discuss aviation issues in general including safety issues . On issues relating to adherence to standard operating procedures (SOP), these are normally handled under the Mandatory Occurrence Reporting (MOR) system.
This system encourages operators and aviation personnel to report directly to the CAAF any violation or non-adherence to SOP. Additionally, the CAAF conducts workshops based on need or hire experts to conduct such courses.
CAAF conducts workshops on responsibilities of Check and Training Captains, Lead Auditor and Safety Management System on request. Crew Resource Management (CRM) training is a requirement for all pilots who conduct public transport flights every two years and airlines arrange and conduct their own training.
2. CAAF and the operator should ensure that the company operations manual properly reflects the organisational structure and operational function of the company. This should include the requirement that no personnel management changes likely to affect the operational safety and integrity of the company be implemented prior to approved amendment of the operations manual.
CAAF response - The Air Navigation Regulation (ANR) was amended in 2004 to include the requirements for the contents of the Operation Manual which includes the naming of persons responsible for performing safety duties, ANR s43 (4). This requirement is reinforced by ANR s34 (2) and is also a condition of the AOC where Operators are required to notify all management changes in key safety positions to the Authority.
Further, CAAF has recently revised its form for assessing a "Fit and Proper" person to hold a senior appointment in the company.
3. CAAF and commercial aircraft operators should develop appropriate recurrent crew resource management training programs. These programs should take account of the various cultural influences that may otherwise mitigate against successful implementation of such training.
CAAF response - This recurrent training is carried out every two years.
4. The government of Fiji should engage the services of an internationally recognised emergency response specialist. The specialist should examine all aspects of the response capability of government and non-government agencies. The review should include an assessment of the adequacy of communication resources and procedures.
CAAF response - The Ministry of Home Affairs has commenced reviewing with all stakeholders this issue through the revising of our National SAR plan.
5. The government of Fiji should ensure that there are appropriate procedures in place to enable timely and accurate toxicological information to be obtained.
CAAF response - In 2009 the Authority produced the Civil Aviation (Occurrence Reporting and Investigation) Regulations 2009 that details the requirements for the investigation of accidents.
In the regulations, there are provisions made for Medical Examination which among others provides for "a complete autopsy examination of fatally injured flight crew and, subject to the circumstances, of fatally injured passengers and other crew members, by a pathologist, preferably experienced in accident investigation, in accordance with guidelines as notified by the ICAO."
Since 1999, testing facilities have been established locally to conduct the tests that previously had to be sent abroad.
6. CAAF should ensure that procedures contained in the Manual of Air Traffic Services for the alerting of emergency response agencies adequately meet their intended purpose. Particular reference should be made to establishing appropriate time frames for the various response phases.
CAAF response - This is already incorporated in the Manual of ATS. Regular communication exercises are conducted to consolidate these procedures.
7. The operator should ensure that the position of chief pilot is accorded executive authority and support to enable full accountability for the safe operation of aircraft in accordance with the company operations manual.
CAAF response - The key positions required under the Air Operators Competency (AOC) Certificate which are accountable for and share safety responsibilities within the company are:
1 Accountable Manager
2. Chief Pilot (CP)
3. Chief Engineer (CE)
The Accountable Manager takes full responsibility for the safe operation of the company aircraft although in the day to day operations some of the safety decisions are done by the CP, CE and others licensed by the CAAF such as Engineers and Pilot In Command.
8. The company should review its flight following procedures to ensure that aircraft flight progress is adequately monitored and that emergency response agencies are promptly advised when uncertainty exists as to the safety of an aircraft.
CAAF response - International standards require that international operators have flight watch or unit responsible for monitoring and supervising aircraft while in flight.
In addition, ATC surveillance complements the airline flight following process.