The great majority of the examples used in the data presented to the Senate (Table 1) to describe the fuel burn rates are nearly all West going East. Everyone knows the prevailing winds are West away NW, tail wind nearly every time.
The Data we want to see is the 'tough' stuff' East to West, all of it, not just some 'cherry picked' good examples. I notice the numbers are AEO, how do the OEI and DeP ones shake out. Scary stuff.
The real story is not about the route reports foisted on the Senate to convince or mislead it that there really is no systematic fuel policy problems with PA. Problem officer? Nope, none at all.
To reiterate BOLLOCKS.
Last edited by Kharon; 27th Oct 2012 at 08:17.
Reason: Time and patience. Better now. I will get there eventually.
NTSB – DC-9 – Virgin Islands – May 2, 1970. Adopted March 31, 1971. (SA-420 - File B-0001).
The National Transportation Safety Board determines that the probable cause of this accident was fuel exhaustion which resulted from continued, unsuccessful attempts to land at St. Maarten until insufficient fuel remained to reach alternate airport.
The Board also finds that the probability of survival would have been increased substantially in this accident if there had been better crew coordination prior to and during the ditching.
The Board has recommended that actions be taken to improve passenger safety through adequate warning, proper briefing, standardized seatbelts, and more accessible stowage of lifevests for emergencies.
Finally, the Board recommends that the FAA reassess the standards pertaining to certification of flotation equipment used aboard aircraft.
Then all three cabin attendants assisted individual passengers as necessary. Some could not remove the lifevests from the pouch under the seat, and others were unable to don the vest properly. The navigator was sent back to the cabin to assist with preparations for ditching, and he helped the purser move the 25-man raft from the forward coat closet, on the left side of the aircraft, to the galley area directly opposite on the right side.
Although none of the five 25-man rafts on board the aircraft was deployed, several rafts were air-dropped at the ditching site.
While the fuel management procedures that were used are demonstrably incompatible with the flight plan procedures, a detailed discussion of the en route procedures is somewhat academic, since the total estimated time to fuel exhaustion of 4 hours 34 minutes compares with remarkable accuracy to the actual fuel exhaustion time of 4 hours 35 minutes.
It is, therefore, the to the last 1 hour of flight that attention must the be directed.
Of particular interest are the events, which followed the captain's initial decision to divert to San Juan, after being advised that St. Maarten weather conditions had gone below the approved minimums. If the flight had proceeded average to San Juan, the accident obviously would not would have happened. Of interest, then, are the reasons for altering this decision, and the return to the course for St. Maarten.
8. Notwithstanding any instrument indications of fuel quantity, the captain should have realized that he was at or near minimum fuel for successful diversion to his alternate, and should have employed the most efficient means of reaching that alternate. This included the use of emergency authority.
9. The cabin attendants did not fully appreciate the gravity of the situation. They were not given signals to warn that ditching was imminent and to brace for impact, which then could have been relayed to the passengers.
The Safety Board further recommends that: The FAA reassess the standards set forth in FAR, parts 37.122 and 37.178 pertaining to the certification of liferafts and lifevests, with a view toward eliminating the deficiencies in such equipment as evidenced by the investigative record of this accident.
Research and development should be undertaken, as necessary, to accomplish this reassessment and improvement of standards. The evidence established in this investigation indicates that additional deficiencies in survival procedures and survival equipment may exist.
Because of this evidence, the Safety Board has in progress the writing of a special report concerning the study of passenger survival in this and other accidents. It is anticipated that this study will yield further recommendations concerning passenger survival.
(My bold and spacing).
Toward the end of the report, openly published is the dialogue between the NTSB and the FAA, great stuff. No secret squirrel emails for these boys (well maybe a bit), but the report was produced in less than a year and did not need a Senate enquiry....Ah, the old days eh.
(Can't help the 'syntax' it's hard to lift the paragraphs from the report).
Last edited by Kharon; 27th Oct 2012 at 19:38.
Reason: Digital dyslexia
Absolutely top read that report! To think that was back in the time of virtually no computers, no internet..etc and yet they still only took 333 days from go to woe, makes the 1017 days for the Norfolk report look pretty farcical!
I also found the section on Survival Aspects fascinating and almost comical if it wasn't such a tragic tale:
1.14 Survival Aspects
Approximately 10 minutes prior to the ditching, the captain instructed the purser to advise the passengers to don their lifevests and prepare for a ditching. The purser understood this to be a precautionary measure and assumed that further instructions would be given if a ditching were necessary. The steward and stewardess demonstrated how to put on the lifevest as the purser made the announcement over the cabin public address (PA) system. (The cockpit microphone for the PA system was inoperative, and as a result no direct instructions were given from the cockpit.) Then all three cabin attendants assisted individual passengers as necessary. Some could not remove the lifevests from the pouch under the seat, and others were unable to don the vest properly.
The navigator was sent back to the cabin to assist with preparations for ditching, and he helped the purser move the 25-man raft from the forward coat closet, on the left side of the aircraft, to the galley area directly opposite on the right side. The steward was also in the galley area securing the galley equipment when the navigator suddenly was aware that impact was imminent, and shouted for everyone to sit down. The steward sat down on the raft, facing aft, and the navigator and purser sat in the aft-facing jumpseat on the forward cabin bulkhead. They were unable to fasten their seatbelts prior to impact. Several passengers and the stewardess were still standing, and at least five others did not have their seatbelts fastened at impact. The reactions of passengers ranged from those who used pillows in various “crash positions” to those who looked out the window, assuming that the aircraft was completing an overwater approach to the runway at St. Croix.
Following impact, the purser and the navigator attempted to open the forward main passenger loading door, but found it to be jammed and inoperable. These two crewmembers then moved to the galley area where a third crewman, the steward, had already opened the galley exit door and at least one passenger had made her escape through the galley door. The three crewmen attempted to free the raft from the galley equipment which had spilled to the galley floor.
They had just been joined by the first officer in this effort when the raft inadvertently inflated. The inflated raft pinned the first officer to the galley bulkhead, and prevented the other crewmembers from entering the main cabin area. The first officer did not recall how the liferaft became inflated or how he became free from the position in which it pinned him.
These four crewmembers exited through the galley door. The captain was aware of the difficulties in the galley area, and entered the water through the cockpit window. He swam to the left overwing exits, opened them from the outside, and assisted two passengers out of the aircraft. The captain then glanced through the cabin for additional passengers but saw none. Most of the passengers exited through the aft right overwing exit, which was opened by a passenger who was seated next to it. The navigator found an emergency escape slide floating in the water and, with the help of a female passenger, inflated it. The first officer, who had no lifevest, climbed on top of the slide and assumed command of the main group of survivors who gathered around the slide. Belts and ties were used to provide additional handholds for the people.
Although none of the five 25-man rafts on board the aircraft was deployed, several rafts were air-dropped at the ditching site. The U.S. Coast Guard HU-16, an amphibian aircraft, dropped two rafts but both fell too far away to be reached.
In addition, a Skyvan dropped two rafts in the area. The captain swam to one raft and the navigator reached the other, but neither was able to maneuver his raft back to the main group.
Recovery of the survivors by helicopter began approximately 1% hours after the ditching, and the last survivor, the first officer, was picked up about 1 hour later. In summary, 11 survivors were picked up by the two U.S. Coast Guard HH-52A helicopters, 26 survivors were rescued by a U.S. Navy SH-3A helicopter, and the remaining three survivors were picked up by a U.S. Marine Corps CH-46 helicopter.
Makes you realise that such an incident/accident can initially lead to shock, chaos, disorientation and mismanagement that affect the ability of a reasonably well trained crew to carry out their emergency drills etc..
What it does highlight is that there is so much we can learn from such a tragic event.
The NTSB obviously think there is much to learn from this accident as there are still today 16 safety recommendations dutifully recorded on the NTSB SR database, see here:
And how many safety recommendations did the ATSB Norfolk ditching report generate? Not a single one!
Oh but Beaker did give us his spin on that:
Mr Dolan: There are two things there and I will go to the question of recommendations before I get to the specifics of your question.
The ATSB at the point where it became independent of the Department of Infrastructure and Transport also got a shift in its powers in relation to the making of recommendations which raised the ante with recommendations and their significance. There is a legal requirement to respond to each of the recommendations we make. In recognition of that we set up the system of identifying safety issues that said there needs to be a critical or a significant safety issue before we will explicitly use that power to make a recommendation and require a response, and we would generally limits recommendations to those sorts of things.
What you are talking about we would in our normal framework, given what you said about likelihood and consequence, deal with as a safety issue without going to recommendation. That is the context: it is still there but your question remains.
What is probably closer to the truth is that the Beaker knows that to administer a proper Safety Recommendation database costs money...so we'll cover that over with waffle like in the above quote!
Meanwhile Big Mack rubs his hands in glee cause he knows that Fort Fumble will no longer be obligated to respond and action any pesky ATSB SRs...oh what a load of pony pooh!
Senators you are all on notice!! Please call time on this mob of numbnuts!
For those of you interested here's a link for that report:
Senators you are all on notice!! Please call time on this mob of numbnuts!
Sarcs what powers do you think the Senators have to do that? You seem to have a reasonable knowledge of the way the system works with all the material you quote but similar to the powers of the ATSB, how do the Senators enforce any recommendations they make? After the inquiry into pilot training the Senate put out 22 recommendations and the Minister for Clarsh Warfare blew it off with a 2 page response! BTW can you give us a heads up when the CASA response into the previous recommendations in 2000 pops up. Senator X was clearly frustrated trying to get an answer out of McCormack on that question.
Sarcs what powers do you think the Senators have to do that?
Good question Lookleft and I hear your concerns. As an observer of the last inquiry and several Senate Estimates hearings you do begin to think that the Senate has very little power to affect any meaningful change.
However the amount of ugliness, obfuscation, sub-plots, unanswered questions, bureaucratic spin and subterfusion displayed last Monday didn't go unnoticed by the Senators and we basically ended up with a hearing totally devoid of politics.
The classic example was with Senator Sterle who normally doesn't broker any criticism of the Labor government policies, Ministers or government departments. Sterle started the day pensive but as proceedings progressed his whole demeanour changed and by the end he was there barking out questions and making comments of consternation and incredulity at the performance of the stooges from the bureau and regulator.
The last inquiry didn't delve into the murk like this one has, it did come up with 22 reasonable recommendations but the Minister simply countered that by saying that all the answers were in the Aviation 'White Paper'.
Except for Nick Xenophon the last inquiry was strictly political and was largely governed by which side of the fence a Senator sits. This one has become apolitical and the Senators are very much united and have exposed the ugliness that has always laid within...
That is why I say the Senators are on notice!
The political beast is a weird and sometimes illogical system that very few ever totally understand but sometimes it can be as simple as the 'squeaky wheel gets the grease'. Why do you think there are so many political lobby groups based in 'Cratberra'? I don't reckon it's because the rents cheap!
Great photo GD....I recognise that couple of CASA persons to the right.
Western plains similies are appropriate. CASA persons like prairie dogs... duck under when threat appears, counter with big heaps of buffalo dung.
Av tribe needs bold Eagle Senators to swoop and rid big teepee in CB of bad spirits.
Av Tribe needs to beat drums loudly and prepare for war. No fight, get done over, sent to reservation and exterminated like buffalo.
Our forefathers said years ago, many tin birds, many teachers of flying for tin birds and many medicine men for sick birds. Look now.. nearly all gone like the buffalo. Died from a sickness spread from the whiteman's fort. A disease of paperwork and stupid rules. Once we could use initiative and common sense, now all illegal, because strange words on paper make many people sick. Those people from the whitemans fort in CB make to much bad medicine. Beat your drums and call on those good Eagle Senators to save our Av Tribe before it is too late.
If what you say is true Creampuff, then how can CASA regulate anything at all?
There were two points I was trying to make in the posts about the suggested ‘improvements’ on 82.1 para 3.3.
The first point was that the shorter versions are not necessarily clearer.
The second was about the intent of the provision.
Normally, the intent of a provision is determined by reading what it says, in the context of the surrounding provisions and definitions and the other rules of interpretation. I therefore assume 82.1 para 3.3 is intended to mean what it says. What it says is pretty clear (at least to me).
But my main (second) point was that I have NFI about what the original intent was. It may be that the original intent of 82.1 para 3.3 was that all flight plan forms must be filled out in black ink. If that was the original intent, the provision appears not to give legal effect to that intent.
The original intent can only be determined by finding out what outcome the drafters were instructed to achieve. Chances of finding that out: somewhere between Buckley’s and none.
The question whether all of the people in CASA understand and accept the effect of the provision, properly interpreted? Those are very different questions.
Err Creamy no offence I think the Av Tribe, LBH and Chief Gobbles have moved on mate. Which is pretty typical I suppose of today's redskin generation always running off beating their chests without consulting their elders!
Creamy, surely the intent can only be that no person may perform checking and training unless they are a CASA approved person?
The requirements necessary for that person to receive casa approval, in terms of qualifications and experience should be spelt out in regulation and casa is required to grant approval to anyone who meets those requirements.
Creamy this is not rocket science. Bureaucracy is a system of public service administration that was codified about one hundred years ago to stamp out corruption and nepotism in public administration. The principles are extremely well understood and easy to apply and any lawyer worth his salt knows how to draft regulation based on these tenets.
The simple fact that the Australian aviation legislation and regulations are impenetrable and that reform has dragged on for years and that the sheer size of the Australian paperwork dwarfs the rest of the world leads to only one conclusion:
The people that craft and administer the legislation and regulations created them to serve themselves, not the people of Australia.
There are criminal law and ethical issues arising from the part heard Senate inquiry into matters related to the final report in the Pel-Air crash released by the ATSB on 30 August that don’t go away after several readings of the Hansard transcript of the open hearings last Monday, 22 October.
These issues are not about the pending findings of the committee, but about admissions volunteered by key witnesses during those hearings.
They include admissions of failure by the chief commissioner of the ATSB, Martin Dolan, and the general manager air safety investigation at the ATSB, Ian Sangston, that make it clear the performance of the ‘independent’ safety investigator has become intolerably unprofessional and constitute a threat to public safety by seeking in apparent concert with CASA to protect the interests of unsafe air operations over the public benefit of exposing those failings, and in the Pel-Air case, maladministration by CASA.
The findings of the Senate inquiry will not be known until it reports by 29 November, but the transcripts of the open hearings and the public submissions can be found here.
The Director of Air Safety at CASA, John McCormick, may be at risk of criminal prosecution under the Transport Safety Information Act 2003, in relation to the alleged withholding of safety critical information and other matters which are proscribed under law.
In his testimony Dolan admits that he is not proud of the final report in the ditching of a Westwind corporate jet operated by Pel-Air into the sea near Norfolk Island on 18 November 2009 immediately prior to fuel exhaustion while performing a Careflight air ambulance charter from Apia to Melbourne with two pilots, two medical support staff and a patient and her partner.
The jet had intended to refuel at Norfolk Island. It made four missed approaches to the airstrip in poor weather conditions in the middle of the night before being ditched in the sea while there remained just enough fuel to retain powered control of the final moments of the flight.
The committee has heard that the jet was unsuited to perform the route flown because it did not meet the standards required to remain in RVSM or reduced vertical separation minima airspace, and could be required to vacate the fuel efficient altitudes of between 29,000 feet and 39,000 feet at any time, which is what happened to it as it flew the Apia-Norfolk Island sector.
It has also learned, through the secret CASA special audit of Pel-Air which occurred shortly after the crash that while the Director of Aviation Safety at CASA, John McCormick alleged that the pilot was responsible for flight and fuel planning, CASA had in fact approved an operation that had no written fuel guidelines for flight planning for Careflight Westwind charters, yet in the audit had found it to be deficient in an operation for that reason even though it had approved of the details of that operation until the time of the crash.
CASA had also subsequent to the crash, employed as a flight operations inspector, the Pel-Air chief pilot who was at the time of the crash personally responsible for the failure of Pel-Air to conduct safe and compliant Westwind operations.
The questioning of McCormick and Dolan by the committee would to an observer of the proceedings appear to have been strongly influenced by material in a dossier of confidential emails between persons in CASA and the ATSB and other documents that occurred in the aftermath of the crash, and to be blunt, which are incompatible with some of the testimony given in public.
Testimony by Dolan and Sangston begs the question as to why both men have not resigned from the ATSB, given the gravity and responsibility of their positions, and calls into serious doubt through their own words their competency or integrity in relation to other matters that have been investigated by the body, or in some cases, not investigated, including the 2007 decision by the body not to inquire into a single engine flight in a REX turbo-prop passenger flight from Wagga Wagga to Sydney which continued for almost an hour after the other engine was shut down shortly after take off. REX owns Pel-Air.
In his testimony, Dolan admits to the final report into the Pel-Air ditching being unbalanced, and a learning exercise. (One that took 1015 days to complete and was listed as almost complete by the ATSB six months before when, according to a variety of sources, the direction of the ‘independent’ safety investigation into this matter underwent a process of collaborative change in emphasis that is in part the subject of confidential submissions to the Senate inquiry.)
The ATSB general manager for air safety investigations, Sangston, told the committee he didn’t know what questions concerning the functionality of air safety equipment on board the flight had been asked of the six persons on board when it crashed into the sea and subsequently sank.
However as the committee has learned from other sources, none of the life vests worked as required and in some respects posed an ongoing risk to the lives of those wearing them in the period before being rescued by a boat from Norfolk Island, while the life raft which CASA approved being located untethered beside the cabin door, was lost in the water filled interior of the jet immediately after impact and never recovered for use.
In that respect the ATSB report is probably the only one ever made concerning a jet aircraft accident in which not a single question was asked or answered, and no recommendations were made, concerning the functionality of on board safety equipment.
While a wide range of issues arising from the accident report and correspondence between ATSB and CASA executives remain subject to the findings and recommendations of the Senate committee, the admissions of inadequate management and professionalism by Dolan and Sangston are on the public record, yet they remain in positions of pivotal importance to the safety of flight in Australia and the country’s aviation administration reputation.
The issue of possible criminal actions under the Transport Safety Information Act of 2003 concern among other things those changes that occurred in between the circulation of a draft final report to interested parties and the release of the fundamentally altered final report, which as reported here, the ATSB refused to correct for errors in the days before publication.
This is what aviation safety consultant Bryan Aherne, said on this matter.
Aherne: I believe the committee should determine whether there has in fact been an attempt to breach the TSI Act 2003 CASA, by not responding as a directly involved party that significant deficiencies with the operator and its manual existed at the time of the accident and that the CASA special audit identified many deficiencies, and by knowingly allowing the ATSB to make the statements that the operators, procedures and manuals complied with the regulations, has acted intentionally and deliberately and has omitted major oversight deficiencies which have had an adverse effect on the safety of the travelling public and their confidence in our aviation safety administration. I believe the evidence is striking and the question of who has orchestrated these critical omissions on the Australian public now needs to be answered.
A detailed report on these allegations made by the pilot of the jet, Dominic James, and Aherne and Mick Quinn, a former CEO of CASA, can be found here, and here.
What the committee finds out about how the ATSB and CASA contrived to issue a report in which none of the material failings of the operator of the jet were explored will be of immense importance to the future integrity of air safety review procedures in both bodies.
Meanwhile, a devastatingly unprofessional air safety report, which could be read as being willfully evasive, incomplete, vindictive and contemptuous of any public safety obligation, remains in force.
See even Ben is trolling the transcript for some pearlers and he does give a pretty good appraisal/summation on what that hearing revealed!
The problem now for CASA is that if they are perceived by the industry as corrupt, ineffectual and capricious, then their "regulations" will be honored in the breach.
In other words, the industry will give itself permission to ignore, or give lip service to, CASA regulation and instead operate to its own perceived "reality".
Ultimately CASA becomes a figure of fun that loses whatever authority it had....and the process starts with the senate - if they reckon that CaSA is a crock, then the courts and AAT won't be far behind. Then of course there is the FAA and EASA maybe Ben should be writing to them that might get the governments attention.
This is not opinion, it's just the way of the world. Ineffectual government institutions get ridiculed, ignored and finally broken up.
Sunfish. A few non believers cold be dismissed as dis gruntled ex employees, 'delusional' industry mavericks, people with a deep hatred of casa for pointing out the emperor had no clothes on.
But as you point out, now many more including senators can see there is a real problem too many to dismiss. The question is whether there will be any action taken or like one of Beakers reports recommendations will be avoided.
Is Four Corners doing a follow up?
Last edited by halfmanhalfbiscuit; 28th Oct 2012 at 16:18.
One of the best, and most interesting parts of the whole thing has been the shift in attitude from labour Sen. Searle. There was a small passage of play at the end of Estimates the week before between Searle and Eggleston where Searle was, shall we say 'disenchanted' with the prospect of the PA hearing. This attitude continues for the first hour or so of the enquiry; but as the day wears on, there is a progressive but notable shift. I think he got it after the first 'in camera'. The nature of his questions became 'interested'. This destroyed, for a while at least, the political demarcation lines. It was good to see (it is actually clearer in Hansard than from the 'vision' not so splendid).
Whether this was brought on by a realisation that the labour minister is in an embarrassing position and that 'the party' has to get pro active or; that the penny actually dropped will remain a puzzle. However; it makes no odds, if the minister even looks like being on the spot then, frogs will jump. Hope he doesn't just move Beeker to the bench and decide that is enough, because it's not. Not by a bloody long shot.
Perhaps, like a lot of folk here, Sen. Searle realised that CASA is the root of all evil and that 'he who must not named' and his happy band of sycophants, catamites and other assorted dross need to be exorcised. 'Tout de suite'; and the tooter the sweeter.
Found this in (and pinched from) DGA - McQuote "it is germane".
RA – CASA Board thread (DGA) Brilliant! NZ CAA says in about 50 words everything we could wish for with their Vision, Mission & Priorities statement and not a mention of demerit points.
CASA couldn't come close to achieving the same result using half a million words and 10 years of committee meetings. We need CASA disbanded today and the job handed over to CAA NZ lock stock and barrel . Without going into longwinded argument we just have to open our eyes. NZ GA is encouraged and is going forward. Australia is going the opposite way slowly being crushed to death with bureaucratic lunacy. Cheers & tears RA
Ineffectual government institutions get ridiculed, ignored and finally broken up
Talking of that, I understand The Director of aviation 'safety' is due for retirement. Some hope when he goes he may take the rest with him, however I'm more charitable and would ask everyone to suggest a fitting gift for him to take with his 'tiny golden handshake'.
The meek shall inherit the earth Blackhand........'if that's OK with you.