Firstly, the PIC put the aircraft into a situation where he and his pax were at risk. Pure and simple. He stuffed up and he deserves to face the consequences. The second issue is CASA surveillance combined with an operator who were bereft in their duty of care. But their derelict behaviour did not lead to this occurrence.
Mr James was not cognisant of the risk of an isolated aerodrome. And that came with consequences.
Again and again, pilots are found to show little sympathy for their colleagues who are hurt or die; some simplifying explanation is immediately hit upon to reassure the others that the same fate would not be theirs.
Peter Garrison, Pilot Error
We see that sentiment alive and well in the alleged short comings in the crews performance being made by some posters.
"There but for the Grace of God, go I", springs to mind about this whole event and indeed I think many people are being wise after the event.
So true A37575. Many have found themselves caught short as the following examples show. Not shoe string operations either.
CASA Research report B2004/0246 (Risks associated with the Australian operational rules for weather alternate minima) details many, many occurrences where crews found themselves in exactly the same predicament as young Dominic for exactly the same reasons. They range from Chieftains, to A320, 767 and 747 operated by this nations operators.
Boeing 747-438
During the approach to Sydney, the crew reported that the weather was observed to be significantly worse than that indicated in the 3-hour trend forecast held by the crew. After several attempted approaches on different runways the crew were required to perform an auto landing on runway 34L due to the aircraft's fuel situation.
Boeing 747-438
Air traffic control advised the crew of the Boeing 747, VH-OJN, that holding would be required due to unforecast severe weather at Brisbane. The aircraft was inbound to Brisbane from Auckland, and carried insufficient fuel to divert. The crew advised the controller they had sufficient fuel to hold for 50 mins.
Boeing 747-438
The aircraft landed at an alternative airport with insufficient fuel due to unforecast fog at the destination. Prior to departure, weather forecasts had indicated that the carriage of extra fuel or provision of an alternate was not required.
A320-211
The aircraft departed with sufficient fuel to reach its destination, but not to continue to an alternate, as there was no requirement to carry extra fuel, based on the weather forecast.
When the aircraft arrived at its destination, fog was spreading across the airfield. The flight crew conducted two instrument approaches at their destination, but were not able to land because of the fog. They then conducted a category three autoland instrument approach at the destination and landed without incident. The destination was not equipped or certified for a category three instrument landing.
PA-31-350
After studying weather forecasts for King Island, Wynyard and Launceston, the pilot planned the flight with enough fuel to fly to Wynyard, conduct a GPS arrival plus a VOR approach if necessary, and then for a diversion to Launceston if necessary. At the time of planning there was no holding requirement on Launceston.
The pilot conducted the Wynyard GPS arrival, but did not become visual at the minima; he then conducted the VOR approach, but again did not become visual, so he diverted to Launceston. Launceston ATIS advised that an ILS was required. Unexpectedly having to fly the ILS added more flight time than originally planned. On completion of the ILS and landing, the fuel on board the aircraft was 50 litres, which was 25 litres out of the planned fixed reserve. While flying the ILS the pilot also discovered that the weather at Launceston was worse than forecast or advised by flight service. He subsequently submitted an incident report complaining about the inaccuracy of the weather forecasts.
SA227-AC Metroliner
When the aircraft arrived in the Broken Hill circuit area, the pilot observed the airfield covered in fog. After failing to become visual during an instrument approach, he decided to divert to Wilcannia. The pilot declared an emergency during the diversion, as he expected to arrive at Wilcannia with less than minimum fuel. The aircraft landed at Wilcannia with about 25 minutes of fuel remaining.
Investigation showed that the Terminal Area Forecast (TAF) requested by the pilot prior to the flight did not include a forecast of fog or any other significant weather at Broken Hill. At the time of issue of the forecast (1850 Z), the conditions at Broken Hill were considered to be too dry for fog to develop. Satellite images did not show any fog on the ground. At 2125Z, after receiving advice of increased moisture levels at Broken Hill and reports of fog at Mildura, the TAF for Broken Hill was amended to include a 30% probability of fog. The incident aircraft arrived overhead Broken Hill aerodrome at 2128 UTC and began an instrument approach.
Another company aircraft had landed at Broken Hill approximately 30 minutes earlier, and had advised the pilot of the incident aircraft that there was no fog.
Boeing 767-338ER
The pilot reported that the TAFOR Brisbane used for flight planning specified no requirements for Brisbane. A special weather report received ten minutes prior to arrival indicated 800 metres visibility in fog. The flight continued to Brisbane with Coolangatta as an alternate. The pilot was concerned that fuel carried for the flight may have been insufficient as a result of the inaccurate forecast, had a diversion been required.
SA 227-DC Metroliner
The aircraft departed Melbourne with 2,200 pounds of fuel, which was more than required for the indicated weather conditions. On arrival, weather conditions were worse than forecast and two IFR approaches to the minima were unsuccessful. The crew then elected to divert to Swan Hill where two IFR approaches were also unsuccessful. The aircraft was cleared back to the original destination and arrived with 400 pounds of fuel remaining. The crew of another aircraft, which was ahead, agreed to hold thus allowing them to carry out an IFR approach first. This time they became visual at 900 ft and landed without further incident
SA227-DC Metroliner
When about 60 NM inbound to Adelaide, at about 1830 CST, the pilot of the Metroliner was advised by ATS of hazardous weather conditions at the destination airport. The pilot requested current weather conditions for the planned alternate aiports and was advised of the weather by ATS. The actual conditions indicated that those planned alternate airports now had alternate requirements, hence were not suitable for a diversion. The pilot declared a PAN* phase due to insufficient fuel for a suitable alternate.
The pilot was cleared by ATS to conduct an ILS approach, and landed the aircraft safely on runway 23.
Boeing 767-238
During the descent, the crew was advised that the weather conditions at Melbourne had deteriorated below those reported in the current weather forecast. The crew reported that no fuel allowances had been made for weather based on the forecast.
Boeing 747-438
The aircraft landed with insufficient fuel due to unforecast fog at the destination. Prior to departure, weather forecasts had indicated that the carriage of extra fuel was not required.
A 146 going into Norfolk has already been mentioned where they had to descend over the water to get visual because they found themselves in exactly the same situation as did Dominic. Their get out of jail card was it was daytime, not night as in Dominics case.
The report further says,
“The comparisons in this study suggests that the use of Australian rule sets alone to assess the risk of deteriorated weather at a destination airport by themselves does not ensure a level of safety as described in the International Civil Aviation Organization Continuing Airworthiness Manual. The fact that there have been very few serious incidents or accidents associated with landing at a destination with unforecast deteriorated weather, suggests that one or more other factors are also reducing risk. From this it may be suggested that although other risk mitigants appear to be effective, they may not be known or consistently managed.”
Recommendation R20000040
I post the following from the above link because I’m cynical enough that given the circumstances it may “disappear”. Note the date.
Date Issued: 22 February 2000
Background:
SUBJECT - RELIABILITY OF NORFOLK ISLAND FORECASTS
SAFETY DEFICIENCY
The meteorological forecasts for Norfolk Island are not sufficiently reliable on some occasions to prevent pilots having to carry out unplanned diversions or holding.
FACTUAL INFORMATION
Related Occurrences
During the period 1 January 1998 to 31 March 1999, occurrences involving unforecast or rapidly changing conditions at Norfolk Island reported to the Bureau included the following:
199801482
A British Aerospace 146 (BAe146) aircraft was conducting a regular public transport (RPT) passenger service from Sydney to Norfolk Island. The terminal area forecast (TAF) for Norfolk Island indicated that cloud cover would be 3 octas with a cloud base of 2,000 ft. Approaching Norfolk Island, the crew found that the area was completely overcast. After conducting an instrument approach, they determined that the cloud base was 600 ft, which was less than the alternate minima. Fuel for diversion to an alternate airfield was not carried on the flight because the forecast had not indicated any requirement.
199802796
Before a Piper Navajo Chieftain aircraft departed for an RPT passenger service from Lord Howe Island to Norfolk Island, the TAF for Norfolk Island did not require the carriage of additional fuel for holding or for diversion to an alternate airfield. Subsequently, the TAF was amended to require 30 minutes holding and then 60 minutes of holding. The pilot later advised that he became aware of the deteriorating weather at his destination only after he had passed the planned point of no return (PNR). However, the aircraft was carrying sufficient fuel to allow it to hold at Norfolk Island for 60 minutes. When the aircraft arrived in the Norfolk Island circuit area, the pilot assessed the conditions as unsuitable to land due to low cloud and rainshowers. After approximately 45 minutes of holding, the weather conditions improved sufficiently for the pilot to make a visual approach and landing.
199804317
A BAe146 aircraft was conducting an RPT passenger service from Brisbane to Norfolk Island. When the crew were planning the flight, the Norfolk Island TAF included a steady wind of 10 kt and thunderstorm conditions for periods of up to 60 minutes. Approximately 30 minutes after the aircraft departed, the TAF was amended to indicate a mean wind speed of 20 kt with gusts to 35 kt. As the aircraft approached its destination, the Unicom operator reported the wind as 36 kt with gusts to 45 kt. The crew attempted two approaches to runway 04 but conducted a go-around on each occasion because of mechanical turbulence and windshear. The pilot in command then elected to divert the aircraft to Auckland. The wind gusts at Norfolk Island did not decrease below 20 kt for a further 3 hours.
199900604
While flight planning for an RPT passenger service from Lord Howe Island to Norfolk Island, the pilot of a Piper Navajo Chieftain found that the TAF required the carriage of fuel sufficient for a diversion to an alternate aerodrome. As the aircraft was unable to carry sufficient fuel for the flight to Norfolk Island and then to an alternate aerodrome, the flight was postponed. Later in the day, the forecast was amended to require the carriage of 60 minutes of holding fuel and the flight departed carrying the additional fuel. Approximately 20 minutes after the aircraft departed Lord Howe Island and more than one hour before it reached its point of no return (PNR), the TAF was amended again to require the carriage of alternate fuel. The pilot did not request or receive this amended forecast and so continued the flight.
Following the flight's arrival overhead Norfolk Island, the pilot conducted a number of instrument approaches but was unable to land the aircraft due to the poor visibility. After being advised of further deteriorations in conditions, the pilot made an approach below the landing minima and landed in foggy conditions with a visibility of 800m. Subsequent investigation determined that the actual conditions at Norfolk Island were continuously below alternate minima for the period from 2.5 hours before the aircraft departed from Lord Howe Island until 6 hours after the aircraft landed.
Meteorological information
The Norfolk Island Meteorological Observing Office, which is staffed by four observers, normally operates every day from 0400 until 2400 Norfolk Island time. When one or more observers are on leave, the hours are reduced to 0700 until 2400 daily. Hourly surface observations by the observers, or by an automatic weather station when the office is unmanned, are transmitted to the Sydney Forecasting Office where they are used as the basis for the production and amendment of TAFs and other forecasts.
Weather conditions are assessed by instrument measurements, for example, wind strength, temperature and rainfall, or by visual observation when observers are on duty, for example, cloud cover and visibility. There is no weather-watch radar to allow the detection and tracking of showers, thunderstorms and frontal systems in the vicinity of the island. The wind-finding radar on Norfolk Island is used to track weather balloons to determine upper level winds six-hourly when observers are on duty. It cannot detect thunderstorms or rainshowers.
Pilots in the Norfolk Island area can contact the Met Office staff on a discrete frequency for information about the current weather conditions.
The reliability of meteorological forecasts is a factor in determining the fuel requirements. As forecasts cannot be 100% reliable, some additional fuel must be carried to cover deviations from forecast conditions.
A delay of one hour or more can exist between a change occurring in the weather conditions and advice of that change reaching a pilot. The change has to be detected by the observer or automatic weather station and the information passed to the Forecasting Office. After some analysis of the new information in conjunction with information from other sources, the forecaster may decide to amend the forecast. The new forecast is then issued to Airservices Australia and disseminated to the Air Traffic Services (ATS) staff who are in radio contact with the pilot. It is then the pilot's responsibility to request the latest forecast from ATS.
Alternate minima
Alternate minima are a set of cloud base and visibility conditions which are published for each airfield that has a published instrument approach procedure. The alternate minima are based on the minimum descent altitude and minimum visibility of each of the available instrument approaches. When the forecast or actual conditions at an airfield decrease below the alternate minima, aircraft flying to that airfield must either carry fuel for flight to an alternate airfield or fuel to allow the aircraft to remain airborne until the weather improves sufficiently for a safe landing to be conducted.
A pilot flying an aircraft that arrives at a destination without alternate or holding fuel and then finds that the weather is below landing and alternate minima is potentially in a hazardous situation. The options available are:
1. to hold until the weather improves; however, the fuel may be exhausted before the conditions improve sufficiently to enable a safe landing to be made;
2. to ditch or force-land the aircraft away from the aerodrome in a area of improved weather conditions, if one exists; or
3. attempt to land in poor weather conditions.
All of these options have an unacceptable level of risk for public transport operations.
The alternate minima for Norfolk Island are:
1. cloud base at or above 1,069 ft above mean sea level (AMSL) and visibility greater than 4.4 km for category A and B aircraft; and
2. cloud base at or above 1,169 ft AMSL and visibility greater than 6 km for category C aircraft.
The available alternate aerodromes for Norfolk Island are La Tontouta in Noumea (431 NM to the north), Lord Howe Island (484 NM to the south-west) and Auckland NZ (690 NM to the south-east). Lord Howe Island may not be suitable for many aircraft due to its short runway. Flight from Norfolk Island to an alternate aerodrome requires a large amount of fuel, which may not be carried unless required by forecast conditions or by regulations.
Australian regulations
Prior to 1991, the then Civil Aviation Authority published specific requirements for flights to island destinations. For example, flights to Lord Howe Island were required to carry fuel for flight to an alternate aerodrome on the mainland Australia, and flights to Norfolk Island and Cocos Island, where no alternate aerodromes were available, were required to carry a minimum of 2 hours of holding fuel.
In 1991, Civil Aviation Regulation (CAR) 234 was enacted. This regulation provided that an aircraft would not commence a flight unless the pilot in command and the operator had taken reasonable steps to ensure that the aircraft was carrying sufficient fuel and oil to enable the proposed flight to be undertaken in safety. The regulation did not specify the method for determining what was sufficient fuel in any particular case. Civil Aviation Advisory Publication (CAAP) 234-1(0) dated March 1991, provided guidelines which set out one method that could be used to calculate fuel requirements that would satisfy CAR 234. CAAP 234-1 did not contain any special considerations or requirements when planning a flight to an island destination.
In August 1999, Civil Aviation Order 82.0 was amended to require all charter passenger-carrying flights to Norfolk Island and other remote islands to carry fuel for the flight to their destination and to an alternate aerodrome. The alternate aerodrome must not be located on a remote island. This requirement to carry additional fuel does not apply to regular public transport flights to a remote island.
European Joint Aviation Regulation
The European Joint Aviation Regulation (Operations) 8.1.7.2 states: "at the planning stage, not all factors which could have an influence on the fuel used to the destination aerodrome can be foreseen. Consequently, contingency fuel is carried to compensate for ... deviations from forecast meteorological conditions."
Traffic levels
In February 2000, approximately 11 regular public transport aircraft land at Norfolk Island every week, including Boeing 737 and Fokker F100 aircraft. An additional 20 instrument flight rules and 12 visual flight rules flights are made to the island every week by a variety of business and general aviation aircraft.
ANALYSIS
Reports to the Bureau, including those detailed in the factual information section above, indicate that the actual weather conditions at Norfolk Island have not been reliably forecast on a number of occasions. Current regulations do not require pilots of regular public transport aircraft to carry fuel reserves other than those dictated by the forecast weather conditions. The safety consequences of an unforecast deterioration in the weather at an isolated aerodrome like Norfolk Island may be serious. (Comment: as Dominic found out)
The present level of reliability of meteorological forecasts and the current regulatory requirements are not providing an adequate level of safety for passenger-carrying services to Norfolk Island. (Comment: as Dominic found out)
SAFETY ACTION
As a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands.
The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the Bureau of Meteorology should review the methods used and resources allocated to forecasting at Norfolk Island with a view to making the forecasts more reliable.
Initial Response
Date Issued: 27 April 2000
Response from: Bureau Of Meteorology
Response Status: Closed - Accepted
Response Text:
In response to your letter of 25 February 2000 relating to Air Safety Recommendation 20000040 and the reliability of meteorological forecasts for Norfolk Island, the Bureau of Meteorology has explored a number of possible ways to increase the reliability of forecasts for flights to the Island.
There are several factors which determine the accuracy and reliability of the forecasts. The first is the quality and timeliness of the baseline observational data from Norfolk Island itself. The second is the information base (including both conventional surface observational data and information from meteorological satellites and other sources) in the larger Eastern Australia-Southwest Pacific region. The third is the overall scientific capability of the Bureau's forecast models and systems and, in particular, their skill in forecasting the behaviour of the highly localised influences which can impact on conditions on Norfolk Island. And the fourth relates to the speed and responsiveness with which critical information on changing weather conditions (forecast or observed) can be conveyed to those who need it for immediate decision making.
As you are aware, the Bureau commits significant resources to maintaining its observing program at Norfolk Island. While the primary purpose of those observations is to support the overall large-scale monitoring and modelling of meteorological conditions in the Western Pacific, and the operation of the observing station is funded by the Bureau on that basis, it is staffed by highly trained observers with long experience in support of aviation. As far as is possible with available staff numbers, the observers are rostered to cover arrivals of regular flights and rosters are adjusted to cover the arrival of notified delayed flights.
The Norfolk Island Terminal Aerodrome Forecast (TAF) is produced by experienced professional meteorologists located in the Bureau's New South Wales Regional Forecasting Centre in Sydney. The terminal forecast provides predictions of wind, visibility, cloud amount and base height and weather routinely every six hours. Weather conditions are continuously monitored and the terminal forecast is amended as necessary in line with air safety requirements. The forecasters have full access to all the Bureau's synoptic meteorological data for the region and guidance material from both Australian and overseas prediction models. As part of the forecasting process, they continuously monitor all available information from the region including the observational data from Norfolk Island itself. When consideration of the latest observational data in the context of the overall meteorological situations suggests the need to modify the terminal forecast, amendments are issued as quickly as possible.
Despite the best efforts of the Bureau's observing and forecasting staff, it is clear that it is not always possible to get vital information to the right place as quickly as it is needed and the inherent scientific complexity of weather forecasting means that occasional serious forecast errors will continue to be unavoidable. That said, the Bureau has carefully reviewed the Norfolk Island situation in order to find ways of improving the accuracy and reliability of its forecasts for aviation through a range of short and longer-term means.
As part of its strategic research effort in forecast improvement, the Bureau of Meteorology Research Centre is undertaking a number of projects aimed at increasing scientific knowledge specifically applied to the provision of aviation weather services. Research projects are focussed on the detection and prediction of fog and low cloud and are based on extensive research into the science of numerical weather prediction. However, with the current level of scientific knowledge, the terminal forecasts for Norfolk Island cannot be expected to be reliable 100 percent of the time. Based on figures available for the period January 1998 to March 2000 (some 12 000 forecast hours), the Bureau's TAF verification system shows that for category A and B aircraft when conditions were forecast to be above the minima, the probability of encountering adverse weather conditions at Norfolk Island airport was 0.6%.
As part of its investigations, the Bureau has considered the installation of a weather watch radar facility at Norfolk Island with remote access in the NSW Regional Forecast Centre. Although routine radar coverage would enable the early detection of precipitation in the vicinity of the Island, investigations suggest that the impact of the radar images in improving forecast accuracy would be on the time-scale of one to two hours. This time frame is outside the point of no return for current aircraft servicing the route. It was concluded that the installation of a weather watch radar would be relatively expensive and would only partially address the forecast deficiencies identified in Air Safety Recommendation R20000040. The Bureau will however keep this option under review.
To increase the responsiveness of the terminal forecasts to changes in conditions at Norfolk Island, the Bureau has issued instructions to observing staff to ensure forecasters at the Sydney RFC are notified directly by telephone of any discrepancies between the current forecast and actual conditions. This arrangement will increase the responsiveness of the system particularly during periods of fluctuating conditions. In addition the Bureau has provided the aerodrome manager with access to a display of the latest observations to ensure the most up to date information is relayed to aircraft. (Comment: not much help if out of VHF range, he not being permitted to use the HF)
The Bureau is actively participating in the review of fuel requirements for flights to remote islands being undertaken by the Civil Aviation Safety Authority.
I regret the delay in replying to your letter but the Bureau has felt it important to look carefully at all aspects of the Norfolk Island forecast situation and consider the full range of possibilities for forecast improvement within the resources available to us. We will continue to work on forecast improvement for Norfolk Island as resources permit.
Let’s remember a quote from Phillip Capper - Safety is everyone’s responsibility -“Responsibility lies with those who could act but do not, it lies with those who could learn but do not and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer”.
CASA, and to a lesser extent the Operator, are the ones who could have acted but did not.
GADRIVR, I get the feeling, rightly or wrongly, that you may know young Dominic. If so, please pass on my sympathy for what he has been through, and my wishes that he can overcome.