When this accident first came to light it raised significant, multi layered concerns covering a broad spectrum of issues. I had then, and continue to have the following 4 concerns:
1.The level of Operational Support and Oversight for the Fight Crew - from instigation to completion.
2.Imposed Pressure (Commercial, Medical or Personal) on the Flight Crew, Operator or Tasking Agency for the flight to be conducted, or continued.
3.Ongoing Fatigue Monitoring and Assessment by the Flight Crew or Third Party as a flight is undertaken. (Plan B if time constraints are pushed).
4.The Conditions and Processes when considering if a task should be undertaken, deferred or delayed.
For a task crossing vast open oceans and International Flight Regions to remote islands, this is a complex undertaking in which risk mitigation is essential by all interested and vested parties, not just the Pilot in Command.
The concerning aspect of this accident is well detailed by the following excerpt from an article by Ben Sadilands 7/09/2102 (my bolding):
“At Qantas we have ALL the systems in place that Pel-Air was lacking. We have a stringent fuel policy that includes decision points for depressurisation, ETOPS and single engine operations. We have a flight planning department that prepares our plans, weather, NOTAMS and makes all calculations for us. We are flight followed and the company lets us know if amended weathers are issued that will adversely affect our flight. Our operations department operates 24/7 and is available for us on the SAT phones they give us. At the end of the day, we are only the final layer of defense in that we check all these other factors before we depart. The Pel-Air audit found them lacking in all these respects.
Without any of these layers available to him, the Pel-Air Captain was the only defense. At Qantas, a lot of holes in a lot of layers of Swiss cheese have to line up for mistakes of this magnitude to happen; at Pel-Air it seems that there was only one layer, the Captain.
While he made mistakes, he seems to be the only one being held accountable by CASA and the ATSB.”
A well said and considered opinion!
I would hope the investigations that follow from the ATSB report will alleviate my concerns and instigate a sharpened view and conduct on how flights such as this are undertaken in the future.
The Four Corners program raises even more concerns regarding the conduct, processes and culture of CASA and the ATSB.