Here's an interesting exercise to compare/assess how far the ATSB has come (or not) compared to the old BASI.
Some would say that the PIC of the DC3 that ditched into Botany Bay was also made a scapegoat by the authorities. However it is still worth comparing the two final reports as they both dealt with a controlled ditching where all POB survived. This may perhaps highlight the differences in the current Beaker regime 'final report' to a BASI compiled 'final report'.
Botany Bay ditching:
http://www.atsb.gov.au/media/24341/a...401043_001.pdf
Norfolk ditching:
http://www.atsb.gov.au/media/3970107...-072_Final.pdf
Perhaps the most revealing is the synopsis or in the ATSB report the 'Safety Summary'.
SYNOPSIS
On Sunday 24 April 1994, at about 0910 EST, Douglas DC-3 aircraft VH-EDC took off from runway 16 at Sydney (Kingsford-Smith) Airport. The crew reported an engine malfunction during the initial climb and subsequently ditched the aircraft into Botany Bay. The DC-3 was on a charter flight to convey a group of college students and their band equipment from Sydney to Norfolk Island and return as part of Anzac Day celebrations on the island. All 25 occupants, including the four crew, successfully evacuated the aircraft before it sank.
The investigation found that the circumstances of the accident were consistent with the left engine having suffered a substantial power loss when an inlet valve stuck in the open position. The inability of the handling pilot (co-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and
organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non-adherence to operating procedures and lack of skill of the handling pilot.
Organisational factors relating to the company included:
• inadequate communications between South Pacific Airmotive Pty Ltd who owned and operated the DC-3 and were based at Camden, NSW and the AOC holder, Groupair, who were based at Moorabbin, Vic.;
• inadequate maintenance management;
• poor operational procedures; and
• inadequate training.
Organisational factors relating to the regulator included:
• inadequate communications between Civil Aviation Authority offices, and between the Civil Aviation Authority and Groupair/South Pacific Airmotive;
• poor operational and airworthiness control procedures;
• inadequate control and monitoring of South Pacific Airmotive;
• inadequate regulation; and
• poor training of staff.
During the investigation, a number of interim safety recommendations were issued by the Bureau.These recommendations, and the CAA’s responses to them, are included in this report.
And the Norfolk version:
SAFETY SUMMARY
What happened
On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger.
On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft’s fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.
What the ATSB found
The requirement to ditch resulted from incomplete pre-flight and en route planning and the flight crew not assessing before it was too late to divert that a safe landing could not be assured. The crew’s assessment of their fuel situation, the worsening weather at Norfolk Island and the achievability of alternate destinations led to their decision to continue, rather than divert to a suitable alternate.
The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not minimise the risks associated with aeromedical operations to remote islands. In addition, clearer guidance on the in-flight management of previously unforecast, but deteriorating, destination weather might have assisted the crew to consider and plan their diversion options earlier.
The occupants’ exit from the immersed aircraft was facilitated by their prior wet drill and helicopter underwater escape training. Their subsequent rescue was made difficult by lack of information about the ditching location and there was a substantial risk that it might not have had a positive outcome.
What has been done to fix it
As a result of this accident, the aircraft operator changed its guidance in respect of the in-flight management of previously unforecast, deteriorating destination weather. Satellite communication has been provided to crews to allow more reliable remote communications, and its flight crew oversight systems and procedures have been enhanced. In addition, the Civil Aviation Safety Authority is developing a number of Civil Aviation Safety Regulations covering fuel planning and in-flight management, the selection of alternates and extended diversion time operations.
Safety message
This accident reinforces the need for thorough pre- and en route flight planning, particularly in the case of flights to remote airfields. In addition, the investigation confirmed the benefit of clear in-flight weather decision making guidance and its timely application by pilots in command.
Which kind of speaks for itself, however it is also very interesting to compare the two 'Safety Actions' sections of the report as this more than highlights the previous 'ballsy', big cohuna attitude of BASI compared to the neutered, lapdog, Beaker version of the ATSB!
