PPRuNe Forums - View Single Post - Norfolk Island Ditching ATSB Report - ?
View Single Post
Old 9th Nov 2017, 05:12
  #1098 (permalink)  
VH-MLE
 
Join Date: Mar 2005
Location: America's 51st State
Posts: 294
Received 45 Likes on 18 Posts
Back around 1998 or 99, I recall an RPT operator in a Chieftain going to Norfolk and arrived not long before the end of daylight, to conditions not too dissimilar to VH-NGA, and which were deteriorating. The aircraft made several unsuccessful approaches and on the final one used the ARO’s vehicle at the threshold with its flashing light as an indication of where the threshold was. Aircraft subsequently landed in conditions of approximately 200m vis and 100ft cloud base. The pilot did a fantastic job in getting the aircraft on the ground in one piece (but probably shouldn’t have been there in the first place as an alternate requirement existed on the TAF - which was changed from a Tempo enroute & the PA31 was not capable of proceeding to Norfolk and then to an alternate). The PA31 is not a Westwind I know but I offer this as another example of how a similar incident was dealt with.

The only other comment I would like to make regarding the original accident report was that in the years preceding this accident, the ATSB were utilising the Reason Model, which in effect, was identifying all the pieces of “Swiss Cheese” i.e. the defences in place that failed to prevent an accident or serious incident. In virtually every accident, the pilot(s) is always the last piece of Swiss Cheese i.e. the last line of defence. Although the Reason Model doesn’t appear to have been used in this particular accident investigation, it is quite clear to me that the ATSB focussed its investigation primarily on that last piece of cheese at the expense of many other very relevant pieces which I would have thought should include at least the Operator (supervision, procedures etc), Regulator (adequate oversight etc), ASA etc. While I’m not usually a believer in conspiracies, it does look like there’s been political interference at play considering who was on the parent company’s board...

As far as I’m concerned the pilot has been punished enough (although the co-pilot does not seem to have had any adverse treatment whatsoever).

VH-MLE
VH-MLE is offline