Originally Posted by
CharlieLimaX-Ray
About to be made into a feature film for the silver screen.
Article in today’s aviation section of the Australian.
The inevitable movie depiction of the Pel-Air air ambulance saga has been announced and one can foresee where the populist storyline might lie. As was attempted with the movie of the Cactus ditching on the Hudson River, the investigation agency will be depicted as a bunch of Keystone Cops and the pilot as the hero, a victim of the ‘system’.
The fact that the NTSB questioned Sullenberger‘s decision-making around what he might be able to achieve with his powerless aeroplane and that he had to go to the effort of ‘proving’ himself is a matter of record. But Sullenberger has also criticised the derisive manner in which the NTSB were portrayed in the movie. We might have expected such sensationalist portrayal from Hollywood, but who is going to stand up for the ATSB? Are they so much the enemy that no-one cares?
First, we need to dispense with the inevitable (and understandable) wave of sympathy for the captain of VH-NGA, and I think that’s been dealt with in the incident thread. Then we have to process the concomitant and ever-so-slightly guilty ‘there but for the grace of God go I’ declarations from other pilots (slightly worrisome, because they tend to sound like ‘If I ever got myself into a similar position (and I think I easily could) I would hope to get the benefit of the doubt and plenty of slack too’ confessions), we might take a dispassionate look at the material the film-maker has available.
This story revolves around the professional performance of a flight crew (most especially the captain), relevant aviation legislation of the time, and the methodology employed by the independent investigating agency. Three principal dimensions, plus the connected matter of two ATC agencies forgetting or not bothering to pass on weather information.
The performance of the flight crew/captain—as in most investigations—is what it is… it always is. Actions and activities of personnel who are, thankfully, still around to be interviewed are relatively easy to examine and document against relevant proscription (regulatory and company requirements). So the captain’s role and performance was recorded by the ATSB’s original investigation and not much about that has changed with the release of the second report.
On the other hand, the original report was considered by commentators to have placed an unfair burden of blame on the pilot, who—although he made errors—was determined to have acted within CASA guidelines that were considered less-than-robust. It was also revealed that his employer had been examined by the regulator and been judged seriously deficient in numerous respects a fact on which the original report had been silent.
So, the captain was operating within existing regulations which—if we take account of his plea for fairness—apparently excused him from having to uplift maximum fuel if he so judged. Except that of course it did not. The new report also says the pilot was operating within rules set by Pel-Air which were inadequate and have been addressed since the first report was released. The new ATSB report expresses surprise that CASA has indicated it intends to address some of the deficiencies in its regulations governing long distance air ambulance flights, but has not yet done so.
After considering the pilot’s professional performance, these two aspects—an inadequate regulatory environment and an employer’s administrative deficiencies—constitute the other two dimensions of the saga. These latter have been somewhat addressed, however scantly. But most importantly, they have been more meaningfully deliberated in the second report than they were in the first. So the fairness demanded by the media and politicians has been accorded belatedly and it is left to observers to decide how much difference this has made to the outcome for the implied victim.
But the fundamental issue with this incident is that the captain always had choice. None of the CASA or Pel-Air deficiencies precluded him from proceeding with prudence and circumspection. What CASA and Pel-Air did or didn’t do is summarised above and we might hope that the investigation(s) of this incident and associated outcomes will result in a stronger ‘system’.
Now to examine the captain’s actions. The captain of this passenger-carrying jet aircraft;
• decided not to uplift full fuel for the flight. Company policy did not require or demand that he decide thus
• did not discuss, or think to discuss, flight planning aspects with his FO. His company didn’t require him to; does that mean he didn’t have to?
• asserted he made a phone call to the company from Apia for which there is no record. The ATSB extended him the benefit of the doubt
• asserted that he truncated his call to the Brisbane ASA briefing officer because he (the pilot) thought he was beginning to irritate him (the officer). The audio of this conversation does not support the pilot’s contention
• does not recall a weather forecast upgrade having been provided to him although the CVR reveals him acknowledging it
• did not calculate a viable PNR while enroute
• did not proactively seek enroute weather information for his destination
• forgot the fuel gauge anomaly at a time when he desperately needed reliable knowledge of fuel remaining, (and did not seek an alternative indication via the fuel status indicator), as a result of which he…
• ditched the aircraft before he needed to and deprived the flight of the possible benefits of another couple of approach attempts
• neglected to use the ditching checklist even though it could be reasonably argued that there was adequate time to have done so
• did not transmit or instruct his FO to transmit a Mayday call
• forgot his landing gear was down until reminded of it by his FO
• landed the aeroplane too slowly with the result that it impacted the water harder than it needed to (this VERY possibly being what initiated the structural breakup that might otherwise not have happened)
• did not manoeuvre the aircraft optimally for the run-of-swell. The ‘slow-down’ pitched-up attitude meant the crew had no view of and could not gauge the state of the sea they were about to land on
• did not ensure his FO provided correct and useful information to the cabin occupants regarding the liferafts and use of lifejackets
• did not discuss the conduct of the ditching manoeuvre with his FO and could not recall what the checklist said about the airspeed for a ditching
• did not provide advice to outside agents on the intended location for the ditching
• landed in a direction away from land and at a greater distance from it than he needed to
• evacuated the aircraft ahead of all other occupants without providing assistance either to them or to his FO.
This is a litany, not a lashing. As I stated at the beginning, the pilot’s actions (or not) were what they were. No amount of human concern for him can change that, and although one can acknowledge that it’s easy to be critical, if we take that reality as meaning we therefore shouldn’t criticise, then the performance of individuals in an accident is somewhat concealed, is it not, and our opportunity to learn positive lessons is diminished?
As well as acknowledging what environmental conditions might have been wrong to begin with (the systemic weaknesses and failures), the process of determining what went wrong in these incidents, what was DONE wrongly, and what choices were made that were sub-optimum, requires dispassionate scrutiny of everyone’s actions. It is a burdensome responsibility that every pilot accepts that they will inevitably be subject to the most acute focus in the event of any accident investigation. It goes with the territory, and regulatory and instructional deficiencies do not remove the pilot’s obligation to make prudent decisions. Pilots tend to receive the lion’s share of blame for ‘error’, that has been their lot. But statistics surely reveal that pilots are more likely to be in error than is any other party to an aeroplane prang. This is simply because of the confoundedly exposed position in which pilots place themselves just by accepting their role. Any ordinary human emotional proclivity towards feeling empathy for such a person—utterly understandable and utterly appropriate in human terms—simply clouds the issue when dispassionate examination is required.
Investigations will always look at a person’s past for any evidence of a clue to their behaviour at the time of an incident. That is normal, it is expected, and it’s sensible. In this case, the records of both crew members showed past deficiencies in meeting operational competency standards at one time or another. The reader is left to surmise about whether there might be any connection between these incidents and the state-of-mind (or default behaviours) that contributed to this ditching.
This crew did have some luck. They were flying what must be one of the better aeroplanes in which to have to ditch. Mid-wing, no under-wing engines, clean belly presented to the water. Almost an amphibian.
Will the film-makers take reasonable account of all of these matters? Probably not, since that might tend to make the project look like a documentary. And only Mike Moore makes money from documentaries… right?
The captain is back at that exposed sharp end (albeit ICUS) and the FO has a ‘real’ airline job. One wishes them all the best.
The actual victims in this incident were the cabin occupants. Ruined health and—in some cases, prospects… in one case terminally—and no meaningful financial compensation. Hereat lies the pathos the film-makers will be searching for.
I will await the film with bated breath…. and a largish popcorn tub to vomit in.