Norfolk Island Ditching ATSB Report - ?

[PaulDamian]

Its been almost 2 years and still no report...
When do you think it might be issued?

I tried looking for the old thread, but guess it might have been removed.
Just wondering when the report might be issued, not wanting to speculate or re-invent past discussions.
Cheers,
PD

[Wally Mk2]

"PD"............Shzzzzzzzz, be quiet, the report along with the plane has gone to the bottom, it sleeps with the fishes as the Sicilians would say:E

The guy ran out of gas, it ain't rocket science! (or was about to depending on which version of the evnets you believe)


Wmk2

[baswell]

Given how quick the head honcho was to praise the actions of the pilot, it's almost like he's got something to hide.

My money is that they didn't top up before departure because a) fuel was more expensive deeper into the pacific and b) you burn more when you haul more.

Yeah, it was probably (barely) legal, but it'd be fun to know if that was unwritten company policy to save some bucks...

[megle2]

Seems odd that its shrouded in silence
Can the ATSB squash and hide an investigation report

[S.E.A.L.11]

Looks like it may be a NZ run investigation for some reason. Or else they are just helping: http://taic.org.nz/Currentinquiries/tabid/89/Page/2/language/en-US/Default.aspx. It's on page 3 - #09-008

[bentleg]

I tried looking for the old thread, but guess it might have been removed.



Might be this one (http://www.pprune.org/dg-p-general-aviation-questions/423316-norfolk-ditching-license-back.html) or this one (http://www.pprune.org/dg-p-general-aviation-questions/400603-merged-norfolk-island-ditching-3.html)


Looks like it may be a NZ run investigation for some reason


ATSB has a file (http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-072.aspx) - but no report as yet

[PLovett]

My suspicion on this is that the flight was legal, right up to the point where the pilot decided to continue the planned flight rather than divert due to weather. However, it was only legal because of dispensations or approvals granted by CASA and was certainly not prudent.

So, given that affected persons and organisations have the opportunity to review an ATSB report, I suspect that they are taking the opportunity to delay the publication by suggesting changes while they boiler-plate their back-sides for the inevitable kicking that is going to come their way.

[Jamair]

Gunna hafta debate that suspicion Plovett - it was a Charter, not Airwork, so the CHTR regs on fuel did apply.... ergo he shoulda had more go-juice on board.

[jas24zzk]

Hmm,
did this pilot make a bad decision? I think not. If it were so we'd be talking about in another thread here.

Strikes me as good planning gone to sh*t by the things we cannot control.

Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed

Just my half cent

Jas

[compressor stall]

Strikes me as good planning gone to sh*t by the things we cannot control.


I just coughed on my weetbix when I read that comment. :ugh:

[Horatio Leafblower]

Strikes me as good planning gone to sh*t by the things we cannot control.

There was nothing out of control on that flight except the decision making process BUT subject to the right combination of organisational culture and operational pressures I fear many of us could have ended up in the same spot.

How many times had he done the same or similar trips?
How many times had he managed to get in when the wx was marginal?
Had he ever received a butt-kicking for making a precautionary diversion for fuel that turned out to be unnecessary?

He didn't go past that CP for diversion knowing they would end up in the drink. He would have been confident that he could get in.

....right up to the point where he wasn't. :eek:

Personally, I would love to know how this event has changed the HF culture and the training accross the Rex group :hmm: :rolleyes:

[Lookleft]

As far as the report goes I think QF32 has probably soaked up a lot of resources so this report just gets put on hold until the investigator can get back to it. The only reason an investigation would be terminated would be if the accident was caused by terroism or a deliberately illegal act e.g. the Kingair barrel role over Mt Hotham.

[PLovett]

Jamair, you may be right but I was under the impression that aeromedical work was AWK and not CHTR. :confused:

Even if it was CHTR I believe that a CASA dispensation is possible (and I think in this case probable) from the fuel requirements for flights to islands. If this was granted then it was a very poor decision from our regulators. :(

IIRC this point was debated at some length on one of the previous threads on the topic. :8

[Jabawocky]

Hmm,
did this pilot make a bad decision? I think not. If it were so we'd be talking about in another thread here.

Strikes me as good planning gone to sh*t by the things we cannot control.

Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed

Just my half cent

Jas

You have got to be kidding me.

- He departed underfuelled - refer Jamairs post, and regardless of whether or not there was an exemption, he still did not carry prudent fuel.
- He could have diverted to New Cal after he received WX advising that he was now below the alternate minima. Had he been departing that point in space with that WX it would have required an alternate or suitable holding fuel. He had neither the fuel nor the brains to divert.
- He arrived with WX that was even worse still, and knowing he was low on fuel he never declared it or an emergency.
- He flew several VOR approaches which are not runway aligned by a mile or two from memory and require a circle to land.
- After a couple of them he tried yet again.
- He had a F/O that was not endorsed on GPS approaches, yet he was, but they never tried one. The RNAV for RWY 11 IS RUNWAY ALIGNED.
- He could have had the the FO call the numbers for distance and height to the SNFWM and flown a 3 degree profile watching the Radar Alt which it should have had, and flown the RNAV as a sudo ILS, and landed the thing on the runway. Might have been hard work and scary but should work.
- Some folk will argue "but that is descending below the MDA why would I be encouraging busting the minima, well he went well below the minima when he crashed it on the water :ugh:.

Bloody lucky of the highest order that anyone lived, let alone the patient. Lucky the bloke who spotted them stopped where he did, by rights he had no reason to belive he should have.

So......poor planning, poor in flight monitoring, poor decission making in the cruise and poor decission making once it all turned to sh!t .

So show me one area of this guys flight operation where you can honestly cut him some slack? Maybe commercial pressure prior to departure? If so then he should have diverted in the first instance, and that extra cost would have shoved it right up the ar$e of the company for being so stingy. Of course he did sink a perfectly servicable jet on the bottom of the sea in return.

I too think the ATSB will be getting all manner of requests to distort the facts to minimise the arse covering required for the obvious.:hmm:

[MakeItHappenCaptain]

Gunna hafta debate that suspicion Plovett - it was a Charter, not Airwork, so the CHTR regs on fuel did apply.... ergo he shoulda had more go-juice on board.


Shouldn't matter if the company ops manual specifies adhereance to CAAP 234-1.

[ForkTailedDrKiller]

Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed

As I understand it, the bath came as a bit of a surprise for all concerned!

Dr :8

[Andu]

Kudos to the pilot for a safe touchdownCan only agree. However, I cannot help but harbour a slight suspicion that this particular successful touchdown might bear some strong parallels with the story (told, I think, by EK Gann in one of his books [FITH?]) of the Catalina that 'landed' in IMC on a snow-covered Greenland hillside during WW2 - much to the surprise of the Catalina's crew.

Edited to add: I hadn't seen the post immediately above until after posting this observation.

[Wally Mk2]

'Jaba' I have to agree with you here pretty much on this one with what you wrote.

Going below any min is justifiable when under emerg conditions so all bets are off by this stage. Not declaring an Emerg means I believe one of two things he either was more concerned of the ramifications if he did declare an Emerg due paperwork retribution etc (which is plausible) or he simply believed that he was going to get in & say nothing chalking it up latter to sh!t I'll never do that again !, one way humans tend to learn.
There would have to have been some commercial pressure on this guy as apart from total ignorance nobody would intentionally put themselves or others in harms way by going skinny on the gas.
I personally will be very keen to see/read the outcome of this one as it's somewhat close to my heart ( done Pacific Aer-Med B4) as it can be very challenging out there over the Pacific with limited options flying wise.

They where damned lucky that is was a Westy jet as you couldn't pick a better small jet airframe to land on water if you tried. Mid wing, eng's out of the way & even with the gear down (likely to be the case here) a water landing would be doable due to bugger all of the wheel protrudes blw the fuse.


Wmk2

[Jamair]

WM2 - re the commercial pressures - I hope the ATSB report discusses the medical decision making as well, to proceed on an overwater flight of some several thousand km by night to collect what can only be described as a non-urgent patient who subsequently trod water for 90 min then took a commercial flight the next day....:rolleyes:

Plovett, the air ambulance / AWK criteria do not apply because the operator (Pelair) was not the medical provider. The aircraft was chartered by Careflight from Pelair.

Jaba - you forgot leaving the FO behind unconscious in her seat while making his escape over the top of all the other occupants.

Were the CVR & FDR recovered?

Should be interesting reading, IF we ever see it.

[Wally Mk2]

'Jamair' that's a valid point you make re the nature of the med condition etc.

That being the case(low priority) there would still be an element of commercial pressure as with any med retrieval, time= money.You keep the team (med & tech crew) on the ground for another day or so for say better wx or daylight Ops & the costs start to escalate.
The tech crew where not in a position to access the condition of the patient as the very fact that it's a long distant costly transfer done outside of normal commercial ops alone means some level of urgency so making ops decisions based on that alone means commercial pressure.
The insurance Co's couldn't care less about details of any particular flight (delays etc due WX) they just want it done quickly to keep costs down.

Commercial reality is very real in that part of aviation.


Wmk2

[Jamair]

Hell yeah Wally, I am agreeing with you! If the med crew had said, for example, that the patients condition did not warrant the risks associated with a long overwater night flight as advised by the tech crew (if indeed that issue was even discussed), then the patient may have elected to take commercial transport the next day, or the insurer may have decided on commercial transport or (gasp!) another service provider; thus denying the anointed company the income.

[Wally Mk2]

All true 'J':-) Retrieving someone from afar is fraught with hassles as this case in question has shown.
Typical Eg & this may very well have been the case with this patient. Person gets sick on holidays for whatever reason.(I've seen them with broken spines to being shot in the head!) They have travel insurance & the local Dr says it's best we get this patient to a main land facility asap, mainly 'cause the Dr doesn't want any complications on his nice easy quiet Island:-) The Ins Co. is advised & immediately they start looking at cost effective options to get this person to where it's going to cost them (the ins Co)the least.They look at commercial flights after learning that the patient isn't too serious (& this is often used in Australia & OS) & could go by large public jet with assistance. They find out that being Norfolk the options there are limited, not enough seats available the following day as an Eg only. So next option get a recognized Aero-med organization to do the task. Get a quote, it's a cut throat business to it's the cheapest they can secure. Ins Co goes down the path hiring said Co & wants it done quick. Now the fun begins & the commercial pressure starts with the Tech crew now on an OS mission. Possible end result? Exactly what we have here!

Of course all of the above is just a fictional story but very believable!

They all survived that's the main thing & hopefully many have learnt that going out there over the Pacific Ocean at night in a small twin eng jet to a tiny island is damned risky/dangerous even when the suns out!!



Wmk2

[Jabawocky]

Jaba - you forgot leaving the FO behind unconscious in her seat while making his escape over the top of all the other occupants.

Jamiar......... Yes indeed, I did think about it earlier in my rant, but figured I would leave it to the operational details. So he was a gutless moron too:ugh: Not quite the hero portrayed in the papers hey.;)

As Wally said, they survived that is the main thing, and I bet he has trouble sleeping at night knowing what he did...... or he should do.

[GADRIVR]

So Jaba..... Have you ever considered contacting both pilots and getting their version of the events?! Just a thought.
Cheers,
DRIVR

[Jabawocky]

From reading the initial report, doing some calculations, and they were checked by folk who did this work, it became clear the comments I have made are pretty factual. Receiving weather, diversion points, number of VOR's shot and missed, then into the drink.

If I am wrong, please detail it. There are quite a number of us perplexed as to what another version of events could have lead to all these events. Or has the ATSB reports and many other witness reports got it so wrong.

Gadrver, if memory serves me correctly you take a line of...was not like that... But refuse to offer a detailed plausible alternative.

Quite happy to be proven wrong, but it needs to be a convincing argument. We are all keen to hear what you know.

[j3pipercub]

I have it on very good Authority that the report will be released in next months Cleo...

j3

[Dora-9]

Jaba, I'm with you all the way on this one....

[Dogimed]

Jaba +1

But isnt this rather like mentioning the war..... I recall the threads were sunk last time faster than Westwind out of fuel, out of options and out of time...

Dog

[Jack Ranga]

Jaba + 10 (or whatever it is now!!)

and I bet he has trouble sleeping at night knowing what he did...... or he should do.

I don't reckon he does mate :cool:

[Jack Ranga]

I have it on very good Authority that the report will be released in next months Cleo...

Gold :D

Good to have you back :ok:

[Jabawocky]

GADRVER

Any chance you can fill in the blanks for us misguided folks?

[Brian Abraham]

Have you ever considered contacting both pilots and getting their version of the events?! Just a thought.That was tried by one of the Prooners in an effort to provide resources to help the Captain. To no avail. Understand the Lass now has a front row seat with Virgin - just a rumour heard, good on her if so.

[Jabawocky]

Brian, she probably was not as silly as her captain that day.

Here is an interesting news article link from last month just emailed to me....ohhh dear.

Star match: Simmone Jade Mackinnon and Dominic James set to battle it out in court | News.com.au (http://www.news.com.au/entertainment/celebrity/star-match-simmone-jade-mackinnon-and-dominic-james-heads-to-court/story-fn907478-1226165471637)

[Wally Mk2]

Christ 'Jabba' who sends you this crap?? :E
Dom the hero?........oh brother!!!
I must start buying Cleo the magazine, there's gotta be more interesting aviation articles in there:E



Wmk2

[Jack Ranga]

A Brietling watch? Are you joking' me?

That alone shows a lack of judgement :cool:

[Mr.Buzzy]

Leave the bloke alone!
He cocked up but does anyone deserve to have their mortgage details posted? Where is the bad judgement now?

There but for the grace of God go us

Bbbbbbbbbzbzbzbzbzbzzzzzzzzzz

[ForkTailedDrKiller]

Leave the bloke alone!
He cocked up but does anyone deserve to have their mortgage details posted? Where is the bad judgement now?
There but for the grace of God go us
Bbbbbbbbbzbzbzbzbzbzzzzzzzzzz

I'm with Buzzy on this!

Jaba, have you no shame? This is a rumour network - facts have NO place here.

Dr :8

[ALLAH]

Never a weather problem, only a fuel problem. Anyone operating to a single runway airport in this part of the world WITHOUT an alternate, regardless of weather, day or night is mad. Forget the rules and whats legal...airmanship is the answer.

[megle2]

Can't afford to pay for a watch, must be with a LCC

[pcx]

ALLAH
Maybe you should check your facts before you post. It might add a bit of credibility to your reputation while you are busy giving us the benefit of your vast experience.

http://www.airservicesaustralia.com/aip/current/dap/SNFAD01-115.pdf

[Checkboard]

pcx, I think you missed ALLAH's point - fog is never a problem if you have enough fuel to simply curse at it before going somewhere else. :rolleyes:

[pcx]

Sorry I don't see any mention of fog in ALLAH's post.
All I see is mention of a single runway destination which is clearly incorrect.
ALLAH posted without verifying the basis of his statement and thus, to my mind, displays his complete lack of credibility.
By all means post your thoughts on this or any other thread.
However, we are supposed to be professionals.
We should at least get our basic facts correct.

[Capt Fathom]

Anyone operating to a single runway airport in this part of the world WITHOUT an alternate, regardless of weather, day or night is mad.

That is a big call! Why is this part of the world different?

[compressor stall]

Never a weather problem, only a fuel problem. Anyone operating to [an] airport WITHOUT an alternate, regardless of weather, day or night is mad. Forget the rules and whats legal...airmanship is the answer.

That's my $0.02

[404 Titan]

pcx
All I see is mention of a single runway destination which is clearly incorrect.
It may be a revelation to you but it isn’t uncommon in countries outside Australia, regulators require airlines and crew to consider airports with crossing runways as single runway airports when calculating fuel requirements pre-flight and when calculating in-flight reduction of fuel. I’ll leave it to you why this may be the case.

Capt Fathom
That is a big call! Why is this part of the world different?The question that should be asked is why is Australia different to the rest of the world in regards to alternate fuel requirements?

[pcx]

We could discuss this all day and seemingly go round and round.
My point was very basic and simple.
Clearly ALLAH did not do his or her research. That is not the mark of a professional pilot.
The comment made by ALLAH was that an alternate should have been carried because YSNF has a single runway. This is obviously incorrect and adds nothing to the debate. If he or she had commented on the potential risks of an aerodrome with intersecting runways then great. That would prompt us all to consider these factors.
Was I tough in my reply to ALLAH? I would say "yes".
Maybe, just maybe, ALLAH will be really p...ed of with me and will be just that little bit more determined not to make the same type of mistake ever again. It just might help in what I sincerely hope will be a long and enjoyable incident free career.

[KRUSTY 34]

Don't know if poor old Dom' works for any airline these days. Stand to be corrected though?

[MACH082]

I'd hardly call him an airline pilot.

You have to be working or have worked for an airline to gain that title.

[mustafagander]

Are both runways at NF rated for the aircraft in question?

As I hear it, the report is coming along but the FOI is kinda busy ATM.

[601]

All I see is mention of a single runway destination which is clearly incorrect.

Some folks consider a cross runway configuration a single runway airport for obvious reasons.

A forecast cross wind exceeding the the limitations on one of the runways would also make it a single runway aerodrome for planning purposes.

One runway not meeting either the width, strength or length for the aircraft type and operation would make it a single runway aerodrome for planning purposes.

[framer]

With all due respect pcx, I think you have missed the intent of Allah's post. It was simply an opinion about airmanship, not something you would have to research,and certainly not enough to warrent That is not the mark of a professional pilot.
it's just an opinion, quite forcefully put, but quite well put.
Is English your second language? (I'm not being facetious, just wondering if thats causing the disconnect).

[Wally Mk2]

A professional pilot would ALWAYS consider an intersecting rwy layout a SINGLE rwy AD especially out in the Pacific Ocean, that's what being a Capt is all about. Every time I went into any Pacific Is AD especially at night (due rwy lighting considerations) I had a plan B.

One day sometime ago now I was sitting at the gate of a Nth Qld AD on a nice sunny day after having landed a few mins earlier & watched a lighty from outside my cockpit window slide on in on the smaller crossing rwy only to do a bit of 4x4 work before coming to rest with the prop dug into the grass just a few mtrs from the gable markers of the main rwy, that's exactly the situation that could happen anywhere at any time so one should never rely on an AD with intersecting rwy's as being suitable.


Wmk2

[Fantome]

" an intersecting rwy layout a SINGLE rwy AD " ???

[Deaf]

" an intersecting rwy layout a SINGLE rwy AD " ???

Abbreviation for "The aerodrome has a single point of failure for it's runways" which is a summary of several pages of risk analysis.

[compressor stall]

Have a read of CAO 82 Appendix 5, 7 Table 1 to see how the multiple (separate) runways for a diversion is considered to be of lower risk than a single runway.

Even if YSNF had parallel runways and ILS, it should have an alternate though. Out of interest, what other countries in the world permit operations to aerodromes with no alternates (without even getting into the issue of Island aerodromes).

[Mach E Avelli]

PNG allows no alternates; basically copies Aussie rules with INTER & TEMPO fuel provisions. Not a good idea in that part of the world....only a mug would NOT carry an alternate. Whether one would stack the INTER or TEMPO fuel on top of the alternate (should the alternate itself require it) is a matter for individual judgement on the day. Personally I think that is a crock as I don't subscribe to double-jeopardy - alternate plus 30 has got me by all these years. The lowest fuel I ever landed with was 20 minutes which I admit was a bit tight.

The Oz situation is rather unique because of the excessive distances involved, so should not be copied in places where the distances are not so much as to be limiting. NLK - NOU is from memory a piddling 55 minutes at jet speeds.

PS: Am in agreement with Jabawocky's assessment - harsh as it may seem.

[dogcharlietree]

Jaba. I agree with you taking into account the following exceptions So......poor planning, poor in flight monitoring, poor decission making in the cruise and poor decission making once it all turned to sh!t .


So......NIL planning, NIL in flight monitoring, NIL decission making in the cruise and NIL decission making once it all turned to sh!t .

This is the worst example of a "captain" (notice small c) that I have ever heard about. John Cleese must be making a training video.

[404 Titan]

dogcharlietree

I think Jaba said “Poor” not “Nil”. Big difference.

[dogcharlietree]

404. Please re-read what I said and what I quoted. helluva big difference. That's why I said it! :ugh:

[Jabawocky]

He must have done some planning......or blindly followed company plans perhaps.

The more you look atit though, nil is possibly a better word to use.

[KRUSTY 34]

From what I understand, at the time AWK ops, and for that matter Charter, were not required to carry an alternate for Norfolk! WX/Notams notwithstanding of course. Hello CASA, was anyone home! Now from a command point of view, I'd be extremely cautious about embarking on such a flight without at least another option up my sleeve. I'm assuming of course that the captain had calculated his relevant PNRs/CPs.

That brings us to the question, at what point did the crew learn the Wx at norfolk required an alternate, and was this information passed to them in time to take a different course of action?

[Jabawocky]

It's a fair question to ask krusty, and from distant memory when myself and a couple of others reviewed times distances and the weather being passed to the pilots, they could have made New Cal.

Probaly a good reason they did not want to!

[Ejector]

Ignore - Deny - Deny - Till the issue fades away :D

CASA Style :ok:

[Sarcs]

Jingles old mate that is SOPs for the regulator and bureau these days...the word in bold says it all I'm afraid:A ditching, Air-work category, jet, night time, in the ocean! Unless you have big pockets or a roo on your tail, nothing of consequence in other words, then noone gives a rat's rear end!

Gobbles sums it up perfectly:

A tough regulator is not afraid to take the big boys on, head on, and not willing to allow its testicles to be squeezed by the Minister, Board and other lines of protection. This is your starting point to achieve a higher standard of safety in the industry. Every time one of the 'big guys' f*cks up CASA should be throwing a rope around the accountable persons neck in that airline and punish them in accordance with the civil aviation act. You only have to do it once and the indsutry CEO/COO rogues will quickly take their money and run for safer grounds. Until that starts to happen there will be absolutely no improvement in safety or minimisation of risk. It's time for CASA to stop playing hand puppets with farmhand chopper pilots and chasing operators who forget to tuck in their uniforms while on duty, it is time to asctually oversight safety.

[Sarcs]

Justice seeker rule 101 from the "bureaucratese" Ops manual, "if in doubt circle the wagons and prepare for a long seige and....."

http://i1238.photobucket.com/albums/ff498/004wercras/ostrich20ignorance-resized-600.png

..do not resurface until the coast is clear!":ok:

[Al Fentanyl]

Was not Airwork (ie air ambulance), was a Charter of aircraft and crew from Pelair by Careflight.

[aroa]

On long oceanic legs any pilot that had no alternate or is not fazed by the wx either,.. imho ...has steel balls and can land anything anywhere...or just a lead brain. PVT, CHTR, AWK...does it matter.

The guy that should get THE medal was the one who used his initiative and had a look from some high ground and spotted a faint light....as rough indicator as where to go with the boat.
Had that not occured..or the view been obscured by rain, it would be another AE type mystery...where DID they end up, apart from in the water. How about that for a 'miracle'?

Well I supose you could say he could land anything, anywhere....except it just was not the desired destination. :sad:
Scary.

[catseye]

Jinglie, believe Al is correct. The client specified their flights to be operated to charter standard together with a whole bunch of other requirements.

ATSB report is due shortly I am told.

:D

[Al Fentanyl]

Jinglie, in order for it to be Airwork Category, ie an Air Ambulance operation, the patient or patients representatives must have contracted with Pelair to provide that aeromedical service. As I understand it, they did not. The clinical coordination was done through Careflight who accepted the case and chartered an aircraft and crew from Pelair as they did regularly. So for Pelair, it was a Charter.

If you have different info, would be glad to hear it.

Regardless of that though, to launch on that flight with air in the tanks and the load capacity to take more weight in fuel cannot be a wise decision.

Aroa is dead right about the only hero in the whole sorry saga - give that man a medal!

[Al Fentanyl]

You may be right - or not. I will await with interest the outcome of the report.... if I haven't died of old age by the time it comes out.

[Checkboard]

What if that Air Ambulance flight is also carrying a passenger (i.e. not a patient or flight crew or medical staff)?

[blackhand]

Was it legal - PEL-Air? Was it legal CASA?......
Was what Legal? Do you have evidence that something was not (legal)?

[Wally Mk2]

I think it matters none what Cat this flight was conducted under (Air Work according to the report so far) it's still an A/C carrying people but the one underlying problem here is that less than max fuel was carried to an remote Is at night where the Wx was or could have been sus (as it turned obviously was very sus) in a light twin,that's the part that needs to be hammered home,simply be smart about the operation from a safety stand point not from a commercial stand point.
They where damned lucky it was a West Wind Jet you couldn't pick a better airframe to ditch with, engines up out of the way,fair amount of fuse blw the wings making it like a canoe with large outriggers!
Doesn't matter what the report says or will say eventually does anybody ever learn from the mistakes of others in aviation?....rarely!



Wmk2

[Up-into-the-air]

I hope it won't result in an in-effective report like the Darwin Brasilia, where "....the Company involved has now gone to simulator training....so this won't happen again..."

Sorry - my paraphrasing of the report that came out sans any SR's [safety recommendations] by ATSB.

Anyway, casa never take any notice of them anyway.

We will see - ATSB you are on notice.

[john62]

The report should be released next thursday. It has been a long time coming. We will see if the lion share of blame is laid at the feet of the regulator, the operator or the pilot.

Jinglie may be close to the mark about a circus.

[adsyj]

Yes shall be very interesting to see. Surely Operator and Pilot won't be left unscathed.

We got lucky this time with no loss of life, so lets hope lessons will be learned.

[Capt Fathom]

The captain is always to blame. Do you have anything else to speculate on before the official report?

[john62]

From what I have heard, most of the blame is directed at the crew. There are only minor criticisms of the operator and regulator.

Cookies must be enabled | Herald Sun (http://www.heraldsun.com.au/news/national/crash-report-criticises-glamour-pilot-dominic-james/story-fndo317g-1226458015144)

It appears someone has sent a copy to the media. The slant of this article suggests it is not good news for the pilot.

Four Corners is going to tell the "real story of what happened that night." So I guess they have also got a copy if they have produced a story over the last couple of weeks. Hopefully it will be better than the 60 minutes story at the time.

[prospector]

The crew made four attempts to land in darkness before deciding to ditch after running out of fuel.

Decided to ditch?? Makes it sound as if they had options.

[Dogimed]

Its out...

Here (http://atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-072.aspx)

Dog

[bdcer]

They refer to HUET (helo underwater escape training) in the report. As the helicopter will sink very quickly & most likely roll with all the weight above the roofline. The drill is to crack whatever door you can & get out. Maybe the captain was following that drill ??

[Sarcs]

Unlike the ATSB report planetalking has no problem heaping it on to one and all of the various stakeholders that were party to this incident::ok:


Which also means CASA’s rules, contrary to the posturing of the safety regulator after the accident, were so weak that Pel-Air wasn’t obliged to carry enough fuel for a diversion caused by weather or other circumstances right up to the point where it overflew its intended destination.
But three years later, CASA ‘intends’ to fix the problem.
This triumph of prompt regulatory intervention, follows an incident in which poor pilot decision making by an apparently fatigued Pel-Air employee, resulted in six people, comprising two pilots, a nurse, an attendant, a patient, and her companion, flying four missed approaches to the Norfolk Island airstrips, and then making a controlled water landing at around 160 kmh after which the jet broke into two parts and sank 48 metres to the sea bed, leaving those on board to tread water or cling to wreckage before being found by a boat that had been looking in the wrong area when its skipper fortuitously glimpsed the pilot’s torch from afar.
It also confirms the truth of the astonishing comment by Pel-Air chairman, John Sharp, the morning after the near disaster, that the pilot, Dominic James, had set off from Apia with no plan B in the event that the flight couldn’t land on the island where it was to refuel.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
:ugh::ugh:

Pel-Air ditching report hurts the more as it sinks in | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/08/30/pel-air-ditching-report-hurts-more-as-it-sinks-in/)

There is also more evidence of the ATSB's 'softly, softly' approach in accident/incident reports over the last few years:


The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisations. In addressing those issues, the ATSB prefers to encourage relevant organisations to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.


Sheesh....bring back the BASI and the Crash Comic (hardcopy)!:{

[Brian Abraham]

Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia?

[john62]

Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia?

If so then surely something else other than fuel should have been left behind.

[Mach E Avelli]

...or a more suitable aircraft should have been contracted for the job......or a fuel stop made at Nadi.
While not wishing to become an armchair umpire after this sad event, it is all too common for aircraft operators to enter into deals with unsuitable equipment simply because they already have it. And clients all too keen to accept such equipment on the basis of price alone.

[flying-spike]

It is also interesting that they refer to the conversation between the pilots and the Unicom operator however they didn't release the tape. They released their own video so why not the tape. Also they refer to the briefing and flight planning conversation for the return trip but no transcript or actual recording.

[john62]

And clients all too keen to accept such equipment on the basis of price alone.

In fairness, I wonder if the client necessarily has the information and understanding required to make these assessments. It has taken 3 years for the investigator to release this report. Some issues (eg sufficient fuel for OEI) are fairly technical in nature.

Different operators will have different price structures and different profit margins. Is the client really expected to determine the underlying reason for the lowest price? After all, it is a more significant decision that brand name versus no name brand at the supermarket.

The client may well expect that the regulator and operator will ensure that the operator will conduct operations in a safe and appropriate manner.

[Kharon]

Plane Talking - Instead the report, which is a master class in how to write commercially inoffensive copy that will avoid raising public concerns, notes only that CASA has “advised of their intent to regulate Air Ambulance/Patient transfer operations in proposed Civil Aviation Safety Regulations …. to safety standards that are similar to those for passenger operations.” But sadly it has and it's getting worse. The MOU between ATSB and CASA needs to destroyed, it's evil. The Miller report is probably the most cynical, self serving document ever inflicted on industry.

Bit tragic to see the integrity of the once modestly proud, fearless, independent BASI become a cats paw for spin and dross. I wonder what the NTSB would have made of this, not a three year meal. That's siccar.

[blackhand]

K, do you ask for more regulation, surely not:eek:

[601]

Reading the report, the crew did have fuel for a diversion to Noumea between approx 0905 and 0930.

They had 3 Speci reports (2 in this 25 minute period), each getting worse. Once the first Speci was received at 0800 indicating that the weather at LHI was not as forecast, the process to assess the actual weather at Nandi and Noumea should have started. This should have been the main focus of the crew for the next 90 minutes up to the PNR for Noumea.

As the weather at YNSF was deteriorating from the Specis received during this period, 90 minutes is more than enough time to determine the time and fuel required for a diversion to Noumea.

The crew state that they were not sure of the winds to Noumea. They were in the position of flying in the actual wind. This was probably more accurate than the Grid Wind forecast, if they had it.

It appears no request for the weather at Noumea was made. Why? This would be the first thing asked for once the first Speci for YNSF was issued.

As we are not informed of the weight at departure, we do not know how much extra fuel may have been carried and if that extra fuel would have allowed an approach at YNSF and a diversion to Noumea.

One thing that was not raised is the need for a Company to require an alternate when planning to a single runway airport, especially a remote destination. The Westwind is above the weight allowed for 04/22.

[Jamair]

ATSB have determined it was AWK, fair enough (despite the obvious issue of there being non-essential passengers aboard). I was surprised however to see no mention of the Careflight task management, where the aircrew and medical crew elected to undertake a couple thousand km over-water flight with no alternate nominated, at night, when the patient condition allowed for the flight to be undertaken in daylight. As AWK, the medical crew form part of the operating crew so come under the ATSB scope of examination. A significant contributor to the outcome I would have thought.

On reading the report I formed the opinion that it was somewhat vanilla froth.

[Capt Claret]

4 Corners on September 3rd features this incident.

From my brief glimpse of the promo last night, I thought the aircraft shown was a Lear.

[Going Nowhere]

It may have been covered in the previous pages, so sorry for the double up but...

Does anyone else think that the landing gear looks down and locked? Would a lack of hydraulic pressure cause the gear to fall that straight? If the gear was up, should the fuselage have broken like it did?

Not suggesting it was down, just curious.

[Anthill]

GN,

If the gear was down on landing the force of impact with the water would have torn it off.

Nowhere really spells: Now. Here.

[adsyj]

Thankfully no fatalities resulted from this unfortunate incident.

I would suggest it is probably not over for Pel -Air you would think that the ATSB report provides some ammunition for a Civil Claim. Or has this already commenced?

Is there are valid reason why the Captain would exit the Aircraft first. That seems a bit odd or has the report left some detail out.

[blackhand]

Nowhere really spells: Now. Here.
And Norfolk spells Nor. Folk. :confused:

[john62]

You would have to imagine the legals were waiting for this report before doing anything. The report states that care flight had not done a audit for a long time. That seems a bit out of line and could also be significant

[aussie027]

GN, I doubt the gear was down for the ditching. Well hopefully it wasn't.

1 line of thought tho for off field Emerg landings on LAND tho is to lower the gear as it is a very strong component and will help absorb impact forces as it is possibly torn off by the impact. This means, hopefully, less forces to be absorbed by the fuselage/cabin area thus a greater chance of survival. Obviously every situation is different and requires a judgement call at the time.

[Going Nowhere]

Thanks for the replies, like you said Aus, one would HOPE the gear was up. It does look pretty well locked down though! :confused:

[desmotronic]

Going Nowhere,
If you read the report you would know it says in part:

The wreckage came to rest on a sandy seabed. Video footage showed that the two parts of the fuselage remained connected by the strong underfloor cables that normally controlled the aircraft’s control surfaces. The landing gear was extended, likely in consequence of the impact forces and the weight of the landing gear. The flaps appeared to have been forced upwards from the pre-impact fully extended selection reported by the PIC.

[Up-into-the-air]

From the ATSB report:

The decision to continue to Norfolk Island

Under conditions of increased stress or workload, working memory can be constrained and may limit the development of alternative choices and the evaluation of options. Depending on whether the available options are framed in a positive (lives saved) or negative way (injuries and damage), a decision maker can be influenced by how they perceive the risks associated with each option when making a decision.

When decision-makers are confronted with options that are considered as a choice between two different benefits, decision makers tend to be more risk averse. They tend to prefer a guaranteed small benefit, compared with just the chance of a larger benefit. On the other hand, when decision makers are faced with a choice between two options that are considered as two separate losses, they tend to be more likely to accept risk.

In this instance, the flight crew described the choice when they first comprehended the deteriorating weather conditions at Norfolk Island as being between diverting to Noumea and continuing to the island in terms of assessing competing risks. Given the weather and other information held by the crew at that time, including their not having information on any possible alternates, their perception that the higher risk lay in a diversion was consistent with the greater number of unknown variables had they diverted.Come on ATSB, where are the numbers to show the real data or is this just a "soft out" for the failure of casa to surveil another operator?? to the point where more people have been put at serious risk??

Is this another "SeaView" ??? in failed procedures and surveillance??

[mustafagander]

I have difficulty in criticizing the captain for being first out of the exit. Just imagine - he's gone back to the cabin to open the exit and get his pax out, his primary responsibility - now there is an open exit. Can you imagine his trying to fight his way back forward in the cabin when the pax REALLY want to exit? I imagine that he was fired out of the exit almost like toothpaste out of a tube.

His other decisions might well have been questionable though IMHO. Real men don't divert!!

[Brian Abraham]

I was surprised however to see no mention of the Careflight task management

The retrieval organisation has a document posted here http://www.isas.org.au/img.ashx?f=f&p=christchurch_2010%2FDitching+off+Norfolk+Island+-+Paul+Smith.pdf

[Checkboard]

Reading the report, I was surprised:
that there was no weight and balance analysis - or even a suggestion that one was completed. Even simple GA reports produced in a month or so have a statement similar to "the aircraft was within the weight and balance envelope." As this report relates to the amount of fuel uplifted, and it was a long flight, it seems very pertinent.
that there was no mention of the "passenger on an airwork flight" issue. As the airwork category allowed a reduced level of safety (no alternate planning), then permitting passenger travel is a pertinent issue.
The PIC received the latest aerodrome forecast (TAF)7 for Norfolk Island from the briefing officer during the submission of the flight plan. The poor briefing, and the Captain's statement that internet access was difficult is a major failure in the report - and the system defence for that is obviously the quality of availability of correct information, I am surprised there is no assessment of the quality of information available from the briefing office. As the Captain received the information "during the submission" of the flight plan, it seems obvious that the plan was already completed before any briefing material was obtained.
the report mentions that the company check required the calculation of CPs and PNRs as part of the endorsement/check to line, and that this training was not required to be recorded. There is no mention of any test to see if the accident Captain, or any other of the company's crew (or any of their representative industry pilots) are actually capable of calculating an off track CP and off track PNR under cockpit conditions. (http://www.pprune.org/tech-log/273717-cp-pnr-calculation.html) I say this because I doubt 20% of pilots in the industry can, and that is a failure of the exam system as the exam system focuses on very high accuracy which leads itself to systems of calculating which are not practical in the real world. That is why the company manual had the simplified fuel flow/planning information in it, and why the Captain stated The PIC indicated that for operations in the Westwind, there were effectively two refuelling options; either the aircraft carried full fuel, or the wing tanks only were filled. (ie. Crew were not confident enough in their fuel planning to specify an accurate (and efficient) fuel load)

[Sarcs]

The Aviation Advertiser, in its article 'CASA revives a dead dog', makes mention of the ELT (fixed), which apparently gave one squawk and then quit, hmm that far overwater (if it was me) I'd be carrying, or have very close to me, one of those PLBs!


The ATSB’s report on the Norfolk Island ditching accident adds a real-time account that puts the realities of ELTs into further perspective:
The aircraft was fitted with a 406 MHz emergency locator transmitter (ELT), which was designed to transmit a distress signal that could be received by a satellite. The ELT could be manually activated by a switch in the cockpit, and it would also activate automatically if the aircraft was subjected to g-forces consistent with an aircraft accident.
The aircraft was also equipped with four personal locator beacons (PLBs) that could be carried separately and manually activated. Two of these beacons were installed in the life rafts, and one of the remaining beacons was equipped with Global Positioning System (GPS) equipment, which would enable it to transmit its position when it was activated. The aircraft occupants were unable to retrieve any of the PLBs before they exited the aircraft after the ditching.
The aircraft-mounted ELT was not GPS-equipped. A geostationary satellite received one transmission from that ELT and the information associated with that transmission was received by Australian Search and Rescue (AusSAR) 38 8 minutes after the aircraft ditched. AusSAR was able to identify the owner of the ELT, but was not able to assess its location from the one transmission.
Obviously the single transmission was impact-activated; however it seems probable that the airframe damage caused the antenna or its connecting lead to fail after that first transmission.


Lady Luck was very definitely on the side of the crew and pax!

CASA revives a dead dog – opinion – aviationadvertiser.com.au (http://www.aviationadvertiser.com.au/news/2012/08/casa-revives-a-dead-dog-opinion/)

[Checkboard]

The careflight document mentioned above states:
EPIRBs
– Personal issue EPIRBs / strobes were not carried by our crew at the time – but now are!
• Crew also now carry their own life‐jackets equipped with appropriate survival aids
... so the careflight staff are no longer relying on the quality of lifejacket & survival equipment provided by their contractors, and are providing their own.

Edit: I might also add, that I am surprised that in this computer day and age a contracted jet aircraft is still relying on manual flight planning for an international overwater flight!

The industry standard is to pay the reasonable fees of a professional third party planning company, such as Universal Weather & Aviation Inc (http://www.universalweather.com/triptools/online-flight-plans/), or Jeppesen (http://ww1.jeppesen.com/aviation/business/planning-solutions.jsp). In that way, the plan could simply have been faxed to the pilot's hotel - and you are not relying on a tired pilot not making an arithmetic error (or a simple inability to correctly determine the critical contingency point).

[Up-into-the-air]

From page 29 of the ATSB report:

Part A Section 9.11.2 of the operations manual titled Critical Point required pilots to calculate a CP on ‘appropriate’ flights over water that were greater than 200 NM (371 km) from land and on all other flights for which the availability of an ‘adequate aerodrome’52 was critical. There was some disparity between that section and Part B section 6.1.2 of the operations manual titled Calculation of Critical Point, which omitted the need for an available adequate aerodrome, instead stating that a CP was to be calculated for flights where no ‘intermediate aerodromes’ were available.Does this mean that casa has not "again" failed to surveil the operator??

Smell like Lockhart River??

And then at page 35:

Five different operators were interviewed and provided relevant sections of their operations manuals for review. Those manuals generally reflected the requirements of CAAP 234-1 but also had individual operational requirements appended. However, they either had no guidance, or did not provide consistent guidance on the process to be used when deciding whether to continue to a destination in circumstances similar to those affecting the flight to Norfolk Island.

When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided.This goes even further, into the failure of casa in it's surveillance methods [or lack of them]

Now, as I read on, is there any SR to be found on the topic???

[Bonniciwah]

This Monday's Four Corners on ABC TV is all about this incident. Should make for interesting viewing.

[Kharon]

UIA- When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided. Neither should there be; it only leads to more prescriptive, draconian, criminal based law being produced and misinterpreted, by all. Command discretion is an essential given; in theory, it's why you get paid the big bucks. It would be grossly unfair and harsh to criticise CASA in this case.

I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.

The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.

No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.

BH - K, do you ask for more regulation, surely not. No mate, not me; but have a long hard look at the report from a purely operational viewpoint; no amount of regulation would, or could have helped ?. Nah, can't blame Aunty CASA for this one. (would if I could - but fair dooze).:D

[john62]

This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).

[Kharon]

John62 - This particular operator is rumoured to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).

This is a very good point, amongst the many good ones here. And it's one reson why I say it's unfair to blame the regulator, no one can legislate effectively against a bad culture.

The stuff not written which carries the full weight of 'company' rules and a bollocking. Don't buy fuel at ABCD – to expensive; don't land at EFGH – we barred; don't ask for RTOW charts, etc. etc. We all have heard or seen it. Minimising uplift at 'expensive' ports and tankering fuel at 'cheap' ports is a game often and well played. It's called operating a service, as is saving a ton of fuel or finding the best flight level, or any of that unwritten, command type stuff. But, even if the rumours related to Noumea were true, I'd pick a night in French pokey over a swim in dark, any old day of the month.

[Sarcs]

Agree "K" you can't regulate for sheer stupidity or a severe case of 'pushonitis', although the philosophy is very much akin to the regulator's i.e. 'flying with the blinkers on'!:E

However one does wonder why it took so long to complete? Political correctness, sense and sensibilities, who knows? Also what's with the wishy, washy soft cock approach by the bureau??:ugh:

[601]

Also what's with the wishy, washy soft cock approach by the bureau??

It is like red ink all over a school project- cannot criticise anyone as you may harm or upset their delicate nature -

OR

they may learn from their mistakes - we could not have that now, could we.

[27/09]

This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).

I had wondered this particular point a while back, perhaps also the same applied at Nadi?

[27/09]

Kharon

Neither should there be; it only leads to more prescriptive, draconian, criminal based law being produced and misinterpreted, by all. Command discretion is an essential given; in theory, it's why you get paid the big bucks. It would be grossly unfair and harsh to criticise CASA in this case.

I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.

The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.

No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.

have a long hard look at the report from a purely operational viewpoint; no amount of regulation would, or could have helped ?

I agree 100%. As pilots we have been licenced to make the correct decisions.

[john62]

I had wondered this particular point a while back, perhaps also the same applied at Nadi?

There would have to be a pretty good reason for planning on Brisbane as an alternate when flying Sydney to Samoa via Norfolk Surely you would proceed to Noumea instead of turning around and going to Brisbane. I could even understand Auckland. However Brisbane doesn't make any sense.

I had missed this point in the report. Good catch Kharon.

[lk978]

Didn't pull the tabs down on the tip tanks?

[Kharon]

This is the bit vexes me. Long, complex, subjective, prescriptive, variable interpretation regulation.

ATSB - CAO 82.0 expanded on a number of the CAR 234 requirements for application in specified circumstances, including passenger-carrying charter operations to defined remote islands, such as Norfolk Island. As an aerial work flight, the aeromedical flight to Norfolk Island was not subject to these CAO 82.0 requirements, but they nevertheless provide useful context. Everyone sliding off the hook into the mind numbing tedium of prescriptive wriggle room. Endless, pointless circular legal arguments about wether the flight was 'legal' in strict compliance with the MINIMUM rules and who's arse is covered when the music stops. When the 'game' is compliance and only compliance, this sort of incident results. Fact - it's a small island in a lonely corner of the world. It's a bloody long march to the nearest friendly place (fully equipped with dancing girls and cold beer).

ATSB - Although not assessed as part of the study, the importance of the PIC as a risk mitigator in the case of un forecast deteriorated weather at the destination was discussed in the conclusion to ATSB Research Report B2004/0246 titled Destination Weather Assurance – Risks associated with the Australian operational rules for weather alternate weather (available at Australian Transport Safety Bureau Homepage (http://www.atsb.gov.au)). Now this makes for interesting Sunday morning reading. (It does, like a long winded, old money crash comic).

ATSB report - here. (http://www.atsb.gov.au/media/32921/b20040246.pdf)

Chapter 3 is the one you want – sure, it's a little tedious (nature of the beast) but I'd like to see a copy in every technical library. The ATSB can and do put some great educational tucker on the table, it's just that it's so hard to find. Food for thought – you betcha.http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif

More real life education – less micro managed compliance bollocks. :ugh:

[Frank Arouet]

In the good old days one had an option to declare a "mercy flight" and not many suffered the chopping block for working outside the required minimas. Unless it all went tits up of course. Anyone using the two way communicative device would assist to help make the flight a success.

How many would dare attempt such a thing today?

Operating an EMS service with an AOC pertaining to same is a different thing I guess?

[27/09]

When the 'game' is compliance and only compliance, this sort of incident results. Fact - it's a small island in a lonely corner of the world. It's a bloody long march to the nearest friendly place (fully equipped with dancing girls and cold beer).

I have done a small amount of longish over water flying with remote destinations. When it comes to fuel requirements, PNR's, Critical time points, divert options and divert times etc and the decisions around theses items especially with remote destinations like Norfolk it doesn't matter in my book whether its a private flight or an ATO. Compliance has nothing to do with it. Carry the fuel, monitor the conditions, know what your options are and use them if necessary. Only 100 metres is too far to swim.

What experience did the P in C have on this sort of Op? Did he have a a good understanding of the vagaries the the weather at Norfolk? Even if he didn't, I still don't understand the decision not to divert while there was still time.

[john62]

A fuel policy that pushed things to the very edge of the legal limit with no thought whether this was sensible (aerial work so no alternate). A pilot who pushed things even further (no OEI). A sense of complacency (not getting en route weather and not monitoring a deteriorating situation). Possible difficulties at Noumea. Poor CRM (not asking FO to check calculations).

How else was this going to end up. This all reads like a recipe for disaster. In the end they got themselves backed into a tight corner.

There is more than enough blame to go around. The crew did the wrong thing, but they were not the only ones.

[Joker89]

why no mention of the decision to not fill the tip tanks?

Also, why were they made to climb/descend when surely as an aero med flight it would have had a STS?

As for not having current weather/notams for possible diverts enroute.:ugh: Is there no fax machine on Norfolk? We can get by without the net.

Seems to me he called up with the flight plan then said by the way whats the TAF? No need for that trend from 1500 best be on my way.

[Dangly Bits]

Just noticed it on my Internet TV guide. Should be interesting.

DB

[hoggsnortrupert]

Was always standard operating procedure for our company, in fitting with a favorable TAF! add into that any TEMPO, and it had to be re-thought:

Even with a favorable TAF, We got caught out going into Funifuti, 5 missed, and we got in on the 6th! power back at minimum, M-Apps, at lowish power, was not a very nice feeling!

And before you ask, 10 minutes before the PNR, Nadi had given us via HF a suitable Metar, and TAF! so anything can happen especially when the CTZ gets down below 15 Sth:

When I asked the F/O what he thought of bringing one to Idle power and Feather, he nearly choked. ::eek::sad::ooh::suspect::{

H/Snort:

[Lookleft]

Given that the crew had put themselves between a rock and a hard place, would it have been possible to set up a v/s of 800'/min on the A/P, keep vor/loc coupled and come down to 200' to try and get visual? Given the performance of a Westwind I imagine that a go-around would have been successful from a low altitude. They seemed to have persisted with VOR approaches to the minimum even though they had been told that the cloud base was 200'.

[hoggsnortrupert]

I am not prepared to say what I went down to, get into Funifuti, BUT! 200 Ft while not being legal, in a circumstance such as this? is ample!:=:=
H/Snort:

[b_sta]

There's a line in the report stating that on the last approach they went below the minima to try to get visual, but it doesn't detail how they did so, nor how far below they went.

[Sarcs]

Preview for the 4 corners program tomorrow night:

Crash Landing - Four Corners (http://www.abc.net.au/4corners/stories/2012/08/30/3579404.htm)

[Wally Mk2]

I tell ya what being down at 200 ft at night doing an NPA (well Blw the Min) very close to the AD with minimal fwd vis virtually zero room left to maneuver & with rain pelting against the screen, the fuel gauges showing 'E' & you know that going around from this means possible death or ta least career ending actions would have any pilot almost at their maximum level of capability.

Like I've said b4 on this subject I bet my left one (the right one I lost in a bet years ago!:E) that commercial pressure was the main criteria that found Dom in this ugly mess.That along with possibly not enough experience & poor flight planning in these Ops means a LOT of young pilots can & will find themselves in similar situations maybe not as drastic as this one but still life changing.
As has been said it's got zip to do with what's legal here (AWK PVT Etc) there's still flesh & blood being carried regardless of the regs.
A good Capt Commands:ok:
Most of these light jets are capable of carrying full fuel (or close to it) in an average Aero-Med config. Taking off with less than full fuel on such missions means there's some external force making that decision.
They survived & lets hope that something good can or has come good of this.

At the very least this accident might make some young buck one day think twice about going skinny on the gas due Commercial pressure!

As for the final report on this?............well that's just a waste of time to even be put together. Too much legal jargon & ass protecting to be of any benefit really.


Wmk2

[T28D]

Impossible on any form of TV journalism to get the nitty gritty out in the open, in house lawyers will be controlling every word.

CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[gobbledock]

CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
That is a given, but only because they are protected by a 'higher source'! There is truly something powerful within the realm of voodoo, black magic and sorcery!

http://t3.gstatic.com/images?q=tbn:ANd9GcTgPu7FmJOAYPIZud2qPBbLqE9PeLwQ2-r4Lh9WLLq6uHGlE_8i&t=1

[Kharon]

You mean 4 Mourners don't ya. Three years in the making, oh roll up, roll up.

The stats are interesting, CASA reports to the Minister, the ATSB reports to Minister, the ABC depend on the Gummint for Dollars, (if not sense); and we cannot have the Minister' s wee boat rocked. Yup, the 4 Mourners show should be worth the cost of the carbon rich electricity.

Tony the Tiler - Smoke and mirrors is the new act, normally reserved for the corporate management thug types, but now adapted for the Elephant hiding act. Now, as everyone knows, elephants are very hard to hide. But, in a light bulb moment, the elephant hiding ringmasters have decided that the next best thing to hiding an elephant is making it disappear. Wow, the crowd is silent in anticipation, a disappearing elephant act, can it really get any better. Sadly, the act is only part way through and my source is unable to report on the outcome of this new and daring act. But so far there is a lot of smoke and distraction and something called unity. Unity is mentioned by the ringmasters at every opportunity, what can it mean and where will it end?

Legendary stuff – on your ABC. :D

[601]

A month later, the Civil Aviation Authority (CASA) took away James' pilot license and his reputation was all but destroyed

4 Mourners need to get an Australian (or English) spell checker.

I wonder what else they will get wrong.

[flying-spike]

At the risk of being accused of harping on about professionalism (or the lack of) and over simplifying the analysis of the accident you need only look at the writing between the lines in the "Celebrate the professional pilot" thread, now closed.
Of over 2000 views only one pilot had the testicular fortitude to admit that he was coerced into "non compliance". Even on this forum that thrives on anonymity, nobody else could put their hand up and say that they had stood up to coercion from their employer. Either too afraid speak up or just plain had never exercised command judgement. Hopefully it is not the latter.

Combine that GA upbringing and an organisation culture where blind obedience to a figure that had and exercised the power to make or break a career then you set the stage for this sort of accident. You only have to wait for the players to walk on stage.
Even worse you condition the pilots to replicate the same behavior in the cockpit.

[john62]

Ben Sandilands seems to know what angle Four Corners is taking, so we can assume that Ben was a source interviewed for tonight's episode.

He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report.

Pel-Air exposé on ABC 4 Corners tonight is a must view report | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/09/03/pel-air-expose-on-abc-4-corners-tonight-is-a-must-view/)

Pel-Air exposé on ABC 4 Corners tonight is a must view

The ABC TV show 4 Corner’s exposé on the Pel-Air ditching (http://blogs.crikey.com.au/planetalking/2012/08/30/pel-air-ditching-report-hurts-more-as-it-sinks-in/) near Norfolk Island that airs tonight goes directly to the honesty and candor with which aviation safety regulation is pursued and discussed in Australia. It is a must see program.
The issues of transparent and fearless public administration of air safety regulation and investigation have been central to Plane Talking for five years but their pursuit by a well resourced national television program is an important breakthrough.
Tonight’s program is more evidence that the flawed regulatory performance of CASA, the air safety regulator, and the supposedly independent safety investigator the ATSB, include a systemic failure to fully and unambiguously keep the public informed about substandard operations.
4 Corners will disclose matters arising from a CASA audit of Pel-Air, conducted immediately after the Norfolk Island incident, that ought to have been included in the ATSB final report into the crash.
The non disclosure of such matters raises the question as to whether CASA, the ATSB and by association, the responsible minister, are deliberately acting to protect the airlines or aviation services providers and their regulator from better informed scrutiny of their respective capacities to follow or draft effective safety regulations.

[Brian Abraham]

The reason I mentioned the lack of a weight analysis in an earlier post is this taken from another 1124A accident.
Because of the Westwind II design, a small change to the aircraft's load can result in a relatively large shift to the aircraft's centre-of-gravity (C of G) position. The aircraft's C of G envelope is published in Section VIII-21 of the Westwind II Airplane Flight Manual . The lower portion of that envelope identifies two separate zones. The manual indicates that, if the aircraft's zero fuel weight falls within zone 1, then fuel may be loaded up to the maximum ramp weight without exceeding the C of G limits. However, in order to maximize the aircraft's payload, the aircraft's C of G at its zero fuel weight is normally adjusted to the aft-most limit of zone 1. As passengers, baggage, and fuel are then added, the C of G will move progressively ahead, toward the forward limit of the operating C of G range. This adjustment to the zero fuel weight C of G position is accomplished through the use of removable ballast.

Prior to departing from the Edmonton Municipal Airport, the flight crew had positioned 100 pounds of removable ballast (four 25-pound bags of lead shot) into the aft baggage compartment in order to configure the aircraft's C of G to allow for the loading of eight passengers at Meadow Lake.

The aircraft's weight and balance for the re-positioning flight to Meadow Lake were within prescribed limits. Its weight for the time of the accident was estimated to be 18,138 pounds, and the distribution of that load would have placed the aircraft's C of G at the aft limit of the aircraft's C of G operating range.
So did the CoG have any implication for not filling the tips?

[Sarcs]

The two comments (so far) from Ben's blog article are interesting...


1
http://0.gravatar.com/avatar/21b60ac190c348d8e493a7713f62753a?s=32&d=identicon&r=G (http://en.gravatar.com/site/signup/) comet
Posted September 3, 2012 at 11:12 am | Permalink (http://blogs.crikey.com.au/planetalking/2012/09/03/pel-air-expose-on-abc-4-corners-tonight-is-a-must-view/comment-page-1/#comment-13406)
There should be a Royal Commission into air safety regulation in Australia, as it has descended to third world standards. Political donations from airlines and aviation companies should be banned.
2
http://1.gravatar.com/avatar/5bc5ded40a04c96c9bf9d2c1c9f16f74?s=32&d=identicon&r=G (http://en.gravatar.com/site/signup/) pa31 (http://www.pa31site.com/)
Posted September 3, 2012 at 12:48 pm | Permalink (http://blogs.crikey.com.au/planetalking/2012/09/03/pel-air-expose-on-abc-4-corners-tonight-is-a-must-view/comment-page-1/#comment-13408)
The reading of the PelAir report is very similar to the recent Brasilia report from Darwin, where there are just vague references by ATSB to “….changes by the operator, which involve use of a simulator program….hence there won’t be any more problems….”
ATSB has released a report that takes 3 years and is extremely light weight.
This report is similar, to the Brasilia one, in that this report identifies systemic problems in CASA surveillance of the operator “……but changes since the accident …..fix the problem …………..”
It even says that other operators have similar problems when surveyed.
Surely this goes to the heart of the matter, in that CASA is failing to properly undertake it’s role. We are not looking for “over-the-top” micro-management, but surely, where there are large over-water ops, there needs to be a standard met in this area.
Remember SeaView – This has some of the same hallmarks.
This is both for the regulator and the operator

[PaulDamian]

What are the pilot (Dominic?) and the Co-Pilot doing now?

Are their careers in aviation over???

(Presumably) taking a Westwind for a swim is not good for your cv and job prospects.

[Joker89]

What are the pilot (Dominic?) and the Co-Pilot doing now?

Are their careers in aviation over???

(Presumably) taking a Westwind for a swim is not good for your cv and job prospects.

It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is in the RHS at virgin.

[ForkTailedDrKiller]

It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is in the RHS at virgin.

Read that as, "It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is a virgin."

That kinda got my attention, but I did wonder at the relevance!

Dr :8

[Worrals in the wilds]

He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report.The traditional APS/ADF Four Corners Test (how will this decision look if it all goes pear shaped and ends up plastered all over Four Corners :ooh:) seems to have been joined by the Crikey Test.
I wonder what sort of mark CASA will get.

[Bozzo]

I believe Dominic will achieve immortality as this accident becomes the centre of many future CRM courses.

Hogsnortrupert, there is a big difference descending to 200ft at Funafuti where the highest point is a coconut tree, to 200ft at Norfolk with higher ground in the vicinity.

[Joker89]

Looking at the plates for the vor 29 and 11 the inbound tracks are displaced along way from the rwy centreline. This would not be ideal in weather below the minima.

Perhaps the rwy 04 approach would have been worth a shot. Although its shorter, the rwy is lit and the inbound track is only 2 degrees off meaning the threshold at least would have been straight ahead. I'm sure 4700ft would have been long enough for a very light Westwind in the wet.

Maybe that approach was not available at that time.

[Mach E Avelli]

In an emergency low fuel situation coming down to 200 ft at Funafuti would be no biggie if flown accurately, because the highest tree is only about 50ft. Cyclones usually knock them over if they try to grow any higher.
Groping around at 200 ft at Norfolk, at night, would probably be terminal for the occupants of any aeroplane so foolishly flown. For all that he got so wrong, finally coming to the conclusion that he had to ditch (even if it was in the wrong place) was proper. All on board owe their lives to that decision rather than the alternative of attempting a landing with no visual contact with the runway.
The weather at NLK is tricky. They can be calling it below minima from the ground yet sometimes the approach and landing can be completed without busting any limits. On other occasions - and sometimes even within a few minutes of being OK - it is just impossible to see anything at the minima - or even a bee's dick below minima (altimeter error, honest it was).
Given the way the weather was coming through in waves on this occasion, I certainly would have tried as many approaches as I had fuel for - up to the point of being able to divert to NOU. But being at NLK with no diversion fuel - not done that since the Bae 146 did the run, when PNR was at top of descent. But then we had to be absolutely sure it was OK to continue. One crew nearly got caught out once and gave themselves a good fright, and I am sure there were others less publicised.
Then, praise be, the rules changed to require an alternate for RPT and charter. Obviously paying passengers' lives are more important than patients flying courtesy of insurance (don't get me started on double standards in aviation!)
This ditching appears to be the direct result of inexperience being exploited by a loophole in the regulations. Poor judgement being the by-product of inexperience. Loophole in the regulations being the by-product of an incompetent regulator.

[scumbag]

kharon, spot on the money...

pathetic

:yuk:

[GADRIVR]

The really interesting part of the whole saga is that a fair chunk of evidence can't be produced unless there's a senate enquiry. Even with what was produced tonight though should be enough to get people asking questions as to the relationship between CASA the ATSB.......and the clowns that run Pelair and Rex.
Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case.

[Marauder]

After that incompetent perfrance, the Screaming Skull should be cleaning out his desk. Even his former right and man turned on him.

What's misleading performance , yes Skull 40 years ago when you began your legendary career etc etc, something's never change, the regulator is never wrong, and yes CASA had no problems with the Captain retaining his license for six weeks, but pulled it on Christmas Eve, reprehensible scum

[Frank Arouet]

I think the skull had make-up.:*

[scarediecat]

Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case.

:ok:

I didn't operate in a vacuum. I operated as a pilot that belonged to a company that was overseen by a regulator. You can't isolate one thing from all the others and say that's a fair appreciation of what took place.

Sum's it up ok I reckon.

[Nulli Secundus]

What really hit me from tonight's Four Corners programme:

The Head of CASA denigrates the pilot for not demonstrating an ability to plan a flight ex Samoa without software. He's clearly angered by this. Its almost as if he's found the smoking gun. Pretty much a 'gotcha' moment from the CASA head.

He seemed argumentative, defensive & abrasive. This guy appears to be a guy who makes his mind up and locks on to a belief when clearly there are contributing factors way beyond simple pilot error.

To say none of the Pel-Air breaches would have contributed to this accident is simply wrong. When CASA identified PA as failing to comply with fatigue management systems, THEY CONTRIBUTED TO THE ACCIDENT.

How does CASA repeatedly fail to find these breaches in time?

[scarediecat]

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.

That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.

MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...

GEOFF THOMPSON: So it might be a mistake.

MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.

GEOFF THOMSON: And he did.

Three years it took for this report to be published yet just last week they confessed and changed critical details. Are they serious?????

[PLovett]

The program was an opportunity lost to explore the mess that CASA and the ATSB has become under commercial pressure and the compromises it is producing. It did, however, reveal the problems surrounding obtaining weather information and the complete shambles that Pel Air had for flight planning.

Fair doos to Mr James for being prepared to face questioning. I would have liked more information on the differing fuel calculations as to fuel remaining had they diverted to Noumea. From the pilot's perspective I can understand why 8 minutes is not inviting based on their figures.

[Nulli Secundus]

The story should have placed a far greater spotlight on CASA and the ATSB. This poor standard in regulatory oversight has happened before and logic says it will happen again.

Tonight I will write to the minister and ask for the Head of CASA to be removed.

[Jabawocky]

GADRIVR

I am as critical of CASA as the next guy, the oversight, the company, the lack of sleep, the bad planning, the conflicting weather, and everything in-between is just not kosha with most people who read this stuff.

I see your point about Dominic being the soft target, and yeah I feel for the guy, but at the beginning of the day, he had the ability to pull the pin. And should have.

PelAir should have had all his planning done for him, just like a good supportive company operating into these places should do. But clearly the did not.

Back of a beer coaster planning is fine for Mudgee to Dubbo, but not across the oceans of the south pacific. No way!

At several points, the lack of sleep. The lack of wx and planning. The fuelling choices. The wether reports and conflicts, all should have been triggers something does not add up.

Three strikes you are OUT principle applies when bush flying, local flying and when the company, the systems etc are letting you down, the 3-strikes rule could well save the day.

I understand, the circumstances all conspired against him, but what he did with them was poor, and you could easily blame fatigue etc, but he himself did not believe that was a factor. There were options, and 4 corners did not explore them at all.

Hate to say it, but criticising JMAC over his comment is a bit lame.

As T28D has pointed out there are other choices that are more runway aligned, and none used. The ones tried are nowhere near the runway, and were futile really.

One thing is for sure, I bet Dominic never makes that mistake again!

[my oleo is extended]

There was a lot in this interview to be disected, no doubt. But 3 things were extremely disturbing;

a) The fact that the ATSB's reputation for unbiased, clear and concise investigation reports has absolutely hit '**** bottom'. CASA has been a bureaucracy for decades so there is nothing new or shocking there, however the ATSB in the past few years under Dolan's direction has become a complete joke. He was caught off guard, looked awkward, stumbled and looked like Beaker off the Muppets. Reports containing piffle and bollocks are now the norm. Investigations are absolute light weight ****e. The same methodology is employed at the ATSB and ASA and it sure as hell stands out. At least Russell got the heave ho from ASA, but it might be time to get some of the old ATSB gang back on deck?

b) The return of Herr Quinn! We wondered where the wiley old rascal had been hiding. After being pineappled by the Skull a few years back (at least the Skull had the balls to do it unlike Byron) and he has been waiting to fire a bullet. So for Quinn I imagine it was more an act of sour grapes and payback. The same applies for his 'sidekick' who also featured on the show, he is most certainly a former CASA employee who lasted just over a year, and has many chips on his shoulder against the authority also. There is a lot more to the Quinn/Aherne stage show but best let sleeping dogs lay.

c) The Skulls make-up. Fair dinkum, he looked like a dolled up Ladyboy! 4 Corners should sack its make-up artist immediately. When the angry man watches the replay tomorrow he will be reaching for the stoogies and going nuts over his poor performance (he sounded very nervous and didnt even look like cutting loose and throwing some office furniture). Heaven help the first Inspector or operator to screw up Tuesday morning as the Skull will be raining down fire and brimstone, not to mention the phone calls that he and Dolan will be receiving from the Minister for Mascot.

Which one is Beaker????

http://t1.gstatic.com/images?q=tbn:ANd9GcRo1KKB6K7oCCbfd21mNsRhns3ZeEprwA1xBavUxwG tD9XE_1_qPQ&t=1 http://www.itsasafety.org/images/uploads/Martin_Dolan_Australia.jpg

Mememememememememe.

[Wally Mk2]

What a shambles that whole saga was & totally unnecessary!!
The extensive footage of the LE 35 on the program (same one I used to drive) brought back memories of crappy nights out there over the Pacific in a tiny 2 eng plane. A place where there was no decision on how much fuel you took you simply filled it to the gunnels & made sure that you had an escape at every point along the intended route. SE or Depress Ops usually meant max fuel anyway. At least I had great support from a great Company.

I'd like to think that something good might come from all this by way of strong directions & rules from the regulator so that young pilots can learn from Dom's life changing event.



Wmk2

[TOUCH-AND-GO]

It most certainly was an interesting watch! :ugh:

Tonight I will write to the minister and ask for the Head of CASA to be removed.

Good luck with that. :}

Quick question, Should the passengers be compensated?

[strim]

Quick question, Should the passengers be compensated?

Absolutely. No contact from Pel Air since the accident is outrageous.

Also, for the head of CASA to be so black and white about where the blame lies when any layperson watching 4 corners could see the issue is complex and multi faceted, in my opinion makes him completely unsuitable to hold that position.

My girl didn't know whether to be amused or concerned when I told her he was the head of the 'safety' regulator. "THAT guy's keeping you safe?!?!"

[Chimbu chuckles]

As a former Chief Pilot of a International medivac operation (Falcon 200) I would offer the following insight.

1/. You're typically operating under the 'guidance' of a CASA FOI who doesn't know $hit about jet operations let alone corporate jet operations...never mind medivac operations across international borders, to the middle of nowhere, in the middle of the night.

2/. But he wants an endorsement on your aircraft for free.

3/. Companies doing this sort of work invariably have the wrong aircraft for the job - they get the cheapest jet they can find whether its the right aircraft or not. That is why you have LR31/35s and Jew Canoes running around the Pacific in the middle of the night - just because you get away with it for a few years doesn't make it the right aircraft. That corporate imperative eventually killed off the operation I was in charge of.

4/. A jet is a jet. In my operation we never, EVER went anywhere without an alternate...period. What the rules say is irrelevant.

5/. Fatigue management systems are a sick joke. CASA tried to make us have one. We spent large $ on getting the program software - ran a bunch of scenarios through it and found it would allow us to do trips with 2 pilots we currently did with 3 (Singapore- Kathmandu-Singapore) and not even come close to flagging us as fatigued - but we arrived back shattered even with heavy crew. I rang CASA and literally told them the fatigue software was "fcking dangerous and anyone pushing its use is a moron" - then the fella I was talking to allowed as how HE was one of the fellas from Uni of SA who designed it...before becoming a consultant to CASA.

"So? - we will be staying on CAO48 - there is NO WAY I or my pilots will be operating under your FMS" It instantly went from being a 'requirement for renewal or your AOC' to "Ok you can keep using CAO48".

I think this young pilot made some very basic mistakes that night - why was the gear down when he ditched? We wasn't he more proactive getting weathers for a place he MUST have known could be dodgy?

He was clearly impaired by fatigue.

I have been as tired as he was...only difference was I wasn't backed into a corner when that tired. Our operation had FAA trained dispatchers (ex SingAF navigators) and our flight plans/wx/notams were faxed to the hotel we were staying at and picked up by the crew at checkout (already lodged by our dispatchers of course). We had a satphone. One of our dispatchers (there were 3) was on duty for the entire time we were away from base keeping an eye on us. Contacting them from ANYWHERE/24hrs a day, via satphone, was as complicated as ringing your mother on mother's day.

This young pilot fcked up - but CASA/PA fcked up more. I bet young Dom would be the first to admit his mistakes (he virtually did on 4C)

CASA and PA NEVER will. It seems more and more obvious that ATSB doesn't have the staff/resources to carry out its statutory role at any level that could be deemed effective.

After the Falcon operation ended I flew a C441 casual out of SEQ for a few months before getting back into airlines - I did one trip out east of Fiji in it. I arrived in Nadi to find my employer hadn't even bothered to inform the Fijian immigration people I was coming - no accom booked etc. I rang the boss from Nadi in the middle of the night just to wake him up. I managed to smooth things over with the Fijians, find accom, get suitable rest and complete the task safely. When I got back I just looked the boss in the eye and said "That won't happen again".

It didn't.

Looks to me like that was the level of backup young Dom got.

I hope this doesn't permanently effect his career. After that night he will be the safest pilot around - and the first to tell his employer "That won't be happening" and mean it.

Good luck to him.:ok:

[BPA]

Have a read of the CASA audit document the ABC have on the 4 corners site. The only good part of Pelair back then appears to be the Saab/Metro operation. Can't say the same or the Medivac/Jet Charter and the MIL Ops out of Nowra.

[Brian Abraham]

why was the gear down when he ditched?It wasn't CC. That was a result of impact damage.

[Chimbu chuckles]

It doesn't look that way to me - I reckon they forgot the gear in the multiple approaches and that is the reason the aircraft snapped in half. The underwater film shows main gear down and locked...not forced out on impact.

[Wally Mk2]

'CC' I don't believe the gear was actually down for the water landing but it could have been. The 'Westy' would have to be one of the better airframes to drop into the drink even with the gear down as little of the gear protrudes beyond the lower part of the fuse anyway. It sounded like the TAWS was going off in the Vid clip on the 4 Corners show 2nite meaning that it activated due the A/C not configured for a normal Ldg which would have been the case in a planed ditching (gear selected up)

Anyway there's no doubt more to come on this one.

Wmk2

[A37575]

I think this young pilot made some very basic mistakes that night - why was the gear down when he ditched

Bryan Abraham answered that from the ATSB report. The impact forced down the gear. "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. The pilot must have done a first class job of ditching in the dark. The rate of descent at impact must have been perfect and IAS perfect for ditching. With absolutely no forward vision even though the landing lights were on but not displaying the waves, from what I can guess his ditching technique was spot on.

Earlier he was given a met report indicating cloud base 6000 ft which tied in roughly with the weather the day before. He believed it and let's face it, so would have most pilots at the time. Also given that a diversion to Tontouta would have him arriving there with eight minutes of fuel, no wonder he discarded that idea. So would have most pilots.

We should not shy away from giving the man the credit he richly deserved; and that is he made a successful ditching on instruments under conditions you would never try to create in a simulator because no one would believe you.

[601]

It sounded like the TAWS was going off in the Vid clip on the 4 Corners show 2nite meaning that it activated due the A/C not configured for a normal Ldg which would have been the case in a planed ditching (gear selected up)

Where did 4C get the info to re-construct this clip.

[R555C]

1. I wouldn't believe anything that came out of the 4 Corners program. The reporter couldn't even get the name of the two main agencies correct (Civil Aviation Aviation and Safety Authority/Australian Transport and Safety Bureau????? what was the reporter thinking, zero credibility to start with!

2. Three Westwinds lost by the operator in just over 20 years.(Pel-Air was two separate AOC's for many years, one for the Jets and one for the Turbo-Props)
VH-IWJ – Oct 1985
VH-AJS - Apr 1995
VH-NGA – Nov 2009

3. The use of the term “High Quality” VHF Radio as against the “Poor Quality” HF. If you had any doubts about the accuracy information you hear on the HF you confirm it. Good RT practice especially when its safety critical information.

4. Its really that hard to get the weather by phone, and plan safely without access to a computer or the internet, or is it just easier to reverse your outbound plan and have a guess, don't forget though you will always use more fuel flying west!

The actions of the crew both in flight and during planning has to be questioned and was probably deficient in many areas, but how were they able to get themselves into the situation in the first place. It comes back to an organizational culture that has never been up to scratch and lack of training. Lets just hope that all involved learn from the event, and not point the finger in any one direction.

PS, I may be wrong, but the Westwing alternate landing gear extension operates by discharging high pressure nitrogen into the landing gear hydraulic system (up-lock, extension and down-lock). It is actuated by control cable from the cockpit that runs aft. It is likely that during the accident sequence as the airframe failed the cable tension activated the system, possibly even after the aircraft came to a stop.

[Gate_15L]

The IAI1124 uses hydraulic pressure to keep the gear up. There is no mechanical uplock.

As soon as the hydraulics are breached from the gear side, the gear comes down. It's fairly heavy and will swing down and locked quite easily... even without using the blow down bottle. (I've seen it first hand while dealing with a complete hydraulics failure on a Westwind...)

Chimbu does have a point about aircraft selection, however I believe the Westwind is suitable for this type of operation. Quite simply, if one goes to a remote island constantly, without a plan B (alternate), eventually one will get bitten. Who cares what the law says, its bloody common sense! Just because it's legal, doesn't make it a good idea!

That was about 1 hour worth of fuel that was not taken by not filling those tip tanks. More than enough for one approach and diversion to NWWW.

As for that bad excuse of a joke as Director of Civil Aviation, I'm sure he would be quite happy if we all started planning our RPT ops using manual calculations for oceanic flights. "Back in my day..." yes well back in your day, you probably had a navigator and radio operator too. :rolleyes:

Still, it was quite a shock to read in the special audit report that there was no specific flight planning method for the Westwinds nor could the software under consideration consider enroute winds. If you can't afford or just won't pay for the proper tools (UVAir etc), then you shouldn't be doing that sort of operation. Fanging around from Darwin-Alice-Adelaide is completely different to long overwater oceanic routes...

[dogcharlietree]

I don't think anyone has mentioned the negligence of the co-pilot.
She was part of the CREW and as such has a responsibility and should have insisted on being consulted on the flight plan, fuel requirements, weather etc. From what I have read, she contributed nothing to the safety of this flight. This is NOT the good old days where co-pilots (gear up, flaps up, shut up) were xxkgs of excess freight.
I'm not saying the pilot in command (I would not call him a captain) did not screw up. He did, big time. But He is not alone.
I've ALWAYS INSISTED that my right hand seat check my work and my figures. That is what CREW's are about. Remember it's not who's right, but what is right!

[ypph1]

CASA caught playing the man not the company in ABC TV exposé on Pel-Air ditching


The ABC TV 4 Corners report into the Norfolk Island Pel-Air ditching has this evening shown CASA’s director of safety, John McCormick, making an attack on the flight’s captain, Dominic James and excusing every single deficiency the regulator uncovered in the company during a safety audit as not being a cause of the accident.

However the program is also posting online the safety audit that CASA tried to keep secret and which materially contradicts McCormick in that the safety regulator he heads found among many things that Pel-Air was in breach of the safety rules and was inadequate in its management of fatigue.

The interview and the audit read side by side support the program’s opening premise that CASA scapegoated James in preference to carrying out its obligations under law to pursue the company.

McCormick would well know, and has insisted before the Senate Inquiry into pilot training and airline safety, that it is the airlines or operators that are responsible for safety outcomes.

As pilot James said near the end of the program, he was the pilot of a company that was being overseen by a regulator. Last night, on national television, the head of CASA unloaded all the blame for the accident on a pilot who had not even slept properly for two nights, and was employed by an operator that was so poorly overseen by CASA that it uncovered massive safety deficiencies, while benefiting from a defective CASA rule that excused it from operating as an air ambulance without sufficient fuel to fly to an alternate airport if for any reason a remote refueling airport in the middle of the ocean was rendered unavailable by bad weather.

McCormick’s performance and statements on air are not only inconsistent with the body of law on airline or operator responsibility for pilot training and standards, but were manifestly unfair to the pilot, even though the pilot undoubtedly made serious mistakes in the preparation of the flight, its fueling, and in dealing with the available weather information as the Westwind jet approached Norfolk Island from Apia.

(The 4 Corners report by Geoff Thompson also uncovered evidence the critical weather information had not been passed on to James at a point where had he known of the real situation at Norfolk Island he would have diverted to Nadi in Fiji rather than passing the point of no return where he had to continue to the intended tech stop.)

A fair question arising from McCormick’s performance is whether or not he is capable of taking direct public action against a high profile airline or operator other than Singapore owned Tiger Airways, given the severity of a series of safety failures at Jetstar that were also declared to be unworthy of investigation by the ‘independent’ safety regulator the ATSB.

Regulatory matters aside, the human suffering caused by the unsafe operation of the air ambulance flight by Pel-Air was movingly documented by the program, as was the vigilance and determination of their rescuers on Norfolk Island that brought all six souls to safety from the wild and dark sea in which they had to tread water for close to 90 minutes.

It is utterly shameful to hear that Pel-Air has not once been in touch with Bernie Currall or her husband Gary since the accident, and to see the ruin and despair that the operator’s unsafe and negligent conduct brought to their lives, as well as to Karen Casey the nurse who has lost her livelihood and suffers continued pain from her injuries.

McCormick heads a safety regulator that approved the removal of special life rafts from Qantaslink turbo-props serving Lord Howe Island, and has been unable to release any safety case or statement as to why it allowed this to happen other than the downwards harmonization of Australian standards to the depths of world’s best practice.

It is also an organization that has never explained the safety case that saw it determine that the sort of aerial work performed by the Pel-Air flight didn’t need to carry enough fuel to make a diversion from an oceanic airstrip in bad weather, although it has only recently expressed an ‘intention’ to change a rule it should never have tolerated in the first instance.

The 4 Corners program is an indictment of shamefully deficient standards and oversight by our safety regulator, as well as its disposition to crucify a pilot rather than the company responsible for the flight and safety standards of its operations.

The program, and the supporting documentation, will be readily found on the ABC site in the near future.

Pel-Air exposé catches out air safety regulator | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/09/03/casa-caught-playing-the-man-not-the-company-in-abc-tv-expose-on-pel-air-ditching/)

[john62]

Quick question, Should the passengers be compensated?

They will all be compensated big time. The operators insurers will offer a large out of court settlement. The passengers may not settle for this - depending on the amount offered & whether they are angry enough to have their day in court regardless.

It will be a sizable settlement. Medical expenses - ka-ching. Lifetime loss of earnings - ka-ching. Pain and suffering - ka-ching. Psychological trauma - ka-ching. Post trauma stress, PTSD etc - ka-hing. It will make south pacific fuel look very cheap.

The outcome is bad enough to justify a large settlement. However the special audit is gold to the lawyers. They will be drooling over this today and sharply revising their idea of a reasonable settlement. I wonder who had to call Singapore and explain the audit had been leaked to the media.

The audit is damning, and paints a picture even worse than all the rumors over the years. It will take more than one reading to get across all the issues raised.

The broader issue is how such a damning special audit got so watered down in the final report.

[blackhand]

Also, for the head of CASA to be so black and white about where the blame lies when any layperson watching 4 corners could see the issue is complex and multi facetedWhere as any pilot watching knows who is responsible for ensuring there is sufficient fuel to complete the flight.
the safety audit that CASA tried to keep secret It is supposed to be confidential, I feel the release of the audit report into the publc domain has undermined the system

[truth boy]

It looks to me that all agree that the crew,CASA,ATSB and pelair have a roll to play in what happened that day. Its just the % of blame that is up for discussion.

My question is what do you expect to happen to Pel Air now ?

Closed down the operation ? Persue them in the courts ?

I say this because i spent many years in pelair and know through discussions with current employees that it is a very different beast today.

Original owners Gone
Original managers Gone
original pilots Gone
Darwin ops Gone
metros Gone
Freight Gone

the way they operate has changed and this began before the incident.
REX come in and after some time gauging the operation changes started.I was around for the start of this and things looked ok. But change takes time and it will never be know if the changes/improvements in operation would have helped this be avoided.
Today they operate completely differently to the pelair many on hear claim to know. REX internal auditing system i am told is deeper than many external auditers go. Add to this the military auditing process that goes on for that part of the busines and the fact they are now and forever will be in CASAs sights. I can honestly say that parts of my existing employers operations would not stack up as well.

I guess i just have a soft spot for some parts of the operation and the people still there now that have either rode out the bad times or come on board and improved the operation. To the good guys. You know who you are. well done for improving the operation.
To the not so good. Well i guess you are another operators problem now.:eek:

[KLN94]

This was a serious transoceanic flight.

Pelair dispatched the crew on the mission.

Would things have been different if they had rostered a much more experienced Co-Pilot; one with an ATPL and the ability to cross check Dom's flight plan? The challenges of this flight were vastly different to those of a normal flight around Australia and should have warranted a far greater degree of support from Pelair Flight Ops than was actually provided, including a Co Pilot who wasn't a junior.

Would things have been different if Pelair planned for pilot fatigue and duty time?

Would things have been different if the Chief Pilot consulted with Dom in Apia cross checking his flight plan and wx? If Dom didn't have internet, why didn't Pelair fax the flight plan and wx to him?

Would things have been different if Dom had received the correct wx from Nadi (600', not 6000') and crucially, that Auckland ATC passed on the actual wx report 300' ceiling to him when the Unicom operator advised as such?

After the incident, it was the Chairman of Pelair who immediately hailed the pilot as a hero. Was this a classic spin doctor tactic; to elevate the pilot to the public to deflect attention on where it should have been, so he could then be devoured by a hungry media looking for a hero and for blood, in particular, that ridiculous 60 Minutes report?

The conduct of CASA and the ATSB borders on criminal.

As unfortunate as this incident was, it will probably be the catalyst to force much needed change in the way the regulator, accident investigator and the airline operators relate to each other.

This will no doubt save many lives in the future.

That is the good thing to come out of this incident.

Due credit should also be given to Dominic James for electing to remain silent on this matter until now, waiting until the ATSB report was released so he could finally comment on the 'facts' as discovered by the ATSB.

Dominic conducted himself professionally throughout the whole aftermath of this incident. Lesser men would have taken the easy option and succumbed to the media feeding frenzy. He demonstrated patience, professionalism and humility.

[Mach E Avelli]

It is to be hoped that any litigation includes CASA as co-respondent. While Pelair is clearly culpable on many fronts, the regulator allowed them to get away with it.
No wonder the Skull was in such denial on the 4 Corners program.

[flying-spike]

"It sounded like the TAWS was going off in the Vid clip on the 4 Corners show 2nite meaning that it activated due the A/C not configured for a normal Ldg which would have been the case in a planed ditching (gear selected up)"

Ah yes, I can't wait for the amateur accident investigators to come out with their analysis based on a YouTube recreation using Microsoft Flight Sim.
Did you know that FDR and CVR are still sitting at the bottom of the briney? So what was the recreation based on? Or should I say, on who's version of events?

I wouldn't put too much credence in the recreations last night what with the changes in aircraft type etc. and no input from the copilot.

You really need to read the audit report to get a better understanding of the goings on at the operator.

From what I have been told by somebody involved there CASA was there after the accident to perform two separate tasks. One was the investigation of the accident and the other, with mostly different people performing the special audit of the whole organisation. Two tasks and two different courses of action taken on the findings made. I will spell it out, one punitive and one not.The gentleman involved advised me the non-punitive spirit of the audit was followed to the letter of the law.

For a bit of extra CASA hilarity, check out the date the audit report was produced. One could be excused on the basis of that for thinking that CASA saw this accident coming?

[nitpicker330]

I feel sorry for Dom but......

His flight planning skills were terrible
As such he should have taken Full Tanks
He should have worked out PNR's and CP's

Norfolk island is isolated and has a reputation for bad wx. Always have a backup plan.........At the very least he should have worked out how much fuel to divert 1 hour before and at TOD. That was worked out later after the event!! This should have been known to him before he departed.

Why didn't he bust the minima a bit? Maybe he did but won't say?
Why didn't he coordinate better his ditching position with the operator on the airfield BEFORE ditching?

Lots of holes in the Swiss Cheese lined up that night, as the PIC he should have been the last safety backup......

[aroa]

Thats our "regulator" ! Had the outfit that created this schemozzle been a smaller operator without airline connections..it would have been all over for them.
AOC cancelled, CP approvals cancelled, pilots not "fit and proper", licences withdrawn. Finito the lot.! :eek:

Was interesting to see how ABC put it all together.

And even more fascinating to see the very highly paid head honchos of both agencies, giving their cringeworthy performances.:D:D

For the money, the industry should get better than that.
But with CASA ( because of prior histories) at least we know we wont get better than that. Its CYA 101 in full swing. :mad:

Thats the nature of the beast....and what we have to live with.. unfortunately. :mad::mad:

[gordonfvckingramsay]

I watched the program and couldn't help noticing that everyone was blaming everyone else! The plain fact of the matter is that he and his co-pilot made too many assumptions for what was a flight with few emergency/WX diversion options available. They did it fatigued, ill informed and with all the discipline of a crew with no experience on trans oceanic flights. They as the crew and ultimately he as the PIC, should have done what was right, not what they could get away with or what was easy or even legal. Citing CASA as a causal factor because they didn't impose more rules on them is a woefully inadequate excuse, you are the PIC for gods sake, act like one :ugh:

Thou shalt not run out of fuel!

[mates rates]

There is no busting the minimum at Norfolk.If you get visual over the water you have to climb up through the cloud to get to the runway.

[gobbledock]

Below, The Screaming Skull after having his 'Four Corners' pre-television make-up apllied!

http://www.casa.gov.au/wcmswr/_assets/main/media/gallery/images/tfarquharson1-small.jpg

[Mach E Avelli]

The decision not to depart APW with full tanks was certainly wrong, unless payload prevented it. Most of us agree that, regardless of any management desire to save a buck on fuel, we would have gone full tanks, or stopped in Fiji for a top-up. Maybe management prohibited that or would not pay for it, or had no fuel credit in Fiji? The report glosses over commercial pressures.
Earlier I mentioned a Bae 146 crew that gave themselves a good fright at NLK. Back then the rules did not require an alternate if the weather forecast met the usual mainland criteria. It was usual to go to a PNR which was normally about top of descent. Subject to what the unicom operator had to say, the decision was then made to divert or descend. Once the descent started it was a total commit to a landing.
On this occasion the weather outsmarted both the unicom and the crew and they did bust minima by heading out to sea, letting down until visual then clawing their way back up to the runway. It cost the Captain his command for a while. A bit harsh in the circumstances, but typical of the blame game that authorities and managements play to cover up their own inadequacies and poor policies.

[Capt Claret]

Saving a few $$ on fuel, or reducing fuel burn by not carrying more than requiredis a good commercial practice. I mean a dollar saved is a dollar saved.

Just because the airframe can't be used again, who cares! :eek:

[KLN94]

Ben Sandilands sums up this incident perfectly;

The Pel-Air incident ought to be a lightning rod for immediate action by federal parliament, with some remedial action in terms of transparency as a legislative priority followed by an appropriate committee hearing and ministerial intervention at the top of CASA, the air safety regulator, and the ATSB, the air safety investigator.

CASA and the ATSB ought not be responding to this report, but to a parliament seized with the seriousness of these failings in the public administration of air safety.

Pel-Air and CASA damned by safety audit documents | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/09/04/pel-air-and-casa-damned-by-safety-audit-documents/)

Bring on the Senate Inquiry.

[Melba459]

Seems odd that its shrouded in silence
Can the ATSB squash and hide an investigation report

[BPA]

Like I said last night, read the audit report. Ben is on to it, Pel-air should have been grounded based on that audit report. I've been Chief Pilot for regional airline and a large turboprop charter company and if we got that many RCA's they would have grounded us.

Pel-air had RCA's for training, operational control, maintance issues etc. And it appears the MIL ops had/have their own culture and don't really care about civil regs although they operate under a civil AOC.

[outnabout]

There are many, many factors at work here, but a few things stand out for me:

The comment was made:

GEOFF THOMSON: With six people safely on board, they take off from Samoa just before dark.
Captain Dominic James had flown patients to Australia from islands in the South Pacific about 50 times in the two years he'd been a Medevac pilot.

So in two years in the South Pacific, he never picked up that weather at Norfolk was dodgy / changeable at the best of times? If he hadn't flown it personally, surely it would've come up in the pre-flight briefing with the CP, or at some point over hangar beers (don't know Pel Air's culture, so I'm guessing here).

Yes, there are many factors contributing that can be blamed which have been listed in other posts but at the end of the day, there is only one bum in the left hand seat.

As Richard de Crespigny (QF32) points out - a flight deck is not a committee.

I was reminded of a comment by the late, great, Gordon Smith who said (or quoted) - a superior pilot uses his superior intellect to keep out of situations where his superior flying skills are required.

The true heroes (for me) are the blokes who took their boat out through a narrow gap in the reef, at night, in crap weather, with no information but guesswork, and came back in again safely. And the bloke who went and stood on the lookout, and looked all around, to see the torch. Quite scary to consider that survival came down to a bloke, on a hill, who used his eyes (no radar, no Spiderwatch, no Flight Tracker) to look in the wrong direction (West, not South, as assumed).

[aroa]

The CASA Pel-Air audits should both be made public. Then we can play "spot the difference".
That the "Safety" agency should hide behind keeping these off the record, should be of very serious concern of the Minister. There is one ??:sad:

"Government (and its agencies) efforts to manipulate or block information should be presumed to be anabuse of power" .

CASA has the power. And they sure hell know how to use it and abuse it.
As we know. :mad:

Senate Enquiry desperately needed.:ok:

[nitpicker330]

Yes I find it incredible that he didn't keep close contact with the CAGRO during the ditching telling exactly where they were all the time basically up until contact with the water. There were 2 Pilots for gods same!!

They were extremely lucky to have been found that night.

[Sarcs]

The transcript and the extended interviews for skull and ..dddoollan are worth the time to read, view and absorb!!

Transcript link:Crash Landing - Four Corners (http://www.abc.net.au/4corners/stories/2012/08/30/3579404.htm#transcript)

Extended interview link: Crash Landing - Four Corners (http://www.abc.net.au/4corners/stories/2012/08/30/3579404.htm)

Me thinks its past time for a top down culling!:E

ps anyone with the know how to copy and upload to utube be much appreciated??

[balance]

Personally, I see this as two separate issues. 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.

[gobbledock]

It is time that a royal commission into Australia's aviation decline was held.
CASA doesn't know how to regulate, ATSB no longer know how to investigate, and ASA no longer know how to navigate.

The past 10 years has seen a massive trend upwards in incidents, not to mention crashing Westwinds, Brasillia's and not far off our shoreline Dash 8's. This excludes the ongoing issues with a number of Australian Operators which is simply overlooked, dismissed due to potential political fallout or simply because the oversighting bodies are incompetent and incapable of recognizing risk.
How much is enough? How big must the smoking hole be?

As an absolute beginning there should be an immediate 'plank walking exercise' initiated that should include the removal of the CASA Director, Deputy Director, Associate Director, CASA Board, ASA Board, ATSB Commisioner and his two sidekicks, and Minister Fumblenese.This group has lost it's direction if it ever existed. Has nothing been learned from Lockhart and Seaview for Christ sake?

The systemic issues highlighted in the Norfolk 'special audit' are unbelievable. How the hell did CASA and the ATSB overlook this generated report? The Skull and Co are always talking the talk about safety systems, company cultures, the 'Swiss cheese' model etc, yet The Skull can only manage to get on TV and ramble on about the Captain James and overlook all the other evidence? What more proof do you need that the regulator is being run by out of touch and outdated pensioners. Time to put them to pasture. The ATSB has become an embarrassment. I feel for the last few 'old timers', the decent investigators being hamstrung and 'softened' by a spin spewing **** machine more concerned about playing hide the sausage with Government bureaucrats. And as for ASA, well at least Russell is gone, ran away like a spineless lamb but at least he went, but that doesn't alleviate the systemic issues at ASA. Then you have in politicians lingo 'the overarching' mucous that binds all this dross together in one tightly packed parcel of pony pooh - The Minister. What an embarrassment. No wonder the FAA wanted to downgrade Australia's safety level. This country's aviation ability to enforce, oversight and adjust safety, standards and systems is now probably worse than bloody China, Africa, Russia and Indonesia......Shame shame shame.

Tick tock

[KLN94]

The state of Australian medical air transport:

If you have an accident and need urgent medical extraction, you will be sent a shiny new PC12, King Air or similar to pick you up.

If your injuries are non-life threatening and only need patient transport, you will most likely be sent a 30 or 40 year old Chieftain, Navajo, Westwind, etc.

Why? Because the charter companies engaged by the govt and insurance companies to contract such services are driven by the lowest common denominator: price.

The parameters for the tendering of medical transport services need to be widened to include age of fleet and operational standards, not just the cheapest price...

[outnabout]

KLN94 - not quite sure how the age of the aircraft played a part in this accident. Can you assist?

PS: In NT & SA, all medical transfers - whether emergency evac or patient transfer between hospitals or clinic runs with non-RFDS health staff - is done in shiny new PC12s.

[my oleo is extended]

Because the charter companies engaged by the govt and insurance companies to contract such services are driven by the lowest common denominator: price.
The parameters for the tendering of medical transport services
need to be widened to include age of fleet and operational standards, not just
the cheapest price...
Good point indeed. Would that include a two-bit hack outfit in FNQ with prehistoric Dash 8's that does medical evac wotk to places like PNG while not having said permission granted to them on their AOC?

[KLN94]

outnaboutKLN94 - not quite sure how the age of the aircraft played a part in this accident. Can you assist?

Just to clarify, I am not suggesting the age of this particular Westwind was a contributing factor in this incident.

I am however suggesting that typically, charter companies that also provide medical transport services, generally have a fleet with an older average age rather than a younger fleet like RFD etc.

This is because they are a commercial operation and subject to ruthless commercial pressures in order to stay afloat, and the insurance companies and government agencies that contract such services [generally] pick the charter company that has the cheapest price rather than youngest fleet.

[aussie027]

I don't think age was a factor at all, the Pelair Westwind 1 & 2's are some of, if not the highest time Westwinds in the world.
There have been a few incidents and failures directly related to age in the past few yrs. 1 was a roof outer skin panel blowing out and causing a rapid decompression, I think that was due to age and corrosion/stress fractures from memory.

[Sarcs]

Gobbles mate there is no doubt about it you really know how to cut through the pony pooh and lay it out for everyone to see...but it still seems like individuals want to pussyfoot around and continue to ignore the couple of elephants in the corner!!

This bit Gobbles is oh so true..The ATSB has become an embarrassment. I feel for the last few 'old timers', the decent investigators being hamstrung and 'softened' by a spin spewing **** machine more concerned about playing hide the sausage with Government bureaucrats.

Probably best summed up by this bit in the transcript..

GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.
MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.


What gets me is it takes three years to complete a report (not even Lockhart took that long!) and even then they still couldn't get it right:ugh::ugh:.....nah mass top down culling is what's needed here!:E

[LeadSled]

----probably worse than bloody China,

Gobble,
Go easy on China, CAAC is a seriously competent organisation these days, with a set of rules based on the FARs, with some JAA/EASA influence evident in the maintenance area.
CAAC is also a damned sight easier to deal with than CASA.
Tootle pip!!

[KLN94]

Pilots group wants new investigation into Norfolk Island crash

Start listening from 19 min 25 second mark
The World Today - Pilots group wants new investigation into Norfolk Island crash 04/09/2012 (http://www.abc.net.au/worldtoday/content/2012/s3582296.htm)

[john62]

The special audit is damning.

One thing I noticed is that it seems like a tale of 2 airlines. Rex was compliant and safe PelAir was a problem.

It does make sense that they left existing management in charge at PelAir when they merged some years ago. However the net effect is that Rex appears very well insulated. I guess Rex is where the real revenue is.

Someone is always left looking for a chair when the music stops. Dom is one. Wally didn't fare to well either. Anyone heard what he is doing now?

[Brian Abraham]

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 (http://www.atsb.gov.au/publications/recommendations/2000/r20000040.aspx)

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.

[spinex]

Interesting list of incidents, but with respect there is a world of difference between running out of fuel at night over the sea - and landing safely at an alternate with less than your legal minimum fuel. My take on it, is that you can list as many others as you like who bear some blame, but the PIC screwed the pooch and has to carry the can for that.

[Jinglie]

Guys, a big miss here is that the A/C was non RVSM. Do the fuel figures at FL 280? No alternate possible, or very iffy. Also, apparently, Pel-Air banned from operating to Noumea for not having EGPWS and TCAS 11. Kind of important stuff!!! NZ regulations don't allow non RVSM A/C in their airspace without 4 hours warning!

[CaptainInsaneO]

"The true heroes (for me) are the blokes who took their boat out through a narrow gap in the reef, at night, in crap weather, with no information but guesswork, and came back in again safely. And the bloke who went and stood on the lookout, and looked all around, to see the torch. Quite scary to consider that survival came down to a bloke, on a hill, who used his eyes (no radar, no Spiderwatch, no Flight Tracker) to look in the wrong direction (West, not South, as assumed)."

--> The 'bloke' that spotted them was told that he wasn’t needed and directed to go home....!!! He spotted them on the way home! :eek:

I'm still in awe that these 6 people are alive today. It is nothing short of a miracle that they are still here.

[Mach E Avelli]

Thank you Brian Abraham. CASA most certainly could have acted a lot earlier to put some sort of control on this operation. Three years before this ditching, when OzJet had a RPT service to NLK, one of their inspectors directed that the company's B737 aircraft could not DEPART from NLK unless the weather was at or above alternate minima, and forecast to remain so for 60 minutes from ATD. An inter or tempo within that time frame had to be considered as well. So we often had the ludicrous situation where we could land legally but not depart. When challenged that this was a restriction over and above both the Australian rules and ICAO standards, the answer was basically "stiff sh!t you will do what we direct". It cost that company hugely as there were numerous occasions when the weather hovered just below alternate minima but adequately above minima for a return to land in an emergency. Aircraft were stuck there for days on end while other operators came and went without restriction.
So for the Skull to now be hiding behind the regulations as they existed at the time is hypocritical to say the least.
Regardless of regulations in force, CASA can impose additional limitations on almost anything they choose if it is in the name of "safety".

[ramble on]

The accident is symptomatic of the "low cost", maximum profit and low quality world we are now living in.

Pel Air didn't provide flight planning or operations support and suffered the consequence.

Why is there no ILS at Norfolk if there are that many RPT flights there?

Probably for the same reason that we have capital city airports in a state of shambles and capital city secondary airports that are being strangled.

Australian infrastructure is 50 years behind the population, being milked by private hands, for profit and executive bonuses rather than being cultivated for the future.

[gobbledock]

ramble on, Absolutely spot on with your post. Good to see someone thinking outside the box. All people have to do is dig a little and all the answers, and causal factors, are there. Mature ramblings indeed :ok:

[Jabawocky]

ramble

Why is there a GPS RNAV with a better approach than the VOR's and yet the operator did not have the equipment or ratings etc to use it.

I think your cost V safety argument is the hammer on nail.:hmm:

[diddly squat]

You could not be serious Jaba? No GPS RNAV?:mad:

[Ex FSO GRIFFO]

I'm with Ramble,

21years on......"Your Safety Will Be Enhanced, And It Will Cost You Less"

By Guess Who......remember??

What is happening here is the logical sequence of that philosophy.
Do companies of today operate on such a 'tight' budget, that they are not able to provide support in the form of pre-flight flight planning, met briefing, and other operational information to their pilots?
Or, do they simply leave that up to their captains, who may or may not have their own subscriptions to third party services?

I know about commercial pressures, as I have been subject to them, as we all have. But, there IS a cut-off point, and this appears to be a prime example.

I get the impression (from the TV program) that fatigue was a major factor in that what would ordinarily be a logical thought process for thorough planning, became a series of assumptions, and a 'need' to get the patient home, clouding the real issue of a thorough flight plan....or am I being too generous?

However, The final responsibility for go / no go, and how, still sits in the LHS.

But a good rest, and assistance from the company, would have maybe, broken the chain. (?)
I feel sad. And not just for the crew....

[Roger Greendeck]

I seem to recall that there were no RNAV (GNSS) approaches on the day but they were issued very shortly after.

[Dances With Dingoes]

Government company and all (ABC) . I wondr how much $$$ was offered to any one that took part. Will have to ask "Back Chat" for that info I suppose.

[Jinglie]

I know Pel-Air had restrictions on Noumea, but no-one told the PIC they were lifted!

[higherplane]

It's nice to know that as a Captain CASA will F##k you over before they actually bother to do deal with the real problem ... pretty much all the GA operators out there. Serioulsy how many of you, that have done the "hard yards", don't look back and shudder at how dodgey all those outfits are?

[halfmanhalfbiscuit]

If you look at the Barry Hempel's thread and this one you might form a clearer indication of where some of the problems lay.

Some of you may not be aware the four corners site has the CASA audit report, ATSB letter and extended interviews.

Crash Landing - Four Corners (http://www.abc.net.au/4corners/stories/2012/08/30/3579404.htm)

For the audit report expand the tab 'show background information'

[Jabawocky]

Didley and Roger

The RNAV's existed alright, Forkie and I say here in my lounge with the current at the time chart discussing what options may have been at hand, and that was the one. Runway aligned, lower and heck, sooner or later there was descent below a minima, surely its better to fly a predetermined glide slop, the FO monitoring the GS all the way, double checked with the RAD ALT, and make it into a dodgy ILS/LOC approach. Carefully planned and executed, albeit not exactly legal, they may have all needed a change of undies, but in one piece.

Just my thoughts, not enough outside the box thinking. Perhaps they did not have the endo so did not carry them:confused:

Of course the company and the regulator led them there. But when your back is against the wall is ditching your only option?

[Maisk Rotum]

Would someone please post a link to the video on this that might be hosted somewhere other than ABC. It's not on Youtube and a Google seach reveals nothing. Those of us unfortunate enough not to be in Australia have no way of watching this on the ABC website as Iview blocks access to anyone out of the country. Ta.

[flying-spike]

Yes CASA, Pelair, REX group and the ATSB have many serious issues to answer for as highlighted by the legislation, the level of oversight, organizational structure and effectiveness, depth and clarity of investigation etc. etc.

The fact still remains that when all of these are over the horizon and you are seated at the pointy end of a jet, the decision to proceed with the return journey when you know (or should know) even by company standards you are fatigued, the decision to take less than full fuel and the decision to fly past possible alternates are all COMMAND Decisions.

The patient could have stayed in hospital at Apia with the extra care from the Careflight doctor and nurse for another 12 hours until the crew were rested. The lady did survive a ditching and was not in a critical condition.

Bitch and moan about royal commissions, more investigations, better navaids, better weather reporting, changes in legislation and putting the cleaners through every organisation that have had anything to do with this near multiple fatality but the fact remains had different decisions been made the return trip would have been nothing more than a log book entry.

[topdrop]

For those overseas, use iviewnapper to download.
iViewNapper Homepage (http://users.on.net/~m.elliott/ivn/index.html)

[hoggsnortrupert]

Well put together, jolly good info::ok:

Chr's
H/Snort.

[Falling Leaf]

The patient could have stayed in hospital at Apia with the extra care from the Careflight doctor and nurse for another 12 hours until the crew were rested.

That would be the logical thing to do - especially if there had been a basic risk management exercise done regarding flight safety v patient safety! But as one who has worked in this industry - that is not how things are done!

Companies bid for these international medivac's, and can be aware of the potential job 1-2 days out. However, once they are awarded the job by the travel insurance company, the scramble button is pushed - usually for time zone reasons late afternoon/early evening (Insurance head offices are in US and Europe signing the checks). From that point on, the insurance company does not want to run the risk that they have an unfavourable outcome (patient dying) when they have already fronted with the cash. This pressure is passed onto the provider to get the patient back to Oz ASAP, regardless.

Just one example. Launched early evening to get a patient out of Honiara. Remote Island, much more remote then Norfolk! Land at mid-night, patient walks on, chatting and obviously in good health. Land back in Oz for breakfast. Crew awake for 24 hours. Remote Island with known forecasting inaccuracies. Risk to patient getting to the airport after dark in Honiara (there had been a head placed on a spike on the road out a few weeks earlier).

Was the flight legal. Yes. Could it have been delayed by 12 hours. Yes.

That is the problem with this industry that CASA needs to address. Commercial pressures. And of course, regulating to at least charter standards!

[Queenslander]

It will be interesting to see if Senator FAWCETT starts asking questions, and if so, the replies that he gets from the departments involved.

[Up-into-the-air]

Here is another story that appeared on ABC radio with champion of aviation Ben Sandilands

http://mpegmedia.abc.net.au/news/audio/twt/201209/20120904-twt7-smallplanes.mp3

[john62]

Watching the show again last night, I was struck by another comment. Words to the effect that "only the pilot can decide if he is fatigued."

The science on this is in. Fatigue impairs judgement and leads to irritability and impatience. Fatigue itself impairs the ability to recognise fatigue and take appropriate action.

This is why we now have fatigue management systems (in various forms) in place. If the computer states you are fatigued, then you are fatigued. If you feel fatigued, then you should overrule the computer even if it says you are OK. Maybe you had a poor sleep in a strange bed, or maybe you are getting a cold. So yes you should always rely on your perception of fatigue. This is an extra line of defence. But this is very different to saying you should simply rely on your own perception.

It is a circular argument to say you can't reply on your perception and need to use an objective pre-determined system, and then after it has gone wrong and if fatigue management policy was not followed say something like "only the pilot can determine if he is fatigued." The agenda here appears to be to blame the pilot and ignore the underlying corporate problems.

Delaying the return trip may (or may not) help. I am sure we have all struggled to sleep during a rest period. Uninterrupted restful sleep in a strange environment does not always come easily. Being off-duty and getting adequate sleep can be quite different things. You can still be fatigued even if you have had an adequate off-duty period. Dom doesn't seem to know how much sleep he got and has given different answers to this. Whatever it was, it does not seem enough. So what if he elected to delay for another 10 or 12 ours. What he he still didn't sleep properly and was still not rested? What if the FO had slept during the initial rest period, but then couldn't sleep when this rest period was extended? Because trust me, this is the real world.
I also wonder about the effect on the doctor or nurse when we delay. They sometimes have to keep working when we clock off. Sure they are responsible for only one life, not six.

I don't have any easy answers to any of this. After endless discussions over many years, I don't think anyone else does either.

[KLN94]

A comment posted on Plane Talking.... Pel-Air and CASA damned by safety audit documents | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/09/04/pel-air-and-casa-damned-by-safety-audit-documents/#comments)

The Insider
Posted September 4, 2012 at 6:06 pm | Permalink
The Chief Pilot of Pel Air at the time of this accident (John Wikham) is now working for CASA….seriously.

If true, this would represent a huge Conflict of Interest by CASA if it hired the Chief Pilot of the AOC holder being investigated and then had that same person involved in the subsequent CASA investigation of the incident.

Sure guarantees that that the CASA investigation won't find against the company, but rather the Pilot....

Someone please tell me this is not true...

If this was NSW jurisdiction, it would go straight to ICAC...

[Up-into-the-air]

http://i1175.photobucket.com/albums/r623/soilmaster/pel-airauditDecember2009B.jpgJohn Wickham is an FOI in the Bankstown office [now Elizabeth Street, SYDNEY]

Was a REX SAAB captain for a lengthy period of time on South Coast runs from Sydney.

[flying-spike]

Not all the same people Lester, especially looking at the systemic problems so it was a fresh set of eyes on those issues.

[Horatio Leafblower]

All those names were Bankstown flight ops & AWI's at the time.

Was Pel-air managed from CASA's Mascot office at that stage, or from the GA office at BK? With the SAABs, Metros and Jets I would have assumed that the Mascot office had more appropriate expertise.

Outside the BK office, Ben Cook (now back with DILLIGAF or whatever the RAAF human factors office is called) is a very capable guy and I doubt there would have been any fear or favour colouring his audit findings.

Cheers

[my oleo is extended]

Not all the same people Lester, especially looking at the systemic problems so it was a fresh set of eyes on those issues.
Agreed. Often when a relatively high level investigation is undertaken by CASA they don't use the field office that oversights the operator being investigated. It is a measure to rule out any claims of nepotism or mates rates etc. I have seen this occur on several occasions. On this occasion relating to the Norfolk ditching CASA used some individuals from field offices that did not include Bankstown or Mascot.
C'mon lads, you need to dig a little deeper to find out all the facts.

Outside the BK office, Ben Cook (now back with DILLIGAF or whatever the RAAF human factors office is called) is a very capable guy and I doubt there would have been any fear or favour colouring his audit findings.
Agreed. BC had no reason to fluff up any of his findings either, nor does he operate that way.

It would appear that the special audit that was conducted by frontline people was actually quite a good piece of work. Any failings for that report not being released, passed on to others including the public is no fault of the frontliners who conducted the audit, those decisions on who gets to see the additional reports are made higher up the decison chain, well above the inspectors and field office managers, of this I can assure you.

[john62]

ATSB Pel-Air report excluded critical fuel factor | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/09/05/atsb-pel-air-report-excluded-critical-fuel-factor)

No RVSM!!!

This raises a plausible explanation for not taking full fuel. He had to get to FL390 soon after departure, and he had 6 POB. Could a WW do this with full fuel? Or did he need to go light on the fuel to comply?.

When told to descend from 350 to 270 he instead requested 390 due fuel consumption.

The alternative presumably would have been to plan full fuel and cruise below RVSM, with a higher fuel cost.

[ozaub]

Some including gobbledock at #192 are asking for a Royal Commission but there’s no need. Justice Staunton did a fine job with his Commission of Inquiry into the loss of Seaview’s Aero Commander on 25 July 1994. From watching 4 Corners, reading the ATSB Report and especially reading CASA’s audit report, clearly little has changed. There’s nothing to distinguish between Seaview in 1994 and Pel-Air in 2009. Both orgs callously disregarded regulation; suffered imbalance between commercial and safety imperatives; fiddled defect reporting; and fudged the distinctions between charter and RPT at Seaview and between charter and airwork at Pel-Air;

Some of Staunton’s pithy quotes seem reflective of both orgs and are worth repeating:

- “Evident throughout was an approach by the CAA to unsafe practices or breaches of the law by operators............To the extent that outside pressures (legal, political, industry and managerial) affected the ability or resolve of officers to take decisive and forceful action may be termed ‘institutional timidity’, then that expression is probably an accurate description...”

- There was a body of evidence before the Commission which suggested that the problems identified with Seaview Air were certainly not confined to that Company...”

- “Seaview Air.... remained a haphazard organization”. It was not receptive to criticism and wrote internally before the accident that “Seaview has operated in our current manner for 5 years now – why has it has suddenly become such an issue is beyond me – quite frankly I have stepped on larger cockroaches than some of the CAA cretins I have encountered over this”.

- “It is plain that before the crash on 2 October 1994 Seaview Air was not subjected to close scrutiny by CAA...........on a significant number of occasions Seaview Air was guilty of serious regulatory breaches. Its aircraft were often overloaded. Its pilots cheated on maintenance releases. Cargo was transported unrestrained......”

There’s one significant difference between Seaview and Pel-Air. Seaview’s deficiencies were detected before the accident by a diligent Airworthiness Inspector, but his complaints were overruled under CAA’s ambit that “You are a servant of the Industry whether you like it or not”. Whereas nobody at CASA even noticed Pel-Air’s shonky practices.

[john62]

Well CASA noted problems in earlier audits (2007 and again in 2008). It is not clear what was done following these audits, but clearly not enough.

Fortunately CASA state these deficiencies were present, but were not thought to be significant or relevant or causal to the accident. What would the implications be if they were found to be relevant?

[catseye]

John 62,

believe the ones mentioned together with a whole lot of others things were also picked up by a Careflight audit prior to contract signing.

rumoured all the causal factors had been mitigated by changes to Pelair policy and procedures dictated by Careflight at start up across the program. vis carriage of sat phone, intl flight following,fuel to RTOW, consideration of alternate to match patients medical needs not just aviation altn , decision making for EMS pilots program, specified and nominated pilots, computerised flight planning for intl sectors, two sets of Jepps, catering for all on board, hotel/day room for transit, etc etc etc.

in the best python voice.... very naughty boys.

:ugh:

[Lookleft]

Does NZ prohibit non-RVSM aircraft in RVSM airspace? My understanding was that it was up to the controller and the volume of traffic in that airspace as to whether you are given a clearance. If the WW was not RVSM compliant then wouldn't that suggest that extra fuel be taken in case higher levels were not available?
I still can't accept that the crew (I include the F/O and not just the PIC) are victims of the system and could not influence the events of that night. That Pel-Air were deficient in their manuals or their support of the air-med operations is obvious, that CASA are subservient to the demands of industry rather than regulating without fear or favour requires a separate investigation and that the ATSB could have done a better report is probable, but all this could have been negated by a crew deciding that flying to a remote destination without a Plan B was a risk not worth taking.

[john62]

If the WW was not RVSM compliant then wouldn't that suggest that extra fuel be taken in case higher levels were not available?

You would have thought so. Instead, the thinking may have been to be light enough to reach 390 if unable to operate at RVSM levels. We don't know this was the underlying intent during the flight planning, but this was what transpired. They requested to go above RVSM instead of below due to fuel burn, and they were capable of reaching 390 (possibly because not full fuel).

After 3 years how did this not find its way into the report?

[Lookleft]

So RVSM doesn't go to FL410 in NZ airspace? I would have thought that RVSM levels would be standardised across different FIR's

[ftrplt]

dont assume higher is always better heading westbound - its not unusual for 390, or even 350; to give a worse SGR than high 20's if in the jetstream.

[A31J]

One would be naive in thinking the "front-liners" of the CASA investigative team couldn't turn up very close to the same list of transgressions with any of the providers of this sort of service in Aus. or further afield for that matter.

It does appear to depend on the quality/experience/capability of the local office staff during audit as to what they are able to turn up..or not. :mad:

When the insurer is after the cheapest quote..

[john62]

One would be naive in thinking the "front-liners" of the CASA investigative team couldn't turn up very close to the same list of transgressions with any of the providers of this sort of service in Aus. or further afield for that matter.

Possibly true. However no other operator has ditched a perfectly serviceable ac in the ocean.

dont assume higher is always better heading westbound - its not unusual for 390, or even 350; to give a worse SGR than high 20's if in the jetstream.

Yes, however they requested 390 rather than 270 specifically because of decreased fuel burn. So the assumption (right or wrong) seemed to be the higher the better. A significant factor in this accident was the higher than expected headwind. Once established at 390 the headwind was 80kts (they had assumed 50kts). The increased duration necessitated a reduced cruise to reach Norfolk with required reserve, which put them even later into Norfolk at a time when the weather was deteriorating. Had the wind been 50 they may have got in before weather deteriorated. If not they would have more holding (or may have been confident to reach Noumea when they were aware weather was deteriorating). Had they known the wind was 80 they would hopefully uplift more fuel.
Sobering to think things were cut so fine that a 30kt increased wind could make a difference on a 3 hour flight.

[Checkboard]

Possibly true. However no other operator has ditched a perfectly serviceable ac in the ocean.
Really? This is the first ever serviceable aircraft ditching the world has ever seen? Wow! :hmm:

The planning error for this accident was one of omitting to cover a contingency. That means that TWO "cheese holes" had to line up - the lack of planning AND the contingency occurring. I am certain that many operations have taken place with "good outcomes" where the first occurred, and the second didn't - so your comment isn't a valid argument. :rolleyes:

[john62]

Really? This is the first ever serviceable aircraft ditching the world has ever seen? Wow! http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/yeees.gif

Of course not. The original comment referred to Australian providers of this sort of service (ie airmedical). Of the top of my head I can't recall another Australian airmedical operator ditching.

The point I was attempting to make is Pelair can't whinge about being subject to special attention from CASA. Other operators may have similar deficiencies, although the list is impressive & comment is made of underlying cultural problems. The key difference is Pelairs luck ran out. CASA can't investigate all operators to this level. But a serious accident will result in an indepth audit. So if you are going to breach regulations it is best to be lucky.

If you are pulled over for speeding it doesn't help to argue you were doing the same as everyone else.

[Checkboard]

You want to limit your comment to "Australian airmedical" operations? That's a pretty small group!

[halfmanhalfbiscuit]

CASA can't investigate all operators to this level. But a serious accident will result in an indepth audit. So if you are going to breach regulations it is best to be lucky.

A regulator that investigates after the event is not much use to anyone. They are there to regulate the industry not be wise after the event. If you allow people to cut corners and take chances the good operators will be the ones disadvantaged and suffer. Standards will decline and the safety risk increases.


It does appear to depend on the quality/experience/capability of the local office staff during audit as to what they are able to turn up..or not.
Exactly, it also depends on resources available. A number of people have been critical of resources used for overseas trips, business travel across country and removing staff from regional airports like banks town and moorabbin.

[Kharon]

Perspective and context are a thing the media seem to lack when it comes to the Australian regulator (amongst other things) and matters aeronautical.

A comparison of the PA and Airtex audits and result of audit provides a fair idea of how the CASA system works :- the crew that 'did' the PA audit were mature, experienced and probably had their fair share of marbles. They certainly wouldn't miss much of great significance. The slack culture and operational deficiencies were exposed, reported and a cure was effected.

The Airtex audit was conducted by what can only be described as the "b" team they discovered very little of any significance; substantially much less than the PA crew found. The main ingredients of that audit consisted of allegations, statements and assertions which could never be used in court and barely withstood scrutiny in the AAT. In fact the evidence of one 'super star' was completely abandoned, the other was not allowed to perform for any great period of time.

One company ended up 'shut down', the other survived. Well, I was curious so:-

Both teams reported to the same manager, who is only obliged to respond to the team reports, not to investigate. The manager is also obliged to support and may not easily over rule a FOI. The 'stuff' his dogs drag home is 'dinner', whatever it may be.

The manager cannot become involved in the 'hunt'. It's also fair to say that 'he' should be able to completely and utterly depend on the reporting crew.

So to the differences; the experienced audit team got things sorted with the PA management and the operation continued, warts and all. The CASA manager could 'sign off' on the recommendations and reports the audit crew provided. Conscience clear (well, near enough for Gummint work).

At Airtex the 'b' teams efforts were afforded the same unstinting support of the manager, who responded to the presented reports. There is little scope, resource or time available to allow any dodgy areas to be re-examined and why would the team in the field be doubted?

Once the pathway is set, CASA launch, full steam ahead and will support it's officers. It is one of very few, probably the only character trait of the director to which a grudging respect is given.

PA were I think, treated fairly, reasonably and honestly by a sensible crew 'on the ground'. The PA management responded in a mature way. Airtex were subject to the absolute very worst the system has to offer and it was a travesty, make no mistake about that fact.

The differences and inconsistencies in these two similar cases are where CASA need to look if credibility with the industry is to be regained. There are some excellent, first class people at the 'coal face', but there is some real bloody rubbish lurking in the corners. There are many, so many cases which reflect badly on the CASA organisation; but at the roots, there is almost always the rotten apple somewhere which makes the barrel look bad.

An honest Minister and director would conduct an open inquiry into industry complaints made against individuals, examine the claims and stand away from those within the organisation who make it the target of derision. Shame really, Australia could be so very good.

Song of the Men's Side. (http://www.poetryloverspage.com/poets/kipling/song_of_mens.html)

[Sarcs]

Wow this thread is sure starting to become a classic case of joining the dots, however I still get the feeling the end picture is still going to be a massive pile of pony pooh (to borrow from Gobbles)!

ozaub said Some including gobbledock at #192 are asking for a Royal Commission but there’s no need. Justice Staunton did a fine job with his Commission of Inquiry into the loss of Seaview’s Aero Commander on 25 July 1994. From watching 4 Corners, reading the ATSB Report and especially reading CASA’s audit report, clearly little has changed. There’s nothing to distinguish between Seaview in 1994 and Pel-Air in 2009. Both orgs callously disregarded regulation; suffered imbalance between commercial and safety imperatives; fiddled defect reporting; and fudged the distinctions between charter and RPT at Seaview and between charter and airwork at Pel-Air;

ozaub’s reference and comparison to Seaview v PA is particularly relevant, however there are some very big differences in the philosophy, methodology and motivation of the various stakeholders.

Take a look at the ATSB/BASI reports, in particular the Findings and Safety Action sections, from both accidents. Here are the links for the two reports:
Seaview from page 41 conclusions/findings to safety actions page 44.
http://atsb.com.au/media/24362/aair199402804_001.pdf (http://atsb.com.au/media/24362/aair199402804_001.pdf)
Norfolk from page 43 findings to safety actions page 45.
http://www.atsb.gov.au/media/3970107/AO-2009-072_Final.pdf
From the outset it is quite obvious that back in 1995 BASI totally pulled apart the whole Seaview operation from the top down. There were no holds barred, including the CAA/CASA relationship with the company, prior audits, AOC changes, CAA/CASA surveillance etc..everything was fair game and all totally within their remit.

Although at the time certain observers and people in the know felt that BASI might have missed certain critical elements causal to the accident, on the whole BASI conducted a good, fair, unbiased and thorough investigation to the best of their abilities and resources.

How the worm has turned in the eighteen years since! The Norfolk report must make former (and some current) bureau investigators seethe with anger and disappointment with what was once the last bastion of truth and integrity in aussie aviation. The Norfolk report aside, the performance of the ‘topdog’ of the aviation safety ‘watchdog’ in the 4 corners extended interview was nothing short of abysmal. How that joker can lie straight in bed while prattling on about a special audit report, which reflected a substandard almost toxic culture within the PA operations, not being remotely causal to the ditching just beggars belief!

The report’s ‘Findings’ and ‘Safety Actions’ sections are watered down, devoid of any safety recommendations or statements that maybe construed as a ‘negative finding’ against either the operator or the regulator. Also within the four days since the 4 corners programs there has been several revelations/deficiencies highlighted within the report:
(1) the wx report 6000’ vs 600’:
GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.
MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.

One wonders how our esteemed bureau could possibly overlook such a critical bit of information?
(2) As discussed the negative RVSM approved Westwind, effectively ruling out 12000’ of airspace that the flightcrew could operate in; and
(3) The total lack of an objective top down look at the Operator and the culture within, instead we get spin from the topdog effectively abrogating all responsibility… “as that is a matter for the regulator…outside our remit…blahblahblah”
….there will be more little nuggets in there they just need to be teased out!!:ok:
So it would appear that our totally independent air safety investigator has not only succumbed to the ‘dark side’ of big brother (lapdog rather than watchdog!) but also to the millstone of ‘regulatory capture’. Will someone for god’s sake scrap the MOU and get rid of that patsy!:yuk:

Oh and that’s before we get to the performance of that blinkered, mephistophelian, reptilian, individual from the ‘dark side’. Although I think “K” rather sums up the state of play and players from that camp!:E
Again to borrow from Gobbles...TICK bloody TOCK!:ugh:
Troll alert don't feed the troll! Go crawl back onto your barstool..hiccup..burp..splutter

[blackhand]

Firstly I hold PPL H only.
So explain to me - Can I assume an ATPL holder is tested for proficiency to the level that John McCormack said, or is it to another standard?
If I run my little R22 out of Avgas, is this different to what our colleague Dom did?
From people I talk to, non aviation, they don't seem to care about what the AOC holder did, in fact were not aware of such things, there was more concern that the PIC and his "pax" in the RH seat could not do simple mathematics.
APart from Sandilands and Paul Phelan, there seems to be not much ado about anything to do with this in other media. MAybe is of interest to only Ppruners?

Kharon - PA were I think, treated fairly, reasonably and honestly by a sensible crew 'on the ground'. The PA management responded in a mature way.
exactly

Again to borrow from Gobbles...TICK bloody TOCK!:ugh:
Did you miss something? The aircraft ended up in the water, the clock has ticked and tocked all the way to an accident, and sadly for you and your b buddy Gobbles, it was caused by lack of flight planning by pilot, not by the regulator.

[ForkTailedDrKiller]

I have limited experience as a professional pilot and none at all on the type of operation undertaked here, but I have to say that having read the ATSB report and watched the 4-corners program I have a good deal more sympathy for the circimstances in which the PIC found himself.

It is unlikely that I would have taken off without the fuel tanks filled to the max allowed, and I doubt that I would have undertaken the flight without carrying an alternate, regardless of company SOPs - but in my few thousand hours of flying in Oz over the last 35 years, I have arrived at my destination with a CAVOK forcast on the clipboard on three separate occassions, and had to fly an instrument approach almost to the mimima. On each occassion I got in on the first approach, but had I not I suspect that my butt cheek muscles would have contracted more and more with each subsequent approach.

Dr :8

[Creampuff]

28BE Duty to exercise care and diligence

(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.

(2) If the holder is a body having legal personality, each of its directors must also take the steps specified in subsection (1).

(3) It is evidence of a failure by a body and its directors to comply with this section if an act covered by this section is done without a reasonable degree of care and diligence mainly because of:

(a) inadequate corporate management, control or supervision of the conduct of any of the body’s directors, servants or agents; or

(b) failure to provide adequate systems for communicating relevant information to relevant people in the body.For the operator to have escaped responsibility is a travesty. The ATSB report is a (sick) joke.

[Dangly Bits]

From the CASA special audit:

Two years in a row, Mr James flew without a current medical. Once is a mistake, twice is negligence.

[Bonaza]

After watching 4 Corners on Monday night and as a commercial pilot who has worked for 'max payload/min fuel' operators, I can honestly say it sent chills down my spine. I think most of us could imagine the pressure a company like PA would have put on this young captain. In saying that it doesn't excuse what can only be described as abysmal flight planning.

I have many personal friends who work for Airservices Australia and have talked at length at the actual FISO who took Doms phone call on that fateful day. What I took away from our conversation was the casual and ameture approach that was taken with the flight planning and briefing. I don't care if you were taught short hand by John D Rockefeller's personal secretary, you CANNOT obtain the comprehensive brief needed to conduct a complex, long distance flight like this that way. Not only would the PIC need a long brief, you would also require SIGWX, Wind and Temp or a synoptic chart to say the very least. I personally wouldn't depart on a transcontinental flight without that information let alone a transoceanic flight in the middle of the night!

The actual flight planning was another major failure. As it was mentioned on the documentary and from my conversation with the FISO the PIC couldn't give one of the four FIR boundary estimates needed for this flight. He just wanted to flightplan 'reversed' from the previous day. I am shocked but not surprised however that PA would send a crew and aircraft on such a complex
mission without support from a professional back in Oz.

One deficiency in the report and a agency who should carry partial blame
for this accident is Airways NZ. When the Norfolk Unicom operator called this agency to get them to pass on the deteriorating wx to the aircraft there was obviously a breakdown there also. Even if the aircraft was past it's decision point it still was vital information that wasn't made available to the crew.

The oversight from this agency has more ramifications to more pilots than they
realize. I know one of Greg Russell's master plans whilst at Airservices was to hand over the Tasman HF (SP6) over the kiwis. Thus putting these operators under more pressure to possible miss handing over some vital piece of information to another possible crew in this situation in the future.

I can see the holes lining up again already!