Senate Inquiry, Hearing Program 4th Nov 2011
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Thanks ABC for your input which I point to admit was covered in my correction. So that now being fixed,
Am I missing something.
pissant!
Am I missing something.
pissant!
In the readings the FO said she looked back to see how things were going with the patient. From the starboard seat this would be difficult.
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I understand the concept of either seat being PIC. What I'm asking is, was the FO, if sitting in the RHS rsponsible for the radio calls, which I thought was usual, or did he/she have an extra burden, and that burden is PIC + FO in a difficult situation with one pilot not current on the situation?
Who was sitting where?
Who was sitting where?
I understand the concept of either seat being PIC.
In the Norfolk incident the F/O was flying the aircraft from Apia until the go-around from the first approach at which point the PIC took over the flying duties and the F/O then took over the radio duties.
Probably someone else can explain it more clearly but I think Frank you have a "Who's on First" understanding of the situation.
The F/O sits in the RHS and the PIC sits in the LHS.
Anyway for those of you interested there has been some additional submissions posted on the Senate website and a follow up statement from CASA in the additional information section
Here's the link:
Senate Committees – Parliament of Australia
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Foul taste of pooh?
The best bit Sarcs is Point 5 in the Additional Information section. The Screaming Skull eats a sh#t sandwich and apologizes to Sen Heff for his 'mistake and obvious bad memory'!
(Follow the link in Sarc's post above)
The Skulls desk?
(Follow the link in Sarc's post above)
The Skulls desk?
Last edited by gobbledock; 8th Nov 2012 at 07:06.
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With all due respect you do not understand the concept at all.
Why was the FO not handling the radio?
Where were they sitting with regard to standard proceedure?
Frank...
Normal OM Comms Procedure for Multi-Crew Ops. will read something like:
If you haven't flown in a multi-crew operations Frank, then best retire 'hurt' on this one mate, because you're going to go down in 'flames' here (pardon the pun) if you don 't 'concede' I'm afraid. 
Normal OM Comms Procedure for Multi-Crew Ops. will read something like:
Radio Procedures – Crew Duties
For normal operations both VHF radios should be monitored by all flight crew members. During normal operations the PNF is to make any radio transmissions.
For normal operations both VHF radios should be monitored by all flight crew members. During normal operations the PNF is to make any radio transmissions.
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Like most Ambulance configurations a Westwind would have the patient on the starboard side because, the door is on the port side and it doesn't make sense to embark the patient and then swap sides?
In the readings the FO said she looked back to see how things were going with the patient. From the starboard seat this would be difficult.
In the readings the FO said she looked back to see how things were going with the patient. From the starboard seat this would be difficult.
Why was there no female voice in the comms?
Was the PIC doing it all in a difficult situation?
Not difficult or unreasonable questions.
Frank...
We're trying to do that.
Read my previous post:
Radio Procedures – Crew Duties
For normal operations both VHF radios should be monitored by all flight crew members. During normal operations the PNF is to make any radio transmissions.
You do understand the concept of PF and PNF don't you? On the flight in question, the co-pilot was the PF, and the pilot-in-command (DJ) was the PNF - therefore it was the PNF (the pilot in command) making the radio calls.
So...that's why ther are no female voices.
The report states that the pilot in command took over as PF after the initial approaches at Norfolk.
So at that point the copilot was the PNF.
It's really not that hard Frank...but if you still have doubts, then go back to the top of this post and read it again before posting again that there seems to be a problem with no female voices being heard.
And if that doesn't work Frank, then I think we're going to have to agree that we disagree with your X-Files theory I'm afraid, to stop the thread drift that this 'conjecture' is resulting in.
OK?
Simple question requires a simple answer without any flame out.
Why was there no female voice in the comms?
Radio Procedures – Crew Duties
For normal operations both VHF radios should be monitored by all flight crew members. During normal operations the PNF is to make any radio transmissions.
You do understand the concept of PF and PNF don't you? On the flight in question, the co-pilot was the PF, and the pilot-in-command (DJ) was the PNF - therefore it was the PNF (the pilot in command) making the radio calls.
So...that's why ther are no female voices.
The report states that the pilot in command took over as PF after the initial approaches at Norfolk.
So at that point the copilot was the PNF.
It's really not that hard Frank...but if you still have doubts, then go back to the top of this post and read it again before posting again that there seems to be a problem with no female voices being heard.
And if that doesn't work Frank, then I think we're going to have to agree that we disagree with your X-Files theory I'm afraid, to stop the thread drift that this 'conjecture' is resulting in.
OK?
Why was there no female voice in the comms?Was the PIC doing it all in a difficult situation?
Who was sitting where?
I think that the F/O should speak up and tell her version of the events. In the absence of the CVR there is a huge hole in the narrative. Even if she had spoken in camera at the Senate then at least they may have had a clearer picture of the event.
IMHO once she took responsibility for the comms the crew were focusing on the immediate situation and in the absence of any transmission to the aircraft the comms went way down on the list of their perceived priorities. Maybe she was overloaded, maybe she was barely hanging on monitoring the PIC, either way the only way to find out was through the recovery of the CVR. Quite possibly its all too late and its half way to NZ.
LL I like you believed that to be the case but I have it on good authority that requirement isn't enshrined in law, rather it is a stipulation that some operator's choose to adopt as SOP and in their COMs.
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No conspiracy theory's just asking questions. It appears this was not a "normal op" due to the end result. If people don't ask questions, the obsfucation in evidence so far will be perpetuated.
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It appears this was not a "normal op" due to the end result.
DOM is an Alpha male, his profile on Cleo and demeaner in the Senate Hearing shows that, a female pilot would have followed him down the hole.
BTW, the FO was interviewed
Last edited by blackhand; 8th Nov 2012 at 10:07.
Hey blackie while your banging on about the pilot here's a very impressive, factual 19 point appraisal that perfectly summarises the truth behind this whole farcical, sordid, abomination.
The most amazing thing is it is part of a submission from a complete layman (by his own admission). He was also an eyewitness to not only the ditching but all the lies, obfuscation and maladministration displayed by our esteemed Federal aviation safety agencies.
Yet here you are a self professed aviation maintenance expert and consultant that continues to bag the pilot and defends the indefenceable in what can only be for your own self interests, well read this and weep:
Bloody well done Mr Currall my hat's off to you, couldn't of summed it up better myself and may you recieve justice and retribution for all the hurt you and your wife have endured and continue to endure!
The most amazing thing is it is part of a submission from a complete layman (by his own admission). He was also an eyewitness to not only the ditching but all the lies, obfuscation and maladministration displayed by our esteemed Federal aviation safety agencies.
Yet here you are a self professed aviation maintenance expert and consultant that continues to bag the pilot and defends the indefenceable in what can only be for your own self interests, well read this and weep:
I believe a number of factors are pertinent to the investigation and the circumstances surrounding the crash.
1. This was the third crash of a Pel Air aircraft, the other two in 1985 and 1995 each causing fatalities. It could be expected that such a record would require stricter supervision by the regulator but there is no evidence of this.
2. Audits of Pel Air by CASA prior to this crash found no evidence of problems. This reflects extremely poorly on the performance of CASA a point that is confirmed by an audit of CASA conducted by the international regulator, ICAO and the American regulator, the FAA. (see point12.)
3. A special audit of Pel Air by CASA, conducted immediately after the crash, found 31 safety and regulatory breaches. These included systemic issues with flight planning, fuelling, fatigue management and training.
4. The details of the special audit report were to be kept from the public. A point apparently designed to maintain the commercial interests of Pel Air, at that time vying for a lucrative Air Ambulance contract. It would be difficult to imagine any organisation inviting such tenders would even consider Pel Air if these failures were known. Pel Air was subsequently awarded the Air Ambulance contract in Victoria, on Christmas Eve, only 6 weeks after a near fatal crash.
5. Pel Air was allowed to rectify their defects without public scrutiny. The public has a right to make informed decisions about their travel arrangements. Had I been aware of the poor safety record of Pel Air and of the risk involved in taking that flight given the poor state of the regulatory framework, then it is possible that I would have selected a safer option.
6. At least one of the defects uncovered was found by the ATSB to be a “critical safety issue,” that carried an intolerable risk to safety. This involved poor regulatory guidance by CASA and, in a video conference between representatives of the two bodies, CASA appears to have agreed, at that time, that this was indeed a critical issue.
7. The ATSB’s final report downgraded the significance of this critical issue to one of only minor importance with the Chief Commissioner of the ATSB, Martin Dolan, claiming that the issue was immaterial to the cause of the crash.
8. The ATSB did not properly report the findings of the special audit. It is simply incomprehensible that a publicly funded body such as the ATSB, charged with investigating the most serious of accidents, would almost totally ignore the results of a special audit conducted immediately after the loss of a jet aircraft.
9. The ATSB did not believe that the 31 identified regulatory and safety breaches contributed in any way to the crash. This is the most damning reflection on the performance of the ATSB and of Martin Dolan in particular. I believe it would be almost impossible to find any impartial observer who would accept that none of the defects found with Pel Air’s or CASA’s regulations, policies or procedures had any impact upon the circumstances of that flight. Martin Dolan repeated this ad nauseum on the 4 Corners video interview and could offer no satisfactory, rational explanation.
10. CASA too could not accept the findings of their own special audit, ignoring their own identified inadequacies and preferring to blame the pilot. John McCormick, the Director of Safety at CASA could find no problem with the poor state of Pel Air’s flight planning procedures and the fact that each pilot performed the complex fuel calculations in a different way.
Instead, he claimed that as a pilot himself with 40 years experience a pilot is solely responsible for this. His own auditors took an opposing view, and reported that non-standardised flight planning is deficient and issued a Request for Corrective Action.
11. CASA approved the Operations Manual of Pel Air, issuing an Airworthiness Certificate. This is an implicit acceptance of the flaws with flight and fuel planning subsequently found by the special audit and illustrates the systemic problems at CASA.
12. ICAO found numerous problems with the operation of CASA in the months leading up to the crash. This was confirmed by the FAA in an audit of CASA conducted just weeks after the crash.
13 The public was informed of neither of these important findings.
14. As pointed out on the 4 Corners program the ATSB’s final report was flawed, causing it to be quietly withdrawn some 24 hours after publication. The report was then reissued with no form of version control. I now have two versions of the final report and do not know which to believe.
15. The report omitted crucial information on the issue of Reduced Vertical Separation Minima (RVSM). This issue, together with apparent deficiencies of the Operations Manual severely limited the pilot’s ability to plan the flight effectively. This apparently deliberate omission ensured that the blame for poor flight and fuel planning was pinned on the pilot despite the constraints that each of the above placed upon him.
16. There is no attempt by the ATSB to undertake root cause analysis of the issues raised in their final report. This was exemplified by the issue of Threat and Error Management (TEM), a procedure to improve flight safety by identifying potential threats and errors. According to the report ICAO regulations require training in TEM, though not for this category of flight.
CASA regulations however do not require training in TEM. The logical outcome of these points would be to analyse the reasons why there is no such training requirement in Australia and why this flight was in this particular category. If such training is required, or does help prevent accidents and the flight was found to be in an inappropriate category for this type of operation then CASA could be held accountable for this. Instead, the report simply omitted analysis of these issues.
17. Despite the requirement in the Operations Manual neither of the crew had undertaken training in Crew Resource Management (or in TEM). The ATSB’s investigation went further; in a survey of both trainee and experienced pilots the report found inconsistencies in their approach to the legal requirement to divert to an alternate because this is not part of the syllabus for a trainee pilot. Despite these findings the ATSB declined to offer any recommendations that may improve this clearly unsatisfactory situation.
18. Despite all of these findings no adverse comment was made about the lack of CASA regulation regarding training and nomination of an appropriate flight category. No recommendations regarding flight crew training were made neither was there any mention of corrective action in the form of regular audits of Pel Air to ensure that such oversights are not repeated.
19. We were invited by the ATSB to make submissions regarding the draft final report before publication. I made suggestions regarding the wearing of lifejackets during over water operations, the adequacy of emergency locator beacons and the use of audits to ensure compliance. Most of these were ignored and gave the impression that the ATSB was committed to its own agenda and was unwilling to consider simple improvements to practices that would have a tangible impact upon survivability.
1. This was the third crash of a Pel Air aircraft, the other two in 1985 and 1995 each causing fatalities. It could be expected that such a record would require stricter supervision by the regulator but there is no evidence of this.
2. Audits of Pel Air by CASA prior to this crash found no evidence of problems. This reflects extremely poorly on the performance of CASA a point that is confirmed by an audit of CASA conducted by the international regulator, ICAO and the American regulator, the FAA. (see point12.)
3. A special audit of Pel Air by CASA, conducted immediately after the crash, found 31 safety and regulatory breaches. These included systemic issues with flight planning, fuelling, fatigue management and training.
4. The details of the special audit report were to be kept from the public. A point apparently designed to maintain the commercial interests of Pel Air, at that time vying for a lucrative Air Ambulance contract. It would be difficult to imagine any organisation inviting such tenders would even consider Pel Air if these failures were known. Pel Air was subsequently awarded the Air Ambulance contract in Victoria, on Christmas Eve, only 6 weeks after a near fatal crash.
5. Pel Air was allowed to rectify their defects without public scrutiny. The public has a right to make informed decisions about their travel arrangements. Had I been aware of the poor safety record of Pel Air and of the risk involved in taking that flight given the poor state of the regulatory framework, then it is possible that I would have selected a safer option.
6. At least one of the defects uncovered was found by the ATSB to be a “critical safety issue,” that carried an intolerable risk to safety. This involved poor regulatory guidance by CASA and, in a video conference between representatives of the two bodies, CASA appears to have agreed, at that time, that this was indeed a critical issue.
7. The ATSB’s final report downgraded the significance of this critical issue to one of only minor importance with the Chief Commissioner of the ATSB, Martin Dolan, claiming that the issue was immaterial to the cause of the crash.
8. The ATSB did not properly report the findings of the special audit. It is simply incomprehensible that a publicly funded body such as the ATSB, charged with investigating the most serious of accidents, would almost totally ignore the results of a special audit conducted immediately after the loss of a jet aircraft.
9. The ATSB did not believe that the 31 identified regulatory and safety breaches contributed in any way to the crash. This is the most damning reflection on the performance of the ATSB and of Martin Dolan in particular. I believe it would be almost impossible to find any impartial observer who would accept that none of the defects found with Pel Air’s or CASA’s regulations, policies or procedures had any impact upon the circumstances of that flight. Martin Dolan repeated this ad nauseum on the 4 Corners video interview and could offer no satisfactory, rational explanation.
10. CASA too could not accept the findings of their own special audit, ignoring their own identified inadequacies and preferring to blame the pilot. John McCormick, the Director of Safety at CASA could find no problem with the poor state of Pel Air’s flight planning procedures and the fact that each pilot performed the complex fuel calculations in a different way.
Instead, he claimed that as a pilot himself with 40 years experience a pilot is solely responsible for this. His own auditors took an opposing view, and reported that non-standardised flight planning is deficient and issued a Request for Corrective Action.
11. CASA approved the Operations Manual of Pel Air, issuing an Airworthiness Certificate. This is an implicit acceptance of the flaws with flight and fuel planning subsequently found by the special audit and illustrates the systemic problems at CASA.
12. ICAO found numerous problems with the operation of CASA in the months leading up to the crash. This was confirmed by the FAA in an audit of CASA conducted just weeks after the crash.
13 The public was informed of neither of these important findings.
14. As pointed out on the 4 Corners program the ATSB’s final report was flawed, causing it to be quietly withdrawn some 24 hours after publication. The report was then reissued with no form of version control. I now have two versions of the final report and do not know which to believe.
15. The report omitted crucial information on the issue of Reduced Vertical Separation Minima (RVSM). This issue, together with apparent deficiencies of the Operations Manual severely limited the pilot’s ability to plan the flight effectively. This apparently deliberate omission ensured that the blame for poor flight and fuel planning was pinned on the pilot despite the constraints that each of the above placed upon him.
16. There is no attempt by the ATSB to undertake root cause analysis of the issues raised in their final report. This was exemplified by the issue of Threat and Error Management (TEM), a procedure to improve flight safety by identifying potential threats and errors. According to the report ICAO regulations require training in TEM, though not for this category of flight.
CASA regulations however do not require training in TEM. The logical outcome of these points would be to analyse the reasons why there is no such training requirement in Australia and why this flight was in this particular category. If such training is required, or does help prevent accidents and the flight was found to be in an inappropriate category for this type of operation then CASA could be held accountable for this. Instead, the report simply omitted analysis of these issues.
17. Despite the requirement in the Operations Manual neither of the crew had undertaken training in Crew Resource Management (or in TEM). The ATSB’s investigation went further; in a survey of both trainee and experienced pilots the report found inconsistencies in their approach to the legal requirement to divert to an alternate because this is not part of the syllabus for a trainee pilot. Despite these findings the ATSB declined to offer any recommendations that may improve this clearly unsatisfactory situation.
18. Despite all of these findings no adverse comment was made about the lack of CASA regulation regarding training and nomination of an appropriate flight category. No recommendations regarding flight crew training were made neither was there any mention of corrective action in the form of regular audits of Pel Air to ensure that such oversights are not repeated.
19. We were invited by the ATSB to make submissions regarding the draft final report before publication. I made suggestions regarding the wearing of lifejackets during over water operations, the adequacy of emergency locator beacons and the use of audits to ensure compliance. Most of these were ignored and gave the impression that the ATSB was committed to its own agenda and was unwilling to consider simple improvements to practices that would have a tangible impact upon survivability.
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factual 19 point appraisal that perfectly summarises the truth behind this whole farcical, sordid, abomination.
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Senate supplements.
Won a slab from the Bar Room Barristers late last night, for the most accurate predictive CASA response statement. "Spot on old chap" they said and ponied up like the Gents they are. "Cheers boys, but why do I have to share it" – "Club POLICY" they gleefully shouted in chorus. Set up good? Oh yes. (expletive deleted). 
But even poor old Blind Freddy (P18) could see which way CASA would jump, straight into the deep dark hole. Mick Quinn, Brian Aherne and others did not start off by attacking the man, there's not a personal attack printed. The CASA reponse is a silly, desperate, arrogant move really, as 'he who must not be named' is well aware; there are skeletons in every human beings cupboard. In fact, the little attacks on Aherne and Quinn serve very well to illustrate the 'mind set' of a discredited, moribund authority furiously attempting a King Canute imitation. I note Messrs A and Q continue to play the ball, not the man with a couple of first class responses, Brava, well done.
The Davies submission is first rate and well worth the read, sane rational and absolutely no Pony Pooh.
Then comes the slightly less subtle defence of CASA behaviour during the Airtex bun fight, now there are real skeletons and a couple of watch dogs in that cupboard, I imagine the last thing CASA would want would be to draw public attention to that particular event. Considering the circumstances. (Ghosts at weddings. etc.).
But hold, I forgot; we are all delusional criminal fools and it is germane that we be told so. Aye, 'he who knows no shame' is the master of this small universe; just wish he'd go and wave his magic totem somewhere else. I doubt the Senate will swallow it, not again.
Many years ago, my Mama suggested that when you were in a hole, it's better to stop digging. Someone tell the fools, please.
Happy hour at CASA legal?
But even poor old Blind Freddy (P18) could see which way CASA would jump, straight into the deep dark hole. Mick Quinn, Brian Aherne and others did not start off by attacking the man, there's not a personal attack printed. The CASA reponse is a silly, desperate, arrogant move really, as 'he who must not be named' is well aware; there are skeletons in every human beings cupboard. In fact, the little attacks on Aherne and Quinn serve very well to illustrate the 'mind set' of a discredited, moribund authority furiously attempting a King Canute imitation. I note Messrs A and Q continue to play the ball, not the man with a couple of first class responses, Brava, well done.
The Davies submission is first rate and well worth the read, sane rational and absolutely no Pony Pooh.
Then comes the slightly less subtle defence of CASA behaviour during the Airtex bun fight, now there are real skeletons and a couple of watch dogs in that cupboard, I imagine the last thing CASA would want would be to draw public attention to that particular event. Considering the circumstances. (Ghosts at weddings. etc.).
But hold, I forgot; we are all delusional criminal fools and it is germane that we be told so. Aye, 'he who knows no shame' is the master of this small universe; just wish he'd go and wave his magic totem somewhere else. I doubt the Senate will swallow it, not again.
Many years ago, my Mama suggested that when you were in a hole, it's better to stop digging. Someone tell the fools, please.
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Mick Quinn's supplemental is interesting. It appears he is defending his character from attacks made on it by casa. I got the impression if anybody from casa is taking any blame then it'll be Quinn. He states defending the fact he has known dj for 20 years does not mean he cannot view accident objectively. Personally, I'm off the opinion others can't views things objectively.
I reckon this saga will be a case study on accident investigation courses.
I reckon this saga will be a case study on accident investigation courses.
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