Senate Inquiry, Hearing Program 4th Nov 2011
Jinglie perhaps BH was a secret co-author of that infamous hidden report (CASA Accident Investigation Report 09/3) that PAIN found at the tail end of attachment 4 of the FF submission??
Pg 28 of the transcript:
If the ATSB remit is.."focus of our investigations is on error and understanding error" it is beyond belief that the ATSB "scope" of the investigation shouldn't include the following areas (borrowed from Jinglie's post on Norfolk thread
):
Very good question Jinglie but there is also another factor in all this. If we accept Beaker's simplified philosophy (i.e. ATSB deals with error and CASA deals with 'violation'). And we also accept that the bureau's 'standards of investigation' must meet the requirements of both the TSI Act and ICAO Annex 13. What standard does the regulator's (slightly skewed) parallel investigation have to meet in order to possibly be presented as part of a brief to the CDPP, or AAT, or other enforcement action? The bigger question is does it meet that standard?
Pg 28 of the transcript:
Mr Dolan: We see our job as a different job from CASA's. The special audit was in relation to CASA's views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB's final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason's model, would be viewed as violation; and that is principally the responsibility of the regulator.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB's final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason's model of investigation—though we think we have come a long way since Professor Reason's initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason's model, would be viewed as violation; and that is principally the responsibility of the regulator.
):
Simply put, in an accident like this, how can:
ATC
Weather forecasting
Comms
Crash Survivability
ORG issues
Regulatory issues
CRM
Fatigue Risk Management
Aircraft performance
not be adequately covered in the ATSB analysis?
ATC
Weather forecasting
Comms
Crash Survivability
ORG issues
Regulatory issues
CRM
Fatigue Risk Management
Aircraft performance
not be adequately covered in the ATSB analysis?
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Jinglie perhaps BH was a secret co-author of that infamous hidden report
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AOCs THE ultimate SAFETY device!
Nature has left this tincture in the blood
That all men would be tyrants if they could
Daniel Defoe
That all men would be tyrants if they could
Daniel Defoe
As CASA is precluded from the former, it must have to do with safety. In fact it implies the pilot's license is inadequate to conduct such flights without the benefit of an AOC! So what is it about this certification which empowers a pilot to conduct such risky flights? When his license won't allow it.
In Dominic James's case, he lost his license. He was found to be inadequately trained, but his authority to conduct the flight was never questioned because he was guided by an AOC. The AOC was not cancelled as was his license yet it alone made the flight legal. The now proven shortcomings in the AOC documentation had the CASA imprimatur, obtained at great expense after having been exposed to expert scrutiny prior to issue and again at renewal. After the event these same experts have been able to identify numerous (safety) deficiencies yet the AOC is still in place. Surely CASA are selling a defective product! And this for a monopoly.
What makes Pelair so different to receive such lenient treatment. There were numerous AOC holders out there who lost their livelihood for far less, my own included. Could this perhaps explain the delay in the ATSB report, the several versions and exclusions.
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What makes Pel-Air so different?
Stan said:
Perhaps it may have something to do with the Chairman of the Board, the Honourable John Sharp. After all, he rode to fame on the back of Monarch and Seaview and now makes millions as an aviation consultant. I imagine he was able to provide excellent advice to both CASA and the ATSB on how things were within Pel-Air. 
Why hasn't Pel-Air as the AOC holder appeared before the Senate Committee?
What makes Pelair so different to receive such lenient treatment. There were numerous AOC holders out there who lost their livelihood for far less, my own included. Could this perhaps explain the delay in the ATSB report, the several versions and exclusions.
Why hasn't Pel-Air as the AOC holder appeared before the Senate Committee?
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pel air submission to Senate
Last edited by Up-into-the-air; 26th Nov 2012 at 06:30.
All of the submissions are well worth a read.
The ATSB’s flawed approach to investigations is demonstrated by the selective quoting of the transcript of the HF communications. Note the ‘partial transcript’ in Appendix A of the ATSB report finishes at 0803:24, just after the 0800 SPECI was (according to the transcript) transmitted to NGA (at 0802:32).
The Pel-Air submission is very interesting on this point. It says, under the report finding “The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination:
The bolded text is in red in the Pel-Air submission.
So let’s assume the ‘partial transcript’ is accurate and the Pel-Air submission is also accurate in relation to what was transmitted after the period covered by the ‘partial transcript’ ended. Let’s also assume the crew heard and understood everything transmitted.
Based on those assumptions, here’s what was actually transmitted and received, and when, starting from the 0630 METAR:
0801:31 – Nadi: METAR Norfolk at 0630 Zulu wind 300 09 knots 9999, few 6,000 broken 2400 temperature 21 dewpoint 19 QNH norfolk 1011 remarks closed till 1930 UTC go ahead. [Let’s not worry about what was really transmitted, other than to assume the ‘few 6,000’ was transmitted verbatim/]
0802:08 – NGA: Ahhh …copy… just say again the issue time for the METAR.
0802:14 – Nadi: Issue time for the METAR this is the latest 0630 Zulu.
0802:22 – NGA: Victor golf alpha thank you.
0802:26 – Nadi: Victor November golf alpha nadi
0802:29 – NGA: Go ahead nadi victor golf alpha
0802:32 – Nadi: Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at 0800 Zulu... auto I say again auto, alpha uniform tango oscar, wind 290 08 knots, 999 november delta victor, overcast one thousand one hundred , temperature 21, dew point 19, QNH Norfolk 1012...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.
0803:21 – NGA: Thank you nadi… much appreciated november golf alpha.
So over the period of less than one and half minutes, the METAR with the mistake, then the 0800 SPECI, is transmitted and received.
Nadi then passes NGA to Auckland and the ‘partial transcript’ runs out at 0803:24.
According to the Pel-Air submission:
0839 - NGA transferred to Auckland. [CP question: Who said what, to whom, between 0803:24 and 0839??]
0904 - NGA requested the latest weather Norfolk at and were given a ‘0902’ SPECI that said, in part, “broken at one thousand one hundred and overcast one thousand five hundred”.
So here is what the 2 SPECIs said, and NGA received and understood, about cloud (assuming my assumptions about the transcript and Pel-Air’s submission and reception by the crew are correct):
0800 SPECI: Overcast one thousand one hundred. Note also that this SPECI said nil rainfall recorded in the ten minutes prior to the SPECI time and nil rainfall recorded since 0900 local time.
0902 SPECI: broken at one thousand one hundred and overcast one thousand five hundred
On what basis should the PIC have asked for anything more? Should the pilot have said to Auckland: “Thanks for that, is there anything thing else that we should know about the weather at the destination to which you are aware we are proceeding?” Would Auckland have said: “As a matter of fact, there was a 0830 SPECI that said cloud broken at three hundred and overcast at nine hundred. Lucky you asked!”
The ATSB’s flawed approach to investigations is demonstrated by the selective quoting of the transcript of the HF communications. Note the ‘partial transcript’ in Appendix A of the ATSB report finishes at 0803:24, just after the 0800 SPECI was (according to the transcript) transmitted to NGA (at 0802:32).
The Pel-Air submission is very interesting on this point. It says, under the report finding “The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination:
The crew did request actual weather reports (either METARs or SPECIs).
WEATHER PROVIDED BY NADI:
The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. [CP Note: this is the SPECI quoted in the ATSB report’s ‘partial transcript’.] This was the first indication to the crew that the weather at Norfolk Island was becoming marginal.
WEATHER PROVIDED BY AUCKLAND:
[CP Note: According to the Pel-Air submission, this all happened after the end of the ‘partial transcript.]
The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with Auckland would have alerted the crew to the true situation with time enough to divert. At 0839 the aircraft was still around 32 min away from the last diversion point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew.
While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.
WEATHER PROVIDED BY NADI:
The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. [CP Note: this is the SPECI quoted in the ATSB report’s ‘partial transcript’.] This was the first indication to the crew that the weather at Norfolk Island was becoming marginal.
WEATHER PROVIDED BY AUCKLAND:
[CP Note: According to the Pel-Air submission, this all happened after the end of the ‘partial transcript.]
The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with Auckland would have alerted the crew to the true situation with time enough to divert. At 0839 the aircraft was still around 32 min away from the last diversion point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew.
While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.
So let’s assume the ‘partial transcript’ is accurate and the Pel-Air submission is also accurate in relation to what was transmitted after the period covered by the ‘partial transcript’ ended. Let’s also assume the crew heard and understood everything transmitted.
Based on those assumptions, here’s what was actually transmitted and received, and when, starting from the 0630 METAR:
0801:31 – Nadi: METAR Norfolk at 0630 Zulu wind 300 09 knots 9999, few 6,000 broken 2400 temperature 21 dewpoint 19 QNH norfolk 1011 remarks closed till 1930 UTC go ahead. [Let’s not worry about what was really transmitted, other than to assume the ‘few 6,000’ was transmitted verbatim/]
0802:08 – NGA: Ahhh …copy… just say again the issue time for the METAR.
0802:14 – Nadi: Issue time for the METAR this is the latest 0630 Zulu.
0802:22 – NGA: Victor golf alpha thank you.
0802:26 – Nadi: Victor November golf alpha nadi
0802:29 – NGA: Go ahead nadi victor golf alpha
0802:32 – Nadi: Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at 0800 Zulu... auto I say again auto, alpha uniform tango oscar, wind 290 08 knots, 999 november delta victor, overcast one thousand one hundred , temperature 21, dew point 19, QNH Norfolk 1012...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.
0803:21 – NGA: Thank you nadi… much appreciated november golf alpha.
So over the period of less than one and half minutes, the METAR with the mistake, then the 0800 SPECI, is transmitted and received.
Nadi then passes NGA to Auckland and the ‘partial transcript’ runs out at 0803:24.
According to the Pel-Air submission:
0839 - NGA transferred to Auckland. [CP question: Who said what, to whom, between 0803:24 and 0839??]
0904 - NGA requested the latest weather Norfolk at and were given a ‘0902’ SPECI that said, in part, “broken at one thousand one hundred and overcast one thousand five hundred”.
So here is what the 2 SPECIs said, and NGA received and understood, about cloud (assuming my assumptions about the transcript and Pel-Air’s submission and reception by the crew are correct):
0800 SPECI: Overcast one thousand one hundred. Note also that this SPECI said nil rainfall recorded in the ten minutes prior to the SPECI time and nil rainfall recorded since 0900 local time.
0902 SPECI: broken at one thousand one hundred and overcast one thousand five hundred
On what basis should the PIC have asked for anything more? Should the pilot have said to Auckland: “Thanks for that, is there anything thing else that we should know about the weather at the destination to which you are aware we are proceeding?” Would Auckland have said: “As a matter of fact, there was a 0830 SPECI that said cloud broken at three hundred and overcast at nine hundred. Lucky you asked!”
That partial transcript is really, really bugging me
For those with any experience in this area, what are the chances that the visibility in the 0800 SPECI was actually:
The only time I’ve ever heard or read three nines in a row in a forecast or report is when they are followed by …
... another nine.
999 november delta victor
... another nine.
Last edited by Creampuff; 26th Nov 2012 at 09:24.
There is undoubtedly an error in either the transcript of the 0800 SPECI or in what was transmitted.
The ATSB report also includes a list of reports for Norfolk. Here’s what the list says was the content of the 0800 SPECI:
Note the "9999". If that's what the actual SPECI was, there must be an error in the transcript (how many more are there?) or there was (another) mistake in what was transmitted.
Here’s what the list says was the content of the 0902 SPECI:
The ATSB report also includes a list of reports for Norfolk. Here’s what the list says was the content of the 0800 SPECI:
SPECI YSNF 180800Z AUTO 29008KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0
Here’s what the list says was the content of the 0902 SPECI:
SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0
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Why why why?
The question that needs to be asked of Beaker again for clarity and to be put on record is simply "why weren't the boxes retrieved"? Any investigator or investigation bureau knows that the evidence from the boxes is more than likely to be the 'smoking gun'. There can only be two logical, non-tautological explanations here:
(a) Beaker was totally focused on cents and dollars over safety, or
(b) Beaker is completely and utterly out of his league and does not have the cability or understanding to run the ATSB.
Either way, the answer to either of these propositions would indicate he is certainly not the right person to remain in his position.
As for learning from history and mistakes, the example of the AF47 crash and the tenacious efforts by the Bureau d'enquête sur les accidents d'aviation is something the nimrods in Canberra could learn from.
In the case of the Pelair crash the location of the boxes are pretty much known, sitting on the ocean floor like a pearl waiting to be eagerly snatched up by a Diver. It is a crime that these boxes have not been recovered.
Why hasn't the Minister delved into his trough and pulled out a handful of extra coin to be thrown at a Blackbox search and retrieve mission before now?
And the actions of the heirachy in CASA, the Regulator, not understanding the basic concepts of safety and vehemently standing by their statement of only looking at the pilots actions and ignoring all other factors almost leaves me speechless!
Perhaps the Senators, if they haven't already, could review Annex 13 and compare ATSB and CASA actions in relation to this accident? Then they could pose additional questions, if need be, to the upper echelon of these organsiations in the Senate under oath? A further review of 3.2 State Safety Program is also enlightening.
CASA and ATSB = Fail.
http://www.cad.gov.rs/docs/udesi/an13_cons.pdf
(a) Beaker was totally focused on cents and dollars over safety, or
(b) Beaker is completely and utterly out of his league and does not have the cability or understanding to run the ATSB.
Either way, the answer to either of these propositions would indicate he is certainly not the right person to remain in his position.
As for learning from history and mistakes, the example of the AF47 crash and the tenacious efforts by the Bureau d'enquête sur les accidents d'aviation is something the nimrods in Canberra could learn from.
In the case of the Pelair crash the location of the boxes are pretty much known, sitting on the ocean floor like a pearl waiting to be eagerly snatched up by a Diver. It is a crime that these boxes have not been recovered.
Why hasn't the Minister delved into his trough and pulled out a handful of extra coin to be thrown at a Blackbox search and retrieve mission before now?
And the actions of the heirachy in CASA, the Regulator, not understanding the basic concepts of safety and vehemently standing by their statement of only looking at the pilots actions and ignoring all other factors almost leaves me speechless!
Perhaps the Senators, if they haven't already, could review Annex 13 and compare ATSB and CASA actions in relation to this accident? Then they could pose additional questions, if need be, to the upper echelon of these organsiations in the Senate under oath? A further review of 3.2 State Safety Program is also enlightening.
CASA and ATSB = Fail.
http://www.cad.gov.rs/docs/udesi/an13_cons.pdf
So in summary, here’s some of what we know for sure:
1. Neither CASA nor ATSB knows the precise terms of the transmissions actually made by Nadi and Auckland, unless someone from CASA and ATSB listened to the recordings of those transmissions.
2. There are errors in the ‘partial transcript’, or there were errors in the transmissions recorded in the ‘partial transcript’, or both.
3. Neither CASA nor ATSB knows the precise terms of the transmissions actually heard by the crew of NGA, or what the crew interpreted what they heard to mean.
Irrespective of what the precise terms of the transmissions and received interpretations were, it appears (but it is not certain) that:
At around 0757, NGA requested a METAR for Norfolk.
At around 0801, Nadi transmitted a METAR for Norfolk.
At around 0802, NGA requested and Nadi provided the issue time for the METAR.
At around 0802, Nadi transmitted and NGA acknowledge receipt of a report identified as the 0800 SPECI for Norfolk.
At around 0803, Nadi transmitted and NGA acknowledged receipt of an instruction to contact Auckland at DOLSI.
At around 0839, NGA contacted Auckland.
At around 0904, NGA requested the latest weather Norfolk, and were given a report identified as the 0902 SPECI for Norfolk.
NGA was not given the report identified as the 0830 SPECI for Norfolk.
At around 0911, NGA flew beyond the last diversion point to Tontouta (according to the Pel-Air submission).
One of the ATSB’s finding is:
Let’s assume that these words were all received and fully understood by NGA, verbatim, at the noted times (I’m sure they weren’t, but let’s assume for the time being):
0801 Transmitted by Nadi after a request from NGA – “METAR Norfolk at zero six three zero Zulu wind three zero zero, zero niner knots, niner niner niner niner, few six thousand, broken two thousand four hundred, temperature two one dewpoint one niner QNH norfolk one zero one one remarks closed till one niner three zero UTC go ahead.”
0801 Transmitted by Nadi, on initiative from Nadi – “Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at zero eight zero zero Zulu... auto I say again auto, alpha uniform tango oscar, wind two niner zero, zero eight knots, niner niner niner niner, november delta victor, overcast one thousand one hundred, temperature two one, dew point one niner, QNH Norfolk one zero one two, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.”
0904 Transmitted by Auckland after a request from NGA – “SPECI Norfolk at zero niner zero two zulu, alpha uniform tango oscar, wind two zero zero, zero seven knots, seven zero zero zero, scattered five hundred, broken one thousand one hundred, overcast one thousand five hundred, temperature two zero, dew point one niner, QNH one zero one three, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero.”
What more should the crew have done, and when, to “source the most recent Norfolk Island Airport forecast”, or to “seek and apply other relevant weather and other information”?
We know that CASA’s “opinion” is that “good airmanship should have resulted in a diversion”. For those who agree with CASA’s opinion, at what point, precisely, should the decision to divert have been made by the crew of NGA, on the basis of what information, precisely?
1. Neither CASA nor ATSB knows the precise terms of the transmissions actually made by Nadi and Auckland, unless someone from CASA and ATSB listened to the recordings of those transmissions.
2. There are errors in the ‘partial transcript’, or there were errors in the transmissions recorded in the ‘partial transcript’, or both.
3. Neither CASA nor ATSB knows the precise terms of the transmissions actually heard by the crew of NGA, or what the crew interpreted what they heard to mean.
Irrespective of what the precise terms of the transmissions and received interpretations were, it appears (but it is not certain) that:
At around 0757, NGA requested a METAR for Norfolk.
At around 0801, Nadi transmitted a METAR for Norfolk.
At around 0802, NGA requested and Nadi provided the issue time for the METAR.
At around 0802, Nadi transmitted and NGA acknowledge receipt of a report identified as the 0800 SPECI for Norfolk.
At around 0803, Nadi transmitted and NGA acknowledged receipt of an instruction to contact Auckland at DOLSI.
At around 0839, NGA contacted Auckland.
At around 0904, NGA requested the latest weather Norfolk, and were given a report identified as the 0902 SPECI for Norfolk.
NGA was not given the report identified as the 0830 SPECI for Norfolk.
At around 0911, NGA flew beyond the last diversion point to Tontouta (according to the Pel-Air submission).
One of the ATSB’s finding is:
The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
0801 Transmitted by Nadi after a request from NGA – “METAR Norfolk at zero six three zero Zulu wind three zero zero, zero niner knots, niner niner niner niner, few six thousand, broken two thousand four hundred, temperature two one dewpoint one niner QNH norfolk one zero one one remarks closed till one niner three zero UTC go ahead.”
0801 Transmitted by Nadi, on initiative from Nadi – “Roger this the latest weather for Norfolk...SPECI... I say again special weather Norfolk at zero eight zero zero Zulu... auto I say again auto, alpha uniform tango oscar, wind two niner zero, zero eight knots, niner niner niner niner, november delta victor, overcast one thousand one hundred, temperature two one, dew point one niner, QNH Norfolk one zero one two, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero go ahead.”
0904 Transmitted by Auckland after a request from NGA – “SPECI Norfolk at zero niner zero two zulu, alpha uniform tango oscar, wind two zero zero, zero seven knots, seven zero zero zero, scattered five hundred, broken one thousand one hundred, overcast one thousand five hundred, temperature two zero, dew point one niner, QNH one zero one three, ...remarks... romeo foxtrot zero zero decimal zero oblique zero zero zero decimal zero.”
What more should the crew have done, and when, to “source the most recent Norfolk Island Airport forecast”, or to “seek and apply other relevant weather and other information”?
We know that CASA’s “opinion” is that “good airmanship should have resulted in a diversion”. For those who agree with CASA’s opinion, at what point, precisely, should the decision to divert have been made by the crew of NGA, on the basis of what information, precisely?
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Idle speculation.
Norfolk Island suffers from notorious fog. Being a small island the fog often rolls in at short notice closing the airport while aircraft are mid flight from Australia or New Zealand. The disappointed passengers are often told they need to turn back and try tomorrow.
However Norfolk Island’s airport is very primitive and only suited to clear weather flying. Nervous flyers should drink their duty free before boarding. Some pilots will not fly to Norfolk Island due to its lack of emergency services and inadequate night time lighting. Norfolk Island's limited airline traffic means it can not justify sophisticated facilities.
"It's a piece of rock that sits in the middle of the Pacific Ocean subject to sea fog, and if a plane cannot land it's in deep trouble. Ely said that Flight West, the main Australian carrier serving Norfolk Island racked up $40,000 in costs a month due to flights that could not land and had to return to Australia or New Zealand.
It is also intriguing that no one has made a fuel study using SGR and the grid winds, effective TAS at LRC on a Northerly heading to NWWW seems to have been neglected.
0545 TAF OK. - NO PROB FOG ??
0700 METAR - Not received (9999 FEW 008).
0730 METAR - Not received (9999 FEW 006).
0739 SPECI - Not received (9999 OVC 013).
0800 TAFOR - Not received AMEND (7000 SCT 005).
0801 received the 0630 METAR (9999 FEW 006). *Reported as 6000'.
* Issue time questioned, expected 0800 METAR??
0802 received 0800 SPECI (9999 OVC 011).
0803 – NADI HAND OFF.
0830 SPECI – Not received (9999 SCT 005). with NADI.
0841 – Δ DOLSI – and Auckland contact. BINGO 1. No Met requested or offered??
0856 SPECI - Not received (9999 SCT 005). BINGO 2. with AUK. Ditto Met.
0900 METAR - Not received (8000 SCT 005).
0902 SPECI - (7000 SCT 005).
0925 SPECI - Not received (6000 SCT 005).
0928 – Contact NLK.
0940 TOD.
Climate statistics for Australian locations
Norfolk Is to beat fog with $15 billion GPS - Computerworld
Recommendation R20000040
Last edited by Kharon; 27th Nov 2012 at 05:30. Reason: SNAP Creampuff
Reference page 56 Appendix B of the ATSB report:
There was METAR/SPECI reports issued for 0700 METAR, 0730 METAR and an 0739 SPECI and yet the METAR that was passed at 0801 UTC was the 0630 UTC METAR. It is interesting to note that had either the 0730 METAR or 0730 SPECI or (preferably both) had been relayed by Nadi then maybe the Captain and FO would have picked up on the trending weather and then possibly made more inquiries which would have triggered Nadi to relay the 0803 Amended TAF and especially the 0830 SPECI which put the conditions below the landing minima.
Kharon I take your points with the dew point split and the INTER/TEMPO. It would appear that BOM have withdrawn a proper forecasting service for Norfolk Island simply relying on the auto station (for METAR/SPECI). And what is the BOM rule for forecasting PROB FOG?
It is interesting when you look at the TAFs issued over the period of the flight out and back to Norfolk on page 58-59 of the ATSB report you will see the only time a INTER/TEMPO or PROB was forecast was at 0958 UTC, see here:
Maybe the lax forecasting has something to do with the fact that most aircraft are required to carry an alternate for Norfolk, either way it would appear that there was some critical wx info that was issued but not relayed that could very definitely have helped make an early decision to divert, especially that 0830 SPECI!
The most disturbing thing is that the ATSB missed or chose to ignore these factors in the compiling of their final report, oh that’s right it was outside the ‘scope’ of their investigation…bah humbug!
Flight plan submitted at Apia - METAR YSNF 180430Z 29014KT 9999 FEW008 22/18 Q1010 RMK RF00.0/000.0 HZ
METAR YSNF 180500Z 29014KT 9999 FEW015 22/18 Q1010 RMK RF00.0/000.0 HZ
Takeoff from Apia, Samoa at 0545 UTC - METAR YSNF 180530Z 29013KT 9999 FEW010 22/18 Q1011 RMK RF00.0/000.0 HZ
METAR YSNF 180600Z 31011KT 9999 FEW008 BKN025 21/19 Q1011 RMK RF00.0/000.0 HZ
First reported weather observation at 0800 UTC- METAR YSNF 180630Z 30009KT 9999 FEW006 BKN024 21/19 Q1011 RMK RF00.0/000.0 CLOSE TILL 1930UTC
(Note: Reported as 6000ft)
METAR YSNF 180700Z AUTO 29011KT 9999 BKN017 BKN024 21/19 Q1011 RMK RF00.0/000.0
METAR YSNF 180730Z AUTO 29010KT 9999 OVC013 21/19 Q1012 RMK RF00.0/000.0
SPECI YSNF 180739Z AUTO 29010KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0
Second reported weather observation at 0800 UTC and Norfolk Island TAF amended at 1803 - SPECI YSNF 180800Z AUTO 29008KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0
SPECI YSNF 180830Z AUTO 22007KT 9999 BKN003 OVC009 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180856Z AUTO 21007KT 9999 SCT005 SCT012 OVC015 20/19 Q1013 RMK RF00.0/000.0
METAR YSNF 180900Z AUTO 20007KT 8000 SCT005 OVC015 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180925Z AUTO 20008KT 6000 BKN003 BKN008 OVC011 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180930Z AUTO 20007KT 4500 BKN002 BKN006 OVC011 20/19 Q1013 RMK RF00.2/000.2
Arrival at Norfolk Island at 1005 - TAF amended at 0958 - SPECI YSNF 181000Z AUTO 18009KT 4500 OVC002 19/19 Q1013 RMK RF00.2/001.0
Ditching at Norfolk Island at 1026 - SPECI YSNF 181030Z AUTO 16009KT 3000 OVC002 19/18 Q1013 RMK RF00.4/002.4
METAR YSNF 180500Z 29014KT 9999 FEW015 22/18 Q1010 RMK RF00.0/000.0 HZ
Takeoff from Apia, Samoa at 0545 UTC - METAR YSNF 180530Z 29013KT 9999 FEW010 22/18 Q1011 RMK RF00.0/000.0 HZ
METAR YSNF 180600Z 31011KT 9999 FEW008 BKN025 21/19 Q1011 RMK RF00.0/000.0 HZ
First reported weather observation at 0800 UTC- METAR YSNF 180630Z 30009KT 9999 FEW006 BKN024 21/19 Q1011 RMK RF00.0/000.0 CLOSE TILL 1930UTC
(Note: Reported as 6000ft)
METAR YSNF 180700Z AUTO 29011KT 9999 BKN017 BKN024 21/19 Q1011 RMK RF00.0/000.0
METAR YSNF 180730Z AUTO 29010KT 9999 OVC013 21/19 Q1012 RMK RF00.0/000.0
SPECI YSNF 180739Z AUTO 29010KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0
Second reported weather observation at 0800 UTC and Norfolk Island TAF amended at 1803 - SPECI YSNF 180800Z AUTO 29008KT 9999 OVC011 21/19 Q1012 RMK RF00.0/000.0
SPECI YSNF 180830Z AUTO 22007KT 9999 BKN003 OVC009 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180856Z AUTO 21007KT 9999 SCT005 SCT012 OVC015 20/19 Q1013 RMK RF00.0/000.0
METAR YSNF 180900Z AUTO 20007KT 8000 SCT005 OVC015 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180925Z AUTO 20008KT 6000 BKN003 BKN008 OVC011 20/19 Q1013 RMK RF00.0/000.0
SPECI YSNF 180930Z AUTO 20007KT 4500 BKN002 BKN006 OVC011 20/19 Q1013 RMK RF00.2/000.2
Arrival at Norfolk Island at 1005 - TAF amended at 0958 - SPECI YSNF 181000Z AUTO 18009KT 4500 OVC002 19/19 Q1013 RMK RF00.2/001.0
Ditching at Norfolk Island at 1026 - SPECI YSNF 181030Z AUTO 16009KT 3000 OVC002 19/18 Q1013 RMK RF00.4/002.4
There was METAR/SPECI reports issued for 0700 METAR, 0730 METAR and an 0739 SPECI and yet the METAR that was passed at 0801 UTC was the 0630 UTC METAR. It is interesting to note that had either the 0730 METAR or 0730 SPECI or (preferably both) had been relayed by Nadi then maybe the Captain and FO would have picked up on the trending weather and then possibly made more inquiries which would have triggered Nadi to relay the 0803 Amended TAF and especially the 0830 SPECI which put the conditions below the landing minima.
Kharon I take your points with the dew point split and the INTER/TEMPO. It would appear that BOM have withdrawn a proper forecasting service for Norfolk Island simply relying on the auto station (for METAR/SPECI). And what is the BOM rule for forecasting PROB FOG?
It is interesting when you look at the TAFs issued over the period of the flight out and back to Norfolk on page 58-59 of the ATSB report you will see the only time a INTER/TEMPO or PROB was forecast was at 0958 UTC, see here:
TAF AMD YSNF 180958Z 1810/1824
26008KT 9999 -SHRA BKN010
FM181500 16012KT 9999 -SHRA BKN010
TEMPO 1810/1824 4000 SHRA BKN005
RMK T 19 18 17 18 Q 1013 1013 1012 1014
26008KT 9999 -SHRA BKN010
FM181500 16012KT 9999 -SHRA BKN010
TEMPO 1810/1824 4000 SHRA BKN005
RMK T 19 18 17 18 Q 1013 1013 1012 1014
The most disturbing thing is that the ATSB missed or chose to ignore these factors in the compiling of their final report, oh that’s right it was outside the ‘scope’ of their investigation…bah humbug!
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atsb and annex 13
From ICAO's Annex 13 - Reports, section 1.7 is instructive:
Well atsb - Did you meet the requirement in your report???
1.17 Organizational and management information.
Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator; the air traffic services, airway, aerodrome and weather service agencies; and the regulatory authority.
The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices, and regulatory framework.
Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator; the air traffic services, airway, aerodrome and weather service agencies; and the regulatory authority.
The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices, and regulatory framework.
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Well atsb - Did you meet the requirement in your report???
And it is probably a bit to kind to call it a REPORT. It was more a bunch of postulating words scripted in a way so as to tickle the ears of the aviation uneducated.They thought they would get away with it - it didn't work.
The longer this saga continues, the more jittery ICAO and the FAA must be getting.
The Minister is presiding over a fine mess. Maybe he could hire Mary Schiavo to come in and fix the mess?
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Creampuff:
Assuming that Airservices still retained the FIS delivery responsibility for NFI at the time of the accident, as per my other posts and reference to the Airservices Act and the Airspace Act, your question could realistically be rephrased to ask what more could Airservices have done?
Under the provisions of the Australian AIP Gen 3.3-3 para 2.1, pilots are ultimately responsible for obtaining information necessary to make in-flight operational decisions, however Australian ATC also have an obligation under AIP Gen 3.3-4 para 2.5 to assist pilots in the information sourcing process by broadcasting at regular intervals on appropriate ATS frequencies the availability of "pertinent operational information such as: a. meteorological conditions and the existence of non-routine MET products etc" . A SPECI and AMD TAF qualify as non-routine MET products.
If indeed Australia retains FIS delivery responsibility for NFI, then Airservices should have broadcasted on the appropriate HF frequencies, the availability of the 0739, and subsequent, SPECIs as well as the 0800 AMD TAF. Did Airservices fufil its obligations in this regard and, if not, why not? If Airservices had made the appropriate broadcasts on the appropriate SP6 HF frequencies, then the possibility exists that the flight crew of NGA may have been alerted a lot earlier to the changed and fluctuating weather conditions at NFI and taken appropriate diversion action earlier.
Kharon:
Good point and another issue that needed to be investigated and commented on by the ATSB, particularly considering that CASA and the BoM worked on a project sometime around 2000, I think, to look at ways of improving met forecasting at NFI.
What more should the crew have done, and when, to “source the most recent Norfolk Island Airport forecast”, or to “seek and apply other relevant weather and other information”?
Under the provisions of the Australian AIP Gen 3.3-3 para 2.1, pilots are ultimately responsible for obtaining information necessary to make in-flight operational decisions, however Australian ATC also have an obligation under AIP Gen 3.3-4 para 2.5 to assist pilots in the information sourcing process by broadcasting at regular intervals on appropriate ATS frequencies the availability of "pertinent operational information such as: a. meteorological conditions and the existence of non-routine MET products etc" . A SPECI and AMD TAF qualify as non-routine MET products.
If indeed Australia retains FIS delivery responsibility for NFI, then Airservices should have broadcasted on the appropriate HF frequencies, the availability of the 0739, and subsequent, SPECIs as well as the 0800 AMD TAF. Did Airservices fufil its obligations in this regard and, if not, why not? If Airservices had made the appropriate broadcasts on the appropriate SP6 HF frequencies, then the possibility exists that the flight crew of NGA may have been alerted a lot earlier to the changed and fluctuating weather conditions at NFI and taken appropriate diversion action earlier.
Kharon:
The temperature and dew point are very close, the wind is easing and there are clear indications of a bad patch approaching; with NLK being as fog prone as it is makes me wonder why there was no 'FG Prob' on the TAF, or a TEMPO or even an INTER for the later period of the 0700 TAF. The cloud base and visibility are fluctuating, the cloud is being called deteriorating between 1300' and 500' throughout the period.
I don’t see how Airservices has any choice but to retain responsibility for delivery. It can discharge that responsibility by arranging for someone else to deliver, but Airservices can’t alter the fact that Australian-administered airspace includes the airspace over the external territories including Norfolk Island.
It’s interesting to read, again, the Norfolk Island forecasting safety deficiency raised by the ATSB in 2000, and BOM’s response.
Are there any observers left on Norfolk ?
Does the aerodrome manager still have “access to a display of the latest observations”?
What is/was the actual mechanism to “ensure the most up to date information is relayed to aircraft”?
It’s interesting to read, again, the Norfolk Island forecasting safety deficiency raised by the ATSB in 2000, and BOM’s response.
Recommendation issued to: Bureau Of Meteorology
Output No: R20000040
Date Issue: 22 February 2000
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:
[4 occurrences are described. ]
…
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.
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. [Don’t tell me: CASA “expects” that review to be completed “soon”.]
Initial Response
Date Issued: 27 April 2000
Response from: Bureau Of Meteorology
Response Status: Closed – Accepted
…
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.
…
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.
…
Output No: R20000040
Date Issue: 22 February 2000
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:
[4 occurrences are described. ]
…
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.
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. [Don’t tell me: CASA “expects” that review to be completed “soon”.]
Initial Response
Date Issued: 27 April 2000
Response from: Bureau Of Meteorology
Response Status: Closed – Accepted
…
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.
…
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.
…
Does the aerodrome manager still have “access to a display of the latest observations”?
What is/was the actual mechanism to “ensure the most up to date information is relayed to aircraft”?
Creamy in answer to your first question here is a segment from the transcript:
Which would appear to gel with the remark on the end of the 0630 METAR; "CLOSE TILL 1930UTC". So from around that time of the day BoM forecasters are totally reliant on the auto wx station, sat pics and synoptics plus the NFI wx radar to produce a forecast (TAF).
In terms of the forecasts for Norfolk that were put out, I find the TAF AMD put out 0803 the most disconcerting given the METAR/SPECI info prior to 0803, see here:
Just doesn't seem to fit the pattern of trending weather and when you read the 0958 UTC TAF:
Kind of like the forecasters in charge of that region have gone to sleep for 2-3hrs to then wake up and have a "oh fcuk" moment...
By the way the BoM submission has been posted on the Senate submissions page
Senate Committees – Parliament of Australia
Senator XENOPHON: So, regarding the bureau's staffing at Norfolk and Christmas Islands, what is the current position in those two places?
Mr Hanstrum: At Norfolk Island there are three observing staff rostered on duty from around seven o'clock in the morning through until—
Senator XENOPHON: It is four o'clock sometimes? It could be as early as 4 am?
Mr Hanstrum: Normally it is 6 am to 7 am.
Mr Hanstrum: At Norfolk Island there are three observing staff rostered on duty from around seven o'clock in the morning through until—
Senator XENOPHON: It is four o'clock sometimes? It could be as early as 4 am?
Mr Hanstrum: Normally it is 6 am to 7 am.
In terms of the forecasts for Norfolk that were put out, I find the TAF AMD put out 0803 the most disconcerting given the METAR/SPECI info prior to 0803, see here:
TAF issued at 0803 UTC on 18 November 2009
TAF AMD YSNF 180803Z 1808/1824
26008KT 9999 BKN010
FM181500 16012KT 9999 -SHRA BKN010
RMK
T 21 18 18 17 Q 1012 1013 1013 1013
TAF AMD YSNF 180803Z 1808/1824
26008KT 9999 BKN010
FM181500 16012KT 9999 -SHRA BKN010
RMK
T 21 18 18 17 Q 1012 1013 1013 1013
TAF issued at 0958 UTC on 18 November 2009
TAF AMD YSNF 180958Z 1810/1824
26008KT 9999 -SHRA BKN010
FM181500 16012KT 9999 -SHRA BKN010
TEMPO 1810/1824 4000 SHRA BKN005
RMK
T 19 18 17 18 Q 1013 1013 1012 1014
TAF AMD YSNF 180958Z 1810/1824
26008KT 9999 -SHRA BKN010
FM181500 16012KT 9999 -SHRA BKN010
TEMPO 1810/1824 4000 SHRA BKN005
RMK
T 19 18 17 18 Q 1013 1013 1012 1014
By the way the BoM submission has been posted on the Senate submissions page
Senate Committees – Parliament of Australia