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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 4th Sep 2012, 20:43
  #201 (permalink)  
 
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PIC?

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.
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Old 4th Sep 2012, 21:10
  #202 (permalink)  
 
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Brian:

Well put together, jolly good info:

Chr's
H/Snort.
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Old 4th Sep 2012, 21:10
  #203 (permalink)  
 
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For those overseas, use iviewnapper to download.
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Old 4th Sep 2012, 21:32
  #204 (permalink)  
 
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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 medevac'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!
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Old 4th Sep 2012, 21:59
  #205 (permalink)  
 
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It will be interesting to see if Senator FAWCETT starts asking questions, and if so, the replies that he gets from the departments involved.
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Old 5th Sep 2012, 00:34
  #206 (permalink)  
 
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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.
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Old 5th Sep 2012, 00:36
  #207 (permalink)  
 
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A comment posted on Plane Talking.... Pel-Air and CASA damned by safety audit documents | Plane Talking

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...
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Old 5th Sep 2012, 02:36
  #208 (permalink)  
 
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Lester

Not all the same people Lester, especially looking at the systemic problems so it was a fresh set of eyes on those issues.
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Old 5th Sep 2012, 03:07
  #209 (permalink)  
 
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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
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Old 5th Sep 2012, 04:52
  #210 (permalink)  
 
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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.

Last edited by my oleo is extended; 5th Sep 2012 at 04:59.
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Old 5th Sep 2012, 05:23
  #211 (permalink)  
 
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No RVSM

ATSB Pel-Air report excluded critical fuel factor | Plane Talking

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.
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Old 5th Sep 2012, 05:57
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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.
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Old 5th Sep 2012, 06:05
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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?
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Old 5th Sep 2012, 06:31
  #214 (permalink)  
 
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Audit findings.

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.


Last edited by catseye; 5th Sep 2012 at 06:33.
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Old 5th Sep 2012, 07:31
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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.
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Old 5th Sep 2012, 08:45
  #216 (permalink)  
 
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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?
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Old 5th Sep 2012, 09:06
  #217 (permalink)  
 
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So RVSM doesn't go to FL410 in NZ airspace? I would have thought that RVSM levels would be standardised across different FIR's
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Old 5th Sep 2012, 12:24
  #218 (permalink)  
 
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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.

Last edited by ftrplt; 5th Sep 2012 at 12:35.
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Old 5th Sep 2012, 13:44
  #219 (permalink)  
 
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Naivety

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.

When the insurer is after the cheapest quote..

Last edited by A31J; 5th Sep 2012 at 13:51.
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Old 5th Sep 2012, 14:30
  #220 (permalink)  
 
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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.
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