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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

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Old 5th Sep 2012, 16:16
  #241 (permalink)  
 
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Really? This is the first ever serviceable aircraft ditching the world has ever seen? Wow!
Of course not. The original comment referred to Australian providers of this sort of service (ie airmedical). Of the top of my head I can't recall another Australian airmedical operator ditching.

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

If you are pulled over for speeding it doesn't help to argue you were doing the same as everyone else.
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Old 5th Sep 2012, 18:05
  #242 (permalink)  
 
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You want to limit your comment to "Australian airmedical" operations? That's a pretty small group!
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Old 5th Sep 2012, 18:12
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CASA can't investigate all operators to this level. But a serious accident will result in an indepth audit. So if you are going to breach regulations it is best to be lucky.
A regulator that investigates after the event is not much use to anyone. They are there to regulate the industry not be wise after the event. If you allow people to cut corners and take chances the good operators will be the ones disadvantaged and suffer. Standards will decline and the safety risk increases.


It does appear to depend on the quality/experience/capability of the local office staff during audit as to what they are able to turn up..or not.
Exactly, it also depends on resources available. A number of people have been critical of resources used for overseas trips, business travel across country and removing staff from regional airports like banks town and moorabbin.
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Old 5th Sep 2012, 20:42
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Thursday thinking.

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

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

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

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

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

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

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

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

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

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

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

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

Song of the Men's Side.

Last edited by Kharon; 5th Sep 2012 at 21:21. Reason: There's elephants and then there is Elephants -gedit
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Old 6th Sep 2012, 02:23
  #245 (permalink)  
 
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Wow this thread is sure starting to become a classic case of joining the dots, however I still get the feeling the end picture is still going to be a massive pile of pony pooh (to borrow from Gobbles)!
ozaub said Some including gobbledock at #192 are asking for a Royal Commission but there’s no need. Justice Staunton did a fine job with his Commission of Inquiry into the loss of Seaview’s Aero Commander on 25 July 1994. From watching 4 Corners, reading the ATSB Report and especially reading CASA’s audit report, clearly little has changed. There’s nothing to distinguish between Seaview in 1994 and Pel-Air in 2009. Both orgs callously disregarded regulation; suffered imbalance between commercial and safety imperatives; fiddled defect reporting; and fudged the distinctions between charter and RPT at Seaview and between charter and airwork at Pel-Air;
ozaub’s reference and comparison to Seaview v PA is particularly relevant, however there are some very big differences in the philosophy, methodology and motivation of the various stakeholders.

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

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

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

The report’s ‘Findings’ and ‘Safety Actions’ sections are watered down, devoid of any safety recommendations or statements that maybe construed as a ‘negative finding’ against either the operator or the regulator. Also within the four days since the 4 corners programs there has been several revelations/deficiencies highlighted within the report:
(1) the wx report 6000’ vs 600’:
GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.
MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.
One wonders how our esteemed bureau could possibly overlook such a critical bit of information?
(2) As discussed the negative RVSM approved Westwind, effectively ruling out 12000’ of airspace that the flightcrew could operate in; and
(3) The total lack of an objective top down look at the Operator and the culture within, instead we get spin from the topdog effectively abrogating all responsibility… “as that is a matter for the regulator…outside our remit…blahblahblah”
….there will be more little nuggets in there they just need to be teased out!!
So it would appear that our totally independent air safety investigator has not only succumbed to the ‘dark side’ of big brother (lapdog rather than watchdog!) but also to the millstone of ‘regulatory capture’. Will someone for god’s sake scrap the MOU and get rid of that patsy!

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

Last edited by Sarcs; 6th Sep 2012 at 05:06.
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Old 6th Sep 2012, 03:53
  #246 (permalink)  
 
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Firstly I hold PPL H only.
So explain to me - Can I assume an ATPL holder is tested for proficiency to the level that John McCormack said, or is it to another standard?
If I run my little R22 out of Avgas, is this different to what our colleague Dom did?
From people I talk to, non aviation, they don't seem to care about what the AOC holder did, in fact were not aware of such things, there was more concern that the PIC and his "pax" in the RH seat could not do simple mathematics.
APart from Sandilands and Paul Phelan, there seems to be not much ado about anything to do with this in other media. MAybe is of interest to only Ppruners?
Kharon - PA were I think, treated fairly, reasonably and honestly by a sensible crew 'on the ground'. The PA management responded in a mature way.
exactly
Again to borrow from Gobbles...TICK bloody TOCK!
Did you miss something? The aircraft ended up in the water, the clock has ticked and tocked all the way to an accident, and sadly for you and your b buddy Gobbles, it was caused by lack of flight planning by pilot, not by the regulator.

Last edited by blackhand; 6th Sep 2012 at 04:23.
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Old 6th Sep 2012, 04:37
  #247 (permalink)  
 
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I have limited experience as a professional pilot and none at all on the type of operation undertaked here, but I have to say that having read the ATSB report and watched the 4-corners program I have a good deal more sympathy for the circimstances in which the PIC found himself.

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

Dr

Last edited by ForkTailedDrKiller; 6th Sep 2012 at 04:38.
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Old 6th Sep 2012, 04:57
  #248 (permalink)  
 
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28BE Duty to exercise care and diligence

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

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

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

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

(b) failure to provide adequate systems for communicating relevant information to relevant people in the body.
For the operator to have escaped responsibility is a travesty. The ATSB report is a (sick) joke.
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Old 6th Sep 2012, 05:48
  #249 (permalink)  
 
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From the CASA special audit:

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

Last edited by Dangly Bits; 6th Sep 2012 at 05:48.
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Old 6th Sep 2012, 05:57
  #250 (permalink)  
 
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After watching 4 Corners on Monday night and as a commercial pilot who has worked for 'max payload/min fuel' operators, I can honestly say it sent chills down my spine. I think most of us could imagine the pressure a company like PA would have put on this young captain. In saying that it doesn't excuse what can only be described as abysmal flight planning.

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

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

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

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

I can see the holes lining up again already!
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Old 6th Sep 2012, 06:03
  #251 (permalink)  

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I'd hazard a guess that the entire fuel savings of PA have been negated by having an airframe sitting on the bottom of the ocean.

If one always has a plan B, there's a reasonable chance one will not find oneself in such a predicament.

If one can't have a plan B because of payload/fuel capability, the chances of that being the day that it goes pear shaped are reduced, as opposed to always carrying min fuel.
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Old 6th Sep 2012, 06:04
  #252 (permalink)  
 
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CP - For the operator to have escaped responsibility is a travesty.
But Shirley, for the (stuck) record you are not intimating that CASA allowed a dangerous, non compliant operator ofF the hook or that there was some coercion or criminal corruption involved, which simply allowed the operator to correct detected errors?

You cannot legislate against a company culture, stupidity or intent. Sure CASA are playing this one, as they play them all, fast and loose. They are there to protect the Minister, not foster and promote the industry. As long as the emotive catch cry "Safety" and the myth that CASA is some form of demigod exists the pedants insistence 'black letter' law compliance will haunt the industry.

This company complied with the minimum, to dare to reach beyond it is dammed as heresy.

Last edited by Kharon; 6th Sep 2012 at 06:13. Reason: Theres 2 ff's in off.
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Old 6th Sep 2012, 07:26
  #253 (permalink)  
 
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Am I missing something here? This is the PA fuel policy from the ATSB report p 31. Surely this should read "more than" rather than "less than"??

If a successful approach and landing at the destination aerodrome appeared marginal due to weather or any other reason, Part A section 9.11.5 Latest Divert Time/Point required the determination by a PIC of the latest divert time or position from which to proceed to a suitable alternate. No definition was provided in respect of the marginality of an aerodrome. The operations manual stated that if at that point the expected fuel remaining was:
...less than the sum of:
a) Fuel to divert to an enroute alternate aerodrome; and
b) Variable reserve fuel; and
c) Fixed reserve fuel.
The PIC shall either:
a) Divert; or
b) Proceed to the destination, provided that two separate runways are available and the expected weather conditions at the destination enable a successful approach and landing.
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Old 6th Sep 2012, 08:49
  #254 (permalink)  
 
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The tick is clocking.

There are enough aberrations in this scenario to keep a Minister awake at night; we are in trouble and while no one minds a responsible, balanced system in which everyone can 'be compliant', the current problems are deep, troublesome and generally frigged about by lawyers. Why?, because they can. However, I ramble.

BH- Can I assume an ATPL holder is tested for proficiency to the level that John McCormack said, or is it to another standard?
Good point and worth IMO an answer.

Checkboard #106 – "I say this because I doubt 20% of pilots in the industry can, and that is a failure of the exam system as the exam system focuses on very high accuracy which leads itself to systems of calculating which are not practical in the real world". etc.
Good post and worth a read. This is a part of the operational problem; guys are now 'passing' exams, but not carrying forward or able to use the knowledge gained. I think what CB was getting at is that the 'philosophy' or 'savvy' to use the academic stuff is slipping away. IMO it's more a "way of thinking" than of pure mathematics. There is an excuse or two though (i) Never have to do the ETP/PNR calculations in everyday operations (ii) the folks that do need the information have computers to generate the data.

Manually ETP, PNR 1/2 and 'working' a fuel plan at SGR (fuel flow /speed = lbs/nm) are a bit like telephone numbers, easy when you use them all the time; but, if you don't the formulae get 'rusty' and the speed and accuracy decline to an almost dangerous level. This is why these days most proprietary 'flight plan' software calculates the fuel plan for you. Complex plans like the Samoa trip take time and information to plan. It takes about 45 minutes to do it 'proper' and to have a 'multi level' howgozit. The whole thing is only as good as the information you have at planning, once airborne, the fuel checks start at TOC.
Sorry guys, once I get started.

Last edited by Kharon; 6th Sep 2012 at 08:55.
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Old 6th Sep 2012, 08:53
  #255 (permalink)  
 
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Airways NZ Responsibility

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

The oversight from this agency has more ramifications to more pilots than they
realize.
Sorry but Airways NZ has no regulatory responsibility for passing terminal weather on Norfolk Island to aircraft in flight (Refer NZ AIP Gen 3.3-4 para 2.2)
2.2 Auckland Oceanic FIR
2.2.1 Airways provides ATS throughout the Auckland Oceanic FIR (NZZO),
except in the Cook, McMurdo, Samoa, and Tonga sectors and at Norfolk
Island.
and para 2.2.9
Norfolk Island
2.2.9 Norfolk Island is contained within the Auckland Oceanic FIR and
administered by Australia.
A Flight Information Service (FIS) is a sub function of ATS and , therefore under its rules, Airways NZ has no responsibility for passing of terminal weather information on Norfolk Island unless specifically requested by the responsible ATS unit.

As the responsible ATS unit in Norfolk Island's case is Airservices Australia, it does beg the question as to why Airservices (Flightwatch) did not broadcast the YSNF SPECI on the relevant SP6 HF frequencies, notwithstanding the fact that the pilot failed to maintain an adequate in-flight weather watch over his flight by not requesting weather updates on Norfolk Island whilst enroute. That is probably another aspect overlooked in the ATSB's report -the failure of Airservices' responsibility.
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Old 6th Sep 2012, 09:34
  #256 (permalink)  
 
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QSK? Hey bro. Not legal, so just sit on critical info. My limited understanding is ATC are there to help! Didn't do much in this case at a critical time.
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Old 6th Sep 2012, 09:37
  #257 (permalink)  
 
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That's my point Jinglie, Airways is responsible for passing all the functions in 3.1.1 (including Area Flight Information Service) except at Norfolk Island.

I suspect that NZ's AIP is reflecting the situation when Airservices Australia used to offer a directed FIS to all aircraft operating or intending to operate at Norfolk Island. Since Airservices' change to an "on request" FIS (Flightwatch) service, the impact of this change was possibly not relayed to the CAA of NZ or Airways so that they could amend their documents (?)

Yes, airmanship (common sense) is a feature of ATC and if I had been requested by anyone (even a Unicom operator) to pass some weather to an aircraft I would do so regardless of the rules re responsibility.
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Old 6th Sep 2012, 10:29
  #258 (permalink)  
 
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Thanks QSK? Another link in the chain! Can anyone offer an ASA view? And regarding my previous post, anyone got a view on the diversion policy if you don't have enough, divert anyway, or continue!!!!

Last edited by Jinglie; 6th Sep 2012 at 10:35.
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Old 6th Sep 2012, 12:35
  #259 (permalink)  
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Surely this should read "more than" rather than "less than"??

Better read it again
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Old 6th Sep 2012, 13:21
  #260 (permalink)  
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Is it true the PIC was sacked by Qantas?
 


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