Norfolk Island Ditching ATSB Report - ?
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Sarcs, Gobbles, and Kharon, have got this covered! Bring on a Special Commission or at least a Senate Inquiry so the truth can be told! I think Aherne and Quinn may have a bit to say by the looks of 4 C!
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Three strikes?
Audit - Page 12 has an interesting table, showing James landed at NLK in September and again in November with less than company minimum fuel.
Is James is a victim of the 'tick a box' training system? It does not work - Not in the old money, not in the new money and certainly not 1000 miles from home on a bad night. Coming to a Jetstar flight near you - real soon.
Have the protagonists of 'black letter law' compliance have been bitten in the arse by their own dog?.
When is the Senate inquiry into pilot training going to throw out the pathetic 'soft white paper? When are our Pollies going to grow some bollocks, instead of just talking it?.
There, better now.
DB # 254 - Two years in a row, Mr James flew without a current medical. Once is a mistake, twice is negligence.
Bonaza - #255 "What I took away from our conversation was the casual and amateur 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". etc.
Have the protagonists of 'black letter law' compliance have been bitten in the arse by their own dog?.
When is the Senate inquiry into pilot training going to throw out the pathetic 'soft white paper? When are our Pollies going to grow some bollocks, instead of just talking it?.
There, better now.
Last edited by Kharon; 6th Sep 2012 at 21:13.
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Audit - Page 12 has an interesting table, showing James landed at NLK in September and again in November with less than company minimum fuel.
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Blackie
If what you say is correct, why did the ATSB not report on this too?
Just like many other small things, this is a significant casual factor.
The direction of finger pointing is in my opinion 40% each to pilot & company and 20% CASA for not providing active surveillance to prevent this sort of scenario.
I have said it before and will again. CASA surveillance must never be used as tool to ping people, it MUST be used as a partnering tool, partners in achieving safety. Safety by education not legislation.
This is another clear case of where ticking boxes, does not work. Assuming PA had a SMS why did medicals get missed, why did low fuel arrivals not trigger a serious shakeup long before? If they were in the system, obviously they were just stats not action items.
I am at a loss as to why the FO was not being a sticky beak in planning fueling enroute wx and planning. Even if it was a curiosity thing, you know one day I wanna be a captain. Even the smallest of critical oversight from the FO should have triggered something that would have changed the game.
Fair to say both have learned more from this than us reading about it, and will likely never be caught like that again. What have PA and CASA learned and how long will that remain in vivid memory?
If what you say is correct, why did the ATSB not report on this too?
Just like many other small things, this is a significant casual factor.
The direction of finger pointing is in my opinion 40% each to pilot & company and 20% CASA for not providing active surveillance to prevent this sort of scenario.
I have said it before and will again. CASA surveillance must never be used as tool to ping people, it MUST be used as a partnering tool, partners in achieving safety. Safety by education not legislation.
This is another clear case of where ticking boxes, does not work. Assuming PA had a SMS why did medicals get missed, why did low fuel arrivals not trigger a serious shakeup long before? If they were in the system, obviously they were just stats not action items.
I am at a loss as to why the FO was not being a sticky beak in planning fueling enroute wx and planning. Even if it was a curiosity thing, you know one day I wanna be a captain. Even the smallest of critical oversight from the FO should have triggered something that would have changed the game.
Fair to say both have learned more from this than us reading about it, and will likely never be caught like that again. What have PA and CASA learned and how long will that remain in vivid memory?
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I have also wondered what the FO was doing while Dom was trying to flightplan and access the internet. It was company policy that the FO was not required to be involved in this process. Despite this, you would think professional curiosity would mean she would have been interested to go through the exercise for when her turn came.
All will be revealed in time. The FO did not appear on Four Corners, and so we don't know her side of this story. Not yet.
Inevitably it will all come out in subsequent legal proceedings when people are subpoenaed to attend and give evidence under oath. That is unless there is an out of court settlement.
CASA looked at all records from 2002 to 2009. Only 3 instances were found of landing without alternate fuel. All 3 instances were in the two months prior to the crash (one involving the standards manager). This seems to be stretching coincidence, and makes you wonder if something had changed. If so this too will come out in time.
All will be revealed in time. The FO did not appear on Four Corners, and so we don't know her side of this story. Not yet.
Inevitably it will all come out in subsequent legal proceedings when people are subpoenaed to attend and give evidence under oath. That is unless there is an out of court settlement.
CASA looked at all records from 2002 to 2009. Only 3 instances were found of landing without alternate fuel. All 3 instances were in the two months prior to the crash (one involving the standards manager). This seems to be stretching coincidence, and makes you wonder if something had changed. If so this too will come out in time.
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My question is this.Does anyone know if the Norfolk Unicom operator is a trained met observer.I dont believe he would be and therefore the New Zealand AS may not of been able to pass on the up dated weather from him.Isnt it the case Metars come from the Met.office there, and the TAFs from the Australian mainland and are usually way out of date.
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Mmmmmm
So he submitted an incident report about having burnt 7200 lb to get from Apia to Norfolk then on replicating the same leg the next time he uplifts only that 7200lb out of Apia for Norfolk?
Methinks an alarm bell should have gone off in his head!
Methinks an alarm bell should have gone off in his head!
Last edited by flying-spike; 7th Sep 2012 at 06:34.
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So he submitted an incident report about having burnt 7200 lb to get from Apia to Norfolk then on replicating the same leg the next time he uplifts only that 7200lb out of Apia for Norfolk?
His previous Chief Pilot (and now WW Standards Manager) also arrived with less than alternate fuel on the same sector 6 weeks earlier. What example is this to send? The company must be held to account and accept some more responsibility for this accident.
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I missed that bit. Reference please.
page 12 of the CASA special audit.
On 30/SEP/09 same Capt flew Apia - Norfolk. Fuel burn was 7200 (8700 at departure - 1500 remaining on landing).
On 18/NOV/09 (the ditching flight), he flew Apia - Norfolk. Fuel at departure = 7200!
On 5/OCT/09, another Capt (ex-CP) flew Apia - Norfolk. Fuel burn was 7000.
Unless there is an error in this data, it is amazing he had sufficient fuel for 4 missed approaches before ditching. ATS report states he reduced cruise speed aware fuel was tight, and this may have given him the fuel for these missed approaches.
According to Crikey he was operating on the basis that he couldn't legally land at Noumea. TCAS2 and GPWS had just been fitted to the ac but the pilots had not completed training on these items. The training records at Pelair should be able to confirm or refute this.
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Well that leaves a lot of evidence to back up the "inadequate" statement behind, and does not portray amy perspective as to how severe inadequate is.
Clearly this was not just an oops then, it was systemic, and even more reason the company were lacking, and without company surveillance what chance did CASA surveillance have.
This stuff is an all in effort, and even if CASA were perfect, the systems the company and pilots were following was never going to leave even the most proactive CASA folk anything to work with by the sound of it.
Bit like a dog chasing its tail.
Clearly this was not just an oops then, it was systemic, and even more reason the company were lacking, and without company surveillance what chance did CASA surveillance have.
This stuff is an all in effort, and even if CASA were perfect, the systems the company and pilots were following was never going to leave even the most proactive CASA folk anything to work with by the sound of it.
Bit like a dog chasing its tail.
ATSB cannot apportion blame or take disciplinarian action.
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Thanks sarcs, I may not be the most articulate poster by a long shot but I think that was my point a few posts back.
These were obviously serious contributors and casual factors at the same time. They should have been stated in the same context at least.
Not pointing the blame finger......just the bloody obvious if you had the data available. The report does not cover this. If it gets on pprune and the ATSB miss it, well all I can say is, just like the Fiji wx reports this is a sad case of poor reporting.
I don't need to thread drift too far here but if anyone remembers the Whyalla report.......the biggest joke of a report ever produced, despite what some might think this was the biggest joke of all, and nothing has been learned.
These were obviously serious contributors and casual factors at the same time. They should have been stated in the same context at least.
Not pointing the blame finger......just the bloody obvious if you had the data available. The report does not cover this. If it gets on pprune and the ATSB miss it, well all I can say is, just like the Fiji wx reports this is a sad case of poor reporting.
I don't need to thread drift too far here but if anyone remembers the Whyalla report.......the biggest joke of a report ever produced, despite what some might think this was the biggest joke of all, and nothing has been learned.
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they are duty bound to look at all possible factors that maybe causal to the accident,
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despite what some might think this was the biggest joke of all, and nothing has been learned
Sorry Jaba but the lesson learnt was obscure to most but it is germane today, the politics will always win, simply cannot embarrass the minister no matter who dies.
Seaview, Bamaga, lord Howe and all there are enough smoking craters yet the politicians wear fire proof suits.
The will be no change whilst the blame can be sheeted home away from the actual causal events.
Sorry Jaba but the lesson learnt was obscure to most but it is germane today, the politics will always win, simply cannot embarrass the minister no matter who dies.
Seaview, Bamaga, lord Howe and all there are enough smoking craters yet the politicians wear fire proof suits.
The will be no change whilst the blame can be sheeted home away from the actual causal events.
It appears to me that whilst PA Operations manual was found to be inadequate in procedures for fuel planning, Dom was not compliant with the written procedure that was in the manual.
However a good investigator wouldn't stop there they should be asking questions like:
1) Prior to Dom's employment with PA did he display cowboy, risk taking, non-compliant behaviour? Y/N
2) How did Dom perform in previous checks/CRM courses etc i.e. within TCS system?
Then if there were no serious issues/aberrations/non-compliance then one would start to suspect what is called a 'normalised deficiency', which points towards Company operational support.
A good investigator would then start to focus on all the cogs and sprockets that make up the guts or engine room of the operational support team of an operator.
With PA (at the time) this appears to be particularly blurred by previous audit reports, reasonably well written COMs and generally a history of compliance i.e. 'all the boxes were ticked'!
So Blackie what would a good investigator do then?? Yeah you guessed it dig and dig a bit more till you find the nuggets....sadly in this case that hasn't happened, in fact there appears to be some serious 'negligence of duty' with some pretty elementary facts missed!
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Spot on Sarcs, and I hear the real investigators did this, including the non RVSM issue, but got beaten done from on-top! Pathetic. So much for this industry learning from ATSB reports. If the Chief Commissioner thinks its all about what an operator did to fix things, post accident, and therefore not mention it in the final report, then we are doomed, no-one learns a thing! Bring back BASI!