Norfolk Island Ditching ATSB Report - ?

[flying-spike]

Did he file a report

"Not sure about filing a report"
I think that 2.4 of the TSR requires it. If he did and the ops manager did why didn't they learn from that?

[Jabawocky]

T28D

We are agreeing too much....

Having said that I was actually making comment on the quality and accuracy of the ATSB's work, not how well things were learned.

In the Whyalla case the education content that came out from CASA afterwards was equally woeful. Gobsmackingly so when you consider the amount of scientifically proven education material the CASA received but subsequently failed to deliver to GA.

One of the reasons we still have these crazy threads on operating pistons.

Back to this one though, how can industry benefit when the ATSB are publish in reports that may well be 98% brilliant but 2% deficient and that lets the whole side down.

I am far from perfect, and writing reports, you would get the 2%, but these guys are the pro's and leaving out serious chunks of casual factor information makes you wonder what else have they missed.

If a complete outsider read the report he would say, pilot had a once off cockup and the company should have been more helpful. Knowing that there were several incidents of the exact same problem in the months prior, you would surely form a slightly different opinion, and where the corrective effort needs to be in future.

Our tax dollars..... Future loss of life......past loss in vain.....

[Kharon]

T28D # 285 The will be no change whilst the blame can be sheeted home away from the actual causal events.

SPOT ON – until the blame shifting ethos is eradicated from the top down, little will change. The Minister needs to be sharper than this: why? because if it can be proven that the watchdogs (hate that expression) are hoodwinking the public, then not only the minister but the whole government may just take a tumbril (next stop Madam Guillotine).

It may be possible to avoid the chopping block by using the "I trusted the expert" defence, if (big if) the minister was in the dark; but once the lights are on and the Gummint has full knowledge; then things get sticky.

The ATSB and CASA boys and girls at the coal face can only do 'as directed', which is shame. As Jabba says, it would be much better to work with an operator to iron out the kinks before, rather than running about the place trying to cover arse after. Edit - Just read Plane Talking, just about say it all.

Ben Sandilands - Today.

[advo-cate]

casa, atsb and the whyalla accident

While we are at it, it is worth a review as to the Coroners Report for this:

http://www.courts.sa.gov.au/Coroners...20Airlines.pdf

In part it says:

On 14 December 2001, only five days before the ATSB final report was published, the right engine in an aircraft identical to MZK failed.

Upon inspection of the engine, it was established that the crankshaft had fractured, and the appearance of the fracture was strikingly similar to that of MZK’s left engine crankshaft.

The ATSB did not examine the fracture in detail, so the aircraft owner commissioned an examination by an engineer who concluded that the failure was caused by a material flaw, and not by thermal cracking.

A scientific investigation conducted for this inquiry has thrown doubt on a number of ATSB conclusions:

• Professor King, an expert in chemical engineering and Dr Zockel, an expert in mechanical engineering, both agreed with the ATSB that the damage to the right engine was due to end gas detonation;
• Professor King concluded that there was considerable doubt about the ATSB conclusion that lead oxybromides were present in sufficient quantity to be a significant factor in the failure of the left engine;
• Dr Zockel concluded that the damage to the left crankshaft was not caused during the combustion stroke of the engine and so abnormal combustion was irrelevant anyway;
• Dr Zockel also concluded that the failure of the left crankshaft was not caused by bearing failure or thermal cracking as suggested by the ATSB;
• Dr Powell and Mr McLean, both experts in metallurgy, found iron oxide inclusions at the nearby No.5 journal of the left crankshaft of sufficient size to constitute a material defect capable of affecting the tensile and torsional strength of the crankshaft. Although similar inclusions were not found at the fracture site, they could have been lost during the fracture process;
• Mr Braly, an aeronautical engineer, aviator and manufacturer of aircraft components, also disputed that lead oxybromides were relevant to the failure of MZK’s left engine, that the crankshaft could have remained ‘dogged’ as the ATSB suggested, that the aircraft could have maintained 167 knots groundspeed on one engine after 1847:15, and hence that the left engine failed first. He argued that the right engine suffered a partial loss of power at 1847:15, and that it was not until after 1858 or so that the left engine failed;
• Mr Braly also said that the mixture settings adopted by Whyalla Airlines for the climb phase of flight were too lean, and these settings may have caused or exacerbated the damage to the right engine;
• Mr Hood, a metallurgist with McSwain Engineering Inc. in the United States of America also confirmed that the left engine crankshaft in MZK did not fail due to thermal cracking initiated fatigue fracture, that bearing failure was not relevant, and that the crankshaft failure was due to a ‘manufacturing-related material condition’. Like Dr Powell and Mr McLean, they were unable to identify an inclusion in the metal at the fracture site, but he found a ‘pocket’ there, from where an inclusion may have fallen during the fracture process.

Remind us of the PelAir report??? by atsb and the "downgrading" by casa with the use of the MoU??

[Greedy]

Firstly, apologies to Dom. As well as sympathy. If he reads this thread he must feel like a spectator at his own public execution.
I noted that in the report that prior to publishing the ATSB final report "organisations"are invited to comment on the draft. Can some one inform me if individuals ie the Captain and First Officer or other parties are "invited" to comment.
Greedy

[Roj approved]

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?

Umm, i think i know the answer to question 1. Y (maybe a quick chat with some former employers)

and i think the answer to question 2 may not be in his favour either.

[john62]

All the deficiencies and RCAs in the CASA report are symptomatic of an underlying problem. That problem was the culture at Pelair. The audit hints at this in several areas, but does not go far enough IMHO.

Since the accident. Pelair has claimed alternate fuel was not required for aerial work category. That may be strictly legal but it is hardly prudent in that part of the world.

The CASA report states it was not confirmed whether or not these flights were Aerial Work or Charter (page 12). Why not? Why could CASA not determine the category of operations being conducted under the AOC?

The pilots interviewed said they didn't know if they were Aerial Work or Charter (and therefore they could not know what regulations governed their flight planning). The pilots further said they planed as if they were Charter. It appears they did in general. However 3 flights in the 2 months prior to the crash arrived at Norfolk with less that alternate fuel, and so did not comply with Charter requirements. They would only be legal if Aerial Work. The PIC for one of these flights was the former CP and the then WW standards manager.

So what exactly was a junior Captain to make of all this? He screwed up big time. However the system let him down, and I believe most here recognise this. Dom may have a reputation for being too casual in his approach. However he operated in an environment that was equally casual and facilitated this behavior. What Dom really required was an old fashioned kick up the backside long before this flight. I can't see who at Pelair was going to do this.

A marginal fuel policy. Poor oversight of someone who perhaps needed to operate under a very tight system. No RVSM capability. Problems accessing Noumea. Sooner or later luck was going to run out. The only surprise here is that all lived.

[HEALY]

My observation could be really picky and obsolete however I have my own thoughts based on watching the Four Corners doco. At the end of the day the episode shown would only have been watched purely by those who tune in every week for this programme. I would not imagine that many others would have made special effort to watch this EXCEPT for those in the industry discussing this as we read/type.

The crew have been given a good roasting on this forum and as mentioned previously "watched his own execution". Having been under commercial pressures like Dom and have as many others I was willing to have a reserved judgement on his decisions that night and his demeanour thru the interview given the reports findings.....hats off for putting yourself on camera given the media scrutiny!!

Had it of been me going in front of the camera I would have known that it wasn't the usual ABC viewers tuning in every week that I had to convince of my decision making rather my own peers who are picking at my apparent relaxed attitude towards the flight planning and the cowboy attitude that has been hinted on this very forum. For this position to be in (and again I am being very picky here) why wouldnt you show yourself in a very professional light by at least doing the buttons up on your shirt or even go as far as wearing a tie. Having the appearance shown as the Cleo award (which he even mentioned as inappropriate) shows a relaxed and casual approach which is exactly what people are making their decisions about his character

Although it's maybe slightly different you only have to see the QF32 episode to see the difference in how the crew are visually presented to make up minds for Joe public about what the industry is about. Although all rumours about character assassination you can always do yourself a favour.

[thorn bird]

And how many innocent participants have there been in the USA's macabe little ritual killings because the "Media" didnt like their looks or demenor?? And how many innocent pilots have had their careers or businesses destroyed by an unnacountable bureaucrat because of personal vendetas. Perhaps the Skulls performance on the program is a fair indication of how the CASA works, much like Hong Kong I imagine, knives in the back and all.

[Jinglie]

How many people read ATSB reports fully, a few hundred?? 4 Corners has a viewing of 800,000+. How else does a guy like Dominic (who should be referred to as the PIC or CPT not named), get his side of the story out? One guy against 2 very powerful government organisations acting suspiciously! What would you do. This stinks BAD!!!! The PIC has had the guts to stand up and face the questions. All he gets in response is "no comment" from Pel-Air, absolute embarrassing waffle from The CC of the ATSB (cant get any worse), and the Skull telling war stories about doing off-track oceanic diversions by long hand 40 years ago!
The PIC knows what mistakes he made and you can read that through his demeanour on 4 Corners. This report must be withdrawn and a new investigation re-written for the industry to learn from this. Maybe Geoff Thomson could head up the ATSB rather than Beaker!

[blackhand]

@jinglie
Geoff Thompson's woefull understanding of CASA and ATSB would assist how??

[chainsaw]

From crikey:

New evidence undermines credibility of Pel-Air inquiry | Plane Talking

An unedited video of the chief commissioner of the ATSB Martin Dolan taking 18 minutes to insist that Pel-Air wasn’t in breach of the conditions CASA found that it had been in breach of, and attempting to justify the report’s focus on the pilot who was carrying out the his duties according to the standards for which Pel-Air was responsible...

The idiot Minister ought to be asking some really hard questions and having a big arse-kicking party over all of this, but based on past performance, he won't.

[Kharon]

Slight drift.

John -# 295 All the deficiencies and RCAs in the CASA report are symptomatic of an underlying problem.

This statement is made so often, by so many and is so fundamentally wrong it is worthy of a "thread" of it's very own. However I am only going to mildly disagree (it's Sunday). This statement is one of the major causes of AOC and licence /privileges loss, particularly through the AAT system. "Whoa, look at all these RCA, they must be dodgy".

Look at your opposition; you are challenging "the" Gummint sponsored, Minister backed publicly anointed "Heavy weight Champion" of public and ministerial Safety. You pitch up, to tackle the 'Champ' who has a significant advantage before the bell rings and then you offer a 20 point start. Think about it, with 20 or so unacquainted RCA the case against is made before you step into the ring. Then when the previous RCA get tacked onto the pile, it's a hiding to nothing before the first round bell rings

Each RCA issued must be challenged, 'destroyed' and expunged before you even think of taking on CASA in the AAT, nearly everyone overlooks this element. If the RCA list was analysed and even reduced 50% then the case against is weakened. If you can dismiss a further 20% as 'administrative' and have instituted 'corrective' action on the few remaining, then the case against becomes a thing of reality i.e. why are we really here? You cannot and must not allow a major league player (like CASA legal) a 20 point start.

There is nothing wrong with the RCA system when used correctly; but, a Tribunal Member or Judge will make the same wrong assumption. Challenge each RCA, pursue it and always make sure you can provide a written acquittal. It won't prevent the RCA being dragged up, but at least you have a chance of convincing the 'judge' that the 'pile' of heinous charges against you is reduced to a defendable size.

Bit like having a dust up with Missus, you know, "twenty years ago you were late home and said you missed the bus" etc. etc; now empirical evidence of further wrong doings. You know how it works.

[blackhand]

Plane Talking isn’t able to determine the validity of the information provided but the avoidance

@chainsaw, and you call this evidence?
My understanding is that ATSB found that the PIC did not comply with the Procedures as laid down in the approved Procedures Manual.

SEPERATE to this, CASA found that the existing and approved procedures needing expanding. This I can only assume was required to allow for the lowest common denominator - a barely competent Pilot.

As Kharon has pointed out, the number of RCAs, Henceforth to be known as NCNs and previously known as CANs, has nought to do with the argument. One issue can generate several NCNs, each NCN refers to the initial issue but is recorded under a different regulation.
It is important that one identifies Root cause, remedial action and corrective action to get the NCN closed quickly.

[Kharon]

BH # 302 CASA found that the existing and approved procedures needing expanding.

Tricky, subjective business for not just CASA this; they are damned if they do and damned if they don't. All the CASA team can do is recommend (suggest, bully or insist) that a company fuel planning policy is 'compliant'. The easiest way is simply comply with the AFM procedures, that is guaranteed legal. Clear, unambiguous statements in the COM regarding 'fuel planning' policy, flight planning policy and perhaps recommended 'methodology', will cover the operators arse; but regrettably, dump the PIC straight in the cart if policy is not followed. Unless the 'policy is, after the event, proven flawed; round and round she goes etc. Feast day for the legal eagles.

The key (IMO) is company recommended practice and procedure which allows Command discretion (wriggle room) but does not compromise anyone's 'rice bowl'. Deuced tricky problem for all; 20/20 hindsight of course is always through rose coloured glasses.

The problem is that after the event, someone is going to carry the can, if 'they' were part of the problem with 'fuel' then, they can be held accountable. This is most unsatisfactory – for all.

[chainsaw]

An unedited video of the chief commissioner of the ATSB Martin Dolan taking 18 minutes to insist that Pel-Air wasn’t in breach of the conditions CASA found that it had been in breach of, and attempting to justify the report’s focus on the pilot who was carrying out the his duties according to the standards for which Pel-Air was responsible...

http://mpegmedia.abc.net.au/news/fou...Dolan_288p.mp4

chainsaw, and you call this evidence?

Well, seeing as it's a video of Dolan explaining things from the ATSB's perspective, and not hearsay, the answer's YES, especially noting where Dolan stated that the ATSB did not think that it was particularly relevant that PA was breaching regulations and legislation.

[Jinglie]

blackhand,
I didn't mention CASA. And when you look at the CC's 18 minute interview, it's clear who has a woeful understanding, and it's not Thompson.

[blackhand]

that PA was breaching regulations and legislation.

Which ones?

@jinglie Thats Ok bloke, I respectfully disagree.

[chainsaw]

blackhand...

The explanation that you're seeking should be directed at Martin Dolan, because it was him who stated that the ATSB did not think that it was particularly relevant that PA was breaching regulations and legislation.

You ask which regulations PA didn't comply with. The answer to your question was in the CASA Safety Audit Report if you'd bothered to read it. In summary the CASA audit found the following noncompliances in the group:

CAR220(1)
CAR215(2)
CAR 233(3)
CAR 78 and CAO 82.1
CAR 235(1) and (2)
CAR 233(1)
CAO20.7.1B parts 4, 7 & 12
CAR 215(8)
CAO 20.11 parts 11 & 12
CAO 82.1 para 3.3
CAO 40.0 para 5.1, resulting in noncompliance with CAR 215(2)
CAR 215(9)
CASR 92.095
CAR 5.04
CAO 48 para 4
CAR 50
CAR 253(4)
Act Section 28BE paragraph (1), (2), (3a), and (3b).

[blackhand]

if you'd bothered to read it.

Mmmm why the antagonism, this is a discussion with varying opinions.