Norfolk Island Ditching ATSB Report - ?
What has Norfolk taught you?
As accident reports are meant to provide lessons on how to avoid a similar incident occuring again, what have ppruners learnt from this accident?
For me it confirms a few things such as:
For me it confirms a few things such as:
- Always have a plan B
- Just because its the legal minimum doesn't mean its the maximum acceptable.
- Don't trust your employer to be covering your back.
- If the conditions aren't suitable for an approach-hold
- If a ditching is required tell someone where you are
- Know your aircraft and have rough rules of thumb to work out what fuel is required.
- Murphy and his book of rules are a constant companion
- Max landing weight+fuel burn(up to MTOW)-max zero is an acceptable flight planning equation
Join Date: Apr 2012
Location: No fixed address
Posts: 163
Likes: 0
Received 0 Likes
on
0 Posts
Lookleft,
Couldn't agree more! However, I'd like to see the real report that covers all the issues, not this non-offensive waffle that has been produced by the ATSB - and changed due errors, after the final report was released. It begs the question, when is a final report final??? Should there be version control on final reports? Maybe it should be released in "track changes", just to make it easy for us.
Couldn't agree more! However, I'd like to see the real report that covers all the issues, not this non-offensive waffle that has been produced by the ATSB - and changed due errors, after the final report was released. It begs the question, when is a final report final??? Should there be version control on final reports? Maybe it should be released in "track changes", just to make it easy for us.
What has Norfolk taught you?
It takes much more than the books can teach you to be a good captain.
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,055
Likes: 0
Received 0 Likes
on
0 Posts
Willyleaks feed
CS # 307 - The explanation that you're seeking should be directed at Martin Dolan,
Anyway – at great cost and not without some danger; we got a WillyLeaks video feed from the secret, post prang Monday morning meeting.
The observations from the QF pilot in Sandilands article absolutely nails the state of play with the PA ditching report:
It is further summed up by comment 2 of the article:
These coupled with the extended interview with MD, the dismal lack of conclusionary detail and lack of positive safety actions etc in ATSB final reports (in recent years) should be enough to have MD's head on a platter...and FFS scrap the CASA/ATSB MOU!
New evidence undermines credibility of Pel-Air inquiry | Plane Talking
Top call Kharon on this thread, it is definitely past time!
http://www.pprune.org/dg-p-reporting...2011-a-22.html
I am a Qantas pilot and have been reading the ATSB report of the Pel-Air Norfolk Island accident. From my own reading and conversations with fellow professionals, I have become deeply concerned about the accuracy of information presented as “fact” in the report.
Reading the ATSB report, one of the systemic issues that has been missed and a possible error in detail in the report is the part where the ATSB takes issue with the Captain not asking if any amended TAFs [terminal area or aerodrome forecasts] had been issued for Norfolk Island. This seems like a stupid statement as, if it hadn’t been brought to his attention that an amended TAF had been issued, why would he ask for it? TAFs are issued at routine intervals. Amended TAFs are only issued if something fundamental has changed in the weather and are issued ad hoc, therefore, unless someone lets you know one has been issued, you would never know. The ATSB report then goes on to say that “Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew”. Why is this not a “finding” of the report then?
If a TAF is amended and it fundamentally impacts the safety of an aircraft in flight, why wouldn’t it be a requirement to let the Captain know about it? This seems insane! If this is true, the laws need changing and therefore it is a systemic problem and should have been a finding.
That being said, I am not convinced it is true. In the Air Services Australia Aeronautical Information Publication (AIP), section GEN 3.3, paras 2.5.1, 2.5.4 and 2.5.5 seem to indicate that ATC should be providing pilots with flight information services about the existence of non-routine meteorological reports affecting the safety of relevant aircraft. My reading of these paragraphs lead me to believe the either the ATSB is wrong and Nadi was definitely obliged to inform the Captain of the amended TAF so that he could have diverted to a suitable alternate! I believe this is a crucial issue that has been missed by the ATSB. As a pilot with Qantas, it has also struck me as odd that the ATSB has made a lot of noise about the Captains fuel planning and suggestions of what he could/couldn’t have done with varying fuel load options and yet they haven’t included any numbers i.e. where are their calculations?
The reason this has struck me as odd is that some of the comments they have made about depressurised fuel loads don’t match up with my experience at Qantas and I would like to take a look at how they have calculated it to see if the ATSB hasn’t made an error. I will give you an example.
In Qantas jet operations, we have depressurisation decision points calculated for us pre-flight (by the way, right/wrong, safe/unsafe, these are only a preflight requirement… airborne you can burn into these fuels even if it means your decision point would no longer be valid). As the depressurised fuels do not require a variable reserve and two-engine fuel does, nearly always the depressurised fuel required for a flight is actually less than what would be required legally for two engines. My point is, ATSB has said if depressurised fuel had been calculated, the Captain would have had MORE fuel on board than he carried. This hardly ever seems to be the case in my experience and on the odd occasion it is required, it isn’t usually a significant amount. Considering the Pel-Air Captain had enough fuel on board to not only meet his legal two-engine requirements, but also shoot four approaches before ditching (with fuel still remaining), I find the ATSB assertions about fuel planning and options available less than compelling without data to back it up. I have spoken to friends on other fleets and other airlines to me, and I am not the only one who read this part of the report and was left wondering if the ATSB had cocked up their fuel calculations. We’d all be interested to see them. Another thing I find puzzling is that it is not a finding of the report that had the FO [first officer] been at flight planning, she may have been able to act as a hand-brake to the Captain leaving if indeed errors had been made. The FO, by company SOP, was not included in the flight planning. It seemed important enough to the ATSB to mention that Pel-Air has changed this policy, but not important enough to mention it in the preamble or the findings. The scary bit is that this practice was not Pel-Air specific. I have spoken to Qantas, Virgin and Jetstar pilots who started their RPT careers from Skippers, Network Aviation, Qantas Link etc and they have all indicated at their former employers, when acting as FOs, they would be sent to preflight the aircraft while the Captain did the flight planning. One final question I think needs answering is, why did the crew decide to continue? The ATSB report mentions that they didn’t think they could make Noumea, so they continued on. The report doesn’t answer the question as to why they came to this conclusion. I am assuming they just didn’t do this on a whim. Did they calculate a PNR [point of no return]? Were they past any PNR they may have calculated? If they had calculated a PNR (even if it was wrongly calculated) and they were past it, then it wouldn’t just be a case of them being unsure they couldn’t make Noumea, to them it would have been they had no option but to continue. I am sure I have heard somewhere in the media at the time of the prang or on Four Corners, somewhere, that the Captain had calculated a PNR and they had passed it when they finally became aware that the weather had not only gone below alternate minima, it had now gone below landing minima.
Pilots make decisions for reasons and the ATSB has failed to explain what the Captain’s reasoning was. If he had calculated a PNR, where is the data? If he had calculated a PNR, did he use the PNR examples in the Pel-Air manuals? This is vital information missing from the report as the ATSB has made several claims in their report of where they feel real PNRs existed and when decisions could have been made but weren’t.
I’m not for a minute suggesting that maybe the crew couldn’t have been more proactive, but if this report is supposed to explain to aviators why decisions were made that lead to an accident, then where are the explanations? Where are the details? Where are the pilots calculations and where are the ATSBs own calculations? I agree with your conclusion, that the ATSB and CASA seemed to have played the man on this one and the report, as it stands is toiler paper! If they are going to play the man, they could at least show the evidence to support their play. As it stands, playing the man without providing any supporting evidence at all makes me wonder what they are hiding (beyond the CASA adverse findings on Pel-Air that 4 Corners exposed!).
At Qantas we have ALL the systems in place that Pel-Air was lacking. We have a stringent fuel policy that includes decision points for depressurisation, ETOPS and single engine operations. We have a flight planning department that prepares our plans, weather, NOTAMS and makes all calculations for us. We are flight followed and the company lets us know if amended weathers are issued that will adversely affect our flight. Our operations department operates 24/7 and is available for us on the SAT phones they give us. At the end of the day, we are only the final layer of defense in that we check all these other factors before we depart. The Pel-Air audit found them lacking in all these respects.
Without any of these layers available to him, the Pel-Air Captain was the only defense. At Qantas, a lot of holes in a lot of layers of Swiss cheese have to line up for mistakes of this magnitude to happen; at Pel-Air it seems that there was only one layer, the Captain. While he made mistakes, he seems to be the only one being held accountable by CASA and the ATSB.
Reading the ATSB report, one of the systemic issues that has been missed and a possible error in detail in the report is the part where the ATSB takes issue with the Captain not asking if any amended TAFs [terminal area or aerodrome forecasts] had been issued for Norfolk Island. This seems like a stupid statement as, if it hadn’t been brought to his attention that an amended TAF had been issued, why would he ask for it? TAFs are issued at routine intervals. Amended TAFs are only issued if something fundamental has changed in the weather and are issued ad hoc, therefore, unless someone lets you know one has been issued, you would never know. The ATSB report then goes on to say that “Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew”. Why is this not a “finding” of the report then?
If a TAF is amended and it fundamentally impacts the safety of an aircraft in flight, why wouldn’t it be a requirement to let the Captain know about it? This seems insane! If this is true, the laws need changing and therefore it is a systemic problem and should have been a finding.
That being said, I am not convinced it is true. In the Air Services Australia Aeronautical Information Publication (AIP), section GEN 3.3, paras 2.5.1, 2.5.4 and 2.5.5 seem to indicate that ATC should be providing pilots with flight information services about the existence of non-routine meteorological reports affecting the safety of relevant aircraft. My reading of these paragraphs lead me to believe the either the ATSB is wrong and Nadi was definitely obliged to inform the Captain of the amended TAF so that he could have diverted to a suitable alternate! I believe this is a crucial issue that has been missed by the ATSB. As a pilot with Qantas, it has also struck me as odd that the ATSB has made a lot of noise about the Captains fuel planning and suggestions of what he could/couldn’t have done with varying fuel load options and yet they haven’t included any numbers i.e. where are their calculations?
The reason this has struck me as odd is that some of the comments they have made about depressurised fuel loads don’t match up with my experience at Qantas and I would like to take a look at how they have calculated it to see if the ATSB hasn’t made an error. I will give you an example.
In Qantas jet operations, we have depressurisation decision points calculated for us pre-flight (by the way, right/wrong, safe/unsafe, these are only a preflight requirement… airborne you can burn into these fuels even if it means your decision point would no longer be valid). As the depressurised fuels do not require a variable reserve and two-engine fuel does, nearly always the depressurised fuel required for a flight is actually less than what would be required legally for two engines. My point is, ATSB has said if depressurised fuel had been calculated, the Captain would have had MORE fuel on board than he carried. This hardly ever seems to be the case in my experience and on the odd occasion it is required, it isn’t usually a significant amount. Considering the Pel-Air Captain had enough fuel on board to not only meet his legal two-engine requirements, but also shoot four approaches before ditching (with fuel still remaining), I find the ATSB assertions about fuel planning and options available less than compelling without data to back it up. I have spoken to friends on other fleets and other airlines to me, and I am not the only one who read this part of the report and was left wondering if the ATSB had cocked up their fuel calculations. We’d all be interested to see them. Another thing I find puzzling is that it is not a finding of the report that had the FO [first officer] been at flight planning, she may have been able to act as a hand-brake to the Captain leaving if indeed errors had been made. The FO, by company SOP, was not included in the flight planning. It seemed important enough to the ATSB to mention that Pel-Air has changed this policy, but not important enough to mention it in the preamble or the findings. The scary bit is that this practice was not Pel-Air specific. I have spoken to Qantas, Virgin and Jetstar pilots who started their RPT careers from Skippers, Network Aviation, Qantas Link etc and they have all indicated at their former employers, when acting as FOs, they would be sent to preflight the aircraft while the Captain did the flight planning. One final question I think needs answering is, why did the crew decide to continue? The ATSB report mentions that they didn’t think they could make Noumea, so they continued on. The report doesn’t answer the question as to why they came to this conclusion. I am assuming they just didn’t do this on a whim. Did they calculate a PNR [point of no return]? Were they past any PNR they may have calculated? If they had calculated a PNR (even if it was wrongly calculated) and they were past it, then it wouldn’t just be a case of them being unsure they couldn’t make Noumea, to them it would have been they had no option but to continue. I am sure I have heard somewhere in the media at the time of the prang or on Four Corners, somewhere, that the Captain had calculated a PNR and they had passed it when they finally became aware that the weather had not only gone below alternate minima, it had now gone below landing minima.
Pilots make decisions for reasons and the ATSB has failed to explain what the Captain’s reasoning was. If he had calculated a PNR, where is the data? If he had calculated a PNR, did he use the PNR examples in the Pel-Air manuals? This is vital information missing from the report as the ATSB has made several claims in their report of where they feel real PNRs existed and when decisions could have been made but weren’t.
I’m not for a minute suggesting that maybe the crew couldn’t have been more proactive, but if this report is supposed to explain to aviators why decisions were made that lead to an accident, then where are the explanations? Where are the details? Where are the pilots calculations and where are the ATSBs own calculations? I agree with your conclusion, that the ATSB and CASA seemed to have played the man on this one and the report, as it stands is toiler paper! If they are going to play the man, they could at least show the evidence to support their play. As it stands, playing the man without providing any supporting evidence at all makes me wonder what they are hiding (beyond the CASA adverse findings on Pel-Air that 4 Corners exposed!).
At Qantas we have ALL the systems in place that Pel-Air was lacking. We have a stringent fuel policy that includes decision points for depressurisation, ETOPS and single engine operations. We have a flight planning department that prepares our plans, weather, NOTAMS and makes all calculations for us. We are flight followed and the company lets us know if amended weathers are issued that will adversely affect our flight. Our operations department operates 24/7 and is available for us on the SAT phones they give us. At the end of the day, we are only the final layer of defense in that we check all these other factors before we depart. The Pel-Air audit found them lacking in all these respects.
Without any of these layers available to him, the Pel-Air Captain was the only defense. At Qantas, a lot of holes in a lot of layers of Swiss cheese have to line up for mistakes of this magnitude to happen; at Pel-Air it seems that there was only one layer, the Captain. While he made mistakes, he seems to be the only one being held accountable by CASA and the ATSB.
It is further summed up by comment 2 of the article:
Fantastic commentary by the QF pilot you corresponded with. It does now seem ATSB (over)played the man in this incident. He certainly wasn’t blameless, but at the same time was part of a larger systemic safety issue at Pel-Air, which the ATSB seem to have downplayed for some reason. The more interesting question is ‘why?’. Why did they not take a tougher line with the operator? It doesn’t augur well for future investigations which are meant to be utterly objective and beyond reproach. Without the ABC investigation we probably be none the wiser.
These coupled with the extended interview with MD, the dismal lack of conclusionary detail and lack of positive safety actions etc in ATSB final reports (in recent years) should be enough to have MD's head on a platter...and FFS scrap the CASA/ATSB MOU!
New evidence undermines credibility of Pel-Air inquiry | Plane Talking
Top call Kharon on this thread, it is definitely past time!
http://www.pprune.org/dg-p-reporting...2011-a-22.html
Last edited by Sarcs; 10th Sep 2012 at 00:12.
I've learnt that under:
Jepp ATC AU-107 6.1.1
'The objectives of the air traffic services are too:
Jepp ATC AU-107 6.1.1 d
'provide advice and information useful for the safe and efficient conduct of flights'
Is not always the case, and if they fail to pass you the information on, it's your fault for not knowing any better.
Whilst the skipper got himself in a spot of bother, if he had that information at the crucial time passed on time as per the mission statement of ATC, we wouldn't be having this discussion.
Jepp ATC AU-107 6.1.1
'The objectives of the air traffic services are too:
Jepp ATC AU-107 6.1.1 d
'provide advice and information useful for the safe and efficient conduct of flights'
Is not always the case, and if they fail to pass you the information on, it's your fault for not knowing any better.
Whilst the skipper got himself in a spot of bother, if he had that information at the crucial time passed on time as per the mission statement of ATC, we wouldn't be having this discussion.
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,055
Likes: 0
Received 0 Likes
on
0 Posts
Irksome
Well it is. There is no Coroner, no AAT, no Court and no where for this case to go. The Pell Air mess, the associated safety, compliance, ATSB reporting issues all; will simply slide off page one and so, into cyber space history.
There are some first class posts here, valuable logic and operational 'savvy'; all valid in the real world. What will be left behind, apart from a bad taste is the ATSB report. That's it. Future Pollies may use it for toilet paper, or it will be used in some wildly expensive insurance based civil action and that's it. Poof; gone a victim of smoke and mirrors.
Good job boys and girls; not too shabby at all.
Aye well. Beer o'clock, I see the old man has the top off one already. No bloody aviation at dinner, that's the rule.
There are some first class posts here, valuable logic and operational 'savvy'; all valid in the real world. What will be left behind, apart from a bad taste is the ATSB report. That's it. Future Pollies may use it for toilet paper, or it will be used in some wildly expensive insurance based civil action and that's it. Poof; gone a victim of smoke and mirrors.
Good job boys and girls; not too shabby at all.
Aye well. Beer o'clock, I see the old man has the top off one already. No bloody aviation at dinner, that's the rule.
Last edited by Kharon; 10th Sep 2012 at 06:29.
lexicon and etc...
The 4c showed that the Westwind guy had another job , and the coie does too.
Which is good.
At least they weren't "Qadrio-ed" No job, no income, no licence, no career.
J Quadrio didnt drop a Robbo into the water and didnt nearly wipe out 6 people... saved by the Pelair bell were the other?
Which is good.
At least they weren't "Qadrio-ed" No job, no income, no licence, no career.
J Quadrio didnt drop a Robbo into the water and didnt nearly wipe out 6 people... saved by the Pelair bell were the other?
"K" that's very well put yr last post, at the end of the day the whole event from the time they had no option but to ditch to the shambles of a report being filed in the round file it was destined to lead to nowhere.
The flight crew obviously didn't walk out the door that day/night thinking this is gunna end in tears but due to a variety of mistakes made by ALL concerned the end products (the people on board) where the ones that got effected.
Luck, divine intervention call it what ya like the outcome was favorable & so another human induced event fades into the annuls of our aviation history.
Like car accidents we have them daily where people lives are effected 4ever yet we continue to parade them out night after night on the TV & don't learn a damned thing!!!
We humans where never to good at learning from our mistakes we just keep inventing new ones !
Wmk2
The flight crew obviously didn't walk out the door that day/night thinking this is gunna end in tears but due to a variety of mistakes made by ALL concerned the end products (the people on board) where the ones that got effected.
Luck, divine intervention call it what ya like the outcome was favorable & so another human induced event fades into the annuls of our aviation history.
Like car accidents we have them daily where people lives are effected 4ever yet we continue to parade them out night after night on the TV & don't learn a damned thing!!!
We humans where never to good at learning from our mistakes we just keep inventing new ones !
Wmk2
lexicon and etc...
The 4Cs showed that the Westwind guy had another job , and the coie does too.
Which is good. Free to carry on a career. After a night to remember.
At least they weren't "Qadrio-ed" No job, no income, no licence, no career.
J Quadrio did NOT drop a Robbo into the water and did NOT nearly wipe out 6 people... saved by the Pelair bell were the others? Or the effluxion of CASA and ATSB.
Do I detect a certain aroma here?? Or is it just plain old CYA 101?
JQs treatment should now be in the lexicon..
A quadrio. n..ie name of the act, to sh*t on someone, used by the regulator, without due process. ie do a quadrio on someone, a wrongful act without due process.
Quadrio-ed vb. The act of sh*tting on a person, by the regulator, without due process. ie he's been quadrioed... thus becoming the shattee.
Will be most interesting to see how these 2 diverse occurences finally play out.
Maybe the PelAir is over already.
Which is good.
Free to carry on a career. After a night to remember.At least they weren't "Qadrio-ed" No job, no income, no licence, no career.
J Quadrio did NOT drop a Robbo into the water and did NOT nearly wipe out 6 people... saved by the Pelair bell were the others? Or the effluxion of CASA and ATSB.
Do I detect a certain aroma here?? Or is it just plain old CYA 101?JQs treatment should now be in the lexicon..
A quadrio. n..ie name of the act, to sh*t on someone, used by the regulator, without due process. ie do a quadrio on someone, a wrongful act without due process.
Quadrio-ed vb. The act of sh*tting on a person, by the regulator, without due process. ie he's been quadrioed... thus becoming the shattee.
Will be most interesting to see how these 2 diverse occurences finally play out.
Maybe the PelAir is over already.
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,055
Likes: 0
Received 0 Likes
on
0 Posts
Cheers Wally – it's not only the 'shambles' of a report that gets me. There have been a whole series of reports (Jetstar, Air North, Whyalla, Airtex etc. etc) which are effectively useless for industry practical intent and purpose.
They work fine for the CASA and the Minister and for at least one of the insurance companies; but, as far as being of any value in accident prevention, defining preventable accident or cause, producing cohesive guidelines, they are a none event. Think it was Sarcs a page or so back compared the BASI report on Seaview to the Air North Braz. Chalk and cheese.
The fix went in after Staunton (Seaview) to protect the minister, since then in a very legal way, through the Miller report and the MOU, the reports just mirror whatever the party line is at the time. Compare Jetstar reports to Tiger reports and you will see. Perhaps someone can put a link or four up.
I hear the Canley Vale report is due soon, betcha a choccy frog the report is skewed to the max; it will have to be; to protect and enshrine the CASA line taken during the rape of Airtex. Now the differences between PA and Airtex have to be justified and excused. Can't wait, then there will be the Coroners court. Happy days !.
One of these cases will come back and haunt them all, comparable situations, comparable alleged breaches, vastly different AOC outcome, different treatment of Check Training, different treatment of pilots; and, very, very different ATSB reports. Tick tock.
They work fine for the CASA and the Minister and for at least one of the insurance companies; but, as far as being of any value in accident prevention, defining preventable accident or cause, producing cohesive guidelines, they are a none event. Think it was Sarcs a page or so back compared the BASI report on Seaview to the Air North Braz. Chalk and cheese.
The fix went in after Staunton (Seaview) to protect the minister, since then in a very legal way, through the Miller report and the MOU, the reports just mirror whatever the party line is at the time. Compare Jetstar reports to Tiger reports and you will see. Perhaps someone can put a link or four up.
I hear the Canley Vale report is due soon, betcha a choccy frog the report is skewed to the max; it will have to be; to protect and enshrine the CASA line taken during the rape of Airtex. Now the differences between PA and Airtex have to be justified and excused. Can't wait, then there will be the Coroners court. Happy days !.
One of these cases will come back and haunt them all, comparable situations, comparable alleged breaches, vastly different AOC outcome, different treatment of Check Training, different treatment of pilots; and, very, very different ATSB reports. Tick tock.
Join Date: Jul 2010
Location: sydney
Posts: 1,469
Likes: 0
Received 0 Likes
on
0 Posts
There is a real difference between the JQ case and the Norfolk guy.
The first was just a poor country lad.
The latter came from a wealthy background.
A good lawyer could argue the guy breached no rules, lacking experience
and being a tad foolish is not a crime.
His licence was suspended by the Bankstown Ex RAAF baggage handler, but later reinstated so I heard. That wasnt because a well funded lawsuite was in the offering was it?
The first was just a poor country lad.
The latter came from a wealthy background.
A good lawyer could argue the guy breached no rules, lacking experience
and being a tad foolish is not a crime.
His licence was suspended by the Bankstown Ex RAAF baggage handler, but later reinstated so I heard. That wasnt because a well funded lawsuite was in the offering was it?
Compare Jetstar reports to Tiger reports and you will see. Perhaps someone can put a link or four up.
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-136.aspx
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-089.aspx
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-039.aspx
http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-037.aspx
http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-021.aspx
http://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-044.aspx
http://www.atsb.gov.au/publications/investigation_reports/2008/aair/ao-2008-020.aspx
http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-035.aspx
http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-073.aspx
http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-011.aspx
http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-031.aspx
http://www.atsb.gov.au/publications/investigation_reports/2008/aair/ao-2008-049.aspx
Fill your boots with that lot, can't promise you'll learn anything but it is a good comparison and probably shows 'Regulatory Capture' and the MOU in all its glory!
Oh and here is a quote from the Braz training accident in Darwin...
Contributing safety factors
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Other key findings
• Shortly after the accident, when an Australian aviation training facility operating an EMB-120 simulator and its staff were approved to undertake the operator’s training requirements, the operator transitioned the majority of its EMB-120 proficiency checking, including asymmetric flight sequences, to ground-based training at that facility.
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Other key findings
• Shortly after the accident, when an Australian aviation training facility operating an EMB-120 simulator and its staff were approved to undertake the operator’s training requirements, the operator transitioned the majority of its EMB-120 proficiency checking, including asymmetric flight sequences, to ground-based training at that facility.
http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf
I could do the same for Seaview but I don't believe the mods would appreciate it as the same section of that report holds about half a gig of conclusionary and safety action (SRs)...well worth a read though!
http://atsb.com.au/media/24362/aair199402804_001.pdf
Here's a couple more Airbus events for 2012:
http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-116.aspx
http://www.atsb.gov.au/publications/investigation_reports/2012/aair/ao-2012-103.aspx
Last edited by Sarcs; 11th Sep 2012 at 05:23.
Join Date: Sep 2003
Location: S37.54 E145.11
Posts: 639
Likes: 0
Received 0 Likes
on
0 Posts
Norfolk Island FIS Responsibility
Ref post #313
It is a requirement to let the Captain know about an amended TAF and there are international standards covering how delivery responsibility is allocated to the ATS units, however the question in this incident is whose responsibility was it to direct the information to the incident aircraft; Airservices Australia or Airways NZ?
One thing for sure it is not a Nadi ATC responsibility as Norfolk Island is located in the Auckland Oceanic FIR so, under normal circumstances, the responsibility should rest with Airways NZ. However, the NZ AIP (Gen 3.3) specifically excludes Norfolk Island as an Airways ATS responsibility because Norfolk Island is administered by Australia and, therefore, by implication the NZ AIP assumes it is an Airservices Australia responsibility to pass amended TAFs to aircraft operating or intending to operate at Norfolk Island. This was certainly the case when there was an Airservices' Flight Service Unit (FSU) located at Norfolk Island who had the FIS responsibility and flight plans were addressed to the FSU to assist them in their directed FIS delivery function.
When the FSU was decommissioned in the early 1990s and MBZ procedures were established at Norfolk Island, the ATS (including FIS) responsibility should have been transferred to the Brisbane FSC and, in my view, the NZ AIP wording appears to reflect this arrangement. However, in order for Airservices to provide a FIS, the Brisbane FSC would require access to all Norfolk Island flight plans including all those not transiting an Australian FIR. Were the relevant aircraft flight plans redirected to the Brisbane FSC once the Norfolk Island FSU was decommissioned? The alternative was to transfer the FIS responsibility to Airways NZ seeing Norfolk Island was in the Auckland Oceanic FIR, which was obviously not done.
To further complicate matters, Airservices' Flight Service function was subsequently amalgamated with the ATC function and, without access to the required flight plans (particularly those for Apia-Norfolk Island, Auckland-Norfolk Island, Nadi-Norfolk Island which do not go through any Australian FIR) Airservices would not have had the necessary data to provide a directed FIS for Norfolk Island. Furthermore, Airservices Australia then changed FIS responsibility from one where ATC provided a directed FIS service to placing responsibility on a pilot on an "on request" or "self help" basis using Flightwatch.
With all these changes over time, combined with the confusion caused by an Australian territory located in a foreign FIR but operating under Australian regulations and standards, I suspect Norfolk Island FIS delivery responsibility probably "fell through the cracks" between Australia and NZ when the FSU was decommissioned in the early 1990s, which may be another contributing reason why the Pel-Air pilot was not aware of the amended TAF on Norfolk Island; notwithstanding the pilot's own flight plan and in-flight update failings.
So the big question now is:
"DID ANYONE IN CASA OR AIRSERVICES ALERT THE CAA OF NZ OR AIRWAYS NZ OF THE CONTINUED NEED FOR AIRCRAFT FLIGHT PLANS TO BE ADDRESSED TO THE BRISBANE FSC ONCE THE NORFOLK ISLAND FSU WAS DECOMISSIONED IN THE 1990s ? AND FURTHERMORE DID ANYONE IN CASA OR AIRSERVICES COORDINATE WITH THEIR NZ COUNTERPARTS TO ALERT THEM TO THE OPERATIONAL IMPACT THAT THE CHANGE BY AIRSERVICES FROM A DIRECTED FIS TO AN ON REQUEST FLIGHTWATCH FIS MAY HAVE ON THE DELIVERY OF FIS AT NORFOLK ISLAND SO THAT THE NZ AGENCIES COULD REVIEW THEIR AIP AND ATS ARRANGEMENTS? I suspect not.
This issue needs to be resolved for the safety of future operations.
The ATSB report then goes on to say that “Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew”. Why is this not a “finding” of the report then? If a TAF is amended and it fundamentally impacts the safety of an aircraft in flight, why wouldn’t it be a requirement to let the Captain know about it? This seems insane! If this is true, the laws need changing and therefore it is a systemic problem and should have been a finding.
One thing for sure it is not a Nadi ATC responsibility as Norfolk Island is located in the Auckland Oceanic FIR so, under normal circumstances, the responsibility should rest with Airways NZ. However, the NZ AIP (Gen 3.3) specifically excludes Norfolk Island as an Airways ATS responsibility because Norfolk Island is administered by Australia and, therefore, by implication the NZ AIP assumes it is an Airservices Australia responsibility to pass amended TAFs to aircraft operating or intending to operate at Norfolk Island. This was certainly the case when there was an Airservices' Flight Service Unit (FSU) located at Norfolk Island who had the FIS responsibility and flight plans were addressed to the FSU to assist them in their directed FIS delivery function.
When the FSU was decommissioned in the early 1990s and MBZ procedures were established at Norfolk Island, the ATS (including FIS) responsibility should have been transferred to the Brisbane FSC and, in my view, the NZ AIP wording appears to reflect this arrangement. However, in order for Airservices to provide a FIS, the Brisbane FSC would require access to all Norfolk Island flight plans including all those not transiting an Australian FIR. Were the relevant aircraft flight plans redirected to the Brisbane FSC once the Norfolk Island FSU was decommissioned? The alternative was to transfer the FIS responsibility to Airways NZ seeing Norfolk Island was in the Auckland Oceanic FIR, which was obviously not done.
To further complicate matters, Airservices' Flight Service function was subsequently amalgamated with the ATC function and, without access to the required flight plans (particularly those for Apia-Norfolk Island, Auckland-Norfolk Island, Nadi-Norfolk Island which do not go through any Australian FIR) Airservices would not have had the necessary data to provide a directed FIS for Norfolk Island. Furthermore, Airservices Australia then changed FIS responsibility from one where ATC provided a directed FIS service to placing responsibility on a pilot on an "on request" or "self help" basis using Flightwatch.
With all these changes over time, combined with the confusion caused by an Australian territory located in a foreign FIR but operating under Australian regulations and standards, I suspect Norfolk Island FIS delivery responsibility probably "fell through the cracks" between Australia and NZ when the FSU was decommissioned in the early 1990s, which may be another contributing reason why the Pel-Air pilot was not aware of the amended TAF on Norfolk Island; notwithstanding the pilot's own flight plan and in-flight update failings.
So the big question now is:
"DID ANYONE IN CASA OR AIRSERVICES ALERT THE CAA OF NZ OR AIRWAYS NZ OF THE CONTINUED NEED FOR AIRCRAFT FLIGHT PLANS TO BE ADDRESSED TO THE BRISBANE FSC ONCE THE NORFOLK ISLAND FSU WAS DECOMISSIONED IN THE 1990s ? AND FURTHERMORE DID ANYONE IN CASA OR AIRSERVICES COORDINATE WITH THEIR NZ COUNTERPARTS TO ALERT THEM TO THE OPERATIONAL IMPACT THAT THE CHANGE BY AIRSERVICES FROM A DIRECTED FIS TO AN ON REQUEST FLIGHTWATCH FIS MAY HAVE ON THE DELIVERY OF FIS AT NORFOLK ISLAND SO THAT THE NZ AGENCIES COULD REVIEW THEIR AIP AND ATS ARRANGEMENTS? I suspect not.
This issue needs to be resolved for the safety of future operations.
Last edited by QSK?; 11th Sep 2012 at 04:20.
Moderator
Oh and here is a quote from the Braz training accident in Darwin...
I think that says it all for the specifics of the prang.
What didn't impress me was the Report's lack of detail on contributory operator shortcomings which, I presume, existed ...
I think that says it all for the specifics of the prang.
What didn't impress me was the Report's lack of detail on contributory operator shortcomings which, I presume, existed ...
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,055
Likes: 0
Received 0 Likes
on
0 Posts
Now - I love Tuesday.
A 'friend' emailed me a confidential report earlier today, wanted my thoughts on it before sending it off to wherever 'they' want to send it. (Thanks mate, I resisted editing it). It's some 20 pages long and deals with a fatal air accident. Got me thinking (not a usual Tuesday occupation).
OK. For the coveted 'Choccy Frog' which accident does it refer to??.
Your Choccy Frog awaits.
OK. For the coveted 'Choccy Frog' which accident does it refer to??.
Many areas of 'operational' and legal significance have not, in our opinion been satisfactorily addressed or presented. These important, directly related elements, whilst technical are relatively straight forward; and, may be readily comprehended by 'the man in the street'. We believe that this information properly presented could have greatly assisted the Coroner formulate a decision with greater clarity.
From an industry point of view, it appears that the inquiry was ruthlessly driven to an almost forgone conclusion. Primarily by the omission of what is believed to be important information for the Coroner to consider; the inability of the court to interview essential witnesses and examine that testimony. Some of the Coroners remarks seem to reflect this.
One shortcoming, in our view of the ATSB is, that, unlike the USA National Transport Safety Bureau (NTSB), ATSB does not find a “most probable cause” of an accident, or present 'ranked' contributory causes.
From an industry point of view, it appears that the inquiry was ruthlessly driven to an almost forgone conclusion. Primarily by the omission of what is believed to be important information for the Coroner to consider; the inability of the court to interview essential witnesses and examine that testimony. Some of the Coroners remarks seem to reflect this.
One shortcoming, in our view of the ATSB is, that, unlike the USA National Transport Safety Bureau (NTSB), ATSB does not find a “most probable cause” of an accident, or present 'ranked' contributory causes.
Last edited by Kharon; 11th Sep 2012 at 07:25. Reason: It NEEDED editing - curse you Papa.
by the Bankstown Ex RAAF baggage handler,
Give him a break, he was an RAAF Loadmaster ---- he gave the orders to the baggage handlers, pas comme ca. Credit where credit is due, and all that sort of thing.
Tootle pip!!