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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 24th Sep 2012, 05:29
  #341 (permalink)  
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There is no love lost between Rex and Albo. Rex have pretty publically declared which side of politics they support.



I don't think the current Fed Govt would do any favours for Rex. They would do favours for themselves though and make sure there were no embarrassing stories for Albo to answer.

Last edited by Lester Burnham; 24th Sep 2012 at 05:30.
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Old 24th Sep 2012, 05:30
  #342 (permalink)  
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Horatio, owen and Falling Leaf I believe in bureaucratic speak that would be called 'regulatory capture', where the big end of town seeks to find political and regulatory favour with government regulating agencies.

Back in 2008 "RC" got the FAA in a spot of bother when they were dobbed in by a couple of whistleblowers, see here from Wikipedia:
Federal Aviation Administration (FAA)
The Federal Aviation Administration has a dual-mandate both to promote aviation and to regulate its safety. A report by the Department of Transportation that found FAA managers had allowed Southwest Airlines to fly 46 airplanes in 2006 and 2007 that were overdue for safety inspections, ignoring concerns raised by inspectors. Audits of other airlines resulted in two airlines grounding hundreds of planes, causing thousands of flight cancellations.[29]

The House Transportation and Infrastructure Committee investigated the matter after two FAA whistleblowers, inspectors Charalambe "Bobby" Boutris and Douglas E. Peters, contacted them. Boutris said he attempted to ground Southwest after finding cracks in the fuselage, but was prevented by supervisors he said were friendly with the airline.[30]

The committee subsequently held hearings in April 2008. James Oberstar, former chairman of the committee said its investigation uncovered a pattern of regulatory abuse and widespread regulatory lapses, allowing 117 aircraft to be operated commercially although not in compliance with FAA safety rules.[30]

Oberstar said there was a "culture of coziness" between senior FAA officials and the airlines and "a systematic breakdown" in the FAA's culture that resulted in "malfeasance, bordering on corruption."[30]

On July 22, 2008, a bill was unanimously approved in the House to tighten regulations concerning airplane maintenance procedures, including the establishment of a whistleblower office and a two-year "cooling off" period that FAA inspectors or supervisors of inspectors must wait before they can work for those they regulated.[29]

The bill also required rotation of principal maintenance inspectors and stipulated that the word "customer" properly applies to the flying public, not those entities regulated by the FAA. The FAA was directed to stop calling airlines its "customers".[29][note 2]

Southwest was eventually fined $10.2 million for failing to inspect older planes for cracks, according to a 2004 FAA directive.[31]

In September 2009, the FAA administrator issued a directive mandating that the agency use the term "customers" only to refer to the flying public.[32] Prior to the deregulation of the US air industry, the Civil Aeronautics Board served to maintain an oligopoly of US airlines.[33][34]

In a June 2010 article on regulatory capture, the FAA was cited as an example of "old-style" regulatory capture, "in which the airline industry openly dictates to its regulators its governing rules, arranging for not only beneficial regulation but placing key people to head these regulators."[35]
Regulatory capture - Wikipedia, the free encyclopedia

"Culture of coziness"! Not sure if for any amount of regulatory or political favour I'd want to get cozy with the likes of "Voodoo Doctor" or the "Ghost Who Walks!"

Last edited by Sarcs; 24th Sep 2012 at 05:44.
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Old 24th Sep 2012, 09:27
  #343 (permalink)  
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Update to the update!

Planetalking sure is firing up about all this:
*Publication of this post has produced a categorical denial from a Ministerial spokesperson that the ATSB report in question is being replaced or amended.
Of course those who read this post will become aware that this is not the real issue, which is the disgraceful quality of the report that the ATSB issued.

There are rumors circulating that the ATSB final report into the Pel-Air medical evacuation flight ditching near Norfolk Island in November 2009 is to be withdrawn and replaced with a new report.

The Minister for Infrastructure and Transport, Anthony Albanese’s media officers have not responded to a query about the validity or otherwise of this rumor since Saturday morning.

If the rumors are true, it will an heroic admission of exceedingly serious failures on the part of the ATSB, the air safety investigator, and reflect very adversely on CASA, the air safety regulator.

It would also follow from such an admission that both bodies would undergo some serious changes in management and conduct in order to restore Australia’s reputation as a level one state in terms of air safety administration.

If however the rumors are untrue, or there is instead a ‘final’ final report being prepared, which will attempt to repair the damage to process and institutional reputation done by the ‘no longer final’ final report, as well as to the captain of the flight, both bodies will struggle to regain credibility and respect from many stakeholders in aviation in Australia, as well as in the eyes of peer organisations, including ICAO and the FAA.

One way of analyzing the performance of the ATSB and CASA in relation to Pel-Air is to look at how the final report was constructed to load almost the entire blame for the accident on the captain for having inadequately fueled the small Westwind jet for first stage of its medical retrieval flight which was from Apia to Norfolk Island, where it was to refuel and continue to Melbourne, carrying the two pilots, two passengers and two medical professionals.

But even though the ATSB quoted at length Pel-Air’s operating manual for the flight, including the fuel calculations based on its flying at an optimal altitude, it fails to mention anywhere that the jet had not been upgraded to allow it to fly through much of the oceanic airspace it was to traverse at such altitudes under the rules applying to reduced vertical separation minima or RVSM.

Nor could the jet legally plan for or make a fuel diversion to Noumea as it encountered stronger than expected headwinds and higher fuel use because of the RVSM issue because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.

Neither of these critical matters are mentioned anywhere in the report. But they were raised with the investigating officers. The significance of both matters could not fail to be apparent to CASA or the ATSB, making inescapable a conclusion that both bodies were averse to making detrimental findings about the operator and had thus unjustly and deliberately focused all of their negative findings on the pilot.

For the two most important bodies in the public administration of aviation safety in Australia to conduct themselves in this manner is grossly improper.

The captain, Dominic James, was being directed by an airline CASA failed to properly regulate, to fly an oceanic route according to a fuel rule that CASA ought never to have approved, according to standard operating procedures for an altitude unavailable for much of the distance because it wasn’t RVSM equipped, and had not been trained to the regulatory standard required to use New Caledonia airspace in the event a diversion to Noumea, which some have criticised him for not using.
Much of the context for this is made lay friendly by the ABC TV 4 Corners report into the crash. But on its website, under background documents at the above link, 4 Corners also posts a CASA audit of Pel-Air which took place, as had been scheduled before the crash, shortly after the crash.

This audit found multiple serious safety deficiencies in Pel-Air’s operations at the time of the crash. Yet in its previous audit of Pel-Air CASA didn’t find much at all, leaving viewers to wonder whether the operator suffered a precipitous decline in standards in that period, which would surely have required an immediate grounding Tiger style, in the interests of public safety, or whether CASA audits are fundamentally useless before the fact.
The 4 Corner’s program site also hosts uncut videos of interviews with CASA’s director of safety, John McCormick, and the chief commissioner of the ATSB, Martin Dolan. Both interviews are shocking reflections on the processes and attitudes at these vital aviation authorities.

Dolan’s performance is more than 18 minutes of severely compromised testimony, in that he seems utterly unwilling to even acknowledge that CASA found more than 20 safety deficiencies were in effect at Pel-Air at the time of the crash or that they had anything to do with the accident.

Dolan and McCormick are well aware, and on the public record as being aware, that it is the airline or the operator that is ultimately responsible for the flight standards that are delivered to, or upon, the public.

This concept of airline or operator responsibility is the foundation stone of air safety regulation in the developed world. It has been trashed in Australia by this disgraceful ATSB report into the Pel-Air crash.

The performance of CASA and the ATSB in particular has been exposed as severely and dangerously deficient by the Pel-Air report and its aftermath.
One way or another, and without delay, these deficiencies must be remedied.
Oh there is some awful murky waters loaded with pony pooh to navigate before we get to the guts of all this me thinks...scratching my sore noggin!

Yeah Blackie and I forgot to mention the 'Beaker from the Bureau'....hmm that would be a.. on cozying upto that numbnut!
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Old 24th Sep 2012, 10:58
  #344 (permalink)  
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What really concerns me Sarcs is how the incompetence displayed by Dolan in his 18 minutes of 'severely compromised' testimony succeeded only in:

a) totally trashing the reputation of BASI/ATSB that took years and years to establish; and
b) making him THE hot favourite for the 2012 Darwin Awards.

If Dolan's performance during that interview didn't amount to misleading that idiot Albanese (the Minister), then I'll go he!

Little Bighorn...I think you probably need to give Blackhand the benefit of the doubt after post#392. Not so Albanese, Dolan and McF*ckwit...that trio are beyond all doubt (individually and collectively) dumber than dogsh1t.

Bring on the inquiry.
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Old 24th Sep 2012, 11:28
  #345 (permalink)  
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The CASA document at this link is interesting: http://atcvantage.com/docs/CASA_sms-ceo.pdf

In the context of the discussion in this thread, the opening paras seem particularly relevant:
For the CEO of a business that operates through an Air Operators
Certificate (AOC) - that is an airline or charter business - the legal obligations for managing safety are up front in Section 28BE of the Civil Aviation Act
1988. It’s probably worth quoting the key provisions here:

Section 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 it’s directors must also take steps specified in subsection (1).

There are some useful observations to make about these obligations. Firstly, the issue of duty of care is quite clear and places the ultimate responsibility for safety with the operator. Secondly, it is the ‘holder’ of an AOC who carries that responsibility. The vast majority of AOC’s are held by corporate legal entities (a company), so CASA places the practical responsibility on the office holders or ‘key personnel’ of the company as listed in subsection 28 (3) of the Act. The CEO is at the top of the list of those key personnel. So although day-to-day responsibility may be delegated to other officers, should a serious safety issue develop CASA’s main port of call will be the CEO. The third point to note is that the scope of that duty of care is very broad. ‘Every activity covered by the AOC’ and ‘everything done in connection with such an activity’ includes everything from flying the plane and maintaining it to loading, training, dangerous goods management and so on.

Subsection (2) highlights the responsibility that each director of a company operating under an AOC carries for safety. A CEO will in most cases also be a director of the company, and if CASA needed to approach non-executive directors to resolve a safety issue, that in itself would be a sign of potentially serious concern.
And later:
Although analysis over the years has highlighted the dominance of human factors involving technical people in accidents, it is clear that organizational factors in many cases play a major part. Organisational factors are clearly the responsibility of management in the broadest sense, not necessarily just technical management such as a chief pilot. Indeed, in many cases technical managers, even at a senior level, may need the support of more broadly focused managers, including the CEO, to see the system problems and identify system fixes.

But by far the biggest problem (present in well over 80% of accidents) is the human factor—where despite our best efforts, individuals make errors or deliberately engage in unsafe conduct. In managing safety, we must accept that what we are actually doing is carefully identifying risks and putting in place appropriate mitigators to prevent those risks resulting in accidents. Assessments of risks must cover the full spectrum associated with staff, hardware, software and the environment.

Safety management involves judgement, assessing priorities and making decisions. These are all elements of management in its more general sense.
And that’s what a CEO does—manage.

Provided the end result is acceptable, the approach gives industry the flexibility to run their business as they see fit—because that’s where the ultimate duty of care for managing safety sits. The consequence of a less prescriptive regulatory environment is a greater need for the business, particularly the CEO, to manage safety.
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Old 24th Sep 2012, 12:08
  #346 (permalink)  
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... because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.
What's so special about Noumea? Genuine question from one who has had no difficulty at all using EASA airspace. Seems like a red herring to me.
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Old 24th Sep 2012, 21:00
  #347 (permalink)  
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I see "Australian Aviation" have just joined the "oh poor little Dominic" bandwagon - see "In the Drink", by Michael Gistick, October 2012 issue.

So who is Michael Gistick and what are his operational qualifications to write this?

And for the masochist, there is more self-serving twaddle from Dominic. He is quoted as admitting to only ONE mistake during the entire sequence of events.

Gimme strength!
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Old 25th Sep 2012, 00:01
  #348 (permalink)  
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there is more self-serving twaddle from Dominic. He is quoted as admitting to only ONE mistake during the entire sequence of events
Hmmm, obviously did not learn a lesson from the first accident, hopefully there isn't a second accident he has to learn more from!

First up, yes, there were area's in which CASA, the ATSB and Pel-Air should definitely have done and should do better. Some huge area's. However....

Dominic was the Pilot In Command of that aircraft. Dominic was the last line of defence. Dominic failed in several area's, to ensure that the flight was planned accordingly, to ensure that enroute, to a very remote island, he could still carry out a safe landing at the other end. He failed to have some basic airmanship and not carry diversion fuel, regardless of whether he legally needed it or not. You're going to a single airport, a verrrrry long way from anywhere. You just don't do that, without thinking about the "what if's", and then carrying fuel for those "what if's"!

As for his "I don't know why CASA took my licence away from me", cry me a river buddy, you put a jet into the ocean and it probably became fairly obvious early on, that you yourself were deficient in several area's, which contributed significantly to the accident. Of course CASA is going to take your licence off you.

Rant over.

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Old 25th Sep 2012, 00:37
  #349 (permalink)  
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Bless you Morno, for that piece of sanity and reason....
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Old 25th Sep 2012, 01:15
  #350 (permalink)  
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Very much like bringing up your children. You don't educate/train them properly, you don't monitor them properly until they are late teens, and they mess up in the meantime eg ram a reversing car whilst riding on the footpath and break a leg, burn themselves on the toaster, burn the house down trying to light the fire.

Whose fault is that? The kids, of course.
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Old 25th Sep 2012, 04:02
  #351 (permalink)  
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I can understand the licence suspension whilst the investigation takes place, but this happened after the CASA investigation. Additionally, the PIC is then advised he has to re-sit all his ATPL exams which he does and passes for the second time! The FO was completely left alone!
Did the CPT of QF 1 have his licence suspended or have to do his ATPLs again? I don't think so. Interesting that the ATSB report into QF1 attacked the culture in QF, yet in this case, with clear evidence of shoddy practices and non-compliance, Pel-air escape free.
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Old 25th Sep 2012, 04:09
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Did the CPT of QF 1 have his licence suspended or have to do his ATPLs again? I don't think so.
Not really relevant. That involved a lot of other factors that had more to do with CRM.

I can understand the licence suspension whilst the investigation takes place, but this happened after the CASA investigation.
Perhaps they had enough evidence to warrant what they did.

No sympathy, he still was the PIC at the end of the day.


Last edited by morno; 25th Sep 2012 at 04:13.
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Old 25th Sep 2012, 06:52
  #353 (permalink)  
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Yes Brian but they had a plan B and did not end up ditching in the water and if they did ditch then I would imagine that they would have declared a mayday and at least the F/O would have got a radio call to the Unicom to say come look for us on the west side of the island and the pax and crew would have been given a proper emergency brief and I'm pretty sure the Captain would have ensured his passengers and crew got out before he did.

To expand the analogy of bringing up children then if the kids had left home and got themselves jobs and drove their own cars into the swimming pool because they had left the handbrake off then it would be the kids fault!
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Old 25th Sep 2012, 06:56
  #354 (permalink)  
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I'm with Morno. PIC is PIC is PIC!
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Old 25th Sep 2012, 07:46
  #355 (permalink)  
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And Godfreys....because the pilot wasn't operating in a vacuum...
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Old 25th Sep 2012, 10:47
  #356 (permalink)  
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Nahh I am in with dora, morno et al.

They may not want me in their exclusive club though.
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Old 25th Sep 2012, 11:49
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WE all know the Swiss cheese thingy
Apparently not Wally, if you follow dora, morno, blackhand et al. I hope these guys are not responsible for running safety programs in any work place.
Yes Brian but they had a plan B
You're an idiot. They had no plan B. They made it up when presented with the problem, and they would have ended up ditching had it been night time. Because it happened in daylight was the only thing that prevented it resulting in a ditching. Had that happened I'm betting that there would have been a great loss of life.

Last edited by Brian Abraham; 25th Sep 2012 at 11:57.
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Old 25th Sep 2012, 12:27
  #358 (permalink)  
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Thankyou for that quick personality assessment but of course they had a plan B. Plan C would have been to have ditched. They also didn't,t persist with fuel wasting instrument approaches when they knew the cloud was below the minima. Obviously Dom is a mate of yours judging by your posts but when clear thinking and leadership was required the cupboard was bare. What might have helped was an assertive F\O but when the pressure is on look left. The F\O looks at the Captain and the Captain looks at his\her reflection in the window.
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Old 25th Sep 2012, 12:57
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From my business days, I like the term that my lawyer told me about partnerships - "jointly and severally liable".

I think that the pilot was partially to blame for not filling the tanks to the brim, given the remote location. As a link in the chain, his judgement was incorrect.

However, all the other factors played a massive part and could have easily broken the chain of causation.

Yes, give Dom a serve of blame, but look at the other factors as well.

When you look at the other factors, do they reduce Dom's liability?
If certain events did or did not occur, would Dom have diverted?

So, lets put aside the blame - the report itself seems to be wanting of some credibility and doesn;t seem to focus on other factors.
Not very balanced at all.
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Old 25th Sep 2012, 13:14
  #360 (permalink)  
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Well aware of the Swiss Cheese thing. Jaba and I were only talking about it today.

However, Swiss cheese or no Swiss cheese, as the PIC, Dominic had the responsibility to ensure that final hole didn't line up.

I said it before, I'll say it again. The final call, the ultimate responsibility, is with the PIC. If you can prove me wrong on that, I'll eat my words. But I doubt you'll be able to.

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