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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 14th Sep 2012, 01:15
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Senate Inquiry Details!

Here's the relevant details for those contemplating making a submission:

Senate Committees – Parliament of Australia

From Senate Hansard 13/09/2012 pg 24:
COMMITTEES
Rural and Regional Affairs and Transport References Committee
Reference
Senator XENOPHON (South Australia) (11:55): I move:
That the following matters be referred to the Rural and Regional Affairs and Transport References Committee for inquiry and report by 29 November 2012:
(a) the findings of the Australian Transport Safety Bureau into the ditching of VH-NGA Westwind II, operated by Pel-Air Aviation Pty Ltd, in the ocean near Norfolk Island airport on 18 November 2009;
(b) the nature of, and protocols involved in, communications between agencies and directly interested parties in an aviation accident investigation and the reporting process;
(c) the mechanisms in place to ensure recommendations from aviation accident investigations are implemented in a timely manner; and
(d) any related matters.
Question agreed to.

Last edited by Sarcs; 14th Sep 2012 at 01:32.
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Old 14th Sep 2012, 02:28
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When this accident first came to light it raised significant, multi layered concerns covering a broad spectrum of issues. I had then, and continue to have the following 4 concerns:

1.The level of Operational Support and Oversight for the Fight Crew - from instigation to completion.
2.Imposed Pressure (Commercial, Medical or Personal) on the Flight Crew, Operator or Tasking Agency for the flight to be conducted, or continued.
3.Ongoing Fatigue Monitoring and Assessment by the Flight Crew or Third Party as a flight is undertaken. (Plan B if time constraints are pushed).
4.The Conditions and Processes when considering if a task should be undertaken, deferred or delayed.

For a task crossing vast open oceans and International Flight Regions to remote islands, this is a complex undertaking in which risk mitigation is essential by all interested and vested parties, not just the Pilot in Command.

The concerning aspect of this accident is well detailed by the following excerpt from an article by Ben Sadilands 7/09/2102 (my bolding):
“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.”

A well said and considered opinion!

I would hope the investigations that follow from the ATSB report will alleviate my concerns and instigate a sharpened view and conduct on how flights such as this are undertaken in the future.

The Four Corners program raises even more concerns regarding the conduct, processes and culture of CASA and the ATSB.
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Old 14th Sep 2012, 05:12
  #343 (permalink)  
 
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Ratsac (tm) ....??

I'm not sure that there is such a thing from CASA as "unsolicited goodwill"
When you are handed a rat...you'd better smell it first. It might not be dead... and bite back later.

PP is being mighty in his generosity, because CASA being the house of "No Liability and No Accountability"...will have an agenda behind the gesture that's for sure.
A licence returned and a telephone apology from AA in the same week...unprecedented.!! Worries afoot?? $$s to follow???
They must have sniffed the wind that blows from QLD, QPS and the impilcations THAT might yield.

The Sunshine state...nice to think a ray of light comes from under the dunghill..GO QPS, go.
And hopefully we can get some of these buggers behind bars where they belong.
Now that would be a salutory lesson to ponder for those that want to play 'abuse of power', with lack of duty of care, negligence, malicious mis-statements ..and a few others tossed in.
PAINful isnt it..?
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Old 14th Sep 2012, 07:33
  #344 (permalink)  
 
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The Butcher's Dog post is an accurate one. There was however another two 'layers' of defense which failed that night.

The first being a proactive and diligent FO who questioned the PIC fuel load, flight planning and had an inherit interest in the success of the flight.

The second being a less than satisfactory FIS and weather watch service relaying correct and up to date weather to the crew.
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Old 14th Sep 2012, 08:43
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"Unsolicted Goodwill"???? from CASA!!!!
Have a read of the Skull's arrogant, flippant, malicious reply to Mr Quadrio..
Then have a read of all the stories out of Hong Kong related to this individual.
Put the two together and those stories become very believable, add his performance on 4 corners and you really have to wonder "What were they thinking" when they appointed him.
Will CASA as an organisation have the intestinal fortitude now to admit "we were terribly wrong"?? apologise profusely to Mr Quadrio, stump up compensation he should receive considering what they have put him through..
Somehow I doubt it the bottom feeding lawyers will prevent that.
I note the FOI involved in Mr Quadrio's debarcle has been moved to Bankstown...what is it about Bankstown that attracts all CASA's misfits??
There's bugger all industry left at Bankstown for the "Loadmaster" to shutdown anyway.

Last edited by thorn bird; 14th Sep 2012 at 08:49.
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Old 14th Sep 2012, 08:52
  #346 (permalink)  
 
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What the ATSB found

The requirement to ditch resulted from incomplete pre-flight and en route planning
and the flight crew not assessing before it was too late to divert that a safe landing
could not be assured. The crew’s assessment of their fuel situation, the worsening
weather at Norfolk Island and the achievability of alternate destinations led to their
decision to continue, rather than divert to a suitable alternate.

The operator’s procedures and flight planning guidance managed risk consistent
with regulatory provisions but did not minimise the risks associated with
aeromedical operations to remote islands. In addition, clearer guidance on the in-
flight management of previously unforecast, but deteriorating, destination weather
might have assisted the crew to consider and plan their diversion options earlier.

The occupants’ exit from the immersed aircraft was facilitated by their prior wet
drill and helicopter underwater escape training. Their subsequent rescue was made
difficult by lack of information about the ditching location and there was a
substantial risk that it might not have had a positive outcome.


What else should ATSB have found?
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Old 14th Sep 2012, 10:57
  #347 (permalink)  
 
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Unbelievable-the PIC and the F/O have no responsibility because the company manuals were followed and only enough fuel was put on to comply with them! sometimes as PIC you do more than the minimum because the minimum is not good enough. Once they got to Norfolk the decisions made had nothing to do with company manuals or corporate culture. Persisting with approaches and burning fuel when you know it's below the minima is just dumb! If you are going to burn fuel to conduct an approach then why not use the radar alt to get closer to becoming visual but still have a margin from the ground. Being PIC is more than following the magenta line. Not declaring a Mayday was negligent. Not telling the Unicom operated that you were ditching to the west of the island was negligent. Being first out of the aircraft was poor leadership. Leaving your F/O unconscious was poor leadership and negligent. The fact that no-one was killed was more due to good luck than good management. Let the Senate investigate the ATSB report but let's not pretend that the crew of this aircraft were passive victims in some huge conspiracy.
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Old 14th Sep 2012, 11:40
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Conspiracy??

There is no conspiracy here, just cold hard facts! All will be dumped in the Enquiry. 4 corners was bad enough, I can only hope whats going to be revealed in the Enquiry.

Last edited by Jinglie; 14th Sep 2012 at 12:52.
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Old 14th Sep 2012, 12:05
  #349 (permalink)  
 
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If the last enquiry is anything to go by the senate will produce a raft of recommendations and the Minister will respond with a weak response drafted for him by CASA.
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Old 14th Sep 2012, 12:21
  #350 (permalink)  
 
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Lookleft,

If the crew had rung ops and said any one of

"Look, Ive chatted with the doc and the patient is stable and if we wait six hours we can make the fight in daylight,"

Or

" I picked up extra fuel in Samoa even though the plan didnt need it"

Or

"I haven't got Internet so can you run and file my plan, my fax number at reception is xxxxxx. I'll talk to you at Ted-90mins"

Or

"I've got no way of running a plan here, can you run it?

Or

"I went via Fiji even though I had fuel for Norfolk "

Would they still have a job, even if they had got back safely?

I think you might have missed the "else" in the last line of blackhand's post.
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Old 14th Sep 2012, 12:29
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I'm reminded here of that old saying, be careful what you wish for.
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Old 14th Sep 2012, 12:53
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No I think the "else" in Blackhands post sums up his sentiment but ISTBC. Why would the PIC and his F/O need to ring to ask any of those questions? They had a flight to conduct and as a crew they needed to plan and fly it in the safest possible way. If the ops manual doesn't, give enough guidance then your Experience and common sense will determine how the flight is to be conducted. My company don,t want me to take any more fuel than is the minimum legal. That doesn't, leave a lot of options if the lights at Darwin aren,t available or a Baron does a wheels up at Cairns or the unforecast fog rolls in at Perth so I take extra because ultimately I am responsible for the amount of fuel put in the tanks. The company doesn't,t like it but they are as aware as I am of my legal responsibilities and I have never had "please explain" call despite the reputation of the LCC I fly for. Sometimes when you are PIC you have to say this is the fuel I think is necessary and if you as CP are not happy with that then you can do the next medievac from Apia!
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Old 14th Sep 2012, 14:21
  #353 (permalink)  
 
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"I haven't got Internet so can you run and file my plan, my fax number at reception is xxxxxx. I'll talk to you at Ted-90mins"

Or

"I've got no way of running a plan here, can you run it?
Report:
"The PIC indicated that he attempted to contact a member of the operator’s staff in Sydney to request the submission of a flight plan on his behalf, but this staff member did not answer the phone."

Two questions down...

common sense
Interesting concept. Exactly how and where do you get it?
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Old 14th Sep 2012, 21:16
  #354 (permalink)  
 
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@ compressor stall
Not sure those would be findings.
ATSB had to find the root cause of the ditching, and that was from fuel exhaustion.
A different finding would have been listed if it was fuel starvation, or terrorist activity, or any other.
Will be interesting to hear the questions Mr Xenephon proposes in the Senate Hearing
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Old 14th Sep 2012, 21:47
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Rats

I'm not sure that there is such a thing from CASA as "unsolicited goodwill"
When you are handed a rat...you'd better smell it first. It might not be dead... and bite back later. PP is being mighty in his generosity..
..
Sorry about that, but given the parties involved I thought everybody would have recognised it as a spot of irony.
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Old 16th Sep 2012, 20:51
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BA # 351 - found this development in your link extremely interesting. Wonder what brought that about?
Reading Phelan in the AA piece, I notice this:-

"A copy of the report has been made available to the Queensland Police Service to aid the QPS in determining whether misconduct by CASA officials has occurred under Queensland law" etc.
It's not too big a stretch of the imagination to believe that the QPS have just about had enough of CASA in Qld. I know they are still seriously cranky about the Lockhart River fatal, the Hempel fatal, the Dalby investigation and a couple of other similar events; where they were told to shear off and leave it to the grown ups. Maybe, when professional, unbiased investigators get involved and the rules of evidence and testimony are invoked, things change??

BH # 358 - What else should ATSB have found?
I would agree if it were not for the many questions concerning CASA influence over operational management, AAT hearings, Coronial findings, ATSB reporting and the negative safety impact of micro management; all in the name of covering the Minsters sorry, Teflon coated arse. The ATSB has been about as much use three men a way from home since Lockhart River. Technically still sound but; the conclusions since LHR have, to say the least, left much to be desired.

This story goes just a little deeper than 'the chump ran out of noise' (which is true). I took the trouble to download and read the Prune Gate report. It raises some of the deeper issues which may have contributed to placing this crew in that predicament. This is why so many have made useful contributions to this thread and for many searching questions being asked. Click 'Down Load" have a coffee and a read.


Prune Gate.

Last edited by Kharon; 16th Sep 2012 at 21:02.
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Old 16th Sep 2012, 22:59
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Experience and common sense
This is one of the issues- the PiCs lack of experience. At 3500 TT the PiC only just met the requirements for a job at Pel-Air as a First Officer 20 years ago.

As I read the ATSB report, I was struck at the string of bad judgement calls that were made that I have doubts a more experienced and better trained captain would have made. I also recognise the total absense of support from his company and that is also a highly relevant issue. You don't send inexperienced pilots on demanding charters without excellent company support!

What is also concerning is the experience base of the instructor pilots at Pel-Air. During Dom's line training, the changeability of NLK and distance to useable alternates should have been a major discussion point. Was this the case? Have we now reached the point in the industry where inexperienced instructors are now training inexperienced captains? As an example, how many captains flying in Oz can actually use a wx radar properly? As a further example, I am aware of a large turbo-prop that has flown (in the West) through a frontal system, at night with the wx radar turned off! A cabin crew member was badly injured (broken leg)( the aircraft also wound up at FL210 when cleared to FL190). What is happening in our system that allows such poor command judgements to manifest in our operations?

Many South Pacific islands are bad weather factories, NLK probably more than some others. To have gone anywhere near NLK, day or night, without alternate fuel is a travesty of command responsibility. The crew should have known better. The company should have known better. The regulator should have known better
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Old 17th Sep 2012, 01:18
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Well said Anthill.

Reminds me of the conversation I had the other day with a mid twenties pilot who'd done the territory thing and done very well career wise since then.

I'd remarked how incredible it was that a well known caravan operator couldn't find pilots to fly a van as their minimums were 2000 hours.

The young pilot laughed saying with 2000 hours why would you be wasting your time flying a van.
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Old 17th Sep 2012, 08:12
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Whilst I agree that experience is extremely valuable I do wish we could find a better way of expressing it than total time. Relavent experience is so much more important. Low time pilots with good supervision and sensible company policies and good support will always do better than high time pilots in a toxic company environment, especially if their experience is in the wrong area for the operation.

Pilots have to build their hours somewhere and if there are pax involved then the only way we can mitigate the risks is with the support I referred to above.

Discounting those who are only wise after the event, those that have commented on the earlier pages that they would not put themselves in a similar situation to these pilots learned somewhere. Hopefully that was from good leadership rather than bitter experience and luck. I know that I owe the good airmanship I show (when I show it) to the many good examples I received throughout my career. And I have been fortunate that the organizations that I have worked in have respected captaincy decisions even if they were not always agreed with. Not everyone is so lucky.
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Old 17th Sep 2012, 10:59
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Back at post# 327 Kharon alluded to a report that had been forwarded to him, that report was generated by a number of PAIN editors. The passage that Kharon quoted was;
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.
Little Bighorn and Sarcs guessed correctly and so the story goes on and on...

However the PAIN editors have now agreed to release some more relevant quotes from that document (and maybe some others which we have produced). Hopefully this may give motivation to concerned professionals and industry stakeholders to get involved in the upcoming Senate Inquiry. By the way recent intel would seem to indicate that the Senators feel that this inquiry is just the beginning!

As recent posts seem to hinge around the pilot experience, lack of good training and operational support, please find the following quote from our Lockhart River report;
It is not the writers intention to defend or speculate on the reasons why a particular pilot behaves in one way; or, acts in a particular manner during a critical phase of flight. It is acceptable for the aircrew behaviour to measured against accepted 'industry standards'.


In the normal course of events, the industry not the Authority, has a system for identifying, dealing with and, where necessary isolating most of the unstable, dangerous or, inherently rogue elements. Unsuitable people may pass through a flight school phase, qualify, acquire a first job quite easily. Further down the career road to enter an 'airline' environment there are some serious barriers raised which fairly effectively 'weed out' those not suitable. Should the rogue candidate avoid or slip through this system, the safety net of the company Training and Checking System (TCS) provides an effective last line of defence.

In the 'smaller' airline operations the early safety nets may be bypassed, but this is usually more than balanced by the TCS as the TCS pilots are flying 'on line' almost everyday and intimately know and understand their charges. So the balance is maintained.

Not so in this case; there is anecdotal, hearsay information that the pilot was prone to some of the more undesirable traits which, under reasonable circumstances would have been 'hammered out' by the TCS system or, the pilot's employment would have been terminated. This aircrew was not, on the available data, provided with either proper guidance, discipline, training or management. In short, there was a normalised deficiency, produced by a failed, CASA approved and monitored, internal TCS.
It goes on to say;
The pilot in command was clearly undisciplined, incorrectly trained, neither qualified or competent to operate a passenger service into a relatively high risk port.


The co pilot was clearly undisciplined, incorrectly trained, neither qualified or competent to operate a passenger service into a relatively high risk port.

The above comments on the aircrew are not, nor can they be considered the sole fault of the aircrew, essentially they are abandoned by the Training and Checking System, the company and the CASA to fend for themselves, unsupported, as best they may in what was a hostile, subsequently fatal environment.

The lack of training and guidance material precluded a less confident pilot acquiring, through research into the company manuals, the knowledge to safely operate a Regular Public Transport passenger service to this port.
That sounds very similar to this accident scenario, the only differences being that this operation was airwork and didn't involve any fatalities!

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