Norfolk Island Ditching ATSB Report - ?
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!
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!
there is more self-serving twaddle from Dominic. He is quoted as admitting to only ONE mistake during the entire sequence of events
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.
morno
Bless you Morno, for that piece of sanity and reason....
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.
Whose fault is that? The kids, of course.
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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.
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.
Did the CPT of QF 1 have his licence suspended or have to do his ATPLs again? I don't think so.
I can understand the licence suspension whilst the investigation takes place, but this happened after the CASA investigation.
No sympathy, he still was the PIC at the end of the day.
morno
Last edited by morno; 25th Sep 2012 at 03:13.
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!
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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Well excuse me danglybits, morno, dora-9, lookleft.
Surely you are not suggesting that the pilot has responsibility??
Yours are voices in the wilderness. On this thread CASA, ATSB, the refueler, that bloke on the radio from Fiji, Airservices, Epstein's mum are to blame.
Surely you are not suggesting that the pilot has responsibility??
Yours are voices in the wilderness. On this thread CASA, ATSB, the refueler, that bloke on the radio from Fiji, Airservices, Epstein's mum are to blame.
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It's interesting that this thread is still going & it's really now about who is to blame for the end result not so much as to why it got to the stage that Dom found himself in a situation where he had no option but to ditch.WE all know the Swiss cheese thingy,this is a perfect Eg with Dom not being the only one holding one of those peaces of 'cheese'
Obviously as has been said many a times here PIC is PIC,last line of defense etc but this whole event & pretty much a lot of flights that leave the ground for revenue it smacks of COMMERCIAL pressure,something I firmly believe to be the case & as such Dom's decision making albeit lacking was heavily effected by 'forces' acting upon him. The 'Coey' I think was probably just a spectator at the end of the day as she most likely knew no better..
It's all too easy to be a Capt these days,there in lies some of the problem.
Lets all learn from this inc CASA & the ATSB.
Wmk2
Obviously as has been said many a times here PIC is PIC,last line of defense etc but this whole event & pretty much a lot of flights that leave the ground for revenue it smacks of COMMERCIAL pressure,something I firmly believe to be the case & as such Dom's decision making albeit lacking was heavily effected by 'forces' acting upon him. The 'Coey' I think was probably just a spectator at the end of the day as she most likely knew no better..
It's all too easy to be a Capt these days,there in lies some of the problem.
Lets all learn from this inc CASA & the ATSB.
Wmk2
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WE all know the Swiss cheese thingy
Yes Brian but they had a plan B
Last edited by Brian Abraham; 25th Sep 2012 at 10:57.
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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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.
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.
Brian,
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.
morno
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.
morno
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KA350
Yep
60/20/20
Out of a complex mess, that is probably as simple as it gets. PA & CASA set up a situation that sucked him in, but at the the 11th hour, he faled to do what a PIC should have. And repeatedly. And even when the chips were down he kept doing the same thing.
The definition of stupidity is to keep doing what you are doing, expecting a different result.
There were other approaches better suited, and FFS there was another approach with an illegal adaptation that would have worked better than ditching, but never tried. In fact the legal version of it was never tried. A runway aligned approach may have saved the day.
Not one was tried. Nor was a diversion.
60/20/20
Yep
60/20/20
Out of a complex mess, that is probably as simple as it gets. PA & CASA set up a situation that sucked him in, but at the the 11th hour, he faled to do what a PIC should have. And repeatedly. And even when the chips were down he kept doing the same thing.
The definition of stupidity is to keep doing what you are doing, expecting a different result.
There were other approaches better suited, and FFS there was another approach with an illegal adaptation that would have worked better than ditching, but never tried. In fact the legal version of it was never tried. A runway aligned approach may have saved the day.
Not one was tried. Nor was a diversion.
60/20/20
I don't know any of the players in this scenario, and only know what has been published about the incident, however, I do have a bit of training in human activity.
I think the conclusion that the buck stops with the PIC, fullstop ...although technically correct, is, in fact, too simplistic an assessment.
It makes us feel good. Someone is to blame. It makes CASA feel good. Someone is to blame.
The reality is ... no one intentionally makes the wrong decision. Fullstop.
The PIC did not say ... I'm going to stuff this up and get us all in the ****!
We ALWAYS make the right decision ... based on what we believe and have been taught.
However, what we BELIEVE to be true and what we have been TAUGHT, may be incorrect. If that happens, we are open to making decisions that the majority of others believe to be wrong... as, apparently, is the case here.
What we need to do is find out why the PIC believed such and such to be the case or was taught such and such... which led him to his decisions.
And to take it further, the term TAUGHT is very broad. We are taught by teachers, our peers, our Employers, the media, the Government, our friends, our parents and our siblings.
Just because CASA Regulations may attempt to TEACH a certain belief ... doesn't mean that the multitude of other sources are automatically negated. We aren't that clever.
If we are really serious about stopping PIC bad decisions, we need to either:
The bottom line, for me, is that we will never be able to remove all the competing "incorrect" learning sources. We are, after all, only frail human beings.
I think the conclusion that the buck stops with the PIC, fullstop ...although technically correct, is, in fact, too simplistic an assessment.
It makes us feel good. Someone is to blame. It makes CASA feel good. Someone is to blame.
The reality is ... no one intentionally makes the wrong decision. Fullstop.
The PIC did not say ... I'm going to stuff this up and get us all in the ****!
We ALWAYS make the right decision ... based on what we believe and have been taught.
However, what we BELIEVE to be true and what we have been TAUGHT, may be incorrect. If that happens, we are open to making decisions that the majority of others believe to be wrong... as, apparently, is the case here.
What we need to do is find out why the PIC believed such and such to be the case or was taught such and such... which led him to his decisions.
And to take it further, the term TAUGHT is very broad. We are taught by teachers, our peers, our Employers, the media, the Government, our friends, our parents and our siblings.
Just because CASA Regulations may attempt to TEACH a certain belief ... doesn't mean that the multitude of other sources are automatically negated. We aren't that clever.
If we are really serious about stopping PIC bad decisions, we need to either:
- Stop all outside sources having any effect on our learning processes; OR
- Accept that we have competing learning sources and work towards ways of more significantly empahsising "correct" sources
The bottom line, for me, is that we will never be able to remove all the competing "incorrect" learning sources. We are, after all, only frail human beings.
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Excellent summation peuce, especially,
The audit report tells of the corporate shortcomings. As KingAirB350 so eloquently put it
The PIC is merely the final enabler. He pulls the trigger of a weapon that has been primed, loaded and cocked by others. And we sit here and sanctimoniously expect him to be the guardian of everyone else's mistakes.
There was information published (forget where) that had the tanks been full the aircraft would have been stuck at a lower altitude that would have reduced the range even further.
I commented earlier about the lack of detail in the ATSB report re fuel analysis. I would have expected something along the lines of the report below (Avanti force landing on the ice cap due to fuel depletion). The fuel analysis is forensic, as is the ATC functions.
http://havarikommissionen.instant.co...0_2011_33.ashx
I think the conclusion that the buck stops with the PIC, fullstop ...although technically correct, is, in fact, too simplistic an assessment.
"jointly and severally liable"
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
I said it before, I'll say it again. The final call, the ultimate responsibility, is with the PIC
I think that the pilot was partially to blame for not filling the tanks to the brim
I commented earlier about the lack of detail in the ATSB report re fuel analysis. I would have expected something along the lines of the report below (Avanti force landing on the ice cap due to fuel depletion). The fuel analysis is forensic, as is the ATC functions.
http://havarikommissionen.instant.co...0_2011_33.ashx