Norfolk Island Ditching ATSB Report - ?

[blackhand]

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.

This is your opinion and is respected as such, others on here that are ATPLs see it completely differently. You seem to be entralled with James Reason's model. This model is designed to take the responsibility away from the end user and put it on the corporate entity.

The crew (CRM) elected to fly the aircraft with minimum fuel, the risks far out weighed the benefits.

Brian, I read your reference, it's conclusions are about the same as ATSB findings for the Norfolk ditching - what is your point?

[Lester Burnham]

Brian;

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.

Wrong; there was speculation published about this on the Plane Talking blog that isn't supported by the facts. What is the SGR for a WW at LRC at non RVSM levels versus normal cruise at RVSM levels?

There is evidence in the CASA report that in the weeks leading up to the accident the PIC flew the same route in the same aircraft and burnt more fuel than he took off with on the night of the accident. Shouldn't this have rung alarm bells?

[gobbledock]

You seem to be entralled with James Reason's model. This model is designed to take the responsibility away from the end user and put it on the corporate entity.

What a load of crap Blackhand. The Swiss Cheese model is a look at causal factors in an accident. The emphasis on 'factors', plural. No one accident has just one cause. Nowhere in the Reason model is a trigger, formula or method so as to induce blame or throw the monkey on to a corporate identity.
The Norfolk accident contains numerous factors. I agree that the PIC, in this case Dom, was the last line of defence. He stuffed up and became the last hole in this accident. But what has also come to light is some of the other factors that contributed to the accident - inadequate S.O.P's, operational pressure, lack of company support, company culture, fatigue, lame regulatory oversight and the list goes on.

[blackhand]

What a load of crap Blackhand.

The Reason model was desgned for errors in patient care.
It has become a badly understood and widely utilised panacea for all safety issues.
An unsafe act is at the pinacle of the pyramid, and, as in this case, can happen without a causal chain

[Sarcs]

Hmm...Blackie I hope your not peddling that vintage of pony pooh to your clients??

Since your a guru on LAME issues take a look at this quote from a very good (yeah I know....well at least in some areas of the ATSB remit they still set a benchmark) ATSB report:

The errors of maintenance personnel can be the most visible aspects of maintenance human factors, but to understand how and why maintenance errors occur, we need to understand the organisational context in which they occur.

Figure 5 below shows the main causal elements involved in accidents and incidents. It is an adaptation of the ‘Swiss Cheese’ model originally developed by James Reason.

According to this model, accidents or incidents are usually triggered by the actions
of operational personnel, such as pilots or maintenance engineers. However, these
actions occur in the context of local conditions, such as communication, workplace
conditions, and equipment. The task environment also includes risk controls.

These are features such as procedures, checks or precautions designed to manage hazards that threaten safety. Risk controls, local conditions and individual actions can, in turn, be influenced by organisational factors such as company policies, resource allocation, and management decisions.

In order to understand and ultimately prevent accidents, it is necessary to trace the
chain of causes back through all the elements of the system including organisational

influences. This is often referred to as root cause analysis.

And since you are a guru of the 'blackhand world' you should be able to tell me what report that came from because it should be included in any LAME Human Factors course i.e. required reading??

ps Oh in case your stumped here's the link!

http://www.atsb.gov.au/media/27818/ar2008055.pdf

[gobbledock]

The Reason model was desgned for errors in patient care.
It has become a badly understood and widely utilised panacea for all safety issues. An unsafe act is at the pinacle of the pyramid, and, as in this case, can happen without a causal chain

Oh dear. I see that the Reason Model is understood differently in PNG?

Blackie, you better tell Mr Reason that his cheese is being abused by the airline industry. You should also advise the ATSB, NTSB and most Western regulatory bodies that Reason's cheese is really not applicable in aviation and they have all got it wrong.

[blackhand]

Sarcs, I am embarrassed by your praise
Yes, I have a modicum of knowledge on safety systems and regulations pertaining to aircraft maintenance. Have been involved in half a dozen helicopter accident investigations and a couple of fixed wing ones.
In my experience this Reason model allows the blame to be spread for sometimes no tangible benefit.
The maintenance incidents nominated in the Overview of Human Factors in Aviation Maintenance, to me highlight bad maintenance carried out in spite of systems in place.
The mech did not put the orings on, inspectors not finding indications of skin stress etc.

Gobbles, James Reason makes a great living out of his model, I shouldn't imagine he is complaining

Hmm...Blackie I hope your not peddling that vintage of pony pooh to your clients??

Maybe, but I am certainly not adverse to using it to pull them out of the poo.

[Jinglie]

Beyond Reason.

This is beyond Reason! The are so many holes here there is hardly any cheese!!
I'm doing fuel calcs on the leg, and I doubt you can use Noumea as an alternate, particularly non-RVSM. Probably why PEL-AIR had it in Airwork rather than Charter! The ATSB numbers in the report don't add up. Maybe Beaker did them too!

[gobbledock]

The ATSB numbers in the report don't add up. Maybe Beaker did them too!

MEMEMEMEMEMEME

[Jinglie]

Great summation

This I found on Avweb regarding this accident. Great summary.

"Finally, there have been pilot comments on the ATSB's inaccurate statements about fuel calculations and requirements for single engine or depressurised calculations.

Dominic was not without fault, but he has been nailed to a cross of an operator of failed management, a regulator of failed oversight, inadequate equipment, and an unfairly biased if not incompetent ATSB."

I suspect a lot of poo is going to launched about this in the Inquiry. I hear there is more poo to be flung and it is capital B, capital A, and capital D for the ATSB and CASA.

[Sarcs]

Top shot Gobbles! All you need now is a profile shot of Beaker from the Muppets....hmm muppets that's a fairly appropriate description of the bureau's standing in all this..

The ATSB numbers in the report don't add up. Maybe Beaker did them too!

He maybe a beancounter but I'm not sure if he would have had his hands anywhere near this. It's more likely he would have issued a directive to the investigators to narrow their focus on the actions/inactions of the pilot, which ultimately compromised the investigation and the final report version 1..ah.2 or is it now 3, I'm confused!

[Brian Abraham]

The Reason model was desgned for errors in patient care

Not so. His book "Human Error" was first published in 1990 and as the jacket cover says

Modern technology has now reached a point where improved safety can only be achieved through a better understanding of human error mechanisms. "Human Error" spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliability of hazardous technologies. This is essential reading not only for cognitive scientists and human factor specialists, but also for reliability engineers and risk managers. No existing book speaks with such clarity to both the theorist and the practitioners of human reliability.

The medical profession has been addressed in some of his writings however.

One thing Reason said was

Blaming individuals is emotionally more satisfying than targeting institutions.

Human error: models and management

I think we might be seeing some of that on display here.

[gobbledock]

ASIC photo?

MEMEMEMEMEMEMEME

[Sarcs]

That's perfect Gobbles!

Take off the ears and he's a 'dead ringer!'

Top article BA, Tony Kern's books are extremely good references on the subject as well.

[Lookleft]

James Reason never intended to have his model used as a template for accident investigations but it was a theory for why accidents occurred. In this accident the Reason model is a valid explanation for the poor support given to the crew to commence the flight. It is also is useful as a way of explaining how two pilots with not much experience were on the flight deck. It can also be used to explain why the rules governing the flight were not as tight as they could have been (i.e. charter instead of aerial work).

It cannot be used to absolve the PIC from his responsibilties once he realised that the weather was not as forecast and that he did not have the fuel to divert. CRM and TEM are supposed to be the defenses available to crew to prevent that last hole lining up but where were they? I notice that a lot of the PIC's advocates are silent on the decisions (and the lack of decisions when it came to notifying the Unicom of where they were ditching) that were made from ToD, other than the ridiculous assertion that a 146 that made a successful landing when faced with a similar situation proved that the PIC was not responsible for the outcome(and I'm the one claimed to be the idiot!)
This is where Reason exits the stage and CRM is supposed to enter but it didn't happen. The fact that it didn't happen is the crew and utimately the PIC responsibility. If anyone can explain the organisational issues involved in the period from ToD to ditching that were beyond the crew's control I would be interested to read it.

[Wally Mk2]

"LL" interesting post there.
I don't think we need James's or anyone's models for that matter in this case it's really a black & white story that's getting 'coloured' in big time.

From TOD the scene was already set, the organizational issue/s where lacking well before this guy even took off, the fact that he did attempt the mission is almost irrelevant as far as the organizational part of it goes it was doomed to fail anyway, the 'play' had an ugly ending that few even saw inc the regulators.

I love the words CRM, TEM etc etc they are really just warm & fuzzy words to make people feel good & or feel protected. Man has been crashing planes well before the boffins dreamed up those 'feelgood' words & they still continue to crash planes well after those words have been around & will continue to do so 'till the end of time.

You mix man & machine together no fancy words, teachings beliefs etc will ever stop that interaction that brings a plane to a screaming halt in pieces!
Some might say well CRM TEM etc at least reduces the accidents/incidents, well how do we all know that? Lets just say for Eg that we could erase all the previous CRM crap teachings from every pilots minds etc & count the amount of wrecked planes against the hills over the next 10 yrs then re-install the same rubbish & count again to see any difference, well we can't (obviously) so we just now accept that CRM TEM & all the reasoning stuff is better! Way of the future I guess right or wrong.
I do it 'cause I have to & perhaps I 'might' learn something from it (I'll never really know anyway)all but it's not the be all end all that's for sure!The biggest defense in these cases is experience,something that getting cut short more & more due the almighty dollar!

Dom was armed with insufficient knowledge to complete the task on that night & the argument now rests with who's fault it was.Will it fix anything all this bickering blaming etc?....nope it will happen again sometime somewhere you can guarantee it & we'll be right back here going round in circles like man has done since Adam was a boy when he was hit on the head by a falling apple & tried to "reason' it all !!


Wmk2

[Sarcs]

Well said Wally I couldn't agree more, this matter has well and truly moved on from who was at fault.

The issue now is what appears to be a severely compromised Final Report from the ATSB and the reasons why...coercion, political expediency, covering the Minister's ass etc.

Here's a quote from an experienced pilot who reviewed the ATSB report before it was released:

“Tomorrow, the ATSB will release a Final report into an aviation accident at Norfolk Island.

The Final report in it’s current form contains factual errors. These have been brought to the attention of the (name and position withheld), and also the (name and position withheld).

Despite these many areas under dispute having been brought to the attention of both of these men on numerous occasions and requests that the Final report be delayed pending dialogue to resolve the inaccuracies, (name withheld) has determined that this report will be released tomorrow.

(Name withheld) has also let it be known that he is expecting a lot of media attention. I ask what is the point of media attention to a factually incorrect report?

Obviously a report with facts in dispute should not be released. Having spoken to both pilots concerned and as a professional aviator myself, I am left dismayed at the attitude of the ATSB and their willingness to issue such a questionable report. As Minister, I would ask you to stop the release to give all parties involved the opportunity for continued dialogue before it’s release.

At the moment, I am extremely disappointed in the attitude of the ATSB and have been left with great doubts about their investigations. At this point, I would most certainly be advising my colleagues in the airlines that they cannot rely on the ATSB to report the facts nor give them a fair hearing if they are ever involved in an incident.

This is obviously not the reputation that the ATSB should be making for themselves.”

From Planetalking 26/09/2011
Pel-Air report errors ignored by ATSB says expert reviewer | Plane Talking

If Beaker thinks this will all just fade away into the "Never, Never" I've got news for him and it's all bad!

[Lookleft]

There is a Phd in that for you Wally! I agree with Sarcs, people have their positions on the ditching and we are just going around in circles. Maybe its time to start a new thread.

[DBTW]

This is an incredible debate with loads of blame flying around and responsibility appearing to stick nowhere without generating much further debate. In all these discussions, everyone is taking the word of the pilot that he meant to ditch.

What if he didn't mean to ditch?

Let's all face it, the pilot continued on this flight with the information he had to hand, and for one reason or another, he made the decision very early that he was going to land at Norfolk Island. The pilot did land, and it was clearly not quite in the way he expected. Much of the debate is therefore about when he should have made some other decision that he (also clearly) did not make. And of course the follow on to that is who should be responsible for decisions made or not made.

Maybe, in this case, the ATSB and CASA are actually just being polite?

In this case the pilot, having done much planning (regardless of whether it was flawed or not), had a fuel panic, done some instrument approach work, made decisions about not descending below minima or converting to a home made GPS approach, he then decided to fly out over the water and crash...and didn’t really tell anyone about it. Specifically, he didn’t mention it to the Unicom operator.

Does that really sound plausible?

We have all seen situations in aviation where a certain outcome makes an individual create a seemingly plausible explanation as to how they got to where they were in order to make it seem as though they had a plan.

He may have said something inside the cabin as a precautionary measure, but judging by the earlier decisions, and especially the one to continue to NI and land, it seems much more likely that in the end he was over water looking for a cloud break and quite simply found himself in the water.

I have heard of that happening several times before, but in my time I have never heard of anyone trying a controlled, powered ditching at night before...especially when there is a well lit and instrumented runway nearby.

Most aeroplanes when performing instrument approaches successfully manage to descend below the minimum descent altitude without hitting anything, so it stands to reason if he simply tried a stabilised approach using any instrument procedure the chances were good that he would have made it to the runway. If he had done that, there would be no ditching and no story.

Similarly, it has been brought up in this thread that people talk about descending over the sea to get a cloud break if all else fails using traditional instrument approach methods.

In my experience, low altitude over water can be extremely difficult, especially when associated with night, poor visibility, low cloud and rain. In those conditions, the risk of flying into the sea due to lack of awareness and disorientation is high.

We are now really just discussing an unfortunate and unplanned outcome to what could have been a complete non-story. Doesn’t really matter who is right or wrong anymore. The aeroplane is lost and everyone survived. That’s lucky!

[blackhand]

DBTW, that would have to be the most succinct appraisal I have seen on this issue so far.
Much food for thought, and not a bit of cheese in sight.