Norfolk Island Ditching ATSB Report - ?
I recall going to the Norfolk Island Airshow back in April 1996. It was a spectacular event in more ways than one.
I recall the concern about a C172 that come out of Victoria. The pilot landed with some 14 litres of fuel remaining having got lost on the way to Norfolk. He had bought a handheld GPS the week before.
He is now doing Angel Flights.
The other event was a Baron. It came from southern Queensland. It arrived after dark, around 8 pm. No HF. Rain and fog with low cloud. Two airliners gave the approach away and went back home. The Baron (VH-O..) had nowhere to go. Not enough fuel to get back to Australia and Lord Howe is daylight landings only as I recall.
Jim Hazelton, the well known ferry pilot, talked the Baron down using a hand held VHF radio. The Baron got in. Jim deserved a medal for saving those on the Baron.
CASA would have been present. Some 2-3 years later came the CASA edict that if a charter or RPT flight went to Norfolk it had to check the weather in flight and have reserves to go somewhere better. I do not have a copy of that new requirement. Perhaps a reader could quote the fine detail.
It was patently obvious to anyone at that time that if you planned to go to Norfolk, private, aerial work, charter or RPT, that you should have the ability to check the weather enroute and have the ability, and fuel, to go somewhere where the weather allowed a landing if Norfolk was a no-landing destination.
Norfolk has long been known as a place where the weather changes, and changes for the worse, on short notice.
Many years pass and in 2010 we see the ditching of the Westwind.
I for one can only read the ATSB report and the PPrune comments and ask if the lessons of previous years have been forgotten, regardless if the flight was Pvt. AWK, Charter or RPT.
The CASA requirements are the minimum and do not stop an operator from stacking the odds in his or her favour by planning ahead, to have a plan B and have adequate fuel to go somewhere that would allow a landing even if the aircraft had to fly at low level or on one engine.
Having looked at the ATSB report I note a few things that did not seem to get enough press.
Lifejackets were available for all but not all POB were wearing them even when a ditching was imminent.
The thing that saved the POB in the water was the pilot and his handheld torch. This was luckily seen by a Norfolk Is. rescue person on a part of the Island where he was not expected to be.
A lifejacket with a strobe would have been a far better piece of equipment as well as a portable ELT with the crew members. Lifejackets have long been available that have pouches for carrying ELTs and Strobe lights.
These days it would seem that when the lifejacket requirement comes up it is just a tick in the box item rather than what sort of lifejacket it is and what beyond-basic features it has.
There is scant discussion about the lack of advice to Norfolk Unicom about the location for the intended ditching. That is one of the first things that a student pilot is taught when commencing Practise Forced Landings. Location, Location, Location! It did not happen in this case.
I look at the ATSB report and say that there were a number of avenues in the investigation that appear to have been glossed over.
I have no doubt that other pilots will agree.
I recall the concern about a C172 that come out of Victoria. The pilot landed with some 14 litres of fuel remaining having got lost on the way to Norfolk. He had bought a handheld GPS the week before.
He is now doing Angel Flights.
The other event was a Baron. It came from southern Queensland. It arrived after dark, around 8 pm. No HF. Rain and fog with low cloud. Two airliners gave the approach away and went back home. The Baron (VH-O..) had nowhere to go. Not enough fuel to get back to Australia and Lord Howe is daylight landings only as I recall.
Jim Hazelton, the well known ferry pilot, talked the Baron down using a hand held VHF radio. The Baron got in. Jim deserved a medal for saving those on the Baron.
CASA would have been present. Some 2-3 years later came the CASA edict that if a charter or RPT flight went to Norfolk it had to check the weather in flight and have reserves to go somewhere better. I do not have a copy of that new requirement. Perhaps a reader could quote the fine detail.
It was patently obvious to anyone at that time that if you planned to go to Norfolk, private, aerial work, charter or RPT, that you should have the ability to check the weather enroute and have the ability, and fuel, to go somewhere where the weather allowed a landing if Norfolk was a no-landing destination.
Norfolk has long been known as a place where the weather changes, and changes for the worse, on short notice.
Many years pass and in 2010 we see the ditching of the Westwind.
I for one can only read the ATSB report and the PPrune comments and ask if the lessons of previous years have been forgotten, regardless if the flight was Pvt. AWK, Charter or RPT.
The CASA requirements are the minimum and do not stop an operator from stacking the odds in his or her favour by planning ahead, to have a plan B and have adequate fuel to go somewhere that would allow a landing even if the aircraft had to fly at low level or on one engine.
Having looked at the ATSB report I note a few things that did not seem to get enough press.
Lifejackets were available for all but not all POB were wearing them even when a ditching was imminent.
The thing that saved the POB in the water was the pilot and his handheld torch. This was luckily seen by a Norfolk Is. rescue person on a part of the Island where he was not expected to be.
A lifejacket with a strobe would have been a far better piece of equipment as well as a portable ELT with the crew members. Lifejackets have long been available that have pouches for carrying ELTs and Strobe lights.
These days it would seem that when the lifejacket requirement comes up it is just a tick in the box item rather than what sort of lifejacket it is and what beyond-basic features it has.
There is scant discussion about the lack of advice to Norfolk Unicom about the location for the intended ditching. That is one of the first things that a student pilot is taught when commencing Practise Forced Landings. Location, Location, Location! It did not happen in this case.
I look at the ATSB report and say that there were a number of avenues in the investigation that appear to have been glossed over.
I have no doubt that other pilots will agree.
A post from 14 Jan 2010:
...
I wonder if the ATSB report will conclude:
Safety Deficiencies:
The safety deficiencies identified relate to the accuracy of meteorological forecasts for Norfolk Island. The Bureau of Meteorology has advised that forecasts for remote Islands such as Norfolk are difficult to predict with accuracy and un-forecast conditions may occur without notice. Despite this advice the TAF issued at the commencement of the flight did not reflect this position.
Safety Recommendation:
Until the Bureau of Meteorology is confident of the accuracy of its forecasts for remote islands, a "PROB 20" line for constant conditions below the landing minima be added to every forecast to warn pilots of the Bureau of Meteorology's position that these conditions may occur without notice....
I wonder if the ATSB report will conclude:
Safety Deficiencies:
The safety deficiencies identified relate to the accuracy of meteorological forecasts for Norfolk Island. The Bureau of Meteorology has advised that forecasts for remote Islands such as Norfolk are difficult to predict with accuracy and un-forecast conditions may occur without notice. Despite this advice the TAF issued at the commencement of the flight did not reflect this position.
Safety Recommendation:
Until the Bureau of Meteorology is confident of the accuracy of its forecasts for remote islands, a "PROB 20" line for constant conditions below the landing minima be added to every forecast to warn pilots of the Bureau of Meteorology's position that these conditions may occur without notice....
Last edited by Checkboard; 2nd Oct 2012 at 11:34.
How many light aircraft have the fuel to go somewhere else if they can't get into Norfolk. None of them.
After all, isn't that why they are going there in the first place. Because they can't go anywhere else!!!
After all, isn't that why they are going there in the first place. Because they can't go anywhere else!!!
What they do is check on HF that the weather OK for Lord Howe. If no-go they turn around and go back to Australia.
If Lord Howe and enroute to Norfolk they use the radio to check the weather. If no-go they turn around and return to Lord Howe which they have checked is OK and land there during daylight hours.
If coming in the from the east side of Norfolk they should check and recheck that the weather is OK and if not have fuel and a plan to go to somewhere that they can land at. Plan B.
That was a major item in the ATSB report.
Again I note that the weather at Norfokk is fickle. Be warned and go prepared with plan B.
The problem with the Baron, above, was that it left Australia too late in the day, it did not have HF, it had no plan to return to Lord Howe in daylight if Norfolk was un-landable.
If Lord Howe and enroute to Norfolk they use the radio to check the weather. If no-go they turn around and return to Lord Howe which they have checked is OK and land there during daylight hours.
If coming in the from the east side of Norfolk they should check and recheck that the weather is OK and if not have fuel and a plan to go to somewhere that they can land at. Plan B.
That was a major item in the ATSB report.
Again I note that the weather at Norfokk is fickle. Be warned and go prepared with plan B.
The problem with the Baron, above, was that it left Australia too late in the day, it did not have HF, it had no plan to return to Lord Howe in daylight if Norfolk was un-landable.
Plan B: Suitable weather updated prior to PNR. Trend considered too. Otherwise divert to PNR alternate (departure point or off-track PNR landing point). PNR recalculated en-route to account for actual wind vs forecast wind.
How many light aircraft have the fuel to go somewhere else if they can't get into Norfolk. None of them.
After all, isn't that why they are going there in the first place. Because they can't go anywhere else!!!
After all, isn't that why they are going there in the first place. Because they can't go anywhere else!!!
You make a plan, with a suitable alternate and you have a PNR. Plan A is to pick suitable wx and go to Norfolk. You re check the weather prior to your PNR, if it's all good then continue with plan A, if there's any doubt revert to plan B and return/proceed to your alternate.
You re check the weather prior to your PNR, if it's all good then continue
with plan A, if there's any doubt revert to plan B and return/proceed to your
alternate
What happens if you have followed plan A but then the weather turns nasty? Lets assume for the point of the exercise that you are IFR.
By suitable wx I mean wx that suits the aircrafts capabilities. That is if it's a VFR aircraft your wx requirements are going to be much better/higher than for IFR.
Likewise if you're IFR but don't have the endurance to do an approach then divert, your wx requirements will be higher than if you had the luxury of being able to do an approach then divert.
For anyone with out the ability to divert after an approach PNR really is a critical time any doubt at this time a return should be done.
Forecasts, Metars, seasonal wx, the advice of the local met guys etc should all be taken into account when deciding when to go back or when to continue.
If you get all of this info, änd plan according to your capabilities, you are extremely unlikely to have a "What happens if you followed Plan A but then the wx turns nasty" moment.
Last edited by 27/09; 6th Oct 2012 at 08:59.
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KL - but has anything changed?
Then of course there is the reverse side of the coin – Hempel is a good one; but there are better. Anyway, I've probably said it all before.
Last edited by Kharon; 10th Oct 2012 at 18:55.
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Rod's statement 'they don't like people that standup to them'. How very true. Nothing has changed, some of the personalities have as has the name but not the culture.
Flying fiend you have not commented recently?
Flying fiend you have not commented recently?
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Achtung! Ve will not have nobodies standing up to us
Rod's statement 'they don't like people that standup to them'. How very true. Nothing has changed, some of the personalities have as has the name but not the culture.
Flying fiend you have not commented recently?
Inspector Hitler: Ve vill not tolerate oond mischief or complaints from industry who are not pure. Only those who comply vill keep their AOC!
Last edited by gobbledock; 10th Oct 2012 at 23:28. Reason: Avoiding the elephant, jackboots and Swastica in the room
Ben Sandiland's blog has some new info.
Freedom of Information release of full CASA audit of Pel-Air sinks ATSB report into ditching of air ambulance flight in 2009.
" The special audit of Pel-Air conducted by CASA in 2009 after one of its Westwind corporate jets was ditched in the sea near Norfolk Island while performing an ambulance mission for Careflight found that it gave no fuel planning guidance to its pilots when they were using airspace that could be denied to them mid-flight if their jet wasn’t equipped to use Reduced Vertical Separation Minima or RVSM rules...."
ATSB Pel-Air report damned by FOI release of full CASA audit | Plane Talking
joe.
Freedom of Information release of full CASA audit of Pel-Air sinks ATSB report into ditching of air ambulance flight in 2009.
" The special audit of Pel-Air conducted by CASA in 2009 after one of its Westwind corporate jets was ditched in the sea near Norfolk Island while performing an ambulance mission for Careflight found that it gave no fuel planning guidance to its pilots when they were using airspace that could be denied to them mid-flight if their jet wasn’t equipped to use Reduced Vertical Separation Minima or RVSM rules...."
ATSB Pel-Air report damned by FOI release of full CASA audit | Plane Talking
joe.
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Steam On
Did we let it happen? - YES. (Sandilands).
The thing gets me cranky is that the CASA are supposed to iron out the deficiencies they noted before operational approval is issued. The audited deficiencies are not the ATSB fault they are admitted, signed confessions of CASA acceptance /approval of the 'suddenly' now noted deficiencies. The audit damns the CASA: not the operator; if CASA is happy, all is well and the operator is not going to go looking for more grief. The Safety Authority accepted it, must be good.
The ATSB would have been, let's say 'guided' by whoever was in charge of the audit. It is NOT the job of the ATSB to raise noted operational problems until after the event. Sure they were influenced, but who persuaded them to slide around CASA accepted/ approved time bombs left laying about in a company operations manual ????. We know, don't we children.
Steam off - Confirmed.
The thing gets me cranky is that the CASA are supposed to iron out the deficiencies they noted before operational approval is issued. The audited deficiencies are not the ATSB fault they are admitted, signed confessions of CASA acceptance /approval of the 'suddenly' now noted deficiencies. The audit damns the CASA: not the operator; if CASA is happy, all is well and the operator is not going to go looking for more grief. The Safety Authority accepted it, must be good.
The ATSB would have been, let's say 'guided' by whoever was in charge of the audit. It is NOT the job of the ATSB to raise noted operational problems until after the event. Sure they were influenced, but who persuaded them to slide around CASA accepted/ approved time bombs left laying about in a company operations manual ????. We know, don't we children.
Steam off - Confirmed.
Last edited by Kharon; 11th Oct 2012 at 03:46.
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Just a thought
So here is a thought then. The CASA special audit actually is a fairly comprehensive document. Why not get the author of said document and promote he/she higher up the CASA food chain cos that person seems to be the only person in CASA who fully gets it? The ATSB investigation report contained a load of waffle, and so did the published CASA report. It would appear that the special audit author, perhaps a Lone Wolf McQuade type, is the only person who knows or understands the big picture.
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Cactus; the special report was written by the same team who was in charge of surveying Pel-Air prior to the accident. They are the same people who have been bagged on this thread for not doing something earlier. Their hindsight in the report is pretty good, not so sure about their foresight ........"
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Jet a
"Cactus; the special report was written by the same team who was in charge of surveying Pel-Air prior to the accident."
From reading the report and list of auditors that isn't quite correct
Given the date of the audit report the public could be forgiven for thinking that CASA saw this accident coming.
From reading the report and list of auditors that isn't quite correct
Given the date of the audit report the public could be forgiven for thinking that CASA saw this accident coming.
Last edited by flying-spike; 11th Oct 2012 at 07:07. Reason: Found my sense of humour
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There were certainly a few added from other areas Spike, but they are mostly the same. The Audit Coordinator and Lead Auditor certainly were definitely responsible for the oversight of the AOC.