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Norfolk Island Ditching ATSB Report - ?

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Old 30th Oct 2012, 05:36
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PAIN - Norfolk Poll.

The authorities response to the Norfolk ditching if allowed to pass unchallenged has the potential to create a serious, far reaching impact on industry safety management.

The Senate response is crucial to how future events will be defined, reported and dealt with.

The authorities credibility within the aviation community is compromised and needs to be addressed both internationally and domestically.

Your response will assist in defining the direction and management of those events.

The link below will take you to a simple, anonymous poll. There are only five simple YES/ NO questions.


Norfolk ditching poll.
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Old 30th Oct 2012, 12:37
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PAIN

Thanks Pain, done. The ATSB CC must go if not for misleading the Senate, but for being basically incompetence. Its' a national embarrassment. How can he stand up with any dignity after his performance on 4C and the Senate? Time to walk Marty! We deserve better.

Last edited by Jinglie; 30th Oct 2012 at 13:10.
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Old 30th Oct 2012, 20:53
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Off with their heads

Jinglie # 511 - Time to walk Marty! We deserve better.
Indeed, but you can't just blame 'Beeker', who is a career public servant; I expect he only has a vague idea of which end the smoke comes out of. None of the three stooges are properly 'aviation' qualified; some of their very good people are, and I expect there is some head shaking and "I warned you" mutters floating about the place.

For my money, as clearly stated in Hansard 'he who must not be named' decided the outcome and sent his willing accomplice in to do the deed. "Beeker" worried about his budget (always) just went along for the ride. This is not the first time the grubby paws of "the" watchdog have been identified at the scene of the crime; nor is it the first time they have acted improperly and arguably illegally. Lets hope it's the last. Selah.

There is a whole world of passengers out there who, I'm sure would love to know that their life raft will vanish into the night and the life jacket (vest) without a spray hood, strobe, or even a humble whistle will probably kill them, if hypothermia or the sharks don't get 'em first. Three years and the information was just 'sat' on. Disgusting.

I note there is an 'in camera' session of the RRAT today, love to be Sen. Heffernan' s 'mate at the back of the room'. But wait, Blackhand will tell us, he claims to have 'heard' the "puerile, self serving" slop dished up during the last 'in camera' sessions. Senate knocks off at 1800 Blackie; no doubt we'll have a report by half past 1830 o'clock {sent from your Ipad}.

Last edited by Kharon; 30th Oct 2012 at 21:01. Reason: How do you know there's an elephant in the back of a Herc?
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Old 30th Oct 2012, 22:51
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FRMS, Pony Pooh, and 'He who shall not be named'.

So, some points for pondering:

1/ Beaker basically admits that the ATSB report is sprinkled with Pony Pooh.
2/ Mr Skull blames Capt Dom for the entire debacle.
3/ Yet, by his own admission Beaker admits there is more to the story than just Dom screwing up?
4/As has been mentioned, when considering all the contributing factors most admit that FRMS is a contributing factor.
5/ Most people now accept that the 'special audit' that was not considered relevant is actually relevant, and that Pelair had numerous issues including company attitude, fatigue, S.O.P's and other 'unrobust' issues.

So now it gets interesting, and here is the nugget:

CASA approved, sorry, accepted Pelair's FRMS. FRMS was a contributing factor, as it was identified as an issue in the 'special audit'. This then means that CASA, the supposed Regulator, has a part to play in this entire episode and some heavy questions ought to be answered? Maybe the Senators will ask the question 'why was the CASA General Manager Operations moved out of that position into a different role in Canberra prior to all this info coming to light?
Me oh my, I smell a rat, I smell pony pooh, I smell the stench of a Regulator hell bent on absolving itself of any accountability starting to be shown up for what it truly is, don't you?

Tick tock

Last edited by gobbledock; 30th Oct 2012 at 22:53. Reason: Leapfrogging a CASA Inspector
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Old 31st Oct 2012, 02:15
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None of the three stooges are properly 'aviation' qualified
It is interesting to note that this fact didn't go unnoticed by the Senators:
Hansard page 59:Senator FAWCETT: Do any of the commissioners have a background or qualification in aviation accident investigation?

Mr Dolan: I do not believe any of the three commissioners are qualified in aviation accident investigation. I have a reasonably significant background in aviation safety—air security and various other things—and a broader background in safety, including work health and safety and the systems approach to that. The other two commissioners have backgrounds in marine safety and rail safety.
If we look at Mr Dolan’s “significant background in aviation safety” we will find that his experience is totally devoid of any aviation operational experience.
Reference ATSB website:
Mr Dolan has worked as a Commonwealth public servant for 30 years. Prior to the ATSB, he was Chief Executive Officer of Comcare, with responsibility for the occupational health and safety and workers' compensation of Commonwealth employees.

From 2001-2005 he was Executive Director, Aviation and Airports at the Department of Transport and Regional Services, with responsibility for airport sales and regulation, aviation security, aviation safety policy and international aviation negotiations.

Previously, Mr Dolan had undertaken various corporate management roles in the Department of Agriculture, Fisheries and Forestry, including Chief Finance Officer and Head of Corporate Management. He started his public service career in 1980 with AusAid, managing aid projects in developing countries.
Basically the Chief Commissioner is a career-crat who has no aviation operational experience. The other two Commissioner’s have no aviation experience but they do have experience in the other two areas of the ATSB’s remit.


This would appear directly in conflict with the annual report statistics (2010-2011) for the separate areas of the ATSB remit, where we find that a whopping 85% of all the investigations instigated by the ATSB are aviation related.

With Beaker's propensity for tidiness and staying within budget and Big Mack's propensity for bully boy tactics and covering up the failings of Fort Fumble is it any wonder that we ended up with a totally doctored report devoid of any meaningful safety recommendations and missing the valuable lessons normally contained within the 'Survivability Aspects' that "K" alludes to...

Newsflash: Ben has picked up on the tabling of the ATSB Annual Report and makes some astute observations from that report:
ATSB annual report has systemic trouble with the truth

Ben Sandilands | Oct 31, 2012 1:31PM | EMAIL | PRINT


The ATSB annual report has been tabled in Federal Parliament, and is laced with incorrect claims that the authors, and perhaps the Government, might have hoped would pass unnoticed.

At year’s end we had 56 larger aviation investigations on hand which represents a stable workload. This year only four of those investigations are over one year old, which demonstrates that we have reached a sustainable level of activity that allows us to meet our targets for timely investigation while maintaining the high quality of our work.

In fact one of those reports, into the Pel-Air ditching at Norfolk island on 18 November 2009, was already nearly three years old, had been deemed to have been nearly complete in February 2012 on the ATSB web site, and is now following its publication on 30 August, the subject of a Senate inquiry, serious allegations of impropriety and abuse of process, and certain embarrassing admissions by its chief commissioner Martin Dolan and its general manager aviation investigations, Ian Sangston.

The ATSB has been disgraced by the Pel-Air report, which could be read as being willfully evasive, incomplete, vindictive and contemptuous of any public safety obligation, and should be withdrawn and done again so that it actually deals with the safety issues and human and systemic factors that it chose to ignore.

In relation to the unsafe state of air traffic control in Australia, the ATSB report says:

We are continuing our work to understand and mitigate the number of breakdowns of separation (BOS) and losses of separation assurance (LOSA) in air traffic control. Although the rate of these occurrences this year was broadly reflective of earlier years, we continue to examine individual occurrences in order to prevent their recurrence, but have also initiated a safety research investigation to bring the results of completed investigations together and compare their results with each other and the overall occurrence data set. To date, no significant, systemic safety issues have been identified as a result of our ongoing assessment of BOS/LOSA occurrences.

In fact, the ATSB produced in the year to June a series of reports into air traffic control failings which identify incomplete recurrent training issues in occurrences that have included controllers forgetting what they were doing and vectoring airliners into converging paths, in some cases annotated by the second and complete with diagrams that bring the performance of ASirServices Australia into disrepute.

The ATSB appears to operate to a unique meaning of the word ‘systemic’ given the fact that is has identified recurrent and entrenched issues in AirServices Australia and some air operators which it has chosen not to label as ‘systemic’.

We have safety problems in this country, and we have a problem with their full and frank disclosure.





Last edited by Sarcs; 31st Oct 2012 at 03:13.
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Old 31st Oct 2012, 05:39
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I havnt followed this in any detail but its reminescent of the Whyalla air fatal when the Coroners court destroyed the authority of the times technically flawed investigation.
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Old 31st Oct 2012, 06:01
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POLL day 1 results.

Thank you all for a good first day response, particularly the overseas participants.

The 'poll' site provides a map which shows the countries that replies came from, just a simple world map with shading. Well done the Czech Republic, North America, Taiwan, UK and Vietnam.

Q1) 92% Yes – 2.7% **Option – 5.3% No.

Q2) 95.6% Yes – 0.9% Option- 3.5% No.

Q3) 89% Yes – 3.0% Option – 8.0% No.

Q4) 78% Yes – 12.3% Option – 9.7% No.

Q5) 83.2% Yes – 2.6% Option – 14.7% No.

** Option was included to allow an alternate 'soft' option to Yes or No.

Just a caution, although the site is simple and uncomplicated, there are safeguards built into the data base to help keep the poll honest.

P4.
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Old 31st Oct 2012, 06:02
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Tick tock

Sarcs, good post my friend.

This is why aviation safety has gone down the gurgler. Nimwit Governments hell bent on protecting their gravy trains and precious troughs by hiring 'yes men' who are out of their league. 'Yes men' in the form of career bureaucrats, many with PHD's and other assorted non-essential qualifications other than an ability to spin, evade and deflect. The Board members are equally unsuitable.
It is time that the ATSB, CASA and ASA were run by people with industry skill, knowledge and ability. The current mish mash of nupty's are only good for hiding the facts and protecting the Minister and government of the day. All well and dandy til we have the first one or three smoking holes.
It is well past the time to flush out these bureaucrats, leeches, yes men and spin throwers and put knowledgeable people in the drivers seats, and dare I say it - Actually fix the problems!
If we can throw billions at Indonesia and PNG and another 5 billion into bailing out Greece (no, not an exageration, do the research) then we can spend some money fixing our present cluster f&ck.

I've said it before and I will say it again - I only hope the first smoking hole contains politicians, their families and friends when it happens.

Tick tock

Last edited by gobbledock; 31st Oct 2012 at 06:06. Reason: Dodging the control tower in the room
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Old 31st Oct 2012, 06:17
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The case of the invisible co pilot part 1.

I cannot, try as I may to find a case in aviation history where a co pilot, even still warm let alone breathing and walking about was not part of someone's case. Nary a one.

The PIC don't seem to want her supporting statements, the ATSB don't seem to want corroborating evidence, the CASA don't seem to want to even finesse her statements as part of the 'good oil' in defending their lame duck cover up.

I would like to know why?, I really would. I mean what can be so wrong with her testimony that no one seems to want to know about it.

Fee Fie Foe Fum; I smell the pooh from an elephants bum.

And, speaking of olfactory issues, where's the 'Blackie' report???? eh? eh?.

Norfolk ditching poll:

Last edited by Kharon; 31st Oct 2012 at 06:25. Reason: Good numbers P4 - Tanx.
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Old 31st Oct 2012, 06:55
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Kharon; you are assuming she is talking to anyone .....
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Old 31st Oct 2012, 07:03
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LB# 519 - Kharon; you are assuming she is talking to anyone
Bloody good point; I can think of a couple or three where the AFAP have advised a crew member to stay 'stumb'. But Cream Puff can probably best advise (or one of the legal eagles) how long can that last?, if everyone gets determined....Hell of a system where there needs to be advised silence lest we incriminate ourselves. The burden of proof etc.

There seems to be some deep, important issues in this one case alone and it looks as though it's not the stroll in the park envisioned by 'the safety authorities'.
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Old 1st Nov 2012, 05:24
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Poll results

G'day and thank you to participants from Belgium, China, Indonesia, Ireland, New Zealand, Qatar and the UAE.

0530 UTC results.

Q1) 92.7% Yes – 2.0% - Option – 5.3% No.

Q2) 96.7% Yes – 0.7% -Option- 2.6% No.

Q3) 77.5% Yes – 13.9% -Option – 8.6% No.

Q4) 74.3% Yes – 15.8-% Option – 9.9% No.

Q5) 83.6% Yes – 3.3% -Option – 13.2% No.

Tomorrow is the last day of this poll, if you wish to join in.

We have isolated some fairly pathetic attempts to 'tweek' the results, we can adjust the data base to isolate those. So final results Friday afternoon 1645 ESST.

P6. (AKA Ping ping).

Last edited by PAIN_NET; 1st Nov 2012 at 05:27.
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Old 1st Nov 2012, 23:13
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Jaba

"Gadrver, if memory serves me correctly you take a line of...was not like that... But refuse to offer a detailed plausible alternative.

Quite happy to be proven wrong, but it needs to be a convincing argument. We are all keen to hear what you know."

Hi Jaba,
A lot of the of the posts here are fairly accurate.....for a change.
It's taken a while but finally some commonsense is being posted here rather that usual drivel posted by malcontents and individuals with a professional axe to grind.
The state of Aviation regulation in this country is 2nd rate and has been from the early 90s.
Unfortunately, in a typical Australian way, most bitch and whine about the situation however do NOTHING to change things, until now.
If you'd been at the RAAA conference in QLD or any other aviation industry meeting over the last 12 months or so, you'd be able to meet with the clowns running the circus, always entertaining in a 'waiting for the train wreck scene" kinda way.
There's more to come on this , be in no doubt.
For the record, Dom may have made a blue however, like all professional aviators, is only as good as the system that he operates in. He and Zoe were let down in a horrific fashion by their employer and by the regulatory authorities. Could of been any one of us given the same situation.
The next few weeks will prove interesting to say the least.
As I alluded to in previous posts, before making slanderous and amateur remarks on a publicly visible social website in regards to your fellow aviators boys and girls, check your facts first and not rely on gossip and half baked theories sprouted by morons out on the FBO tarmac at Sydney or Brisbane (if I had a dollar for everyone I've heard in the last couple of years)...you may come up with egg firmly planted in face!
Maybe there's hope for the existence of PPrune D&G as a positive indicator of the professionalism of Australias aviators after all!!
Can live in hope I suppose.
[End of self righteous rant!]

...and Jaba, to answer your query...lots!

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Old 2nd Nov 2012, 01:14
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RAAA.

GADvr # 522 -If you'd been at the RAAA conference in QLD or any other aviation industry meeting over the last 12 months or so, you'd be able to meet with the clowns running the circus, always entertaining in a 'waiting for the train wreck scene" kinda way. There's more to come on this , be in no doubt.
Glad you brought up the RAAA conference; very little information coming out of that. I hear some of the speeches made were not as 'diplomatic' as they could be, but rather more robust than is usual. Confirm, deny or take the fifth?
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Old 2nd Nov 2012, 05:33
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Poll last day.

The data base has finished doing it's stuff early; the results. Seasonally adjusted:-

1) 92.6% Yes.

2) 96.9% Yes.

3) 91.2% Yes.

4) 87.6% Yes.

5) 82.1% Yes.

Thank you all again.

P4 a.k.a. (Ping ping).
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Old 2nd Nov 2012, 06:40
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Would not the 'silence' have been negated by recovery of the CVR and FDR? Be REAL interesting to hear what was on those - oh wait, apparently the cost of recovery (two scuba divers with a screwdriver for twenty minutes) made it unviable.... so a USV was sent down instead.
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Old 2nd Nov 2012, 07:40
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Fawcett's Official e-mail!

Remember this bit from the play "Pelgate" Act 5 Scene 4. Setting the scene: This was one of those "GOTCHA" moments where the Heff had been dangling the proverbial pineapple in front of Big Mack's eyes then along came Senator Fawcett who asked this:
Senator FAWCETT: I have got an email here from a fairly senior person within CASA saying: 'Our FOI perforation seems to be evenly split about the need or not to mandatorily divert from an alternate from the last possible diversion if the destination weather falls below the alternate minima. 'It goes on to talk about a range of things to do with that. That is followed up by another email—fairly senior again within CASA—on 20 March 2010, which says: 'I am happy with the path you are taking. My point is and you are addressing it that, as a result of reliance on the AIP, the Aeronautical Information Publication, which has no head of power and contains much that we need to revisit anyway, there is one group of pilots that have one view which leads to a mandatory diversion, and another group with the opposite view. Putting aside the practicalities, both groups believe that they are legally correct'—
and this is talking about FOIs—senior flying people within CASA. 'If we find ourselves in an AAT or a court, we once again could look a bit foolish if we, the regulator, find ourselves in a position where we have to say that there are two conflicting views, one of which has to be wrong, and we have done nothing to rectify that over the years—very untidy.'
What that says to me is that you have written the paragraph here aimed at Mr James which indicates that this body of knowledge and training should enable him to make the right decision in every circumstance, putting aside the fact of fuel planning and all the rest of it—and I understand that. The fact is, within CASA, 50 per cent of your FOIs disagreed with the other 50 per cent over what the legal interpretation of that was.
And here's what the Senator was referring to...by the way it's official everyone at Fort Fumble is 'Official', oh almost forgot and the plebs are 'Officers'.




In regards to 'looking a bit foolish' in the AAT or court I'd have to say it wouldn't be the first time but they still manage to bamboozle the Judiciary with pony pooh and witch doctory!



Quite obviously the 'loop' didn't extend to Big Mack's pa console...Q/ So which little piggy left the muddy trotter prints all over the director's foyer and pa's console??
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Old 2nd Nov 2012, 08:56
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GADRIVR

Almost 12 months to the day, post 14 on page one I think you are referring.

You have got to be kidding me.

- He departed underfuelled - refer Jamairs post, and regardless of whether or not there was an exemption, he still did not carry prudent fuel. TRUE IT SEEMS
- He could have diverted to New Cal after he received WX advising that he was now below the alternate minima. Had he been departing that point in space with that WX it would have required an alternate or suitable holding fuel. He had neither the fuel nor the brains to divert. TRUE
- He arrived with WX that was even worse still, and knowing he was low on fuel he never declared it or an emergency. TRUE
- He flew several VOR approaches which are not runway aligned by a mile or two from memory and require a circle to land. TRUE
- After a couple of them he tried yet again. TRUE
- He had a F/O that was not endorsed on GPS approaches, yet he was, but they never tried one. The RNAV for RWY 11 IS RUNWAY ALIGNED. TRUE
- He could have had the the FO call the numbers for distance and height to the SNFWM and flown a 3 degree profile watching the Radar Alt which it should have had, and flown the RNAV as a sudo ILS, and landed the thing on the runway. Might have been hard work and scary but should work. TRUE
- Some folk will argue "but that is descending below the MDA why would I be encouraging busting the minima, well he went well below the minima when he crashed it on the water . TRUE

Bloody lucky of the highest order that anyone lived, let alone the patient. Lucky the bloke who spotted them stopped where he did, by rights he had no reason to belive he should have. TRUE

So......poor planning, poor in flight monitoring, poor decission making in the cruise and poor decission making once it all turned to sh!t . TRUE or so it would seem

So show me one area of this guys flight operation where you can honestly cut him some slack? Maybe commercial pressure prior to departure?TRUE If so then he should have diverted in the first instance, and that extra cost would have shoved it right up the ar$e of the company for being so stingy. Of course he did sink a perfectly servicable jet on the bottom of the sea in return.

I too think the ATSB will be getting all manner of requests to distort the facts to minimise the arse covering required for the obvious.VERY TRUE in particular Pel Air and CASA
I am not sure why you are singling me out over Jamair morno Forkie and others, but hey I am vocal so happy to take your wrath too. I have said already, I feel for the guy, he had poor culture from the start, this is PA's fault, he had flown this way many times before and gotten away with it, PA again, CASA had poor oversight and poor compliance by education. He had poor hotel, sleep communications, but at the end of the day as PIC he was the final link in the chain, with knowledge, authority and the brains to stop the holes in the swiss cheese from lining up. Maybe you are Dominic? Probably not, but even if you were, I think most folk would agree that the PIC made a bunch of bad decisions, given a crappy hand that he was dealt, and even still he pushed on. And then failed to make some resourceful decisions like trying other options. Running low on fuel doing VOR's that don't work?

The definition of stupidity is to keep doing what you are doing expecting a different result. A VOR 04 or RNAV on any other would have been straight down the runway not a kilometre misaligned. He could have made a scary but illegal landing, even covered it up, and not had a crash. Maybe the good of this is his crash will affect change.

So as you say, he may have made a blue, and the system he was part of was very much an equal part, I have gone out on a limb and said before if I were to guess the blame portions, 20% CASA, 40% Pelair and 40% PIC. You are quite correct, it was not 100% Dominic, I agree, but he had 100% of the opportunity to stop the BS when he awoke from his hotel room.

Thanks for your rant, I do mean that, I think in a way we are mostly agreeing unless I missed something.
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Old 2nd Nov 2012, 09:25
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I think most folk would agree that the PIC made a bunch of bad decisions, given a crappy hand that he was dealt, and even still he pushed on. And then failed to make some resourceful decisions like trying other options. Running low on fuel doing VOR's that don't work?

The definition of stupidity is to keep doing what you are doing expecting a different result. A VOR 04 or RNAV on any other would have been straight down the runway not a kilometre misaligned. He could have made a scary but illegal landing, even covered it up, and not had a crash. Maybe the good of this is his crash will affect change.So as you say, he may have made a blue, and the system he was part of was very much an equal part,
I have gone out on a limb and said before if I were to guess the blame portions, 20% CASA, 40% Pelair and 40% PIC. You are quite correct, it was not 100% Dominic, I agree, but he had 100% of the opportunity to stop the BS when he awoke from his hotel room.
Dunno about most folk but I couldn't have put it better myself Jaba (although I did have a go on this thread). I do accept however that the report is defective in a lot of areas but if you apply the substitution test would a different crew have achieved the same result?

Last edited by Lookleft; 2nd Nov 2012 at 09:28.
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Old 2nd Nov 2012, 09:51
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Jaba,
Just reread my post and realised it seemed aimed at you.... not the intent and when I get in front of a decent keyboard I'll adjust it in an appropriate fashion.
Cheers,
Drivr
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