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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 27th Jan 2015, 21:42
  #641 (permalink)  
 
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Interesting.
I see that the LNP Qld pollies have been flying around looking for votes in a REX Saab.
Given that REX own Pelair, and that REX have recently been awarded the Qld Government TMR contracts, I wonder who is paying the bill for the Saab?
Sorry... Silly thought....the Taxpayers will be paying of course.
BEACH KING is offline  
Old 27th Jan 2015, 23:37
  #642 (permalink)  
 
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http://periodicdisclosures.aec.gov.a...s/51/RINU3.pdf

Donations made in the name of Regional Express.

Top of page 2.
"Do you operate or conduct business under any other names?"
Answer "No."
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Old 28th Jan 2015, 00:31
  #643 (permalink)  
 
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http://periodicdisclosures.aec.gov.a...ns/6/D5785.pdf

As an ex-public servant, I would have to say, that taking 1 hour and 45 minutes, to complete this form, let alone actually admitting it, (in writing - god forbid) is rank inefficiency and incompetence, on a scale, that, had it been a Public / Civil Service person, would have made even Sir Humphry blush ...............

" ............... in this rare, and indeed exceptional case Minister, I must reluctantly agree, that on the face of it, and I must most emphatically emphasise, exclusively, on the face of it, alone ...... Minister, that one could surmise, that it actually does appear to warrant instant dismissal, perhaps even without appeal ......... Minister, but, ........ we must not be too hasty to pre-judge ....... Minister. There may have been .. Minister, circumstances, relevant to........ perhaps .......... the need to conduct exhaustive enquiries, searching past records and returns, that sort of thing ........ Minister, that were vitally integral to ensuring, so far as was reasonably possible, or practical, the accuracy and completeness of the information to be declared, .. Minister, of which we are currently not appraised, which could have taken "quite some time" ......... Minister."

But no, this was in the "efficient" commercial world, and by a "legal" ......... no less.

Nuff said.
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Old 28th Jan 2015, 00:37
  #644 (permalink)  
 
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I always write "5 hours" in that box ... on principle.
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Old 28th Jan 2015, 09:55
  #645 (permalink)  
 
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Vanquished but not forgotten.

Remember this?
Norfolk Island Ditching: Still Many Questions
    If you talk to someone who's been involved in a serious aircraft accident long enough, they'll eventually get around to two things: The accident constantly intrudes in the daily thought process and any external description of it—an official accident report or news reports—won't ring quite true. Experiencing something so traumatic isn't the same as reading someone reporting it.

    I thought of that when I interviewed Dominic James over the weekend. James was the Captain on that Westwind that ditched off Norfolk Island on November 18, 2009. At the time, I blogged that the accident report on this one is going to be interesting. Now that the report is complete, I got what I wished for. It's interesting alright, but for the wrong reasons. This accident appears to be a classic example of the linked chain, but the ATSB's report simply ignores many of the links, speeding apace to its conclusion: The crew was responsible.

    And so it was. The flight crew—James and First Officer Zoe Cupit—had the final vote and sole ability to sunder the accident chain. They failed to do that, but the report itself fails to explain that in some ways, the company, the system and CASA set James up for an accident and left him to his command authority to avoid it. When a perfectly competent pilot throws away a perfectly good airplane, it's often the result of a mindset patterned by past success and both external and internal pressures. This accident seemed to have all of that. As we reported in today's news, James is challenging the ATSB report and an Australian Senate hearing on it is planned for early next month. He says he's not ducking fault or responsibility, but believes the report simply doesn't give an accurate picture of all the factors involved in the accident.

    To refresh, the flight was a Westwind medevac mission with a stable patient from Apia, Samoa to Melbourne, Australia. To save you the trouble of hauling out your atlas, that's some 2800-nautical miles, almost all of it over water. It's the distance from New York to Los Angeles, plus another 700 miles. Norfolk Island was the planned fuel stop, a distance of 1600 miles. James said the Westwind had the legs for trips like this, but only if everything went to plan.

    For James and Cupit, it didn't. With good VFR forecast for Norfolk, neither the company's policy nor Australian regulation required a named alternate, so none was contemplated. In any event, it's doubtful that one could have been reached. The closest was Noumea in New Caledonia, 400 miles north of Norfolk Island. The Westwind departed with 83 percent of full fuel; mains full, tips empty. Even with the tip fuel, Noumea was unlikely, given the fuel required for climb. When the weather tanked at Norfolk, the crew had no option other than to land there. It couldn't and ditching was the only survivable option other than a desperation, homemade, below-minimums approach. The airplane simply lacked the capability to do the trip with contingency fuel.

    The number of links in this accident chain not covered in the ATSB report are too numerous to cover here. But as James explains it, they're obvious to him in retrospect. In hindsight, it is clear how this chain of events led him to the decisions he made. On a previous trip, James had been told Norfolk's automated weather reports were notoriously pessimistic and forecasts for the island were iffy. Other similar aircraft routinely made such trips with no drama, despite Norfolk's exceptional remoteness. Pel-Air seemed to have a loose relationship with regulatory adherence and CASA failed to oversee the company aggressively, as evidenced by an internal report only recently made public. ATSB never mentioned this report.
    Pel-Air airplanes routinely operated in or through RVSM airspace, but the Westwind wasn't RVSM equipped, according to James. Controllers would give the flight a bye on RVSM if they could climb to FL390, which the Westwind could do only if light, thus the decision to leave tip fuel behind. Noumea was potentially a paper alternate, but James said the local authorities there didn't want Pel-Air airplanes arriving because they lacked TCAS II and GPWS, not to mention RVSM. The accident airplane had just had TCAS and GPWS installed, but James and Cupit had never seen it and hadn't been trained in its use.

    The ATSB made a great deal of discussing James' fuel planning, especially the oceanic technique that routinely requires points of no return and/or critical points, which are continuation decision thresholds when few or no alternates are available. The ATSB conceded that based on the forecast, an alternate wasn't required and that the crew had enough fuel for a flight that proceeded normally, but no contingency for a de-pressurization event that would force the airplane to lower, less fuel-efficient altitudes. If the drift down happens in the wrong place, the range can dwindle to the point of neither being able to return to the departure nor reach an alternate. James insists his fuel load covered this and when he asked the ATSB for its fuel calcs, they declined the request. He had the data reviewed independently to confirm his calculations.

    Even with the good forecast, James got an updated METAR for Norfolk from Fiji ATC. The controller misstated the ceiling as 6000 feet rather than 600 feet. A later corrected METAR relayed via HF was garbled in poor atmospherics at dusk. James couldn't explain why he didn't receive it, but he knows he didn't. Fiji refused to release the audio tape of the transmission. "There's no way you sit on your hands for an hour after getting a METAR like that," James said. "You'd have to be a suicidal maniac."

    That missed METAR may have been the final or most critical link in the accident chain. Once the Westwind passed Fiji, it was committed to Norfolk, save for a brief diversionary window to Noumea. I like to think if I'd been in that cockpit, I'd have surely had the threat and error management thing going on and would have diverted sooner, just as any competent pilot should. Maybe you think the same thing. The reality is that given the circumstances, I can imagine myself being sucked down the same dark hole James and Cupit found themselves in. For me, personally, that's a creepy truth, but a truth nonetheless.

    Later in the week, I'll take a look at another accident that is eerily similar to this one. It occurred 42 years ago in the Caribbean.
    Link to the ATSB report. (PDF)
    How about this from the comments?
    Flight Nurse comment from Planetalking blog:
    · Karen Casey Posted November 4, 2012 at 3:49 am When will truth trump cover-ups that are with laced with selfish intent to save ones posterior? How ridiculous to have so many broken rules in an- audit, yet almost get away with it. There is a reason for the truth that is emerging, it’s for air safety & the failure of our regulator & investigative bodies results. It has been the survivors that have been the seekers of the real deal. What a disgrace. With both our Chief Commissioners under the microscope now, the amplification of this ordeal is finally happening. CASA & ATSB have a lot to answer for, dragging this on for selfish intent is criminal & at the least cruel to all on board. The coverup is surfacing and all will be revealed about the incompetencies of all parties involved. How unprofessional this has all been. How disappointing in the treatment of the people who have experienced hell from impact till now with our own government bodies involved. Does our government have enough integrity to investigate the individuals involved and actually DO something about this rather than just go around in circles. To add insult, let’s just throw in the fact that the ex-Pel-Air chief pilot at the time of the incident now works as an investigator for CASA…please!

    Just stop the B.S & tell the truth.

    PAIN comment: Puts a human face to this sordid tale!
    It is absolutely staggering how the more we discover with the PelAir duck-up of the cover-up the more entrenched the Mandarins & the Pollywaffles become in obfuscating the issue - in other words they are flat out in denial... And this is despite the rest of the world acknowledging a long..long time ago that the game was up and the stench emanating from Aviation House and the surrounding precinct was positively rancid...

    An excellent example of this was captured in Hansard - from the 24 Feb '14 Senate Estimates - where the Chair Senator Heffernan said this (in bold) in reply to Dolan's weasel words...:
    Mr Dolan : I and my fellow commissioners very carefully went through the contents of the committee's report and tested it against the information we had available to us in the course of our investigation. There was nothing, in our view, that constituted new and significant information that would lead to a need to reopen the investigation.

    CHAIR: How did it go from a critical incident to a 'don't worry about it' incident?

    Mr Dolan : That is a matter we did rehearse with the references committee. In short, our initial assessment of the issue of guidance as to dealing with the situation, weather deterioration and what was planned, we overassessed it as critical at an early stage and by applying our methodologies we concluded by the end of the process that it constituted a minor safety issue.

    CHAIR: Can I commend you. You look really well. You look less stressed than you used to for some reason.

    Mr Dolan : It is probably the lack of the beard.

    CHAIR: With that particular incident of which I just spoke no thinking person would believe that bureaucratic answer. You cannot go from a critical incident to a minor one or whatever it was without something happening on the journey. Anyway, we will not go back there. To any sensible person it sounds like either a cover-up or a balls-up.
    But enough of rehashing an old sordid tale for we all know that it is bollocks but let us spare a thought for one of own Ziggychick (aka Karen Casey), this from the vanquished but not forgotten..:
    Cui Bono?

    I read with interest how many people on 'Twitter' are concerned with 'human suffering' on both a small and a large scale, selflessly, often without a prayer of changing anything. This makes it incredibly important that when something can be done, a wrong can be righted if you like, we should whenever and wherever possible, lend our support. Even if that support is no more than a simple 'tweet'; there is one of our own who desperately needs all the Karma, good will and, if you are so inclined, prayers to the pagan gods of choice.

    I am amazed that the story has not made it into the mainstream media, for it has all the ingredients of a first class human interest story, in spades, redoubled.

    Soon Karen Casey and her family will be in a court; fighting for dignity, honour and some form of compensation to help her and her family adjust their lives around the fact that Karen is no longer able to work, support herself or foster her children's education. She did not know this was going happen when as a fully qualified, happy, flight nurse her patient was loaded onto a Pel-Air medevac flight, bound for Australia from Samoa. She had no prescience that within a few hours after take off, she would be struggling to keep her patient alive in a dark ocean, miles from the shore of a remote island in the vast South pacific ocean. After the aircraft ditched and broke in half, the patient had be un-strapped from the stretcher and helped into the cold dark sea. After the life raft had sunk, still secure in it's canister all that stood between the survivors and certain death were the life vests. The patient's life vest amongst others partially failed only half inflating; whistle cords hopelessly tangled, lights dim and intermittent. Karen spent 90 long selfless minutes, treading water, supporting her patient while permanently damaging her body, living now on fresh air, hopes of justice and pain killing drugs.

    Here is a potted version of what she is trying to stare down:-

    The Australian Civil Aviation Safety Authority (CASA) who not only allowed operational and systematic flaws to be enshrined within the Pel-Air SOP, directly connect with the causal chain, not only failed to prosecute the Chief pilot responsible, but hired him. Not content with that, they upped the ante and became involved with the ATSB report of the incident. That, standing alone is a remarkable story – See PPRuNe Senate Inquiry, for all the gory details.

    The Australian Transport Safety Board (ATSB) under Doolaly Dolittle who happily cooperated in the farcical report which was to become the subject of a Senate inquiry; where breaches of the TSI Act and ICAO annexe 13 were exposed along with a plan to lay 100% of the blame on the pilot; who admits and regrets his errors.

    The 'Department' and the minister who manage these two autonomous, fully protected bodies and happily admit there is no legal reason for Karen to be compensated.

    Karen simply and happily went to work one day – that's all; her patient and husband, the doctor travelled in good faith. Physical and mental trauma all at no fault of their own, can they expect justice and recompense; can they hell. No matter the political party's did quite well out of it, what with donations happily coinciding with reports and all. Promotions and pay rises all around for the troops. For Karen, well she has the pleasure of dragging her family into a hostile court under subpoena as witness for the opposition.

    She needs a bloody medal and time to heal, not forced into a dragged out, one sided court battle against large corporations, government agencies all intent on protecting (legally of course) their rice bowls. Does it stink – you bet.

    Lear:
    Close pent-up guilts,
    Rive your concealing continents, and cry
    These dreadful summoners grace. I am a man
    More sinn'd against than sinning.

    Selah.
    Sarcs is offline  
    Old 28th Jan 2015, 18:28
      #646 (permalink)  
     
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    Could anyone be forgiven for thinking that Rex threw $250,000 at the Ministers political party, but not of course the Minister, before the ATSB report was released to make sure that the ATSB and CASA blamed the pilot and not Pel AIr for the incident?

    Could anyone be forgiven for thinking that Rex then threw money at the Liberal and Country parties Four months later to stop them questioning the report or raising the matter in Parliament? Why would a company not known for political donations suddenly open its purse?

    Could anyone be forgiven for thinking that, even today, a successor Liberal Government, CASA, the ATSB and the Department of Infrastructure are doing their level best to try and hide a deliberate act of perverting the course of an official investigation? Could there be any other reason for their reluctance to have a totally independent review of the report?

    Why would anyone nominate John McCormick for the Directors position at ICAO, given the ongoing mess that is Australian Aviation regulation?

    Is it not now abundantly clear that the New Director Of Air Safety, Skidmore, does not have a snowballs chance in hell of implementing any meaningful reform of CASA, as called for in the Review, given that all political parties and the Department of Infrastructure have no stomach for it?

    Could anyone be forgiven for thinking that CASA, ATSB and perhaps Airservices are now inextricably mired in corruption and that Australian Aviation jobs, investment and growth will continue to decline because of it?

    Do people not understand that the merest whiff of official corruption sends honest investors running for the exits?

    I therefore hope that none of the above is true.
    Sunfish is offline  
    Old 30th Jan 2015, 21:27
      #647 (permalink)  
     
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    CASA: PelAir 2008 audit and 2009 special audit

    Its worth having another look at the March 2008 audit of PelAir.

    1. An audit had been planned in October 2007, but this audit was terminated as the majority of pilots did not submvit their logbooks. The audit was rescheduled for 12-13 March 2008. Page 3.

    2. PelAir hasd been operating under a Fatigue Risk Manaement System (FRMS) for 11 months. However pilots had not received training in FRMS. This non-compliance was considered by CASA to be an imminent safety threat. On 12 March 2008, CASA issued an immediate Safety Alert, which precluded further operations under the FRMS. On 17 March 2008, PelAir advised CASA the required training had been completed. On 18 March 2008, CASA approved PelAir to resume operations under the FRMS - possibly a record turnaround by CASA. Page 3.

    3. There were other deficiencies in addition to the FRMS training. Review of pilots records showed 80% had no evidence of training in emergency procedures (page 4), and irregularities in the renewal of instrument ratings (page 4).

    4. On 11 October 2008, CASA formally documented that all active pilots had been trained in the FRMS. Page 45.


    Which should be all well and good.

    But it does make you wonder why the 2009 post-crash CASA special audit (only 12 months later) again found serious issues with fatigue and the FRMS. Four pages (22-25) of this 2009 audit deal solely with faitgue management deficiencies.

    "Most crew itentified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective." Page 22.
    There was an "FRMS knowledge gap displayed by the pilots." Page 22.
    "PelAir have not managed fatigue risk to a standard considered appropriate..." Page 23.


    These 2009 audit findings appear at odds with all the training condcuted by PelAir and approved by CASA in 2008, and with CASA approving a return to FRMS operations.


    These audit findings also raise questions why the final ATSB report was not critical of CASA's regulatory oversight of PelAir throughout this period.
    slats11 is offline  
    Old 30th Jan 2015, 22:23
      #648 (permalink)  
     
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    In his more lucid and coherent moments TAFKA P9 has some interesting things to say. I will copy and paste his words on what I think is the most important issue surrounding this accident. All the rest is just so much history rehashed in order to get the thread to the top of the page.

    Karen Casey physically injured through no fault of her own in the Pel-Air air accident, a ditching which could have been prevented, must now decide whether dragging her children through a court hearing process and exposing them to ruthless cross examination will achieve any improvement in the way victims of air accident are treated. There is a lot more at stake here than a simple compensation claim, Karen's case exposes the entire sham of Australia's claim to be an aviation safety doyen of the developed world.
    If Clive Palmer was truly the champion of the Aussie battler he would fund Karen's case rather than Alan Jones v Campbell Newman. What do you reckon Clive? Here's a battler worthy of supporting.
    Lookleft is offline  
    Old 30th Jan 2015, 22:30
      #649 (permalink)  
     
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    Spare a thought cont/-

    Top job slats... (Ps All lovingly reproduced here )

    Not my work but - in light of upcoming events - I thought the following was worth reproducing as well...:
    31. Jan, 2015
    Of games and candles.


    Sitting alone in her garden this morning is a brave women beset by doubt, anxiety and anger facing what must be, for a mother, the most difficult of decisions. Karen Casey physically injured through no fault of her own in the Pel-Air air accident, a ditching which could have been prevented, must now decide whether dragging her children through a court hearing process and exposing them to ruthless cross examination will achieve any improvement in the way victims of air accident are treated. There is a lot more at stake here than a simple compensation claim, Karen's case exposes the entire sham of Australia's claim to be an aviation safety doyen of the developed world.

    The dilemma is clearly defined, stand and expose herself and family to the tender mercies of insurance company barristers; or opt for a quiet life by accepting an out of court settlement. Tough call for someone who has battled five years of extreme physical pain and exquisite mental anguish. It is fitting that we look backward before looking ahead; what was the path which led Karen Casey to this moment, sitting alone in her garden, with only a mug of coffee and a faithful dog as her counsellors?

    @P11 - Slats has provided a very concise summary which details just one of the many issues which formed part of the accident chain. Not immediately apparent to an outside observer is the speed with which the 'problems' were claimed to be fixed and the readiness of the Australian regulator (CASA) to accept that claim. The Senate inquiry into the ditching of the aircraft clearly and unequivocally identified a cynical, politically motivated bastardisation of law, accident investigation and human decency. Those who followed the Senate inquiry need no convincing of this, the proof is recorded in the parliament Hansard and freely available to all. It is no coincidence that the unspeakable PPRuNe engineered a shut down of the Senate inquiry thread for the hearing of Karen's case would raise, once again, the loud voice of public criticism and we can't have that now, can we?

    Not one of the identified problem areas has even been addressed, let alone satisfactorily eliminated; the Pel-Air accident could occur again, from the same root causes. The people who happily engaged in the shabby affair are healthy, employed, swaggering and bullying their merry through the manipulation of air safety systems, designed for the protection of those travelling and working in the skies. Being paid, very well to continue making an art form the blantent mockery of those rules and the investigations of accidents, as and when required, to suit their predetermined purpose.

    The question for Karen; is the game worth the candle? We must hope it is, for on those small shoulders rests a mighty weight.

    Spare a thought for Karen and wish her Godspeed.

    Selah.
    Sarcs is offline  
    Old 30th Jan 2015, 23:32
      #650 (permalink)  
     
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    @ Lookleft

    I will copy and paste his words on what I think is the most important issue surrounding this accident. All the rest is just so much history rehashed in order to get the thread to the top of the page.
    The tragic human cost you refer to is really not in dispute. However with legal proceedings imminent, the key issue will be any finding of negligence that led to the crash and this human cost. Without a finding of negligence, there can be no restitution.

    This means all the events leading up to the crash are highly important.
    slats11 is offline  
    Old 31st Jan 2015, 00:51
      #651 (permalink)  
     
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    Without a finding of negligence, there can be no restitution.
    Would this mean negligence on behalf of Operator and/or Crew?
    Eddie Dean is offline  
    Old 31st Jan 2015, 02:32
      #652 (permalink)  
     
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    Would this mean negligence on behalf of Operator and/or Crew?
    Not sure Eddie. That would be for the Court to decide.

    Very often however (and I am only speaking in general terms here) the employer carries vicarious liability for the acts of an employee.
    slats11 is offline  
    Old 31st Jan 2015, 05:07
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    What CASA office was responsible for the regulatory surveillance of the Westwind operations of PelAir during the 2006/7/8/9 period?
    Creampuff is offline  
    Old 31st Jan 2015, 05:56
      #654 (permalink)  
     
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    the employer carries vicarious liability for the acts of an employee.
    The irony then that Ms Karen Casey's legal team has to show that the pilot was negligent, and would perhaps use the CASA action as evidence?
    Eddie Dean is offline  
    Old 31st Jan 2015, 06:22
      #655 (permalink)  
     
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    Creampuff

    Google "2008 CASA audit PelAir" First result is the 45 page document.

    In October 2008, Malcolm Campbell signed that all pilots trained in FRMS. Page 45.
    slats11 is offline  
    Old 31st Jan 2015, 06:47
      #656 (permalink)  
     
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    Her claim is against her employer.


    Any employer defending any claims made by her is a vexatious defense.


    Her employer would have a claim against the regulator had the rule of law been adhered to regarding apportioning blame, but considering the evidence (which has been compromised), a 'straw' man is expected to 'carry the can' in lieu of the political and expedient dismissal for base cronyism and economy of effort.


    Indeed, what CASA office was responsible for the regulatory surveillance of the Westwind operations of PelAir during the 2006/7/8/9 period?
    Frank Arouet is offline  
    Old 31st Jan 2015, 07:07
      #657 (permalink)  
     
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    True Frank
    But wasn't her employer Careflight?
    Dynabolt
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    Old 31st Jan 2015, 07:23
      #658 (permalink)  
     
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    http://www.lawlink.nsw.gov.au/courtl...d?OpenDocument

    10:00 AM
    2010/00385262
    Karen Marie Casey v Pel-Air Aviation Pty Ltd

    10:00 AM
    2011/00046508
    David Helm v Pel-Air Aviation Pty Ltd

    10:00 AM
    2014/00357770
    Careflight Limited v Pel-Air Aviation Pty Ltd

    Last edited by slats11; 31st Jan 2015 at 07:36.
    slats11 is offline  
    Old 31st Jan 2015, 07:29
      #659 (permalink)  
     
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    I guess the lawyers share the commission.


    Hopefully there's enough left to give Karen some economic, physical and mental vindication.


    What a crooked mess!
    Frank Arouet is offline  
    Old 31st Jan 2015, 08:12
      #660 (permalink)  
     
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    So why is Careflight taking action against Pelair? Are they trying to recover workers compensation claims made against them?
    Lookleft is offline  

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