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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 31st Aug 2012, 01:08
  #81 (permalink)  
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ATSB have determined it was AWK, fair enough (despite the obvious issue of there being non-essential passengers aboard). I was surprised however to see no mention of the Careflight task management, where the aircrew and medical crew elected to undertake a couple thousand km over-water flight with no alternate nominated, at night, when the patient condition allowed for the flight to be undertaken in daylight. As AWK, the medical crew form part of the operating crew so come under the ATSB scope of examination. A significant contributor to the outcome I would have thought.

On reading the report I formed the opinion that it was somewhat vanilla froth.
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Old 31st Aug 2012, 01:33
  #82 (permalink)  

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4 Corners on September 3rd features this incident.

From my brief glimpse of the promo last night, I thought the aircraft shown was a Lear.
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Old 31st Aug 2012, 02:10
  #83 (permalink)  
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It may have been covered in the previous pages, so sorry for the double up but...

Does anyone else think that the landing gear looks down and locked? Would a lack of hydraulic pressure cause the gear to fall that straight? If the gear was up, should the fuselage have broken like it did?

Not suggesting it was down, just curious.
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Old 31st Aug 2012, 03:13
  #84 (permalink)  
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If the gear was down on landing the force of impact with the water would have torn it off.

Nowhere really spells: Now. Here.
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Old 31st Aug 2012, 03:59
  #85 (permalink)  
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Thankfully no fatalities resulted from this unfortunate incident.

I would suggest it is probably not over for Pel -Air you would think that the ATSB report provides some ammunition for a Civil Claim. Or has this already commenced?

Is there are valid reason why the Captain would exit the Aircraft first. That seems a bit odd or has the report left some detail out.
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Old 31st Aug 2012, 04:14
  #86 (permalink)  
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You would have to imagine the legals were waiting for this report before doing anything. The report states that care flight had not done a audit for a long time. That seems a bit out of line and could also be significant
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Old 31st Aug 2012, 04:21
  #87 (permalink)  
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GN, I doubt the gear was down for the ditching. Well hopefully it wasn't.

1 line of thought tho for off field Emerg landings on LAND tho is to lower the gear as it is a very strong component and will help absorb impact forces as it is possibly torn off by the impact. This means, hopefully, less forces to be absorbed by the fuselage/cabin area thus a greater chance of survival. Obviously every situation is different and requires a judgement call at the time.
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Old 31st Aug 2012, 04:27
  #88 (permalink)  
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Thanks for the replies, like you said Aus, one would HOPE the gear was up. It does look pretty well locked down though!
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Old 31st Aug 2012, 05:06
  #89 (permalink)  
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Going Nowhere,
If you read the report you would know it says in part:

The wreckage came to rest on a sandy seabed. Video footage showed that the two parts of the fuselage remained connected by the strong underfloor cables that normally controlled the aircraft’s control surfaces. The landing gear was extended, likely in consequence of the impact forces and the weight of the landing gear. The flaps appeared to have been forced upwards from the pre-impact fully extended selection reported by the PIC.
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Old 31st Aug 2012, 07:02
  #90 (permalink)  
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I have difficulty in criticizing the captain for being first out of the exit. Just imagine - he's gone back to the cabin to open the exit and get his pax out, his primary responsibility - now there is an open exit. Can you imagine his trying to fight his way back forward in the cabin when the pax REALLY want to exit? I imagine that he was fired out of the exit almost like toothpaste out of a tube.

His other decisions might well have been questionable though IMHO. Real men don't divert!!
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Old 31st Aug 2012, 07:02
  #91 (permalink)  
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I was surprised however to see no mention of the Careflight task management
The retrieval organisation has a document posted here http://www.isas.org.au/img.ashx?f=f&...Paul+Smith.pdf
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Old 31st Aug 2012, 07:49
  #92 (permalink)  
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Reading the report, I was surprised:
  • that there was no weight and balance analysis - or even a suggestion that one was completed. Even simple GA reports produced in a month or so have a statement similar to "the aircraft was within the weight and balance envelope." As this report relates to the amount of fuel uplifted, and it was a long flight, it seems very pertinent.
  • that there was no mention of the "passenger on an airwork flight" issue. As the airwork category allowed a reduced level of safety (no alternate planning), then permitting passenger travel is a pertinent issue.
  • The PIC received the latest aerodrome forecast (TAF)7 for Norfolk Island from the briefing officer during the submission of the flight plan.
    The poor briefing, and the Captain's statement that internet access was difficult is a major failure in the report - and the system defence for that is obviously the quality of availability of correct information, I am surprised there is no assessment of the quality of information available from the briefing office. As the Captain received the information "during the submission" of the flight plan, it seems obvious that the plan was already completed before any briefing material was obtained.
  • the report mentions that the company check required the calculation of CPs and PNRs as part of the endorsement/check to line, and that this training was not required to be recorded. There is no mention of any test to see if the accident Captain, or any other of the company's crew (or any of their representative industry pilots) are actually capable of calculating an off track CP and off track PNR under cockpit conditions. I say this because I doubt 20% of pilots in the industry can, and that is a failure of the exam system as the exam system focuses on very high accuracy which leads itself to systems of calculating which are not practical in the real world. That is why the company manual had the simplified fuel flow/planning information in it, and why the Captain stated
    The PIC indicated that for operations in the Westwind, there were effectively two refuelling options; either the aircraft carried full fuel, or the wing tanks only were filled.
    (ie. Crew were not confident enough in their fuel planning to specify an accurate (and efficient) fuel load)

Last edited by Checkboard; 31st Aug 2012 at 07:57.
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Old 31st Aug 2012, 07:52
  #93 (permalink)  
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Let dead dogs lie!

The Aviation Advertiser, in its article 'CASA revives a dead dog', makes mention of the ELT (fixed), which apparently gave one squawk and then quit, hmm that far overwater (if it was me) I'd be carrying, or have very close to me, one of those PLBs!

The ATSB’s report on the Norfolk Island ditching accident adds a real-time account that puts the realities of ELTs into further perspective:
The aircraft was fitted with a 406 MHz emergency locator transmitter (ELT), which was designed to transmit a distress signal that could be received by a satellite. The ELT could be manually activated by a switch in the cockpit, and it would also activate automatically if the aircraft was subjected to g-forces consistent with an aircraft accident.
The aircraft was also equipped with four personal locator beacons (PLBs) that could be carried separately and manually activated. Two of these beacons were installed in the life rafts, and one of the remaining beacons was equipped with Global Positioning System (GPS) equipment, which would enable it to transmit its position when it was activated. The aircraft occupants were unable to retrieve any of the PLBs before they exited the aircraft after the ditching.
The aircraft-mounted ELT was not GPS-equipped. A geostationary satellite received one transmission from that ELT and the information associated with that transmission was received by Australian Search and Rescue (AusSAR) 38 8 minutes after the aircraft ditched. AusSAR was able to identify the owner of the ELT, but was not able to assess its location from the one transmission.
Obviously the single transmission was impact-activated; however it seems probable that the airframe damage caused the antenna or its connecting lead to fail after that first transmission.
Lady Luck was very definitely on the side of the crew and pax!

CASA revives a dead dog – opinion – aviationadvertiser.com.au
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Old 31st Aug 2012, 08:00
  #94 (permalink)  
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The careflight document mentioned above states:
– Personal issue EPIRBs / strobes were not carried by our crew at the time – but now are!
• Crew also now carry their own life‐jackets equipped with appropriate survival aids
... so the careflight staff are no longer relying on the quality of lifejacket & survival equipment provided by their contractors, and are providing their own.

Edit: I might also add, that I am surprised that in this computer day and age a contracted jet aircraft is still relying on manual flight planning for an international overwater flight!

The industry standard is to pay the reasonable fees of a professional third party planning company, such as Universal Weather & Aviation Inc, or Jeppesen. In that way, the plan could simply have been faxed to the pilot's hotel - and you are not relying on a tired pilot not making an arithmetic error (or a simple inability to correctly determine the critical contingency point).

Last edited by Checkboard; 31st Aug 2012 at 11:21.
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Old 1st Sep 2012, 00:30
  #95 (permalink)  
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This Monday's Four Corners on ABC TV is all about this incident. Should make for interesting viewing.
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Old 1st Sep 2012, 01:28
  #96 (permalink)  
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Bloody Nanny state.

UIA- When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided.
Neither should there be; it only leads to more prescriptive, draconian, criminal based law being produced and misinterpreted, by all. Command discretion is an essential given; in theory, it's why you get paid the big bucks. It would be grossly unfair and harsh to criticise CASA in this case.

I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.

The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.

No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.

BH - K, do you ask for more regulation, surely not.
No mate, not me; but have a long hard look at the report from a purely operational viewpoint; no amount of regulation would, or could have helped ?. Nah, can't blame Aunty CASA for this one. (would if I could - but fair dooze).

Last edited by Kharon; 1st Sep 2012 at 01:34.
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Old 1st Sep 2012, 01:45
  #97 (permalink)  
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This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
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Old 1st Sep 2012, 02:06
  #98 (permalink)  
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John62 - This particular operator is rumoured to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
This is a very good point, amongst the many good ones here. And it's one reson why I say it's unfair to blame the regulator, no one can legislate effectively against a bad culture.

The stuff not written which carries the full weight of 'company' rules and a bollocking. Don't buy fuel at ABCD – to expensive; don't land at EFGH – we barred; don't ask for RTOW charts, etc. etc. We all have heard or seen it. Minimising uplift at 'expensive' ports and tankering fuel at 'cheap' ports is a game often and well played. It's called operating a service, as is saving a ton of fuel or finding the best flight level, or any of that unwritten, command type stuff. But, even if the rumours related to Noumea were true, I'd pick a night in French pokey over a swim in dark, any old day of the month.
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Old 1st Sep 2012, 02:43
  #99 (permalink)  
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Agree "K" you can't regulate for sheer stupidity or a severe case of 'pushonitis', although the philosophy is very much akin to the regulator's i.e. 'flying with the blinkers on'!

However one does wonder why it took so long to complete? Political correctness, sense and sensibilities, who knows? Also what's with the wishy, washy soft cock approach by the bureau??
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Old 1st Sep 2012, 07:36
  #100 (permalink)  
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Also what's with the wishy, washy soft cock approach by the bureau??
It is like red ink all over a school project- cannot criticise anyone as you may harm or upset their delicate nature -


they may learn from their mistakes - we could not have that now, could we.
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