Norfolk Island Ditching ATSB Report - ?
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They refer to HUET (helo underwater escape training) in the report. As the helicopter will sink very quickly & most likely roll with all the weight above the roofline. The drill is to crack whatever door you can & get out. Maybe the captain was following that drill ??
Unlike the ATSB report planetalking has no problem heaping it on to one and all of the various stakeholders that were party to this incident:
Pel-Air ditching report hurts the more as it sinks in | Plane Talking
There is also more evidence of the ATSB's 'softly, softly' approach in accident/incident reports over the last few years:
The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisations. In addressing those issues, the ATSB prefers to encourage relevant organisations to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.
Sheesh....bring back the BASI and the Crash Comic (hardcopy)!
Which also means CASA’s rules, contrary to the posturing of the safety regulator after the accident, were so weak that Pel-Air wasn’t obliged to carry enough fuel for a diversion caused by weather or other circumstances right up to the point where it overflew its intended destination.
But three years later, CASA ‘intends’ to fix the problem.
This triumph of prompt regulatory intervention, follows an incident in which poor pilot decision making by an apparently fatigued Pel-Air employee, resulted in six people, comprising two pilots, a nurse, an attendant, a patient, and her companion, flying four missed approaches to the Norfolk Island airstrips, and then making a controlled water landing at around 160 kmh after which the jet broke into two parts and sank 48 metres to the sea bed, leaving those on board to tread water or cling to wreckage before being found by a boat that had been looking in the wrong area when its skipper fortuitously glimpsed the pilot’s torch from afar.
It also confirms the truth of the astonishing comment by Pel-Air chairman, John Sharp, the morning after the near disaster, that the pilot, Dominic James, had set off from Apia with no plan B in the event that the flight couldn’t land on the island where it was to refuel.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
But three years later, CASA ‘intends’ to fix the problem.
This triumph of prompt regulatory intervention, follows an incident in which poor pilot decision making by an apparently fatigued Pel-Air employee, resulted in six people, comprising two pilots, a nurse, an attendant, a patient, and her companion, flying four missed approaches to the Norfolk Island airstrips, and then making a controlled water landing at around 160 kmh after which the jet broke into two parts and sank 48 metres to the sea bed, leaving those on board to tread water or cling to wreckage before being found by a boat that had been looking in the wrong area when its skipper fortuitously glimpsed the pilot’s torch from afar.
It also confirms the truth of the astonishing comment by Pel-Air chairman, John Sharp, the morning after the near disaster, that the pilot, Dominic James, had set off from Apia with no plan B in the event that the flight couldn’t land on the island where it was to refuel.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia.
Pel-Air ditching report hurts the more as it sinks in | Plane Talking
There is also more evidence of the ATSB's 'softly, softly' approach in accident/incident reports over the last few years:
The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisations. In addressing those issues, the ATSB prefers to encourage relevant organisations to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.
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Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia?
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Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia?
...or a more suitable aircraft should have been contracted for the job......or a fuel stop made at Nadi.
While not wishing to become an armchair umpire after this sad event, it is all too common for aircraft operators to enter into deals with unsuitable equipment simply because they already have it. And clients all too keen to accept such equipment on the basis of price alone.
While not wishing to become an armchair umpire after this sad event, it is all too common for aircraft operators to enter into deals with unsuitable equipment simply because they already have it. And clients all too keen to accept such equipment on the basis of price alone.
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Bits missing
It is also interesting that they refer to the conversation between the pilots and the Unicom operator however they didn't release the tape. They released their own video so why not the tape. Also they refer to the briefing and flight planning conversation for the return trip but no transcript or actual recording.
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And clients all too keen to accept such equipment on the basis of price alone.
Different operators will have different price structures and different profit margins. Is the client really expected to determine the underlying reason for the lowest price? After all, it is a more significant decision that brand name versus no name brand at the supermarket.
The client may well expect that the regulator and operator will ensure that the operator will conduct operations in a safe and appropriate manner.
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Soft pedal – (una corda pedal).
Plane Talking - Instead the report, which is a master class in how to write commercially inoffensive copy that will avoid raising public concerns, notes only that CASA has “advised of their intent to regulate Air Ambulance/Patient transfer operations in proposed Civil Aviation Safety Regulations …. to safety standards that are similar to those for passenger operations.”
Bit tragic to see the integrity of the once modestly proud, fearless, independent BASI become a cats paw for spin and dross. I wonder what the NTSB would have made of this, not a three year meal. That's siccar.
Last edited by Kharon; 30th Aug 2012 at 22:56. Reason: Yup – the more I read the siccar I get.
Reading the report, the crew did have fuel for a diversion to Noumea between approx 0905 and 0930.
They had 3 Speci reports (2 in this 25 minute period), each getting worse. Once the first Speci was received at 0800 indicating that the weather at LHI was not as forecast, the process to assess the actual weather at Nandi and Noumea should have started. This should have been the main focus of the crew for the next 90 minutes up to the PNR for Noumea.
As the weather at YNSF was deteriorating from the Specis received during this period, 90 minutes is more than enough time to determine the time and fuel required for a diversion to Noumea.
The crew state that they were not sure of the winds to Noumea. They were in the position of flying in the actual wind. This was probably more accurate than the Grid Wind forecast, if they had it.
It appears no request for the weather at Noumea was made. Why? This would be the first thing asked for once the first Speci for YNSF was issued.
As we are not informed of the weight at departure, we do not know how much extra fuel may have been carried and if that extra fuel would have allowed an approach at YNSF and a diversion to Noumea.
One thing that was not raised is the need for a Company to require an alternate when planning to a single runway airport, especially a remote destination. The Westwind is above the weight allowed for 04/22.
They had 3 Speci reports (2 in this 25 minute period), each getting worse. Once the first Speci was received at 0800 indicating that the weather at LHI was not as forecast, the process to assess the actual weather at Nandi and Noumea should have started. This should have been the main focus of the crew for the next 90 minutes up to the PNR for Noumea.
As the weather at YNSF was deteriorating from the Specis received during this period, 90 minutes is more than enough time to determine the time and fuel required for a diversion to Noumea.
The crew state that they were not sure of the winds to Noumea. They were in the position of flying in the actual wind. This was probably more accurate than the Grid Wind forecast, if they had it.
It appears no request for the weather at Noumea was made. Why? This would be the first thing asked for once the first Speci for YNSF was issued.
As we are not informed of the weight at departure, we do not know how much extra fuel may have been carried and if that extra fuel would have allowed an approach at YNSF and a diversion to Noumea.
One thing that was not raised is the need for a Company to require an alternate when planning to a single runway airport, especially a remote destination. The Westwind is above the weight allowed for 04/22.
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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.
On reading the report I formed the opinion that it was somewhat vanilla froth.
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.
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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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.
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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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
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.
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.
Going Nowhere,
If you read the report you would know it says in part:
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.