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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 6th Nov 2017, 01:14
  #981 (permalink)  
 
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Location: australia
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No astonishing Balloony, ...its their natural way.

Their brains are wired with their supreme knowledge that only WE make the world safe, only WE know whats best for you, and only we can keep you safe from crashing to earth.
That THEY do harm to others in their bastard processes does not compute with them at all eg Quadrio, James and many, many others.

Is the CAsA Empire starting down the road to being FCUKED ?? Well Rome fell in the end, so there is hope.

Here's some recent safety wisdom from the Cowards Castle/Fort Fumble.
Missed log book entry, strict liability criminal offence, now $10500 penalty.
Note: yr log book in yr flight bag or on the shelf at home, will NOT bring down an aircraft.
Smoking in an airliner toilet, which has in the past caused fires and threatens the lives of100s..penalty $900.
"Safety" is all. !!

And as for confusing, convoluted and bs answers in Senate Hearings..its all about CYA 101 thru 120. The KISS principle does not apply.
All power, all control of aviation but NO accountability, NO liability.

Aviation House is rotten with corrupted processes, cronyism, professional BS artists, (and artistes), and perverted legal acrobats.

Only the political process can wreak the long overdue needs and changes to save the Industry.
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Old 6th Nov 2017, 02:27
  #982 (permalink)  
 
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NOBLE CAUSE CORRUPTION.?
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Old 6th Nov 2017, 02:48
  #983 (permalink)  
 
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They’re still punishing this guy, WTF?

He’d have to be the LEAST likely Australian pilot to run out of fuel.

And remember from the Senate inquiry, they didn’t de-licence him... they just “temporarily suspended his privileges” until they could confirm any deficiencies had been rectified.

Is he having to once again go through an entire ATPL flight test? That would appear to me they have essentially cancelled his licence and are issuing a new one.

If the sim is only to demonstrate competency in fuel management, then I could buy the whole “privileges temporarily suspended”. It would be interesting to know the syllabus for this “test” and whether it lines up with the accident or if there’s a whole lot more added in there.

And didn’t he act within the CASA approved Company fuel policy, and plan the flight legally anyway? What particularly has changed? If I were doing his sim test and he planned within the regulatory and Company minimums (like he already did on the accident flight), aren’t I obligated to pass him?

And in said sim test, when he gets to PNR and the destination WX goes below alternate minima but still above landing minima, what should he do? Given that during the senate enquiry 3 CASA FOIs said you have to divert and 3 said you don’t, which option should he take?

The entire thing is an absolute mess.
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Old 6th Nov 2017, 03:08
  #984 (permalink)  
 
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Slippery_Pete, you are probably correct that Dom would now be the last pilot to have a fuel incident.
I like the man, and think he will have good input with AOPA.

From my dealings with CASA, and reading between the lines of the CASA emails that leady posted, I reckon that they are waiting for a mea culpa from old mate Dom.

Their way of thinking, is that he has refused to satisfactorily own his fault in not planning enough fuel, nor making the correct decision before the PNR.

But whatever, as the kids say, it is about time that Dom was allowed to get on with his career.
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Old 6th Nov 2017, 03:17
  #985 (permalink)  
 
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50% of FOIs said you can continue to destination if it drops below alternate but is still above landing minima.

I’m not advocating I’d do that.

But if Dom has to demonstrate diversion under those circumstances to get his privileges back, have those three FOIs been “temporarily suspended” too?

Sure is time he was allowed to get on with it.
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Old 6th Nov 2017, 04:59
  #986 (permalink)  
 
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He and his family should go after individuals in CASA and sue their arses off.

What has CASA cut them loose
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Old 6th Nov 2017, 05:56
  #987 (permalink)  
 
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In the past 8 years Dom James has successfully completed no less than 23 separate checks of his competency. He was required to resit and pass the requirements for his CPL and IR rating. Resit all the ATPL subjects which he achieved with above 90% pass rate.The latest check of his flying skills he recently completed at Flight Safety completing a type rating on a Falcon 20.
The last piece of embuggerance by CAsA is that he complete a flight, to be observed by CAsA, in a Westwind or similar aircraft on an oceanic flight with a diversion at the PNR with a critical fuel scenario. What that is supposed to prove I have no idea because in my opinion and many others, the issue was not diversion related. By the time Dom was made aware the Norfolk weather had deteriorated there was no diversion available to him, therefore it was a weather related incident not a diversion incident, much the same as the Mildura event.

If you want an expert analysis of the Norfolk ditching I suggest you read a submission to the Senate Inquiry by Mr Richard Davies.

His submission is incredibly detailed and is somewhat large to post here so I have taken the liberty to highlight some of his conclusions, which support the prognosis that by the time the commander of the flight became aware that Met. conditions at Norfolk Island were below an acceptable level, a diversion to Noumea was very problematic and in all likelihood the flight would have ended up ditching in open water before reaching that safe haven. For those interested studying the entire submission a link to the Senate submissions;

https://www.aph.gov.au/Parliamentary_Bus...2012/index

Opening gambit:

2. I make this submission as an individual who is concerned regarding the standards and practices of the Australian Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA), as exhibited in the matters relating to the accident on 18 November 2009 involving the Westwind II aircraft, registered VH-NGA, operated by Pel-Air Pty Ltd.

3. I became involved in this matter at the request of parties involved or associated with the accident. My subsequent enquiries and analysis indicated deficiencies by both the ATSB and CASA in aspects that I have reviewed.

I think he smelt a rat.

Fuel System and Fuel on Board

8. The ATSB report (page 15), in its section on ‘Fuel System’, discusses the capacity of the aircrafts fuel system. However, it refers to the capacity in units of pounds (lbs) or kilograms (kg). These figures are incorrect in that they represent a weight (of fuel) and not a volumetric capacity of the tanks.


10. The ATSB report frequently refers to a fuel load of 7330 lbs as being the main fuel tanks containing full fuel (pages 3, 16 and 32).
The statement is incorrect for the reasons specified below. I am not aware where the ATSB obtained this figure from, however it is referred to in Pel-Air documentation as being the standard figure for full main tanks.

Already inconsistencies from the ATSB.

15. The aircraft had fuel tank capacities of 1100 USG for the main tanks, and an additional 230 USG for the wingtip tanks. Therefore, if the aircraft was fuelled to the main tanks being full, and an SG of 0.78 applied (as specified by Pel-Air), the aircraft had 7160 lbs of fuel on board preflight, not the reported 7330 lbs.

16. The ATSB Report had a paucity of information regarding their methods of fuel and flight planning calculations.

Scant details included:

“The investigation used a BoM wind/temperature chart to derive the temperature at the cruising altitude as approximating ISA + 10oC.”
and that the calculation included:
“The application of that temperature to the available aircraft performance figures and the PIC-anticipated 50 kts headwind to the relevant cruise speed from the AFM to the distance from Apia to Norfolk Island of 1,450 NM (2,688 km)”
thus deriving:
“resulted in an estimated planned fuel consumption of 5,550 lb (2,517 kg).”

17. The report does not specify the ATSB’s methodology for calculations. I did obtain a copy of a “Jeppesen FliteMap” calculation, purportedly completed or commissioned by the ATSB for use in the investigation. No weight details are included in the document (eg Takeoff weight). However, for the correlating distance (1449 nm), altitude (FL390) and a 70 knot headwind the calculated fuel used was 5150 lbs.

This is a difference of 400 lbs less despite an extra 20 kts of headwind. The reason for this anomaly could not be identified.

18. The report does not contain details of the calculated fuel remaining at any point enroute. Thus the basis for calculating the viability of diversions whilst enroute cannot be justified.

Some inconsistencies from Pelair;

19. The ‘Pel-Air Operations Manual Part B’ specifies
“16.5.1.1 The following planning data shall be used for Company Westwind operations.”
(my emphasis)
However, in the very next paragraph states:

“16.5.2 Fuel Consumption and Block Speeds

16.5.2.1 The following table is a guide only to planning. Refer to A/C OPS
Planning Manual for precise information.” (my emphasis)
The document then continues with planning information with fuel usage based on hourly time frames, irrespective of the weight of the aircraft. Similarly, a standard figure is used for True Air Speed (TAS), despite this also varying with weight and altitude.

Then CAsA enters the mix;

21. These various statements would appear confusing and contradictory, yet are contained in a manual accepted by CASA that is the primary reference source for the crew.

Dom James was pilloried for not diverting to Noumea when he became aware the Norfolk weather was below minimums, in fact part of Rodger Chambers embuggerance requirements is a check flight in a westward or similar to judge mr James decision making processes and calculation of an inflight diversion. No doubt if he had decided to divert and finished up ditching in open waters short of Noumea, he'd be faced with an inquisition as to why he diverted with insufficient fuel. DAMNED IF HE DID, and DAMNED IF HE DIDNT.

here's the rub from Mr Davies;

Fuel Calculations for Diversion

31. Based on these calculations, the fuel remaining on board at position DOLSI (at time 0839 UTC) was 2282 lbs (assuming the 10 percent Variable Fuel Reserve had been used to this point)
32. The ATSB report identified the “Approximate Last point of safe diversion to Noumea” as being between time 0902 UTC and 0928 UTC
33. At time 0904 UTC the crew received advice of a weather observation (SPECI) issued at 0902 UTC. As identified in the ATSB report, this was the first time the crew assimilated information about the deteriorating weather at YSNF.
34. Time 0904 UTC was 25 minutes after DOLSI, at an average Ground Speed of 352 kts and Fuel Flow of 1326 lb/hr. Therefore, the distance past DOLSI was 146 nm and fuel remaining was 1677 lb (assuming the 10 percent Variable Fuel Reserve had been used to this point)
From a position on track 146 nm past DOLSI to NWWW was 436 nm
Based on a diversion direct to NWWW at that time, at FL390 with a 20 kt headwind component throughout, having used 1409 lbs for the subsequent cruise and descent for the segment (assuming the 10 percent Variable Fuel Reserve has been used), the aircraft would arrive overhead to commence its approach and landing with 269 lbs total at time 1014 UTC
Calculations for this are attached as Annex E.

35. Time 0928 UTC was 49 minutes after DOLSI. Based on the previous figures, the distance past DOLSI was 287 nm and fuel remaining was 1093 lb (assuming the 10 percent Variable Fuel Reserve has been used to this point)
From a position on track 287 nm past DOLSI to NWWW was 410 nm
Based on a diversion direct to NWWW at that time, at FL390 with no wind component throughout, having used 1214 lbs for the subsequent cruise and descent for the segment (assuming the 10 percent Variable Fuel Reserve has been used), the aircraft would not complete its diversion as it would run out of fuel, having a shortfall of 122 lbs

36. By comparison, if the aircraft continued to YSNF (as planned) it would arrive with 709 lbs (Annex D)
37. Based on these calculations, the information contained in the ATSB report is incorrect.

The fateful timeline;

50. The first time the crew became cognizant of a need to consider the option of an alternate aerodrome due to deteriorating weather at YSNF was 0904 UTC; by which time they had passed LPSD for NFFN (time 0845 UTC) (see para 54 and Annex G), and (based on the calculations above) the airport that would result in the greatest amount of fuel being available on arrival was YSNF. (See paras 35 and 36).

269 lb remaining at NWWW (less than FFR), 709 lb remaining at YSNF

The point?

53. At 0904 UTC the latest TAF for YSNF was for conditions below alternate minima, but above landing minima. The latest observation (SPECI 0902 UTC) also identified weather conditions below alternate minima, but above landing minima. As such the crew could have a reasonable expectation of becoming ‘visual’ prior to the completion of an instrument approach and landed.
54. Given that the aircraft was past its ‘last possible diversion’ to arrive with FFR remaining, and at YSNF there were two separate runways, and the expected weather conditions were above landing minima, the crew complied with the Pel-Air procedure (as accepted by CASA).
55. By the time the crew obtained the 0930 SPECI at time 0932 their options were:
Proceed to YSNF to attempt a landing, irrespective of the conditions, or Ditch in open water enroute to NWWW.

Conclusions;

ATSB:

79. As is apparent from the analysis above, the ATSB report contains insufficient factual material to support its analysis and findings. Therefore, the veracity of the ATSB report is questionable.

and CAsA:

83. In the events and conditions associated with this accident it is apparent the risk controls were inadequate and unreliable. This in turn identifies a lack of effective regulatory oversight of the operator by CASA.

Last edited by thorn bird; 6th Nov 2017 at 06:24.
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Old 6th Nov 2017, 06:27
  #988 (permalink)  
 
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So CASA reckons the world will be a safer place if Dominic ‘confesses’ that having complied with the company operations manual, having been given incomplete and misleading weather information, and having made a decision that 50% of polled FOIs said was legal and the subsequent ‘option’ being a certain ditching on the way to Noumea, the outcome was his ‘fault’.

Confess sinner! Confess to the safety gods! Thou’st cannot achieve our required level of perfection without confessing thy sins! We know that if thous’t are given command without confessing, thou will run out of fuel again!

The problem with Mr Davies’ submission is that it is based on facts and analysis of facts, thorn bird. This is about religion (really politics).
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Old 6th Nov 2017, 07:01
  #989 (permalink)  
 
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I think CASA's requirement for the demonstration of innocence of involves a river and a drowning test.
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Old 6th Nov 2017, 07:42
  #990 (permalink)  
 
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He ran out of fuel and crashed. Simply didn't have enough fuel. I don't care WHAT the rule is or the interpretation is. He crashed due to fuel starvation. END OF F'N STORY!
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Old 6th Nov 2017, 08:11
  #991 (permalink)  
 
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zanthus, yes a overly simplistic view however the real question is, how did he get there?


CC
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Old 6th Nov 2017, 09:07
  #992 (permalink)  
 
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Originally Posted by zanthrus View Post
He ran out of fuel and crashed. Simply didn't have enough fuel. I don't care WHAT the rule is or the interpretation is. He crashed due to fuel starvation. END OF F'N STORY!
Even if that were the story and f’n end of it, pull his licence, prosecute him, or both, but don’t torture him for 8 years.

When your time comes to be tortured, zanthrus, you will comprehend why it ain’t so f’n simple. (BTW, you appear not to comprehend the difference between fuel starvation and fuel exhaustion. Simple mistake to make, but fortunately you’ll never be punished for making a mistake in aviation ...)
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Old 7th Nov 2017, 04:40
  #993 (permalink)  
 
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JQ copped similar...CPL not cancelled, but suspended and now jobless. Alto not suffering 8 years of torture, 4 is bad enough .
And when he rang to find out about getting his CPL 're-activated', he was advised that he would have to prove that he was a 'fit and proper person'.
They couldn't exactly say how, but would you like to come down for a gabfest and tell us what you have learnt from this episode. !!
Afraid the response was long, all expletives, and unprintable here. !! Hardly surprising.
What did those CAsA malconents learn from that episode of fcuking someone over.
Nothing, as usual
Next ! And that didnt take long either, but that's another story.

Just keep beating that Judicial Inquiry' drum y'all
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Old 7th Nov 2017, 07:17
  #994 (permalink)  
 
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He ran out of fuel and crashed. Simply didn't have enough fuel. I don't care WHAT the rule is or the interpretation is. He crashed due to fuel starvation. END OF F'N STORY!
Zanthrus,
The only thing I conclude from your post, is that your effective aviation knowledge is as near nil as makes no difference.
The certainties born of ignorance must be quite comforting to you, but are of little use in the real world.
Tootle pip!!
PS: I do hope you are not actually a pilot, that would be of concern.
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Old 7th Nov 2017, 19:36
  #995 (permalink)  
 
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Sully Sullenberger, when his aircraft was going down with double engine failure, was offered a vector to glide to an airport. He decided that he couldn't make that airport and made the decision to ditch. In that moment, when many would have attempted the glide over terrain to a runway, he earned his money.

Dom made the decision to ditch, when many would have attempted a fifth approach below minima and hoped to hit a runway rather than a fence post.

Both Captains made tough decisions in minimum time under high stress which resulted in all of their passengers surviving.

That alone should be recognised as amazing.
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Old 7th Nov 2017, 22:09
  #996 (permalink)  
 
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Sully is lucky he wasn’t flying for a politically-connected operator with poor regulatory oversight, to a neglected and dysfunctional remote territory through third world airspace in the wrong aircraft type for the mission. Had he been doing so, his inability to foresee and avoid the geese, and his failure to acknowledge his responsibility for the geese, would see him subjected to ongoing regulatory torture.
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Old 7th Nov 2017, 23:41
  #997 (permalink)  
 
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I think those putting Jame's actions as an equivalent to Sully's are doing Sully a disservice. Sully had an instant to sum up his situation and make a decision. He also had a good F/O with him. James had from ToD and the opportunity to hold to formulate a plan of action. His decision was ultimately to ditch after IMHO squandering the opportunity to get it on the runway. We are yet to find out how effective the F/O was or whether her inputs were ignored.

If you want to look at an equivalent situation then compare this accident with the Virgin 737 landing in Mildura. That is the same scenario where both crews ended up with no fuel, no alternatives and no options but to work out how to get the aircraft onto the ground safely. The crew at Mildura were also dealing with FG and not a 500' cloud base. The Captain and F/O of the Mildura incident are deserving of more accolade's than they have received.

I do agree though that CASA should have made a decision on Jame's status well before now and not continually make him jump through arbitrary hoops.
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Old 7th Nov 2017, 23:55
  #998 (permalink)  
 
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after IMHO squandering the opportunity to get it on the runway
Wow - based on what?
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Old 8th Nov 2017, 04:40
  #999 (permalink)  
 
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Wow - based on what?
Based on the report. They did not hold and just conducted several approaches to the chart minima and conducting a subsequent go-around on each occasion. The cloud base was about 500' and the chart minima was about 700'. All of this consumes fuel at a greater rate than just holding and working out how you are going to get yourself to a point above the runway that you can land or waiting for an improvement in the weather that the man on the ground could advise you of. Thats what I mean by squandering.
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Old 8th Nov 2017, 09:25
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If you want to look at an equivalent situation then compare this accident with the Virgin 737 landing in Mildura.
BIG call, especially from a well lit air-conditioned office.

There are a couple of big differences between Mildura & Norfolk Is. Mildura is as flat as the [email protected]#t carters hat. Basically any aircraft in a controlled descent will land in a survivable manner. And there's only scrub at the end of the runway if you over-run. Norfolk Is has rising terrain that might not be survivable if you tried the same trick, but landed early. And its not so friendly if you over-run.

And it was overwhelmingly likely that the fog was not on the ground at Mildura (the pilots had an expectation of breaking out of cloud below minima but before touch down - the Norfolk Is case didn't have this expectation) and the Mildura pilots had radio coms with people on the ground observing, both recently landed aircraft and others. I don't recall that being the case for Norfolk Is.

The wind at Mildura was dead calm. Once again, I don't really recall, but I'm not sure you would expect the same from Norfolk Is.

The fog at Mildura may have been thin enough to afford some view of the land or intimation of how thick the fog was. It occurred mid afternoon on a basically fine & sunny day.

The fog at Norfolk Is was probably sea fog. And it was night. The pilot would not have had even the faintest indication of where the ground was.

As I recall the pilot elected to ditch because he felt the survival prospects were better than a crash landing on the ground. At night in unforecast weather, I don't envy him that decision.
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