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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 8th Nov 2017, 10:16
  #1001 (permalink)  
 
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Maybe you need to look at the reports again OA because its obvious that your memory is not reliable. You make it sound as though landing a 737 off an RNAV approach with the cloud base and visibility well below the minima, is just a walk in the park.

Basically any aircraft in a controlled descent will land in a survivable manner.
Ever flown a 737? They also require a hard surface. If they had been just a small fraction off the hard stuff the outcome may have been very different. Plenty of jets have had gear collapse when colliding with runway lights.

The big difference in the weather is the Virgin crew had fog and the Norfolk crew did not. You might want to re-read the Mildura report. It was mid-morning and it was not a thin layer of fog.

The Norfolk crew had visibility below the cloud base and a Unicom operator on the ground who was giving them real time info on the weather.

The pilot would not have had even the faintest indication of where the ground was.
Once again read the report. The Westwind was fitted with a radio altimeter. They used it to work out where the water was. They could also have used it to get closer to the ground and get below the cloud base having first set up a 3degree slope using the V/S function of the autopilot. I don't believe that ditching was the only course of action.

I do work in a well lit airconditioned office but its not that big, it does however travel at 3/4 the speed of sound.
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Old 8th Nov 2017, 10:16
  #1002 (permalink)  
 
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Originally Posted by Old Akro View Post
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.
But apart from the stark differences in the topography and the overrun, land short and lateral excursion risks, time of day, meteorological conditions and availability of authoritative information from multiple local sources about the conditions on the ground at the runways, the circumstances are analogous.
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Old 8th Nov 2017, 20:02
  #1003 (permalink)  
 
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"Once again read the report. The Westwind was fitted with a radio altimeter. They used it to work out where the water was. They could also have used it to get closer to the ground and get below the cloud base having first set up a 3degree slope using the V/S function of the autopilot. I don't believe that ditching was the only course of action."

I can't agree with your suggestion Lefty. In your front office you have all the latest high tech gear to work with. When the Westward was built GPS was just a dream.The aircraft had very basic equipment. Round dials, no FMS an ancient basic trimble retrofitted GPS. You'll note from the ATSB report VOR approaches were flown, the GPS was not up to it. I can't imagine considering the circumstances the crew didn't bust minimums a tad, however Norfolk is notorious for wearing a cap of cloud when a warm moist airstream blows over it. Not unusual to get visual on an approach but be unable to land due to the strip being obscured by low cloud.The terrain around the airport is not flat, its cut by gullies, and lots of those famous Norfolk Island pines, so the slightest error would be disastrous, and night out there is very black. I think Dom chose the option most likely to be survivable.
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Old 8th Nov 2017, 21:30
  #1004 (permalink)  
 
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Originally Posted by thorn bird View Post
I think Dom chose the option most likely to be survivable.

There's a small part of me that wonders whether the ditching was actually "chosen", or "planned".

The lack of mayday, or at least telling the NLK radio operator that they were indeed actually going to ditch and the location, makes me wonder.


Recovering the CVR soon after would have been valuable information for the report.
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Old 8th Nov 2017, 21:46
  #1005 (permalink)  
 
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thorn bird what you are saying is absolutely correct and the situation that the crew found themselves in could not be blamed just on the PIC. Round dials, low cloud very few options, I did my time in GA so I know what it is like however the RAlt was the one bit of equipment that I think could have been used to better effect than to work out where the water was. The cloud base was OVC 002 at the time of arrival. 200' is a CAT 1 minima so for a small jet continuing to 100' on a 3degree slope (which the approach chart states) will give you a good chance of seeing the runway. As I said before I don't think that ditching was the only option.

P.S What have you done with my old sparring partner Gobbledock? He seems to have disappeared.
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Old 8th Nov 2017, 21:50
  #1006 (permalink)  
 
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Iíd love to re-read the report but the ATSB has removed it from the website. The original report is so old, it was at least 3 laptops ago for me and Iíve long since discarded the paper copies that I worked from at the time.

Not the behaviour one expects from a body such as the ATSB with impartial transparent processes.

Iím sure this is an attempt by the ATSB to frustrate comparisons of the last report with the soon to be published (??) new report. But equally, I trust that the PPRuNe community will have saved copies that we can use at the time.

I was in the Ansett 737 SIM recently and we landed it in zero visibility hand flying using the ILS. But it occurs to me that airline pilots using SIMS for recurrent training get to do some things beyond the normal limits like that.

On the other hand, a relatively young charter pilotís experience is likely to only ever have involved doing training in real aircraft doing real approaches and being smacked every time he broke minima by so much as 50 ft.

I still reckon itís a tough call to say he didnít make an optimal decision. Everyone survived. Iíd rather focus on the information upon which he relied to get to that point.

In the Sullenberger accident, I believe they put a number of pilots in SIMS to see if they did better. It would be an interesting excercise to see what they would do given the same met information and ATC directions. Iíll bet the ATSB donít do it.
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Old 8th Nov 2017, 22:09
  #1007 (permalink)  
 
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Love reading all the bullshit from armchair experts. The crew stated that hitting the water came as a shock and the viz zero at impact. The weather on Norfolk was pelting down with low sub minima scudding windy conditions. There are houses in the airport vicinity and very tall Norfolk pines.. right or wrong they all survived and I seriously doubt many of you who so easily attack him could have pulled off the same magic.
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Old 8th Nov 2017, 22:12
  #1008 (permalink)  
 
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Originally Posted by Old Akro View Post
Iíd love to re-read the report but the ATSB has removed it from the website. The original report is so old, it was at least 3 laptops ago for me and Iíve long since discarded the paper copies that I worked from at the time.
Nothing disappears on the internet

https://web.archive.org/web/20121031...-072_Final.pdf
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Old 8th Nov 2017, 22:12
  #1009 (permalink)  
 
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The wind was 180/9 when they arrived and 160/9 when they ditched, hardly gale force. The vis was 4500m.
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Old 8th Nov 2017, 22:16
  #1010 (permalink)  
 
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Original report here too:

https://reports.aviation-safety.net/...W24_VH-NGA.pdf
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Old 8th Nov 2017, 22:37
  #1011 (permalink)  
 
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Nothing disappears on the internet
Love it. Thanks.
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Old 9th Nov 2017, 00:05
  #1012 (permalink)  
 
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Originally Posted by Car RAMROD View Post
There's a small part of me that wonders whether the ditching was actually "chosen", or "planned".
Gear doors not ripped off suggests gear was up and planning to ditch. If the intention was to descend overwater, get visual and then make a low approach to the island under cloud, you would expect gear to be down.

The CVR will tell all I expect.
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Old 9th Nov 2017, 05:12
  #1013 (permalink)  
 
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Back around 1998 or 99, I recall an RPT operator in a Chieftain going to Norfolk and arrived not long before the end of daylight, to conditions not too dissimilar to VH-NGA, and which were deteriorating. The aircraft made several unsuccessful approaches and on the final one used the AROís vehicle at the threshold with its flashing light as an indication of where the threshold was. Aircraft subsequently landed in conditions of approximately 200m vis and 100ft cloud base. The pilot did a fantastic job in getting the aircraft on the ground in one piece (but probably shouldnít have been there in the first place as an alternate requirement existed on the TAF - which was changed from a Tempo enroute & the PA31 was not capable of proceeding to Norfolk and then to an alternate). The PA31 is not a Westwind I know but I offer this as another example of how a similar incident was dealt with.

The only other comment I would like to make regarding the original accident report was that in the years preceding this accident, the ATSB were utilising the Reason Model, which in effect, was identifying all the pieces of ďSwiss CheeseĒ i.e. the defences in place that failed to prevent an accident or serious incident. In virtually every accident, the pilot(s) is always the last piece of Swiss Cheese i.e. the last line of defence. Although the Reason Model doesnít appear to have been used in this particular accident investigation, it is quite clear to me that the ATSB focussed its investigation primarily on that last piece of cheese at the expense of many other very relevant pieces which I would have thought should include at least the Operator (supervision, procedures etc), Regulator (adequate oversight etc), ASA etc. While Iím not usually a believer in conspiracies, it does look like thereís been political interference at play considering who was on the parent companyís board...

As far as Iím concerned the pilot has been punished enough (although the co-pilot does not seem to have had any adverse treatment whatsoever).

VH-MLE
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Old 16th Nov 2017, 13:04
  #1014 (permalink)  
 
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Well, it will be released in a week.

Updated: 16 November 2017

The investigation report has now been approved by the Commission and finalised. As part of our pre-release process, an advanced copy of the report has been sent to all Directly Involved Parties under the provisions of Section 26(1) of the Transport Safety Investigation Act 2003 (the Act).


The public release of the final report will be made available on the ATSB’s website at 10.30am on 23 November 2017 in accordance with subsection 25(1) of the Act.
https://www.atsb.gov.au/publications...r/ao-2009-072/
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Old 16th Nov 2017, 13:23
  #1015 (permalink)  
 
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Originally Posted by lookleft
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'.
Arrival at Norfolk Island at 1005.
TAF amended at 0958


SPECI YSNF 181000Z AUTO 18009KT 4500 OVC002 19/19 Q1013 RMK RF00.2/001.0



Ditching at Norfolk Island at 1026.


SPECI YSNF 181030Z AUTO 16009KT 3000 OVC002 19/18 Q1013 RMK RF00.4/002.4
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Old 16th Nov 2017, 19:37
  #1016 (permalink)  
 
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I suppose if 200í counts as ďabout 500íĒ, LL is correct. Whatís a few hundred feet here or there during an IFR approach?
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Old 16th Nov 2017, 21:35
  #1017 (permalink)  
 
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You need to keep up with the thread LB and not be so selective. Scroll down a bit further and you will see that I wrote this:

Round dials, low cloud very few options, I did my time in GA so I know what it is like however the RAlt was the one bit of equipment that I think could have been used to better effect than to work out where the water was. The cloud base was OVC 002 at the time of arrival. 200' is a CAT 1 minima so for a small jet continuing to 100' on a 3degree slope (which the approach chart states) will give you a good chance of seeing the runway. As I said before I don't think that ditching was the only option.
One can tell from your CASA legal background with this comment :

Whatís a few hundred feet here or there during an IFR approach?
that you have never had to make that call. Must be very comfortable being a private pilot on a government salary. In this instance it was the difference between making a successful landing and ditching it into the ocean.
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Old 16th Nov 2017, 23:02
  #1018 (permalink)  
 
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continuing to 100' on a 3degree slope (which the approach chart states) will
.. on a precision approach with a 3ļ slope - yes.

You know that the 3ļ annotated on the VOR profile is a nominal figure, and that there isn't any slope guidance, right??

On a crappy VOR which isn't aligned with the runway (the VOR is about half a mile to the side of the runway), with terrain (hills, gullys and trees) surrounding the runway (use Google maps 3D to see the area) and the 200' perhaps being 150' - that's a bad statement.

https://www.google.co.uk/maps/place/...5!4d167.954712
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Old 16th Nov 2017, 23:03
  #1019 (permalink)  
 
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Whatís a few hundred feet here or there during an IFR approach?
I think LB was being facetious.
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Old 16th Nov 2017, 23:18
  #1020 (permalink)  
 
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Originally Posted by Old Akro View Post
I think LB was being facetious.
Quite so, OA.

LL: When youíre in a hole, best to stop digging.
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