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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 22nd Nov 2017, 20:55
  #1041 (permalink)  
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I wonder if the ATSB site will handle the flood of downloads?

Bit over an hour and a half to go.
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Old 22nd Nov 2017, 22:31
  #1042 (permalink)  
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It's been like waiting for Santa to come...
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Old 22nd Nov 2017, 22:39
  #1043 (permalink)  
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Santa has arrived !


531 page report
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Old 23rd Nov 2017, 00:14
  #1044 (permalink)  
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That can't possibly be right. Sunfish said that it would be released at Christmas or the Melbourne Cup or the anniversary of JFK's assassination. I trusted his wisdom because he has been a consultant, and worked for various Governments and has numerous relatives and acquaintances whose inside knowledge is infallible. Oh well.
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Old 23rd Nov 2017, 00:34
  #1045 (permalink)  
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only out by 34 days over 2 years
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Old 23rd Nov 2017, 00:47
  #1046 (permalink)  
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The methodology outlined in the press release looks good. We'll see if they followed it!
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Old 23rd Nov 2017, 07:33
  #1047 (permalink)  
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ATSB have started using his and her again instead of the gender neutral rubbish! Much easier to read.
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Old 23rd Nov 2017, 09:40
  #1048 (permalink)  
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PICs response...

Norfolk Island ditching pilot returns fire on investigators 'without a backbone'

Last edited by Slezy9; 23rd Nov 2017 at 09:41. Reason: Added link
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Old 23rd Nov 2017, 14:25
  #1049 (permalink)  
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I've read about half of the report. This one is pretty comprehensive, at least.

Answers quite a few questions missed in the first report.

  • Different fuel planning methodologies, and the results of each.
  • The history of why Australia in the only country to classify air ambulance as "aerial work".
  • Why the flight was "aerial work" even though it carried a person not strictly connected to the operation (the patient's husband).
  • The legal position on taking off without an alternate, then on being advised en-route of a new TAF with weather below the alternate minima, whether there is a legal requirement to divert.
  • The TAF relaibility at remote aerodromes like Norfolk
  • The general industry lack of advice on PNR and CP planning methodologies.

etc. etc.

But Mr James said a larger tank of fuel would not have changed the outcome that day – he would still have had to ditch the plane in the ocean. ...

"If you put anyone else in the pilot's seat that night, it is more than likely that they would find themselves in the same situation...
Well, that's stretching things a bit far. A full tank of gas would have gone a long way that night.
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Old 23rd Nov 2017, 16:14
  #1050 (permalink)  
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Patients husband on board under Australian law, it is still a medical flight, likewise if a spouse travels with their partner in an ambulance it doesn’t become a taxi.

The guts of it again, is inaccurate forecasting, passing incorrect met information, 6000 feet instead of 600, failure to pass deteriorations in weather in a timely faction, gloss over all the organisational short comings, still blame the PIC.

According to ATSB the crew should have joined the dots, but how was that possible when too many dots were missing.

The Qantas\ Virgin Mildura incident should have been a wake up call, ATSB need to grow a set.

Last edited by Marauder; 23rd Nov 2017 at 16:58.
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Old 23rd Nov 2017, 19:23
  #1051 (permalink)  
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Havenít read the entire thing but have made a start.

In the original report, the CVR/FDR supposedly werenít recovered because the CVR was only going to have the last 30 mins... not enough to cover when the PNR fuel calculations and discussions should have occurred.

Interestingly, the new report shows that the CVR was actually a newer model which held over 2 hours of audio.

Apparently the serial number in the maintenance documentation matched the CVR.

So what was the reason it wasnít pulled the first time? Was it political pressure to not have it removed (involving strong ties to an ex-politician), or was it a case of the operator deliberately didnít supply the correct paperwork with regard to the CVR model fitted?

I want to know why the ATSB didnít know it was a two hour CVR.
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Old 23rd Nov 2017, 20:04
  #1052 (permalink)  
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I want to know why the ATSB didn’t know it was a two hour CVR.
Perhaps they did.

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Old 23rd Nov 2017, 20:29
  #1053 (permalink)  
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There is at least one factual mistake by the ATSB associated with an extremely unconvincing excuse for not initially recovering the CVR/FDR. On page 62, the ATSB states that it didn't initially recover the CVR/FDR because the wreck was 'beyond conventional diving range" (ie depth) at 48 metres.

Either the ATSB is a flat out liar (or playing very fast and loose with the truth) or very, very, badly advised. I think it is the former because all ATSB would have needed to do is pick up the phone and ask the Navy who have their own diving staff.

The depth limit for recreational diving on breathing air is 38 - 42 metres, depending whether you were certified by PADI or SSI. "Technical" recreational divers (the nerds of the sport diving world) go to 60 metres and commercial divers routinely work at much greater depths - the record commercial dive is over 500 metres breathing a mixture of gases, not air. Trimix gas certificate holders have a depth limit of 100 metres. DAN (divers alert network) provides insurance on trimix users to 130 metres. This is routine stuff for oil industry divers, there is nothing "unconventional", to reflect ATSB use of words, about diving to 48 metres..

From what I saw, the recovery of the CVR/FDR would have been a doddle. The evidence for this is that the contract was awarded in October 2015 and the diving contractor recovered them in November 2015 by lifting the tail section of the wreck. In my opinion this was probably done with one dive to position lifting slings.

To put that another way, a young stupid sports diver could have reached the wreck. My deepest dive was the "Blackjack" B17 at 42 metres off new Guinea.

As a follow up question, exactly who in ATSB made the decision not to recover the CVR and who advised them about diving?

Last edited by Sunfish; 23rd Nov 2017 at 20:51.
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Old 23rd Nov 2017, 20:45
  #1054 (permalink)  
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It was a bit more than that, because a wing was buried under sand after 6 years on the floor - so they had to dig the wing out.
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Old 23rd Nov 2017, 21:43
  #1055 (permalink)  
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correct - 6 years later, but at the time of the accident?
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Old 23rd Nov 2017, 23:16
  #1056 (permalink)  
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Sunny, whilst a rec diver can go to those depths, I doubt your average one would be able to recover the recorders or rig up hoisting lines. But I get what you are saying- for a pro salvage mob it isn't (wasn't, obviously) that hard. They should have done it asap.

Part of the reason why they decided not to recover the recorders initially was that nobody died. Which leads me to think, if a Boeing or Airbus ditched somewhere in similar circumstances, in about the same depth of water, and nobody died, would the atsb/casa still leave the recorders on the sea floor? I highly doubt it!
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Old 23rd Nov 2017, 23:32
  #1057 (permalink)  
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And - unusually for a report like this - there isn't any transcript.
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Old 24th Nov 2017, 00:02
  #1058 (permalink)  
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And - unusually for a report like this - there isn't any transcript

What do you think Table 10 is then if it is not a transcript? Have a good look at what is stated.To me it seems as though the PIC had his mind set on ditching fairly early on.

There is nothing in this report that suggests the crew had no other option but to ditch. That 4th approach was not a serious attempt to try and get below the cloud base. One thing I hadn't realised was that in addition to the Rad Alt this aircraft had an EGPWS! Fully configured using the A/P in V/S mode would have mitigated the risk of getting lower on the approach. The statement by the PIC:

At 0930, the captain told the first officer that they would not be Ďbustingí any landing minimas,
suggests a complete lack of understanding of the situation they were faced with.

The report finally sheds some light on the F/O's contribution to the event. She was doing a lot of managing upwards. The PIC just seemed to be shutting down to any course of action other than ditching. I'm not sure if the first report stated that she had sustained a serious injury but I am not surprised that she did not want any part of any discussion outside of the ATSB investigation. In my view she did a good job but short of taking over she was restricted by the PIC's performance.

As for whether the CVR/FDR should have been recovered earlier its completely irrelevant now as they were recovered and they have added to the reader's understanding of the events leading up to the ditching. As for the assertions that this would be another cover-up and released at a time when no one was looking (34 days! spare us your hubris Sunfish ) then the assertions are wrong.

Is it going to satisfy those who think that the PIC was an innocent victim? No probably not, but I think that it is able to provide some good lessons to anyone operating to remote airstrips and some good insight into what happens when CRM breaks down.
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Old 24th Nov 2017, 02:25
  #1059 (permalink)  
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Lookleft, well said and to you too Checkboard in post #1049...

I've only had a limited look so far but what I've seen, a number of the questions I had seem to have been answered.

I still think this crew were set up to fail by the company, but having said that, the PIC didn't seem to have made particularly good decisions at times and it's almost beyond belief there was no loss of life in this accident. I acknowledge it's easy to make that statement from the comfort of my living room with coffee in hand...

This accident and the final report offers a huge amount of valuable information and could also constitute an excellent case study example in training crews - particularly to remote locations.

As the saying goes - the only time you've got too much fuel is when you're on fire...


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Old 24th Nov 2017, 03:53
  #1060 (permalink)  
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Same as others I'm still reading through the updated report.
It would appear that unless the PIC is willing to fall on his sword, he will not be an ATPL any time soon.
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