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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 24th Nov 2017, 03:58
  #1061 (permalink)  
 
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ATSB needed to Address Issues in Original Pel-Air Report: Manning - Australian Flying
It's quite simplistic: if I am given the right weather on the night before I leave Samoa, or I get the correct weather handed to me in flight, the accident doesn't happen; it's a weather accident.
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Old 24th Nov 2017, 09:04
  #1062 (permalink)  
 
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ATSB, total bullshit, agenda driven


if there had been a fatality, which fortunately did not occur, a Coroner would have been involved. Imagine the difference


ATSB, embarrassment.
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Old 24th Nov 2017, 12:40
  #1063 (permalink)  
 
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What do you think Table 10 is then if it is not a transcript?
Table 10 is a description of the discussion - it is not a transcript.

- Flight planning in this company was a bit haphazard. There were two "shortcut" methods in the manual approved by the CAA. Testing those shortcuts with the Aircraft Performance Manual showed that the approximations were reasonably accurate for normal operations, but the shortcut systems didn't take into account the regulatory requirement to allow for engine failure or depressurisation en route.

- Training on in-flight fuel planning was almost entirely absent, as the long routes weren't used for training (which was reasonable in itself, due to the nature of AeroMed flights). This is true throughout the industry I think, including major airlines.

- The above, frankly, holds true for all GA companies, BTW. This resulted in most company pilots planning on a "rule of thumb" basis, but mitigating that by carrying large amounts of extra fuel, and normally full fuel on that particular route, and the company had no problem with this and put no pressure on pilots to carry less fuel.

- There is circumstantial evidence that this particular pilot had a habit of not bothering to obtain current winds for return legs but relying on the out-of-date winds from the previous outbound leg. On his 30 September 2009 flight, he reported "the forecast 70kt average headwind turned out to be 155kt." when the 155kt headwind was correct if he read the correct wind forecast. His in-flight planning appeared sloppy as well, not updating times when they were outside the required 2 minutes (12 minutes early at one point) and missing reporting points.

- on this particular flight the pilot decided to carry minimum fuel on an estimated fuel plan. That was the bad decision - either spend the effort to plan accurately and then take minimum fuel OR make sure you take extra to allow for errors.

The pilot said he did this to be light enough to climb above RVSM airspace - but he was permitted to plan in RVSM and as a MED1 priority could expect to maintain that.

The pilot wanted to do this to save the company money - but the fuel at Nadi was half the cost of the fuel at Norfolk, although this flight left from Apia, tankering would likely have been the cheaper option.

The pilot calculated the fuel for the next, shorter, leg at 7500lbs - when he had loaded only 7200 lbs for the accident flight. He also indicated that he would only load 7500lbs even though the FO suggested full tanks. It seems he was fixated on minimum fuel that day, even though he normally took full fuel on these flights in the same way as the other company pilots.

En-route he was given a mistaken weather ceiling of 6000' instead of 600' - but this was corrected a minute later with the 0800 SPECI report, showind ceiling 1100'. He didn't ask for, and wasn't given the 0830 SPECI showing broken cloud at 300'. Had he received this, would he have diverted? The PNR for a diversion to Noumea was about 0844 and the PNR for a diversion to Nadi was about 0900. Using the captain’s reported method, the PNR for Noumea was estimated to be about 0852 and the PNR for Nadi was estimated to be about 0903. As he didn't ask for the 0830 weather, I doubt that he had calculated a PNR - would he have been ready for a minimum fuel diversion to an airport he hadn't obtained a TAF or other weather report for?

Last edited by Checkboard; 25th Nov 2017 at 10:02.
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Old 24th Nov 2017, 20:18
  #1064 (permalink)  
 
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I seriously believe someoneís hacked Lookleftís username. The Ďrealí Lookleft would not have been silly enough to suggest that Table 10 is a Ďtranscriptí. Itís a paraphrasing and summary by a third party. In any event...

A trap was set for the PIC by the system in which he was variously allowed, encouraged and forced to operate. The Ďtripwireí on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC.

The PICís primary sin was that he did not have ESP.

The controversy around the classification and standards applicable to this kind of operation are merely a manifestation of the broader classification of operation dogís breakfast that will never be cleaned up by CASA.
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Old 24th Nov 2017, 21:48
  #1065 (permalink)  
 
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There is enough dirt in this report to besmirch the pilot, Operator, ATSB (for their original report) and, of course CASA.

My opinion of the whole episode is best summarised by the Reason model - swiss cheese slices:

1. The operators sloppy planning and operating practices.

2. The operators training and checking procedures.

3. A pilot who tended to take the easy way out by not paying attention to detail - with the approval of 1. This wasn't detected by 2.

4. The result of 1. 2. and 3. was a flight plan that had no backup alternatives.

5. A weather event that scuttled 4.

6. A system of aviation regulation that, despite its draconian penalties, capricious, unfair and vicious enforcement techniques, failed totally to detect and correct 1., 2., 3. and 4. in time for corrective action to be taken. Relying on fear is not a very good safety regulation method.

7. Compounding all this was an allegedly "independent" ATSB that tried their very best to hide the whole sorry episode under the carpet and was complicit in CASA's persecution of the poor pilot, who, as far as I can tell, was only doing what others had done before him with the full approval of the operator and CASA. This action by ATSB prevented early safety action being taken.

Questions:

Is it possible for the current aviation regulation system to prevent such accidents in future? The answer has to be "No" because the current system goes against every safety mitigation principle, starting with "just culture".

To put that another way, there will be commercial pilots right now, today, who are faced with the double bind - accepting sloppy practices forced on them by their employer in order to keep their job and hoping to God that nothing happens or a merciless CASA finds out.

Is it possible to recover from the current state? Yes, but there is no political will to do so. The only glimmer of hope is that the ATSB produced a comprehensive and cogent report albeit at the direction of the Australian Senate.
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Old 24th Nov 2017, 21:54
  #1066 (permalink)  
 
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Checkboard,
Just some observations on your post. You make a few assumptions not based on facts, unfortunately so did the ATSB in their report. The pilot himself admitted he had made some errors of judgement, haven't we all. He has undertaken a very intensive program to address those errors.
Its a pity the regulatory authorities and so called "safety" authorities and the operating company are not prepared to admit and address theirs.

"didn't take into account the regulatory requirement to allow for engine failure or depressurisation en route."

There was no regulatory requirement to allow for these under Australian law.

"There is circumstantial evidence that this particular pilot had a habit of not bothering to obtain current winds for return legs"

Exactly, "circumstantial".
At a lot of these pacific island destinations communications can and do prove problematic. In this modern era we are used to gaining instant access to whatever at the touch of a key board.
Oh! internet is down!, can't get a phone call out. Sorry patient, you'll just have to die here because I cannot obtain current weather.

"His in-flight planning appeared sloppy as well, not updating times when they were outside the required 2 minutes (12 minutes early at one point) and missing reporting points."

Err, this is the middle of the Pacific ocean, all coms are via HF. These are not the latest units fitted to these aircraft, they are by and large as old as the airplane, maybe forty years old. At times even the modern units have problems out there, it is not unusual to take rather a long time to get your message out, if at all.

"The pilot said he did this to be light enough to climb above RVSM airspace - but he was permitted to plan in RVSM and as a MED1 priority could expect to maintain that."

Not a true statement, in fact in the ATSB report it indicated the aircraft was held at FL270 for a period because of traffic in RVSM airspace. I have never flown a Westwind but those that have have told me they are a bit of a lead slug trying to get altitude when heavy and hot. It also must be born in mind that out there aircraft separation requires very large spacing, it can take some time to get clearance to higher levels.

The fuel question is addressed in a very detailed analysis by Mr Richard Davies in a submission to the Australian Senate inquiry. It is available for your perusal on the Senate Standing Committees Rural and regional Affairs and transport web sight under submissions.
Full fuel or no, wouldn't have made any difference to the outcome of this incident.

To quote lead Ballon:

"A trap was set for the PIC by the system in which he was variously allowed, encouraged and forced to operate. The ‘tripwire’ on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC."


There but for the grace of god go I.
and quite a bit of sucking up leather over the years.
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Old 24th Nov 2017, 22:00
  #1067 (permalink)  
 
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And Sunny, Hear Hear!!!
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Old 24th Nov 2017, 22:04
  #1068 (permalink)  
 
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Sunfish, that is an interesting take on the new report. My understanding is that, for this particular flight, the PIC loaded less fuel than he or any other Pelair pilot had loaded for that leg according to the tabulated data in the report.
To my mind he knew he would not have sufficient fuel for even the slightest deviation from a direct route and straight in approach to Norfolk.
How would the company or CASA have made a difference to this mindset?
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Old 24th Nov 2017, 22:07
  #1069 (permalink)  
 
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Eddie take the time to read the Davies submission.
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Old 24th Nov 2017, 22:07
  #1070 (permalink)  
 
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You would have no idea Lead Balloon, nice try with the Donald Trump technique of prefixing my id with the "real " Lookleft. All it does is make you look as big a buffoon.

What is the real difference between a transcript and a timeline and statements of who said what to whom? Would it really add to your understanding of the flight deck dynamics. I agree with Checkboard's summation of the PIC's flight planning. This bloke was making dodgy and strange decisions all the way along the flight path and not including his F/O in any of it. He was operating on the assumption that the weather he experienced the day before was going to be the same on this flight. There was no trap. There was simply a lack of planning, caution and command judgement. Based on his reported statement that even if he had full tanks the outcome would have been the same then I doubt that he has learnt anything from what happened. He certainly has a cheer squad that think he was the unfortunate victim and that the system forced him to blast on in, conduct 4 approaches to the minima and then ditch without any consideration of how to conserve the limited fuel he had. Those with "real" operational experience however look at the whole episode through a different prism.
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Old 24th Nov 2017, 22:11
  #1071 (permalink)  
 
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So Eddie, are you suggesting that had the company or CASA known that (as you assert) the PIC “knew he would not have sufficient fuel for even the slightest deviation from a direct route and straight in approach to Norfolk”, neither the company nor CASA would have done anything? If so, you make Sunny’s point. If not, you make Sunny’s point.

Which is precisely the point.
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Old 24th Nov 2017, 22:18
  #1072 (permalink)  
 
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Originally Posted by Lead Balloon View Post
So are you suggesting that had the company or CASA known that (as you assert) the PIC ďknew he would have sufficient fuel for even the slightest deviation from a direct route and straight in approach to NorfolkĒ, neither the company nor CASA would have done anything? If so, you make Sunnyís point. If not, you make Sunnyís point.

Which is precisely the point.
Only if CASA or Pelair where standing beside him and holding his hand. For goodness sake mate, he ignored all and any input from his FO, CRM comes to mind.
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Old 24th Nov 2017, 22:28
  #1073 (permalink)  
 
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If thatís true Eddie, why didnít the operatorís C&T system pick up the PICís poor attitudes and decision making, and why didnít CASAís regulatory system pick up that the operatorís C&T system was inadequate to pick up the PICís poor attitudes and decision making?

Thatís Sunnyís point. Which is valid.

Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. Youíre off with the fairies.
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Old 24th Nov 2017, 22:37
  #1074 (permalink)  
 
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You were in CASA LB, are you suggesting that the CASA of your time would have picked up an operator's C&T system not identifiying poor performing pilots? I can tell that you weren't a good lawyer because when you quoted ED you omitted a word that changes the whole meaning of the sentence.

I am not surprised that a desk warrior doesn't see the similarities and stark differences between Mildura and NFI. What may be news to you though is this conversation is about the recently released report of the ditching of NGA. There are fairies abounding but I think they are at the bottom of your garden.
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Old 24th Nov 2017, 22:40
  #1075 (permalink)  
 
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Originally Posted by Lead Balloon View Post
If thatís true Eddie, why didnít the operatorís C&T system pick up the PICís poor attitudes and decision making, and why didnít CASAís regulatory system pick up that the operatorís C&T system was inadequate to pick up the PICís poor attitudes and decision making?

Thatís Sunnyís point. Which is valid.

Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. Youíre off with the fairies.
The PIC did a thing that was out of character for him and for all of the Pelair pilots. You tell me how any person or organisation can mitigate for such a gross error? One that no one else, including himself had done before.
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Old 24th Nov 2017, 23:00
  #1076 (permalink)  
 
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Originally Posted by thorn bird
There was no regulatory requirement to allow for these under Australian law.
CAR 234(3) specifically required that contingencies such as a loss of pressurisation or engine failure be considered when determining the amount of fuel required for a flight. CAR 220 also required the operator to provide specific instructions for situations such as an engine failure. CAAP 234-1 provided additional guidance for these abnormal situations.

Originally Posted by thorn bird
pacific island destinations communications can and do prove problematic ... can't get a phone call out. Sorry patient, you'll just have to die here because I cannot obtain current weather
They had no trouble with phone calls - several were made by several parties. With the internet out, the company officers in Sydney could have planned the flight (and this was reasonably common). Pilots are paid to find solutions, not ignore problems. The doctor stated that, had he been asked, he would have been happy for the patient to wait for a day - the patient wasn't critical (indeed, the patient survived a plane crash and an hour and a half swimming in the sea!)

Originally Posted by thorn bird
this is the middle of the Pacific ocean, all coms are via HF.
At no point has anyone suggested that comms were a problem. HF is HF - it works. The important point about being in the middle of the Pacific is that there is no ATC radar. Separation is purely on pilots reporting accurate times - which is why Airways submitted an occurrence report to the New Zealand CAA when the aircraft arrived at the reporting point (and FIR boundary) 12 minutes earlier than estimated. When your separation is time-based, 12 minutes early can be a mid-air! :o

Originally Posted by thorn bird
the ATSB report it indicated the aircraft was held at FL270 for a period because of traffic in RVSM airspace. I have never flown a Westwind but those that have have told me they are a bit of a lead slug trying to get altitude when heavy and hot.
The aircraft was cleared to FL350 at 0620. At 0628 it was instructed to descend to FL270 due traffic - but they asked to climb and were given a climb to FL390. They weren't held at FL270. They never stated their MED1 status. I have about 1600 hours on Westwinds - climb to FL350 all day. Higher if at lower weights.
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Old 25th Nov 2017, 03:38
  #1077 (permalink)  
 
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Okay Check board, I accede to your obviously superior analytical expertise and experience. The pilot Dunnit.

A question comes to mind though.

In your opinion,obviously CAsA has been derelict in their duty not to charge the pilot with breaches of CAR 234 (3) and CAR 220, both of which carry substantial penalties and a criminal record which would have ensured he never flew again.

What were CAsA thinking?

A quick show trial, where a pilot is required to prove himself not guilty, rather than the other way round. A guilty verdict, under strict liability is almost guaranteed as no mitigation is allowed.

By sheeting home the entire blame to the pilot they would have saved themselves and the ATsB a lot of embarrassment, not to mention considerable angst for the minister at the time, with an added benefit of saving the taxpayer what I would imagine are millions of dollars in obviously unnecessary investigations and reports. The company involved would also have benefited as a political bribe, sorry, donation would have been entirely unnecessary as well.
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Old 25th Nov 2017, 10:21
  #1078 (permalink)  
 
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I don't know the pilot, never met him, and I don't wish bad things on people - but that option is still open for the CAA.

If you asked a representative sample of Qantas, Turboprop and GA piston pilots today to calculate an inflight Off-track PNR and CP ... how many would be capable of doing so in any amount of time, much less 5 minutes or so?

The ATPL exam requires such accuracy from the performance manual based tables, that ATPL methods aren't cockpit friendly.
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Old 25th Nov 2017, 21:43
  #1079 (permalink)  
 
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To answer Thornbirds question,there is no prosecution of the pilot because the operator would be in the dock too and a competent defence would put CASA in there with the pair of them as well.
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Old 25th Nov 2017, 22:56
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I can't imagine either the operator or regulator were keen to go to court with a presumption of innocence until proved guilty, being forced to testify and produce documentation, and with the court deciding what evidence was relevant and admissible.

This 2nd report seems comprehensive and fair. The pilot made his share of mistakes, sure. But there were many latent risks that were the responsibility of the operator and regulator.

Directly interested parties will always want a bit more from any independent review. That is human nature. Perhaps this disappointment (after 8 years of feeling he has been unfairly scapegoated) is the reason for the pilots recent "spray" in the media. I don't think many would agree with some of his recent comments. It is not clear that any other pilot would have got into the final desperate situation he faced, And full fuel would have permitted a diversion (or a long hold while waiting for weather to clear).

However I suspect most independent people will conclude this report is fundamentally fair, and the pilot will have to come to terms with significant criticism of his actions that night, and try and move on. Chester Nimitz (US Navy admiral) who played a large part in winning the Pacific war and for whom an entire class of aircraft carriers is named in his honour started his navy career running a ship aground and being court-martialled. He learned and moved on.

It is very concerning that the ATSB has made clear that CASA has made little progress getting its house in order.

And, I am curious about the reluctance to get the CVR when ATSB must have always known it contained 2 hours (and not 30 minutes) if information. How could that 2 hours ever have been irrelevant? Even the last 30 minutes provided valuable insights into what can happen under great stress in a very rare situation.
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