Norfolk Island Ditching ATSB Report - ?
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!
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!
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 ‘busting’ any landing minimas,
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.
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...
Regards.
VH-MLE
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...
Regards.
VH-MLE
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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.
It would appear that unless the PIC is willing to fall on his sword, he will not be an ATPL any time soon.
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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ATSB, total bull****, agenda driven
if there had been a fatality, which fortunately did not occur, a Coroner would have been involved. Imagine the difference
ATSB, embarrassment.
if there had been a fatality, which fortunately did not occur, a Coroner would have been involved. Imagine the difference
ATSB, embarrassment.
What do you think Table 10 is then if 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.
I seriously believe someone’s hacked Lookleft’s username. The ‘real’ Lookleft would not have been silly enough to suggest that Table 10 is a ‘transcript’. It’s 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 ‘tripwire’ on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC.
The PIC’s 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 dog’s breakfast that will never be cleaned up by CASA.
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.
The PIC’s 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 dog’s breakfast that will never be cleaned up by CASA.
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.
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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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.
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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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?
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?
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.
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.
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.
Which is precisely the point.
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So are you suggesting that had the company or CASA known that (as you assert) the PIC “knew he would 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.
Which is precisely the point.
If that’s true Eddie, why didn’t the operator’s C&T system pick up the PIC’s poor attitudes and decision making, and why didn’t CASA’s regulatory system pick up that the operator’s C&T system was inadequate to pick up the PIC’s poor attitudes and decision making?
That’s Sunny’s point. Which is valid.
Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. You’re off with the fairies.
That’s Sunny’s point. Which is valid.
Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. You’re off with the fairies.
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.
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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If that’s true Eddie, why didn’t the operator’s C&T system pick up the PIC’s poor attitudes and decision making, and why didn’t CASA’s regulatory system pick up that the operator’s C&T system was inadequate to pick up the PIC’s poor attitudes and decision making?
That’s Sunny’s point. Which is valid.
Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. You’re off with the fairies.
That’s Sunny’s point. Which is valid.
Lookleft: You seriously suggested that the ditching of NGA was in operational circumstances analogous to the Mildura event. You’re off with the fairies.