Norfolk Island Ditching ATSB Report - ?
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Casa as Irresponsible in surveilance
From the ATSB report:
Come on ATSB, where are the numbers to show the real data or is this just a "soft out" for the failure of casa to surveil another operator?? to the point where more people have been put at serious risk??
Is this another "SeaView" ??? in failed procedures and surveillance??
The decision to continue to Norfolk Island
Under conditions of increased stress or workload, working memory can be constrained and may limit the development of alternative choices and the evaluation of options. Depending on whether the available options are framed in a positive (lives saved) or negative way (injuries and damage), a decision maker can be influenced by how they perceive the risks associated with each option when making a decision.
When decision-makers are confronted with options that are considered as a choice between two different benefits, decision makers tend to be more risk averse. They tend to prefer a guaranteed small benefit, compared with just the chance of a larger benefit. On the other hand, when decision makers are faced with a choice between two options that are considered as two separate losses, they tend to be more likely to accept risk.
In this instance, the flight crew described the choice when they first comprehended the deteriorating weather conditions at Norfolk Island as being between diverting to Noumea and continuing to the island in terms of assessing competing risks. Given the weather and other information held by the crew at that time, including their not having information on any possible alternates, their perception that the higher risk lay in a diversion was consistent with the greater number of unknown variables had they diverted.
Under conditions of increased stress or workload, working memory can be constrained and may limit the development of alternative choices and the evaluation of options. Depending on whether the available options are framed in a positive (lives saved) or negative way (injuries and damage), a decision maker can be influenced by how they perceive the risks associated with each option when making a decision.
When decision-makers are confronted with options that are considered as a choice between two different benefits, decision makers tend to be more risk averse. They tend to prefer a guaranteed small benefit, compared with just the chance of a larger benefit. On the other hand, when decision makers are faced with a choice between two options that are considered as two separate losses, they tend to be more likely to accept risk.
In this instance, the flight crew described the choice when they first comprehended the deteriorating weather conditions at Norfolk Island as being between diverting to Noumea and continuing to the island in terms of assessing competing risks. Given the weather and other information held by the crew at that time, including their not having information on any possible alternates, their perception that the higher risk lay in a diversion was consistent with the greater number of unknown variables had they diverted.
Is this another "SeaView" ??? in failed procedures and surveillance??
I have difficulty in criticizing the captain for being first out of the exit. Just imagine - he's gone back to the cabin to open the exit and get his pax out, his primary responsibility - now there is an open exit. Can you imagine his trying to fight his way back forward in the cabin when the pax REALLY want to exit? I imagine that he was fired out of the exit almost like toothpaste out of a tube.
His other decisions might well have been questionable though IMHO. Real men don't divert!!
His other decisions might well have been questionable though IMHO. Real men don't divert!!
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I was surprised however to see no mention of the Careflight task management
Reading the report, I was surprised:
- that there was no weight and balance analysis - or even a suggestion that one was completed. Even simple GA reports produced in a month or so have a statement similar to "the aircraft was within the weight and balance envelope." As this report relates to the amount of fuel uplifted, and it was a long flight, it seems very pertinent.
- that there was no mention of the "passenger on an airwork flight" issue. As the airwork category allowed a reduced level of safety (no alternate planning), then permitting passenger travel is a pertinent issue.
- The poor briefing, and the Captain's statement that internet access was difficult is a major failure in the report - and the system defence for that is obviously the quality of availability of correct information, I am surprised there is no assessment of the quality of information available from the briefing office. As the Captain received the information "during the submission" of the flight plan, it seems obvious that the plan was already completed before any briefing material was obtained.The PIC received the latest aerodrome forecast (TAF)7 for Norfolk Island from the briefing officer during the submission of the flight plan.
- the report mentions that the company check required the calculation of CPs and PNRs as part of the endorsement/check to line, and that this training was not required to be recorded. There is no mention of any test to see if the accident Captain, or any other of the company's crew (or any of their representative industry pilots) are actually capable of calculating an off track CP and off track PNR under cockpit conditions. I say this because I doubt 20% of pilots in the industry can, and that is a failure of the exam system as the exam system focuses on very high accuracy which leads itself to systems of calculating which are not practical in the real world. That is why the company manual had the simplified fuel flow/planning information in it, and why the Captain stated (ie. Crew were not confident enough in their fuel planning to specify an accurate (and efficient) fuel load)The PIC indicated that for operations in the Westwind, there were effectively two refuelling options; either the aircraft carried full fuel, or the wing tanks only were filled.
Last edited by Checkboard; 31st Aug 2012 at 07:57.
Let dead dogs lie!
The Aviation Advertiser, in its article 'CASA revives a dead dog', makes mention of the ELT (fixed), which apparently gave one squawk and then quit, hmm that far overwater (if it was me) I'd be carrying, or have very close to me, one of those PLBs!
Lady Luck was very definitely on the side of the crew and pax!
CASA revives a dead dog – opinion – aviationadvertiser.com.au
The ATSB’s report on the Norfolk Island ditching accident adds a real-time account that puts the realities of ELTs into further perspective:
The aircraft was fitted with a 406 MHz emergency locator transmitter (ELT), which was designed to transmit a distress signal that could be received by a satellite. The ELT could be manually activated by a switch in the cockpit, and it would also activate automatically if the aircraft was subjected to g-forces consistent with an aircraft accident.
The aircraft was also equipped with four personal locator beacons (PLBs) that could be carried separately and manually activated. Two of these beacons were installed in the life rafts, and one of the remaining beacons was equipped with Global Positioning System (GPS) equipment, which would enable it to transmit its position when it was activated. The aircraft occupants were unable to retrieve any of the PLBs before they exited the aircraft after the ditching.
The aircraft-mounted ELT was not GPS-equipped. A geostationary satellite received one transmission from that ELT and the information associated with that transmission was received by Australian Search and Rescue (AusSAR) 38 8 minutes after the aircraft ditched. AusSAR was able to identify the owner of the ELT, but was not able to assess its location from the one transmission.
Obviously the single transmission was impact-activated; however it seems probable that the airframe damage caused the antenna or its connecting lead to fail after that first transmission.
The aircraft was fitted with a 406 MHz emergency locator transmitter (ELT), which was designed to transmit a distress signal that could be received by a satellite. The ELT could be manually activated by a switch in the cockpit, and it would also activate automatically if the aircraft was subjected to g-forces consistent with an aircraft accident.
The aircraft was also equipped with four personal locator beacons (PLBs) that could be carried separately and manually activated. Two of these beacons were installed in the life rafts, and one of the remaining beacons was equipped with Global Positioning System (GPS) equipment, which would enable it to transmit its position when it was activated. The aircraft occupants were unable to retrieve any of the PLBs before they exited the aircraft after the ditching.
The aircraft-mounted ELT was not GPS-equipped. A geostationary satellite received one transmission from that ELT and the information associated with that transmission was received by Australian Search and Rescue (AusSAR) 38 8 minutes after the aircraft ditched. AusSAR was able to identify the owner of the ELT, but was not able to assess its location from the one transmission.
Obviously the single transmission was impact-activated; however it seems probable that the airframe damage caused the antenna or its connecting lead to fail after that first transmission.
CASA revives a dead dog – opinion – aviationadvertiser.com.au
The careflight document mentioned above states:
... so the careflight staff are no longer relying on the quality of lifejacket & survival equipment provided by their contractors, and are providing their own.
Edit: I might also add, that I am surprised that in this computer day and age a contracted jet aircraft is still relying on manual flight planning for an international overwater flight!
The industry standard is to pay the reasonable fees of a professional third party planning company, such as Universal Weather & Aviation Inc, or Jeppesen. In that way, the plan could simply have been faxed to the pilot's hotel - and you are not relying on a tired pilot not making an arithmetic error (or a simple inability to correctly determine the critical contingency point).
EPIRBs
– Personal issue EPIRBs / strobes were not carried by our crew at the time – but now are!
• Crew also now carry their own life‐jackets equipped with appropriate survival aids
– Personal issue EPIRBs / strobes were not carried by our crew at the time – but now are!
• Crew also now carry their own life‐jackets equipped with appropriate survival aids
Edit: I might also add, that I am surprised that in this computer day and age a contracted jet aircraft is still relying on manual flight planning for an international overwater flight!
The industry standard is to pay the reasonable fees of a professional third party planning company, such as Universal Weather & Aviation Inc, or Jeppesen. In that way, the plan could simply have been faxed to the pilot's hotel - and you are not relying on a tired pilot not making an arithmetic error (or a simple inability to correctly determine the critical contingency point).
Last edited by Checkboard; 31st Aug 2012 at 11:21.
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casa and surveillance
From page 29 of the ATSB report:
Does this mean that casa has not "again" failed to surveil the operator??
Smell like Lockhart River??
And then at page 35:
This goes even further, into the failure of casa in it's surveillance methods [or lack of them]
Now, as I read on, is there any SR to be found on the topic???
Part A Section 9.11.2 of the operations manual titled Critical Point required pilots to calculate a CP on ‘appropriate’ flights over water that were greater than 200 NM (371 km) from land and on all other flights for which the availability of an ‘adequate aerodrome’52 was critical. There was some disparity between that section and Part B section 6.1.2 of the operations manual titled Calculation of Critical Point, which omitted the need for an available adequate aerodrome, instead stating that a CP was to be calculated for flights where no ‘intermediate aerodromes’ were available.
Smell like Lockhart River??
And then at page 35:
Five different operators were interviewed and provided relevant sections of their operations manuals for review. Those manuals generally reflected the requirements of CAAP 234-1 but also had individual operational requirements appended. However, they either had no guidance, or did not provide consistent guidance on the process to be used when deciding whether to continue to a destination in circumstances similar to those affecting the flight to Norfolk Island.
When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided.
When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided.
Now, as I read on, is there any SR to be found on the topic???
Last edited by Up-into-the-air; 31st Aug 2012 at 23:17. Reason: Just reading on!!
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Bloody Nanny state.
UIA- When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided.
I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.
The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.
No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.
BH - K, do you ask for more regulation, surely not.
Last edited by Kharon; 1st Sep 2012 at 01:34.
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This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
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John62 - This particular operator is rumoured to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
The stuff not written which carries the full weight of 'company' rules and a bollocking. Don't buy fuel at ABCD – to expensive; don't land at EFGH – we barred; don't ask for RTOW charts, etc. etc. We all have heard or seen it. Minimising uplift at 'expensive' ports and tankering fuel at 'cheap' ports is a game often and well played. It's called operating a service, as is saving a ton of fuel or finding the best flight level, or any of that unwritten, command type stuff. But, even if the rumours related to Noumea were true, I'd pick a night in French pokey over a swim in dark, any old day of the month.
Agree "K" you can't regulate for sheer stupidity or a severe case of 'pushonitis', although the philosophy is very much akin to the regulator's i.e. 'flying with the blinkers on'!
However one does wonder why it took so long to complete? Political correctness, sense and sensibilities, who knows? Also what's with the wishy, washy soft cock approach by the bureau??
However one does wonder why it took so long to complete? Political correctness, sense and sensibilities, who knows? Also what's with the wishy, washy soft cock approach by the bureau??
Also what's with the wishy, washy soft cock approach by the bureau??
OR
they may learn from their mistakes - we could not have that now, could we.
This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
Kharon
I agree 100%. As pilots we have been licenced to make the correct decisions.
Neither should there be; it only leads to more prescriptive, draconian, criminal based law being produced and misinterpreted, by all. Command discretion is an essential given; in theory, it's why you get paid the big bucks. It would be grossly unfair and harsh to criticise CASA in this case.
I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.
The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.
No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.
I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against.
The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office.
No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations.
have a long hard look at the report from a purely operational viewpoint; no amount of regulation would, or could have helped ?
Last edited by 27/09; 1st Sep 2012 at 09:28.
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I had wondered this particular point a while back, perhaps also the same applied at Nadi?
I had missed this point in the report. Good catch Kharon.
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Is strict compliance the problem?
This is the bit vexes me. Long, complex, subjective, prescriptive, variable interpretation regulation.
Everyone sliding off the hook into the mind numbing tedium of prescriptive wriggle room. Endless, pointless circular legal arguments about wether the flight was 'legal' in strict compliance with the MINIMUM rules and who's arse is covered when the music stops. When the 'game' is compliance and only compliance, this sort of incident results. Fact - it's a small island in a lonely corner of the world. It's a bloody long march to the nearest friendly place (fully equipped with dancing girls and cold beer).
Now this makes for interesting Sunday morning reading. (It does, like a long winded, old money crash comic).
ATSB report - here.
Chapter 3 is the one you want – sure, it's a little tedious (nature of the beast) but I'd like to see a copy in every technical library. The ATSB can and do put some great educational tucker on the table, it's just that it's so hard to find. Food for thought – you betcha.
More real life education – less micro managed compliance bollocks.
ATSB - CAO 82.0 expanded on a number of the CAR 234 requirements for application in specified circumstances, including passenger-carrying charter operations to defined remote islands, such as Norfolk Island. As an aerial work flight, the aeromedical flight to Norfolk Island was not subject to these CAO 82.0 requirements, but they nevertheless provide useful context.
ATSB - Although not assessed as part of the study, the importance of the PIC as a risk mitigator in the case of un forecast deteriorated weather at the destination was discussed in the conclusion to ATSB Research Report B2004/0246 titled Destination Weather Assurance – Risks associated with the Australian operational rules for weather alternate weather (available at Australian Transport Safety Bureau Homepage).
ATSB report - here.
Chapter 3 is the one you want – sure, it's a little tedious (nature of the beast) but I'd like to see a copy in every technical library. The ATSB can and do put some great educational tucker on the table, it's just that it's so hard to find. Food for thought – you betcha.
More real life education – less micro managed compliance bollocks.
Last edited by Kharon; 1st Sep 2012 at 22:37. Reason: Tip tank questions are a no no.
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In the good old days one had an option to declare a "mercy flight" and not many suffered the chopping block for working outside the required minimas. Unless it all went tits up of course. Anyone using the two way communicative device would assist to help make the flight a success.
How many would dare attempt such a thing today?
Operating an EMS service with an AOC pertaining to same is a different thing I guess?
How many would dare attempt such a thing today?
Operating an EMS service with an AOC pertaining to same is a different thing I guess?
When the 'game' is compliance and only compliance, this sort of incident results. Fact - it's a small island in a lonely corner of the world. It's a bloody long march to the nearest friendly place (fully equipped with dancing girls and cold beer).
What experience did the P in C have on this sort of Op? Did he have a a good understanding of the vagaries the the weather at Norfolk? Even if he didn't, I still don't understand the decision not to divert while there was still time.