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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 4th Dec 2017, 11:16
  #1181 (permalink)  
 
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Originally Posted by blackburn View Post
Let us not forget that when a certain enthusiast became Chairman of the Board of the predecessor to CASA, such items as the mandatory 2 hours Island Holding for Lord Howe and Norfolk Islands were also dispensed with.
Ah Ah, we finally know who is responsible for the WestWind ditching, it was none other than old mate chairman of the board way back when.
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Old 4th Dec 2017, 20:29
  #1182 (permalink)  
 
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the mandatory 2 hours Island Holding for Lord Howe and Norfolk Islands were also dispensed with.
Called I recall, "Island Reserve" ...
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Old 4th Dec 2017, 22:00
  #1183 (permalink)  
 
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I cannot comment on the professional aviation issues here. What concerns me is that despite the detailed conclusions and observations of the report, neither ATSB or CASA has distilled the event into a simple safety message(s) to pilots.

This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.

Were that NOT the case then he would have been prosecuted by now and no doubt convicted.

CASA and ATSB seem unable to draw a line here, close the event off and move on.

This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
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Old 4th Dec 2017, 22:48
  #1184 (permalink)  
 
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Originally Posted by Sunfish View Post
I cannot comment on the professional aviation issues here. What concerns me is that despite the detailed conclusions and observations of the report, neither ATSB or CASA has distilled the event into a simple safety message(s) to pilots.

This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.

Were that NOT the case then he would have been prosecuted by now and no doubt convicted.

CASA and ATSB seem unable to draw a line here, close the event off and move on.

This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
Did you read all of the report? As a low time private pilot I certainly understood the safety message, carefully plan my flight and try to allow for all contingencies. Trust no one and always have an out.
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Old 5th Dec 2017, 04:03
  #1185 (permalink)  
 
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Likewise, although most I know learnt from the original report.

I don't see a need for a safety alert or "lessons learned", but I guess something will appear in FSA sometime.

Conspiracy theorists and ATSB/CASA bashers on this forum will never be happy though.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
You seem to be the one unable to move on.
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Old 5th Dec 2017, 04:31
  #1186 (permalink)  
 
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Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
Do you understand how referral for prosecution works in Australia? CASA and ATSB are not involved, other than CASA referring the proposed case to DPP for them (DPP) to take the case further if they (DPP) consider it (the Case) has merit.
Maybe you could assist CASA by showing which particular transgression warrants prosecution by the DPP.
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Old 5th Dec 2017, 09:22
  #1187 (permalink)  
 
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Originally Posted by Eddie Dean View Post
Do you understand how referral for prosecution works in Australia? CASA and ATSB are not involved, other than CASA referring the proposed case to DPP for them (DPP) to take the case further if they (DPP) consider it (the Case) has merit.
Maybe you could assist CASA by showing which particular transgression warrants prosecution by the DPP.
I am not sure that the DPP gets involved in CASA prosecutions as CASA is a government agency and not a government department. It is one of the reasons CASA has a legal department. However, someone may have a better knowledge of this than I.

Certainly ATSB will not be involved in any prosecution. It is not in their mandate to prosecute and besides much of the evidence they collect would be inadmissible in court.
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Old 5th Dec 2017, 09:31
  #1188 (permalink)  
 
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I think the roles of the regulator (CASA) and the investigator (ATSB) are sometimes misunderstood and conflated by some. It is not the ATSB's remit to 'point a finger' at a person and state the need for prosecution. They set out the facts and they are (usually) careful to look for systemic issues (as well as personal contributory actions). The report itself cannot be used in a court of law.

In this incident, they were criticised for not making enough of some of the systemic issues so they went back, with a different group of investigators, and redid it. The aircraft was recovered and the recorders interrogated. They added quite a bit (I thought) to the context but not much to the story. The newly-added recorder data did little to help the outcome for the captain. He might have been better-served if NGV had remained on the seabed.

The ATSB's investigations are intended to illuminate both failings and failures, and their reports highlight 'What we found' and include recommendations that are predicated on preventing a recurrence. They try to keep emotion and emotive content out of it. It is not their job to ruminate on the hurt feelings or egos of individuals or corporations.

I acknowledge they sometimes take a long time to finish a report, but it has to be understood that in recent years they have had the devil's own job securing a sufficient budget to retain personnel numbers.

Their draft reports go out to all who were involved and they consider all feedback in an effort to ensure factual accuracy in the final report.

CASA may be another story. It is a matter of personal concern to me that in the transport accident investigation space in Australia (various modalities) there is excessive staff cross-pollination between regulators and investigators. Senior bureaucrats inevitably become 'politicians' and I believe political networks have a lot to answer to in the organisational performance that we might be inclined to criticise. The troops, I suspect, work hard to do the job effectively and professionally. It's too bad that public service salaries (at the investigator level) can't match those for experienced airline pilots. Having to live in Canberra probably holds them back too.
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Old 5th Dec 2017, 11:07
  #1189 (permalink)  
 
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Plovett...not quite right there.

The CDPP dont do investigations. (and I have that in writing)
CAsA decides on a prosecution using whatever reg suits their fancy, "investigates" for the evidence, with a view to gaining a prosecution, ( criminal, strict liability etc) and produces material / evidence 'brief' for the for the CDPP to look at.

If CDPP like what they see and reckon a successful prosecution is the go, they'll run with it.

The cruncher is of course the CDPP, in aviation ignorance, doesnt know whether the material presented by CaSA is the gospel truth or a crock of doggy doo.

Just ask three AWIs, namely Retski Larard and Clark, who with brilliant observational skill and professional acumen, all saw and swore, to something that technically and physically could never occur. Not who you would want to be checking your aircraft !

Once advised as to the truth of the matter, the CDPP bolted, and CAsA's 'easy bash'/ "there are those in Canberra who think they can make this stick" (statement of short career "investigator" Cremerius), went tits up. Charge Struck Out

CAsA have been in denial ever since and CYA 101 to protect the guilty ...and they're still at it.
I've even had a 3 page "thesis" since from the good Doctor from LSD (very appropriate) explaining that outrageous sworn falsehoods are not lies or untruths but just discrepancies in the wording !!
I kid you not.!! It caused great mirth among the legal profession, not surprisingly.

The surviving AWI still in CAsA employ, is still pissed off and continues to get his rocks off writing/or causing to be written on toilet walls, my private mobile no.
That is no joke either. We're working towards a legal outcome.
As Carmody spouts... CAsA has culture of Just Arse.
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Old 5th Dec 2017, 11:25
  #1190 (permalink)  
 
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I am not sure that the DPP gets involved in CASA prosecutions as CASA is a government agency and not a government department. It is one of the reasons CASA has a legal department. However, someone may have a better knowledge of this than I.
Well, I am sure that DPP are the people that take the case on. I see that Aroa has beat me to it with a specific case that he has personal knowledge of.
And I was very surprised that Mr Retski allowed himself to become involved in that bit of stupidity, for goodness sake the tailplane was one piece.
He might have been better-served if NGV had remained on the seabed.
This was always a risk that certain contributors to this and previous threads had either overlooked, or were so certain of their "facts" that it(the CVR) would support the pilot.
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Old 6th Dec 2017, 02:23
  #1191 (permalink)  
 
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More spin.

The point of FDRs and CVRs is to assist in determining the facts.

We used to think the ATSB’s job was to do the same.

The calls for recovery of the recorders were, in effect, calls for the ATSB to do its job properly.

If the ATSB had done its job properly in the first place, there would have been no speculation as to what the recorders may have revealed. The ATSB’s reputation might be a little less trashed.

I would still prefer to hear the actual recording from the CVR (and from flight services), rather than relying on the ATSB’s paraphrasing.
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Old 6th Dec 2017, 04:28
  #1192 (permalink)  
 
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I would still prefer to hear the actual recording from the CVR (and from flight services), rather than relying on the ATSB’s paraphrasing.
Lead balloon, do you think that there is a possibility that ATSB has misunderstood or misconstrued the different recordings?

I am now re-reading the ATSB report, and imagining myself in Dom's position during the varous stages of flight. I cannot for the life of me(and it would have been my life) understand his refusal to take full fuel from Apia - does anyone have a reason why he might have believed 7200lbs was sufficient for the flight?
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Old 6th Dec 2017, 05:12
  #1193 (permalink)  
 
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Eddie, the problem is that by not releasing the exact transcripts it leads to suspicion that perhaps things could have been altered/distorted/omitted/added. Not saying that's what was done, but its all about perception. Have things been twisted to suit a certain agenda..? Who knows. But if you print the exact transcripts then it removes any doubt or room for speculation.
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Old 6th Dec 2017, 06:02
  #1194 (permalink)  
 
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"Eddie, the problem is that by not releasing the exact transcripts it leads to suspicion that perhaps things could have been altered/distorted/omitted/added."

According to the pilot concerned thats exactly what happened

"I cannot for the life of me(and it would have been my life) understand his refusal to take full fuel from Apia"

The fuel he took was what was legally required to complete the flight under the rules that applied at the time and in accordance with Pelair's fuel policy. The same fuel others had taken before him, including the Chief Pilot.

It costs fuel to carry fuel, Mr Davies analysis showed even if he took full fuel he would more than likely ended up at Norfolk with the same residual fuel as he had.
There is also the likelihood that he would have been descended to a level outside RVSM airspace due to being to heavy to climb, in which case we wouldn't be having the conversation as he would have had to divert to Nadi to take on more fuel.
To my mind his biggest mistake was leaving Samoa in the first place. A wiser and perhaps more experienced mind would have deduced, I aint had proper rest,
the patient aint critical, its the middle of the night, bugger it, I'll go in the morning.
But then just how much commercial pressure was there to complete the mission?
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Old 6th Dec 2017, 06:09
  #1195 (permalink)  
 
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so our wonderful system of regulation was tested and found wanting. The response was to persecute the tester.
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Old 6th Dec 2017, 07:07
  #1196 (permalink)  
 
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Originally Posted by aroa View Post
Plovett...not quite right there.

The CDPP dont do investigations. (and I have that in writing)
CAsA decides on a prosecution using whatever reg suits their fancy, "investigates" for the evidence, with a view to gaining a prosecution, ( criminal, strict liability etc) and produces material / evidence 'brief' for the for the CDPP to look at.

If CDPP like what they see and reckon a successful prosecution is the go, they'll run with it.

The cruncher is of course the CDPP, in aviation ignorance, doesnt know whether the material presented by CaSA is the gospel truth or a crock of doggy doo.

Just ask three AWIs, namely Retski Larard and Clark, who with brilliant observational skill and professional acumen, all saw and swore, to something that technically and physically could never occur. Not who you would want to be checking your aircraft !

Once advised as to the truth of the matter, the CDPP bolted, and CAsA's 'easy bash'/ "there are those in Canberra who think they can make this stick" (statement of short career "investigator" Cremerius), went tits up. Charge Struck Out

CAsA have been in denial ever since and CYA 101 to protect the guilty ...and they're still at it.
I've even had a 3 page "thesis" since from the good Doctor from LSD (very appropriate) explaining that outrageous sworn falsehoods are not lies or untruths but just discrepancies in the wording !!
I kid you not.!! It caused great mirth among the legal profession, not surprisingly.

The surviving AWI still in CAsA employ, is still pissed off and continues to get his rocks off writing/or causing to be written on toilet walls, my private mobile no.
That is no joke either. We're working towards a legal outcome.
As Carmody spouts... CAsA has culture of Just Arse.
Thanks aroa, I was basing my opinion on a case that occurred in Tassie, where local counsel was briefed for the prosecution. I thought it was CASA who briefed but on reflection perhaps it was the CDPP.

No wonder CASA lives in fantasy land if they believe that a sworn affidavit containing falsehoods is merely a discrepancy. There really will be no change short of a root and branch cleansing of the place, especially at the deputy level.
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Old 6th Dec 2017, 09:54
  #1197 (permalink)  
 
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The fuel he took was what was legally required to complete the flight under the rules that applied at the time and in accordance with Pelair's fuel policy.
Not quite. The fuel he took was insufficient to cater for depressurisation or engine failure en-route, as required by regulations. It wasn't planned in accordance with current wind charts. The Pelair fuel policy didn't cater for engine out/depress either, though.

The same fuel others had taken before him, including the Chief Pilot.
Untrue:
Originally Posted by Westwind report
Of the operator’s 185 flights to remote aerodromes during the period 1 January 2002 to 17 November 2009:
  • 158 (85 per cent) departed with full fuel (1.80–4.77 hours flight time)
  • 12 (6 per cent) departed with 8,000–8,400 lb (1.85–3.80 hours)
  • 5 (3 per cent) departed with 7,400–7,800 lb (1.80–3.00 hours)
  • 10 (5 per cent) departed with full main tanks or just less than full main tanks (1.80–2.50 hours).

...


In terms of the fuel on board for different flight times:
  • All 8 flights with a flight time of 4.25 hours or more departed with full fuel.
  • Almost all (29) of the 30 flights with a flight time of 3.75–4.24 hours departed with full fuel. A 3.80-hour freight flight during the day from Darwin to Christmas Island departed with 8,000 lb.
  • All 19 flights with a flight time of 3.25–3.74 hours departed with full fuel.
  • Most (33) of the 38 flights with a flight time of 2.75–3.24 hours departed with full fuel.

It costs fuel to carry fuel,
The fuel in Samoa was half the cost of the fuel at Norfolk. It would have paid to carry on this sector.
Mr Davies analysis showed even if he took full fuel he would more than likely ended up at Norfolk with the same residual fuel as he had.
That's ridiculous.
There is also the likelihood that he would have been descended to a level outside RVSM airspace due to being to heavy to climb, in which case we wouldn't be having the conversation as he would have had to divert to Nadi to take on more fuel.
As a MED1 priority - probably not. As he never mentioned that priority on the radio, however, he appeared to be unaware of this. In any case, if you have to divert, you have to divert - still not a reason not to carry fuel.
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Old 6th Dec 2017, 10:56
  #1198 (permalink)  
 
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Checkboard: I’d be interested to know if you’ve read Mr Davies’ submission (and supplements) here: https://www.aph.gov.au/Parliamentary...12/submissions and to understand where you consider his reasoning to go astray.
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Old 6th Dec 2017, 11:37
  #1199 (permalink)  
 
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I've seen some media reports and articles around the internet comparing Mr James's actions to that of 'Sully' Sullenberger. Does anyone know if Sully has voiced his opinion on the event? I would love to hear it.
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Old 6th Dec 2017, 12:34
  #1200 (permalink)  
 
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https://independentaustralia.net/bus...ng-lives,11000

Not agreeable on all the statements
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