Norfolk Island Ditching ATSB Report - ?
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A fuel policy that pushed things to the very edge of the legal limit with no thought whether this was sensible (aerial work so no alternate). A pilot who pushed things even further (no OEI). A sense of complacency (not getting en route weather and not monitoring a deteriorating situation). Possible difficulties at Noumea. Poor CRM (not asking FO to check calculations).
How else was this going to end up. This all reads like a recipe for disaster. In the end they got themselves backed into a tight corner.
There is more than enough blame to go around. The crew did the wrong thing, but they were not the only ones.
How else was this going to end up. This all reads like a recipe for disaster. In the end they got themselves backed into a tight corner.
There is more than enough blame to go around. The crew did the wrong thing, but they were not the only ones.
why no mention of the decision to not fill the tip tanks?
Also, why were they made to climb/descend when surely as an aero med flight it would have had a STS?
As for not having current weather/notams for possible diverts enroute.
Is there no fax machine on Norfolk? We can get by without the net.
Seems to me he called up with the flight plan then said by the way whats the TAF? No need for that trend from 1500 best be on my way.
Also, why were they made to climb/descend when surely as an aero med flight it would have had a STS?
As for not having current weather/notams for possible diverts enroute.
Is there no fax machine on Norfolk? We can get by without the net. Seems to me he called up with the flight plan then said by the way whats the TAF? No need for that trend from 1500 best be on my way.
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Two Hours Island Holding:
Was always standard operating procedure for our company, in fitting with a favorable TAF! add into that any TEMPO, and it had to be re-thought:
Even with a favorable TAF, We got caught out going into Funifuti, 5 missed, and we got in on the 6th! power back at minimum, M-Apps, at lowish power, was not a very nice feeling!
And before you ask, 10 minutes before the PNR, Nadi had given us via HF a suitable Metar, and TAF! so anything can happen especially when the CTZ gets down below 15 Sth:
When I asked the F/O what he thought of bringing one to Idle power and Feather, he nearly choked. :
H/Snort:
Even with a favorable TAF, We got caught out going into Funifuti, 5 missed, and we got in on the 6th! power back at minimum, M-Apps, at lowish power, was not a very nice feeling!
And before you ask, 10 minutes before the PNR, Nadi had given us via HF a suitable Metar, and TAF! so anything can happen especially when the CTZ gets down below 15 Sth:
When I asked the F/O what he thought of bringing one to Idle power and Feather, he nearly choked. :
H/Snort:
Given that the crew had put themselves between a rock and a hard place, would it have been possible to set up a v/s of 800'/min on the A/P, keep vor/loc coupled and come down to 200' to try and get visual? Given the performance of a Westwind I imagine that a go-around would have been successful from a low altitude. They seemed to have persisted with VOR approaches to the minimum even though they had been told that the cloud base was 200'.
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What? A 200 Ft base:
I am not prepared to say what I went down to, get into Funifuti, BUT! 200 Ft while not being legal, in a circumstance such as this? is ample!
H/Snort:
H/Snort:
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There's a line in the report stating that on the last approach they went below the minima to try to get visual, but it doesn't detail how they did so, nor how far below they went.
I tell ya what being down at 200 ft at night doing an NPA (well Blw the Min) very close to the AD with minimal fwd vis virtually zero room left to maneuver & with rain pelting against the screen, the fuel gauges showing 'E' & you know that going around from this means possible death or ta least career ending actions would have any pilot almost at their maximum level of capability.
Like I've said b4 on this subject I bet my left one (the right one I lost in a bet years ago!
) that commercial pressure was the main criteria that found Dom in this ugly mess.That along with possibly not enough experience & poor flight planning in these Ops means a LOT of young pilots can & will find themselves in similar situations maybe not as drastic as this one but still life changing.
As has been said it's got zip to do with what's legal here (AWK PVT Etc) there's still flesh & blood being carried regardless of the regs.
A good Capt Commands
Most of these light jets are capable of carrying full fuel (or close to it) in an average Aero-Med config. Taking off with less than full fuel on such missions means there's some external force making that decision.
They survived & lets hope that something good can or has come good of this.
At the very least this accident might make some young buck one day think twice about going skinny on the gas due Commercial pressure!
As for the final report on this?............well that's just a waste of time to even be put together. Too much legal jargon & ass protecting to be of any benefit really.
Wmk2
Like I've said b4 on this subject I bet my left one (the right one I lost in a bet years ago!
) that commercial pressure was the main criteria that found Dom in this ugly mess.That along with possibly not enough experience & poor flight planning in these Ops means a LOT of young pilots can & will find themselves in similar situations maybe not as drastic as this one but still life changing.As has been said it's got zip to do with what's legal here (AWK PVT Etc) there's still flesh & blood being carried regardless of the regs.
A good Capt Commands
Most of these light jets are capable of carrying full fuel (or close to it) in an average Aero-Med config. Taking off with less than full fuel on such missions means there's some external force making that decision.
They survived & lets hope that something good can or has come good of this.
At the very least this accident might make some young buck one day think twice about going skinny on the gas due Commercial pressure!
As for the final report on this?............well that's just a waste of time to even be put together. Too much legal jargon & ass protecting to be of any benefit really.
Wmk2
Last edited by Wally Mk2; 2nd Sep 2012 at 09:27.
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Impossible on any form of TV journalism to get the nitty gritty out in the open, in house lawyers will be controlling every word.
CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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Spooky spooky
CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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You mean 4 Mourners don't ya. Three years in the making, oh roll up, roll up.
The stats are interesting, CASA reports to the Minister, the ATSB reports to Minister, the ABC depend on the Gummint for Dollars, (if not sense); and we cannot have the Minister' s wee boat rocked. Yup, the 4 Mourners show should be worth the cost of the carbon rich electricity.
Legendary stuff – on your ABC. 
The stats are interesting, CASA reports to the Minister, the ATSB reports to Minister, the ABC depend on the Gummint for Dollars, (if not sense); and we cannot have the Minister' s wee boat rocked. Yup, the 4 Mourners show should be worth the cost of the carbon rich electricity.
Tony the Tiler - Smoke and mirrors is the new act, normally reserved for the corporate management thug types, but now adapted for the Elephant hiding act. Now, as everyone knows, elephants are very hard to hide. But, in a light bulb moment, the elephant hiding ringmasters have decided that the next best thing to hiding an elephant is making it disappear. Wow, the crowd is silent in anticipation, a disappearing elephant act, can it really get any better. Sadly, the act is only part way through and my source is unable to report on the outcome of this new and daring act. But so far there is a lot of smoke and distraction and something called unity. Unity is mentioned by the ringmasters at every opportunity, what can it mean and where will it end?
A month later, the Civil Aviation Authority (CASA) took away James' pilot license and his reputation was all but destroyed
I wonder what else they will get wrong.
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The cause distilled
At the risk of being accused of harping on about professionalism (or the lack of) and over simplifying the analysis of the accident you need only look at the writing between the lines in the "Celebrate the professional pilot" thread, now closed.
Of over 2000 views only one pilot had the testicular fortitude to admit that he was coerced into "non compliance". Even on this forum that thrives on anonymity, nobody else could put their hand up and say that they had stood up to coercion from their employer. Either too afraid speak up or just plain had never exercised command judgement. Hopefully it is not the latter.
Combine that GA upbringing and an organisation culture where blind obedience to a figure that had and exercised the power to make or break a career then you set the stage for this sort of accident. You only have to wait for the players to walk on stage.
Even worse you condition the pilots to replicate the same behavior in the cockpit.
Of over 2000 views only one pilot had the testicular fortitude to admit that he was coerced into "non compliance". Even on this forum that thrives on anonymity, nobody else could put their hand up and say that they had stood up to coercion from their employer. Either too afraid speak up or just plain had never exercised command judgement. Hopefully it is not the latter.
Combine that GA upbringing and an organisation culture where blind obedience to a figure that had and exercised the power to make or break a career then you set the stage for this sort of accident. You only have to wait for the players to walk on stage.
Even worse you condition the pilots to replicate the same behavior in the cockpit.
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Four Corners
Ben Sandilands seems to know what angle Four Corners is taking, so we can assume that Ben was a source interviewed for tonight's episode.
He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report.
Pel-Air exposé on ABC 4 Corners tonight is a must view report | Plane Talking
He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report.
Pel-Air exposé on ABC 4 Corners tonight is a must view report | Plane Talking
Pel-Air exposé on ABC 4 Corners tonight is a must view
The ABC TV show 4 Corner’s exposé on the Pel-Air ditching near Norfolk Island that airs tonight goes directly to the honesty and candor with which aviation safety regulation is pursued and discussed in Australia. It is a must see program.
The issues of transparent and fearless public administration of air safety regulation and investigation have been central to Plane Talking for five years but their pursuit by a well resourced national television program is an important breakthrough.
Tonight’s program is more evidence that the flawed regulatory performance of CASA, the air safety regulator, and the supposedly independent safety investigator the ATSB, include a systemic failure to fully and unambiguously keep the public informed about substandard operations.
4 Corners will disclose matters arising from a CASA audit of Pel-Air, conducted immediately after the Norfolk Island incident, that ought to have been included in the ATSB final report into the crash.
The non disclosure of such matters raises the question as to whether CASA, the ATSB and by association, the responsible minister, are deliberately acting to protect the airlines or aviation services providers and their regulator from better informed scrutiny of their respective capacities to follow or draft effective safety regulations.
The ABC TV show 4 Corner’s exposé on the Pel-Air ditching near Norfolk Island that airs tonight goes directly to the honesty and candor with which aviation safety regulation is pursued and discussed in Australia. It is a must see program.
The issues of transparent and fearless public administration of air safety regulation and investigation have been central to Plane Talking for five years but their pursuit by a well resourced national television program is an important breakthrough.
Tonight’s program is more evidence that the flawed regulatory performance of CASA, the air safety regulator, and the supposedly independent safety investigator the ATSB, include a systemic failure to fully and unambiguously keep the public informed about substandard operations.
4 Corners will disclose matters arising from a CASA audit of Pel-Air, conducted immediately after the Norfolk Island incident, that ought to have been included in the ATSB final report into the crash.
The non disclosure of such matters raises the question as to whether CASA, the ATSB and by association, the responsible minister, are deliberately acting to protect the airlines or aviation services providers and their regulator from better informed scrutiny of their respective capacities to follow or draft effective safety regulations.
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The reason I mentioned the lack of a weight analysis in an earlier post is this taken from another 1124A accident.
So did the CoG have any implication for not filling the tips?
Because of the Westwind II design, a small change to the aircraft's load can result in a relatively large shift to the aircraft's centre-of-gravity (C of G) position. The aircraft's C of G envelope is published in Section VIII-21 of the Westwind II Airplane Flight Manual . The lower portion of that envelope identifies two separate zones. The manual indicates that, if the aircraft's zero fuel weight falls within zone 1, then fuel may be loaded up to the maximum ramp weight without exceeding the C of G limits. However, in order to maximize the aircraft's payload, the aircraft's C of G at its zero fuel weight is normally adjusted to the aft-most limit of zone 1. As passengers, baggage, and fuel are then added, the C of G will move progressively ahead, toward the forward limit of the operating C of G range. This adjustment to the zero fuel weight C of G position is accomplished through the use of removable ballast.
Prior to departing from the Edmonton Municipal Airport, the flight crew had positioned 100 pounds of removable ballast (four 25-pound bags of lead shot) into the aft baggage compartment in order to configure the aircraft's C of G to allow for the loading of eight passengers at Meadow Lake.
The aircraft's weight and balance for the re-positioning flight to Meadow Lake were within prescribed limits. Its weight for the time of the accident was estimated to be 18,138 pounds, and the distribution of that load would have placed the aircraft's C of G at the aft limit of the aircraft's C of G operating range.
Prior to departing from the Edmonton Municipal Airport, the flight crew had positioned 100 pounds of removable ballast (four 25-pound bags of lead shot) into the aft baggage compartment in order to configure the aircraft's C of G to allow for the loading of eight passengers at Meadow Lake.
The aircraft's weight and balance for the re-positioning flight to Meadow Lake were within prescribed limits. Its weight for the time of the accident was estimated to be 18,138 pounds, and the distribution of that load would have placed the aircraft's C of G at the aft limit of the aircraft's C of G operating range.
The two comments (so far) from Ben's blog article are interesting...
- 1
comet
- Posted September 3, 2012 at 11:12 am | Permalink
- There should be a Royal Commission into air safety regulation in Australia, as it has descended to third world standards. Political donations from airlines and aviation companies should be banned.
- 2
pa31
Posted September 3, 2012 at 12:48 pm | Permalink
The reading of the PelAir report is very similar to the recent Brasilia report from Darwin, where there are just vague references by ATSB to “….changes by the operator, which involve use of a simulator program….hence there won’t be any more problems….”
ATSB has released a report that takes 3 years and is extremely light weight.
This report is similar, to the Brasilia one, in that this report identifies systemic problems in CASA surveillance of the operator “……but changes since the accident …..fix the problem …………..”
It even says that other operators have similar problems when surveyed.
Surely this goes to the heart of the matter, in that CASA is failing to properly undertake it’s role. We are not looking for “over-the-top” micro-management, but surely, where there are large over-water ops, there needs to be a standard met in this area.
Remember SeaView – This has some of the same hallmarks.
This is both for the regulator and the operator
Thread Starter
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What are the pilot (Dominic?) and the Co-Pilot doing now?
Are their careers in aviation over???
(Presumably) taking a Westwind for a swim is not good for your cv and job prospects.
Are their careers in aviation over???
(Presumably) taking a Westwind for a swim is not good for your cv and job prospects.
It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is in the RHS at virgin.
It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is in the RHS at virgin.
That kinda got my attention, but I did wonder at the relevance!
Dr
