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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

Old 3rd Sep 2012, 13:22
  #141 (permalink)  
Join Date: Sep 2009
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Unsafe skies for all

There was a lot in this interview to be disected, no doubt. But 3 things were extremely disturbing;

a) The fact that the ATSB's reputation for unbiased, clear and concise investigation reports has absolutely hit 'shit bottom'. CASA has been a bureaucracy for decades so there is nothing new or shocking there, however the ATSB in the past few years under Dolan's direction has become a complete joke. He was caught off guard, looked awkward, stumbled and looked like Beaker off the Muppets. Reports containing piffle and bollocks are now the norm. Investigations are absolute light weight shite. The same methodology is employed at the ATSB and ASA and it sure as hell stands out. At least Russell got the heave ho from ASA, but it might be time to get some of the old ATSB gang back on deck?

b) The return of Herr Quinn! We wondered where the wiley old rascal had been hiding. After being pineappled by the Skull a few years back (at least the Skull had the balls to do it unlike Byron) and he has been waiting to fire a bullet. So for Quinn I imagine it was more an act of sour grapes and payback. The same applies for his 'sidekick' who also featured on the show, he is most certainly a former CASA employee who lasted just over a year, and has many chips on his shoulder against the authority also. There is a lot more to the Quinn/Aherne stage show but best let sleeping dogs lay.

c) The Skulls make-up. Fair dinkum, he looked like a dolled up Ladyboy! 4 Corners should sack its make-up artist immediately. When the angry man watches the replay tomorrow he will be reaching for the stoogies and going nuts over his poor performance (he sounded very nervous and didnt even look like cutting loose and throwing some office furniture). Heaven help the first Inspector or operator to screw up Tuesday morning as the Skull will be raining down fire and brimstone, not to mention the phone calls that he and Dolan will be receiving from the Minister for Mascot.

Which one is Beaker????


Last edited by my oleo is extended; 3rd Sep 2012 at 13:26.
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Old 3rd Sep 2012, 13:27
  #142 (permalink)  
Join Date: Mar 2012
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It most certainly was an interesting watch!

Tonight I will write to the minister and ask for the Head of CASA to be removed.
Good luck with that.

Quick question, Should the passengers be compensated?
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Old 3rd Sep 2012, 13:57
  #143 (permalink)  
Join Date: Aug 2006
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Quick question, Should the passengers be compensated?
Absolutely. No contact from Pel Air since the accident is outrageous.

Also, for the head of CASA to be so black and white about where the blame lies when any layperson watching 4 corners could see the issue is complex and multi faceted, in my opinion makes him completely unsuitable to hold that position.

My girl didn't know whether to be amused or concerned when I told her he was the head of the 'safety' regulator. "THAT guy's keeping you safe?!?!"
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Old 3rd Sep 2012, 14:11
  #144 (permalink)  

Grandpa Aerotart
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As a former Chief Pilot of a International medevac operation (Falcon 200) I would offer the following insight.

1/. You're typically operating under the 'guidance' of a CASA FOI who doesn't know $hit about jet operations let alone corporate jet operations...never mind medevac operations across international borders, to the middle of nowhere, in the middle of the night.

2/. But he wants an endorsement on your aircraft for free.

3/. Companies doing this sort of work invariably have the wrong aircraft for the job - they get the cheapest jet they can find whether its the right aircraft or not. That is why you have LR31/35s and Jew Canoes running around the Pacific in the middle of the night - just because you get away with it for a few years doesn't make it the right aircraft. That corporate imperative eventually killed off the operation I was in charge of.

4/. A jet is a jet. In my operation we never, EVER went anywhere without an alternate...period. What the rules say is irrelevant.

5/. Fatigue management systems are a sick joke. CASA tried to make us have one. We spent large $ on getting the program software - ran a bunch of scenarios through it and found it would allow us to do trips with 2 pilots we currently did with 3 (Singapore- Kathmandu-Singapore) and not even come close to flagging us as fatigued - but we arrived back shattered even with heavy crew. I rang CASA and literally told them the fatigue software was "fcking dangerous and anyone pushing its use is a moron" - then the fella I was talking to allowed as how HE was one of the fellas from Uni of SA who designed it...before becoming a consultant to CASA.

"So? - we will be staying on CAO48 - there is NO WAY I or my pilots will be operating under your FMS" It instantly went from being a 'requirement for renewal or your AOC' to "Ok you can keep using CAO48".

I think this young pilot made some very basic mistakes that night - why was the gear down when he ditched? We wasn't he more proactive getting weathers for a place he MUST have known could be dodgy?

He was clearly impaired by fatigue.

I have been as tired as he was...only difference was I wasn't backed into a corner when that tired. Our operation had FAA trained dispatchers (ex SingAF navigators) and our flight plans/wx/notams were faxed to the hotel we were staying at and picked up by the crew at checkout (already lodged by our dispatchers of course). We had a satphone. One of our dispatchers (there were 3) was on duty for the entire time we were away from base keeping an eye on us. Contacting them from ANYWHERE/24hrs a day, via satphone, was as complicated as ringing your mother on mother's day.

This young pilot fcked up - but CASA/PA fcked up more. I bet young Dom would be the first to admit his mistakes (he virtually did on 4C)

CASA and PA NEVER will. It seems more and more obvious that ATSB doesn't have the staff/resources to carry out its statutory role at any level that could be deemed effective.

After the Falcon operation ended I flew a C441 casual out of SEQ for a few months before getting back into airlines - I did one trip out east of Fiji in it. I arrived in Nadi to find my employer hadn't even bothered to inform the Fijian immigration people I was coming - no accom booked etc. I rang the boss from Nadi in the middle of the night just to wake him up. I managed to smooth things over with the Fijians, find accom, get suitable rest and complete the task safely. When I got back I just looked the boss in the eye and said "That won't happen again".

It didn't.

Looks to me like that was the level of backup young Dom got.

I hope this doesn't permanently effect his career. After that night he will be the safest pilot around - and the first to tell his employer "That won't be happening" and mean it.

Good luck to him.
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Old 3rd Sep 2012, 14:20
  #145 (permalink)  
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Have a read of the CASA audit document the ABC have on the 4 corners site. The only good part of Pelair back then appears to be the Saab/Metro operation. Can't say the same or the medevac/Jet Charter and the MIL Ops out of Nowra.
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Old 3rd Sep 2012, 14:24
  #146 (permalink)  
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why was the gear down when he ditched?
It wasn't CC. That was a result of impact damage.
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Old 3rd Sep 2012, 14:36
  #147 (permalink)  

Grandpa Aerotart
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It doesn't look that way to me - I reckon they forgot the gear in the multiple approaches and that is the reason the aircraft snapped in half. The underwater film shows main gear down and locked...not forced out on impact.
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Old 3rd Sep 2012, 14:45
  #148 (permalink)  
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I think this young pilot made some very basic mistakes that night - why was the gear down when he ditched
Bryan Abraham answered that from the ATSB report. The impact forced down the gear. "There but for the Grace of God, go I", springs to mind about this whole event and indeed I think many people are being wise after the event. The pilot must have done a first class job of ditching in the dark. The rate of descent at impact must have been perfect and IAS perfect for ditching. With absolutely no forward vision even though the landing lights were on but not displaying the waves, from what I can guess his ditching technique was spot on.

Earlier he was given a met report indicating cloud base 6000 ft which tied in roughly with the weather the day before. He believed it and let's face it, so would have most pilots at the time. Also given that a diversion to Tontouta would have him arriving there with eight minutes of fuel, no wonder he discarded that idea. So would have most pilots.

We should not shy away from giving the man the credit he richly deserved; and that is he made a successful ditching on instruments under conditions you would never try to create in a simulator because no one would believe you.
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Old 3rd Sep 2012, 14:46
  #149 (permalink)  
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It sounded like the TAWS was going off in the Vid clip on the 4 Corners show 2nite meaning that it activated due the A/C not configured for a normal Ldg which would have been the case in a planed ditching (gear selected up)
Where did 4C get the info to re-construct this clip.
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Old 3rd Sep 2012, 14:50
  #150 (permalink)  
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1. I wouldn't believe anything that came out of the 4 Corners program. The reporter couldn't even get the name of the two main agencies correct (Civil Aviation Aviation and Safety Authority/Australian Transport and Safety Bureau????? what was the reporter thinking, zero credibility to start with!

2. Three Westwinds lost by the operator in just over 20 years.(Pel-Air was two separate AOC's for many years, one for the Jets and one for the Turbo-Props)
VH-IWJ – Oct 1985
VH-AJS - Apr 1995
VH-NGA – Nov 2009

3. The use of the term “High Quality” VHF Radio as against the “Poor Quality” HF. If you had any doubts about the accuracy information you hear on the HF you confirm it. Good RT practice especially when its safety critical information.

4. Its really that hard to get the weather by phone, and plan safely without access to a computer or the internet, or is it just easier to reverse your outbound plan and have a guess, don't forget though you will always use more fuel flying west!

The actions of the crew both in flight and during planning has to be questioned and was probably deficient in many areas, but how were they able to get themselves into the situation in the first place. It comes back to an organizational culture that has never been up to scratch and lack of training. Lets just hope that all involved learn from the event, and not point the finger in any one direction.

PS, I may be wrong, but the Westwing alternate landing gear extension operates by discharging high pressure nitrogen into the landing gear hydraulic system (up-lock, extension and down-lock). It is actuated by control cable from the cockpit that runs aft. It is likely that during the accident sequence as the airframe failed the cable tension activated the system, possibly even after the aircraft came to a stop.

Last edited by R555C; 3rd Sep 2012 at 15:00.
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Old 3rd Sep 2012, 15:37
  #151 (permalink)  
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The IAI1124 uses hydraulic pressure to keep the gear up. There is no mechanical uplock.

As soon as the hydraulics are breached from the gear side, the gear comes down. It's fairly heavy and will swing down and locked quite easily... even without using the blow down bottle. (I've seen it first hand while dealing with a complete hydraulics failure on a Westwind...)

Chimbu does have a point about aircraft selection, however I believe the Westwind is suitable for this type of operation. Quite simply, if one goes to a remote island constantly, without a plan B (alternate), eventually one will get bitten. Who cares what the law says, its bloody common sense! Just because it's legal, doesn't make it a good idea!

That was about 1 hour worth of fuel that was not taken by not filling those tip tanks. More than enough for one approach and diversion to NWWW.

As for that bad excuse of a joke as Director of Civil Aviation, I'm sure he would be quite happy if we all started planning our RPT ops using manual calculations for oceanic flights. "Back in my day..." yes well back in your day, you probably had a navigator and radio operator too.

Still, it was quite a shock to read in the special audit report that there was no specific flight planning method for the Westwinds nor could the software under consideration consider enroute winds. If you can't afford or just won't pay for the proper tools (UVAir etc), then you shouldn't be doing that sort of operation. Fanging around from Darwin-Alice-Adelaide is completely different to long overwater oceanic routes...

Last edited by Gate_15L; 3rd Sep 2012 at 15:40.
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Old 3rd Sep 2012, 16:00
  #152 (permalink)  
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I don't think anyone has mentioned the negligence of the co-pilot.
She was part of the CREW and as such has a responsibility and should have insisted on being consulted on the flight plan, fuel requirements, weather etc. From what I have read, she contributed nothing to the safety of this flight. This is NOT the good old days where co-pilots (gear up, flaps up, shut up) were xxkgs of excess freight.
I'm not saying the pilot in command (I would not call him a captain) did not screw up. He did, big time. But He is not alone.
I've ALWAYS INSISTED that my right hand seat check my work and my figures. That is what CREW's are about. Remember it's not who's right, but what is right!

Last edited by dogcharlietree; 3rd Sep 2012 at 16:04.
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Old 3rd Sep 2012, 16:13
  #153 (permalink)  
Join Date: Apr 2012
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Blaming the Pilot, the CASA way

CASA caught playing the man not the company in ABC TV exposé on Pel-Air ditching

The ABC TV 4 Corners report into the Norfolk Island Pel-Air ditching has this evening shown CASA’s director of safety, John McCormick, making an attack on the flight’s captain, Dominic James and excusing every single deficiency the regulator uncovered in the company during a safety audit as not being a cause of the accident.

However the program is also posting online the safety audit that CASA tried to keep secret and which materially contradicts McCormick in that the safety regulator he heads found among many things that Pel-Air was in breach of the safety rules and was inadequate in its management of fatigue.

The interview and the audit read side by side support the program’s opening premise that CASA scapegoated James in preference to carrying out its obligations under law to pursue the company.

McCormick would well know, and has insisted before the Senate Inquiry into pilot training and airline safety, that it is the airlines or operators that are responsible for safety outcomes.

As pilot James said near the end of the program, he was the pilot of a company that was being overseen by a regulator. Last night, on national television, the head of CASA unloaded all the blame for the accident on a pilot who had not even slept properly for two nights, and was employed by an operator that was so poorly overseen by CASA that it uncovered massive safety deficiencies, while benefiting from a defective CASA rule that excused it from operating as an air ambulance without sufficient fuel to fly to an alternate airport if for any reason a remote refueling airport in the middle of the ocean was rendered unavailable by bad weather.

McCormick’s performance and statements on air are not only inconsistent with the body of law on airline or operator responsibility for pilot training and standards, but were manifestly unfair to the pilot, even though the pilot undoubtedly made serious mistakes in the preparation of the flight, its fueling, and in dealing with the available weather information as the Westwind jet approached Norfolk Island from Apia.

(The 4 Corners report by Geoff Thompson also uncovered evidence the critical weather information had not been passed on to James at a point where had he known of the real situation at Norfolk Island he would have diverted to Nadi in Fiji rather than passing the point of no return where he had to continue to the intended tech stop.)

A fair question arising from McCormick’s performance is whether or not he is capable of taking direct public action against a high profile airline or operator other than Singapore owned Tiger Airways, given the severity of a series of safety failures at Jetstar that were also declared to be unworthy of investigation by the ‘independent’ safety regulator the ATSB.

Regulatory matters aside, the human suffering caused by the unsafe operation of the air ambulance flight by Pel-Air was movingly documented by the program, as was the vigilance and determination of their rescuers on Norfolk Island that brought all six souls to safety from the wild and dark sea in which they had to tread water for close to 90 minutes.

It is utterly shameful to hear that Pel-Air has not once been in touch with Bernie Currall or her husband Gary since the accident, and to see the ruin and despair that the operator’s unsafe and negligent conduct brought to their lives, as well as to Karen Casey the nurse who has lost her livelihood and suffers continued pain from her injuries.

McCormick heads a safety regulator that approved the removal of special life rafts from Qantaslink turbo-props serving Lord Howe Island, and has been unable to release any safety case or statement as to why it allowed this to happen other than the downwards harmonization of Australian standards to the depths of world’s best practice.

It is also an organization that has never explained the safety case that saw it determine that the sort of aerial work performed by the Pel-Air flight didn’t need to carry enough fuel to make a diversion from an oceanic airstrip in bad weather, although it has only recently expressed an ‘intention’ to change a rule it should never have tolerated in the first instance.

The 4 Corners program is an indictment of shamefully deficient standards and oversight by our safety regulator, as well as its disposition to crucify a pilot rather than the company responsible for the flight and safety standards of its operations.

The program, and the supporting documentation, will be readily found on the ABC site in the near future.

Pel-Air exposé catches out air safety regulator | Plane Talking
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Old 3rd Sep 2012, 17:47
  #154 (permalink)  
Join Date: May 2009
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Quick question, Should the passengers be compensated?
They will all be compensated big time. The operators insurers will offer a large out of court settlement. The passengers may not settle for this - depending on the amount offered & whether they are angry enough to have their day in court regardless.

It will be a sizable settlement. Medical expenses - ka-ching. Lifetime loss of earnings - ka-ching. Pain and suffering - ka-ching. Psychological trauma - ka-ching. Post trauma stress, PTSD etc - ka-hing. It will make south pacific fuel look very cheap.

The outcome is bad enough to justify a large settlement. However the special audit is gold to the lawyers. They will be drooling over this today and sharply revising their idea of a reasonable settlement. I wonder who had to call Singapore and explain the audit had been leaked to the media.

The audit is damning, and paints a picture even worse than all the rumors over the years. It will take more than one reading to get across all the issues raised.

The broader issue is how such a damning special audit got so watered down in the final report.
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Old 3rd Sep 2012, 21:45
  #155 (permalink)  
Join Date: Nov 2009
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It looks to me that all agree that the crew,CASA,ATSB and pelair have a roll to play in what happened that day. Its just the % of blame that is up for discussion.

My question is what do you expect to happen to Pel Air now ?

Closed down the operation ? Persue them in the courts ?

I say this because i spent many years in pelair and know through discussions with current employees that it is a very different beast today.

Original owners Gone
Original managers Gone
original pilots Gone
Darwin ops Gone
metros Gone
Freight Gone

the way they operate has changed and this began before the incident.
REX come in and after some time gauging the operation changes started.I was around for the start of this and things looked ok. But change takes time and it will never be know if the changes/improvements in operation would have helped this be avoided.
Today they operate completely differently to the pelair many on hear claim to know. REX internal auditing system i am told is deeper than many external auditers go. Add to this the military auditing process that goes on for that part of the busines and the fact they are now and forever will be in CASAs sights. I can honestly say that parts of my existing employers operations would not stack up as well.

I guess i just have a soft spot for some parts of the operation and the people still there now that have either rode out the bad times or come on board and improved the operation. To the good guys. You know who you are. well done for improving the operation.
To the not so good. Well i guess you are another operators problem now.
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Old 3rd Sep 2012, 22:06
  #156 (permalink)  
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This was a serious transoceanic flight.

Pelair dispatched the crew on the mission.

Would things have been different if they had rostered a much more experienced Co-Pilot; one with an ATPL and the ability to cross check Dom's flight plan? The challenges of this flight were vastly different to those of a normal flight around Australia and should have warranted a far greater degree of support from Pelair Flight Ops than was actually provided, including a Co Pilot who wasn't a junior.

Would things have been different if Pelair planned for pilot fatigue and duty time?

Would things have been different if the Chief Pilot consulted with Dom in Apia cross checking his flight plan and wx? If Dom didn't have internet, why didn't Pelair fax the flight plan and wx to him?

Would things have been different if Dom had received the correct wx from Nadi (600', not 6000') and crucially, that Auckland ATC passed on the actual wx report 300' ceiling to him when the Unicom operator advised as such?

After the incident, it was the Chairman of Pelair who immediately hailed the pilot as a hero. Was this a classic spin doctor tactic; to elevate the pilot to the public to deflect attention on where it should have been, so he could then be devoured by a hungry media looking for a hero and for blood, in particular, that ridiculous 60 Minutes report?

The conduct of CASA and the ATSB borders on criminal.

As unfortunate as this incident was, it will probably be the catalyst to force much needed change in the way the regulator, accident investigator and the airline operators relate to each other.

This will no doubt save many lives in the future.

That is the good thing to come out of this incident.

Due credit should also be given to Dominic James for electing to remain silent on this matter until now, waiting until the ATSB report was released so he could finally comment on the 'facts' as discovered by the ATSB.

Dominic conducted himself professionally throughout the whole aftermath of this incident. Lesser men would have taken the easy option and succumbed to the media feeding frenzy. He demonstrated patience, professionalism and humility.

Last edited by KLN94; 3rd Sep 2012 at 22:21.
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Old 3rd Sep 2012, 22:15
  #157 (permalink)  
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It is to be hoped that any litigation includes CASA as co-respondent. While Pelair is clearly culpable on many fronts, the regulator allowed them to get away with it.
No wonder the Skull was in such denial on the 4 Corners program.
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Old 3rd Sep 2012, 22:16
  #158 (permalink)  
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"It sounded like the TAWS was going off in the Vid clip on the 4 Corners show 2nite meaning that it activated due the A/C not configured for a normal Ldg which would have been the case in a planed ditching (gear selected up)"

Ah yes, I can't wait for the amateur accident investigators to come out with their analysis based on a YouTube recreation using Microsoft Flight Sim.
Did you know that FDR and CVR are still sitting at the bottom of the briney? So what was the recreation based on? Or should I say, on who's version of events?

I wouldn't put too much credence in the recreations last night what with the changes in aircraft type etc. and no input from the copilot.

You really need to read the audit report to get a better understanding of the goings on at the operator.

From what I have been told by somebody involved there CASA was there after the accident to perform two separate tasks. One was the investigation of the accident and the other, with mostly different people performing the special audit of the whole organisation. Two tasks and two different courses of action taken on the findings made. I will spell it out, one punitive and one not.The gentleman involved advised me the non-punitive spirit of the audit was followed to the letter of the law.

For a bit of extra CASA hilarity, check out the date the audit report was produced. One could be excused on the basis of that for thinking that CASA saw this accident coming?

Last edited by flying-spike; 3rd Sep 2012 at 22:41.
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Old 3rd Sep 2012, 23:38
  #159 (permalink)  
Join Date: Jun 2009
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I feel sorry for Dom but......

His flight planning skills were terrible
As such he should have taken Full Tanks
He should have worked out PNR's and CP's

Norfolk island is isolated and has a reputation for bad wx. Always have a backup plan.........At the very least he should have worked out how much fuel to divert 1 hour before and at TOD. That was worked out later after the event!! This should have been known to him before he departed.

Why didn't he bust the minima a bit? Maybe he did but won't say?
Why didn't he coordinate better his ditching position with the operator on the airfield BEFORE ditching?

Lots of holes in the Swiss Cheese lined up that night, as the PIC he should have been the last safety backup......

Last edited by nitpicker330; 4th Sep 2012 at 01:38.
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Old 4th Sep 2012, 00:22
  #160 (permalink)  
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Different strokes for different folks.....

Thats our "regulator" ! Had the outfit that created this schemozzle been a smaller operator without airline connections..it would have been all over for them.
AOC cancelled, CP approvals cancelled, pilots not "fit and proper", licences withdrawn. Finito the lot.!

Was interesting to see how ABC put it all together.

And even more fascinating to see the very highly paid head honchos of both agencies, giving their cringeworthy performances.

For the money, the industry should get better than that.
But with CASA ( because of prior histories) at least we know we wont get better than that. Its CYA 101 in full swing.

Thats the nature of the beast....and what we have to live with.. unfortunately.
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