Norfolk Island Ditching ATSB Report - ?
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He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report.
) seems to have been joined by the Crikey Test. I wonder what sort of mark CASA will get.
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I believe Dominic will achieve immortality as this accident becomes the centre of many future CRM courses.
Hogsnortrupert, there is a big difference descending to 200ft at Funafuti where the highest point is a coconut tree, to 200ft at Norfolk with higher ground in the vicinity.
Hogsnortrupert, there is a big difference descending to 200ft at Funafuti where the highest point is a coconut tree, to 200ft at Norfolk with higher ground in the vicinity.
Last edited by Bozzo; 3rd Sep 2012 at 05:57.
Looking at the plates for the vor 29 and 11 the inbound tracks are displaced along way from the rwy centreline. This would not be ideal in weather below the minima.
Perhaps the rwy 04 approach would have been worth a shot. Although its shorter, the rwy is lit and the inbound track is only 2 degrees off meaning the threshold at least would have been straight ahead. I'm sure 4700ft would have been long enough for a very light Westwind in the wet.
Maybe that approach was not available at that time.
Perhaps the rwy 04 approach would have been worth a shot. Although its shorter, the rwy is lit and the inbound track is only 2 degrees off meaning the threshold at least would have been straight ahead. I'm sure 4700ft would have been long enough for a very light Westwind in the wet.
Maybe that approach was not available at that time.
In an emergency low fuel situation coming down to 200 ft at Funafuti would be no biggie if flown accurately, because the highest tree is only about 50ft. Cyclones usually knock them over if they try to grow any higher.
Groping around at 200 ft at Norfolk, at night, would probably be terminal for the occupants of any aeroplane so foolishly flown. For all that he got so wrong, finally coming to the conclusion that he had to ditch (even if it was in the wrong place) was proper. All on board owe their lives to that decision rather than the alternative of attempting a landing with no visual contact with the runway.
The weather at NLK is tricky. They can be calling it below minima from the ground yet sometimes the approach and landing can be completed without busting any limits. On other occasions - and sometimes even within a few minutes of being OK - it is just impossible to see anything at the minima - or even a bee's dick below minima (altimeter error, honest it was).
Given the way the weather was coming through in waves on this occasion, I certainly would have tried as many approaches as I had fuel for - up to the point of being able to divert to NOU. But being at NLK with no diversion fuel - not done that since the Bae 146 did the run, when PNR was at top of descent. But then we had to be absolutely sure it was OK to continue. One crew nearly got caught out once and gave themselves a good fright, and I am sure there were others less publicised.
Then, praise be, the rules changed to require an alternate for RPT and charter. Obviously paying passengers' lives are more important than patients flying courtesy of insurance (don't get me started on double standards in aviation!)
This ditching appears to be the direct result of inexperience being exploited by a loophole in the regulations. Poor judgement being the by-product of inexperience. Loophole in the regulations being the by-product of an incompetent regulator.
Groping around at 200 ft at Norfolk, at night, would probably be terminal for the occupants of any aeroplane so foolishly flown. For all that he got so wrong, finally coming to the conclusion that he had to ditch (even if it was in the wrong place) was proper. All on board owe their lives to that decision rather than the alternative of attempting a landing with no visual contact with the runway.
The weather at NLK is tricky. They can be calling it below minima from the ground yet sometimes the approach and landing can be completed without busting any limits. On other occasions - and sometimes even within a few minutes of being OK - it is just impossible to see anything at the minima - or even a bee's dick below minima (altimeter error, honest it was).
Given the way the weather was coming through in waves on this occasion, I certainly would have tried as many approaches as I had fuel for - up to the point of being able to divert to NOU. But being at NLK with no diversion fuel - not done that since the Bae 146 did the run, when PNR was at top of descent. But then we had to be absolutely sure it was OK to continue. One crew nearly got caught out once and gave themselves a good fright, and I am sure there were others less publicised.
Then, praise be, the rules changed to require an alternate for RPT and charter. Obviously paying passengers' lives are more important than patients flying courtesy of insurance (don't get me started on double standards in aviation!)
This ditching appears to be the direct result of inexperience being exploited by a loophole in the regulations. Poor judgement being the by-product of inexperience. Loophole in the regulations being the by-product of an incompetent regulator.
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Four Corners Report
The really interesting part of the whole saga is that a fair chunk of evidence can't be produced unless there's a senate enquiry. Even with what was produced tonight though should be enough to get people asking questions as to the relationship between CASA the ATSB.......and the clowns that run Pelair and Rex.
Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case.
Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case.
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After that incompetent perfrance, the Screaming Skull should be cleaning out his desk. Even his former right and man turned on him.
What's misleading performance , yes Skull 40 years ago when you began your legendary career etc etc, something's never change, the regulator is never wrong, and yes CASA had no problems with the Captain retaining his license for six weeks, but pulled it on Christmas Eve, reprehensible scum
What's misleading performance , yes Skull 40 years ago when you began your legendary career etc etc, something's never change, the regulator is never wrong, and yes CASA had no problems with the Captain retaining his license for six weeks, but pulled it on Christmas Eve, reprehensible scum
Last edited by Marauder; 3rd Sep 2012 at 11:40. Reason: iPad, autocorrect
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Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case.
I didn't operate in a vacuum. I operated as a pilot that belonged to a company that was overseen by a regulator. You can't isolate one thing from all the others and say that's a fair appreciation of what took place.
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What really hit me from tonight's Four Corners programme:
The Head of CASA denigrates the pilot for not demonstrating an ability to plan a flight ex Samoa without software. He's clearly angered by this. Its almost as if he's found the smoking gun. Pretty much a 'gotcha' moment from the CASA head.
He seemed argumentative, defensive & abrasive. This guy appears to be a guy who makes his mind up and locks on to a belief when clearly there are contributing factors way beyond simple pilot error.
To say none of the Pel-Air breaches would have contributed to this accident is simply wrong. When CASA identified PA as failing to comply with fatigue management systems, THEY CONTRIBUTED TO THE ACCIDENT.
How does CASA repeatedly fail to find these breaches in time?
The Head of CASA denigrates the pilot for not demonstrating an ability to plan a flight ex Samoa without software. He's clearly angered by this. Its almost as if he's found the smoking gun. Pretty much a 'gotcha' moment from the CASA head.
He seemed argumentative, defensive & abrasive. This guy appears to be a guy who makes his mind up and locks on to a belief when clearly there are contributing factors way beyond simple pilot error.
To say none of the Pel-Air breaches would have contributed to this accident is simply wrong. When CASA identified PA as failing to comply with fatigue management systems, THEY CONTRIBUTED TO THE ACCIDENT.
How does CASA repeatedly fail to find these breaches in time?
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MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.
MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...
GEOFF THOMPSON: So it might be a mistake.
MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.
GEOFF THOMSON: And he did.
Last edited by scarediecat; 3rd Sep 2012 at 11:59.
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The program was an opportunity lost to explore the mess that CASA and the ATSB has become under commercial pressure and the compromises it is producing. It did, however, reveal the problems surrounding obtaining weather information and the complete shambles that Pel Air had for flight planning.
Fair doos to Mr James for being prepared to face questioning. I would have liked more information on the differing fuel calculations as to fuel remaining had they diverted to Noumea. From the pilot's perspective I can understand why 8 minutes is not inviting based on their figures.
Fair doos to Mr James for being prepared to face questioning. I would have liked more information on the differing fuel calculations as to fuel remaining had they diverted to Noumea. From the pilot's perspective I can understand why 8 minutes is not inviting based on their figures.
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The story should have placed a far greater spotlight on CASA and the ATSB. This poor standard in regulatory oversight has happened before and logic says it will happen again.
Tonight I will write to the minister and ask for the Head of CASA to be removed.
Tonight I will write to the minister and ask for the Head of CASA to be removed.
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GADRIVR
I am as critical of CASA as the next guy, the oversight, the company, the lack of sleep, the bad planning, the conflicting weather, and everything in-between is just not kosha with most people who read this stuff.
I see your point about Dominic being the soft target, and yeah I feel for the guy, but at the beginning of the day, he had the ability to pull the pin. And should have.
PelAir should have had all his planning done for him, just like a good supportive company operating into these places should do. But clearly the did not.
Back of a beer coaster planning is fine for Mudgee to Dubbo, but not across the oceans of the south pacific. No way!
At several points, the lack of sleep. The lack of wx and planning. The fuelling choices. The wether reports and conflicts, all should have been triggers something does not add up.
Three strikes you are OUT principle applies when bush flying, local flying and when the company, the systems etc are letting you down, the 3-strikes rule could well save the day.
I understand, the circumstances all conspired against him, but what he did with them was poor, and you could easily blame fatigue etc, but he himself did not believe that was a factor. There were options, and 4 corners did not explore them at all.
Hate to say it, but criticising JMAC over his comment is a bit lame.
As T28D has pointed out there are other choices that are more runway aligned, and none used. The ones tried are nowhere near the runway, and were futile really.
One thing is for sure, I bet Dominic never makes that mistake again!
I am as critical of CASA as the next guy, the oversight, the company, the lack of sleep, the bad planning, the conflicting weather, and everything in-between is just not kosha with most people who read this stuff.
I see your point about Dominic being the soft target, and yeah I feel for the guy, but at the beginning of the day, he had the ability to pull the pin. And should have.
PelAir should have had all his planning done for him, just like a good supportive company operating into these places should do. But clearly the did not.
Back of a beer coaster planning is fine for Mudgee to Dubbo, but not across the oceans of the south pacific. No way!
At several points, the lack of sleep. The lack of wx and planning. The fuelling choices. The wether reports and conflicts, all should have been triggers something does not add up.
Three strikes you are OUT principle applies when bush flying, local flying and when the company, the systems etc are letting you down, the 3-strikes rule could well save the day.
I understand, the circumstances all conspired against him, but what he did with them was poor, and you could easily blame fatigue etc, but he himself did not believe that was a factor. There were options, and 4 corners did not explore them at all.
Hate to say it, but criticising JMAC over his comment is a bit lame.
As T28D has pointed out there are other choices that are more runway aligned, and none used. The ones tried are nowhere near the runway, and were futile really.
One thing is for sure, I bet Dominic never makes that mistake again!
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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 '**** 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 ****e. 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????
Mememememememememe.
a) The fact that the ATSB's reputation for unbiased, clear and concise investigation reports has absolutely hit '**** 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 ****e. 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????
Mememememememememe.
Last edited by my oleo is extended; 3rd Sep 2012 at 12:26.
What a shambles that whole saga was & totally unnecessary!!
The extensive footage of the LE 35 on the program (same one I used to drive) brought back memories of crappy nights out there over the Pacific in a tiny 2 eng plane. A place where there was no decision on how much fuel you took you simply filled it to the gunnels & made sure that you had an escape at every point along the intended route. SE or Depress Ops usually meant max fuel anyway. At least I had great support from a great Company.
I'd like to think that something good might come from all this by way of strong directions & rules from the regulator so that young pilots can learn from Dom's life changing event.
Wmk2
The extensive footage of the LE 35 on the program (same one I used to drive) brought back memories of crappy nights out there over the Pacific in a tiny 2 eng plane. A place where there was no decision on how much fuel you took you simply filled it to the gunnels & made sure that you had an escape at every point along the intended route. SE or Depress Ops usually meant max fuel anyway. At least I had great support from a great Company.
I'd like to think that something good might come from all this by way of strong directions & rules from the regulator so that young pilots can learn from Dom's life changing event.
Wmk2
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It most certainly was an interesting watch! 
Good luck with that. 
Quick question, Should the passengers be compensated?
Tonight I will write to the minister and ask for the Head of CASA to be removed.
Quick question, Should the passengers be compensated?
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Quick question, Should the passengers be compensated?
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?!?!"
Grandpa Aerotart
As a former Chief Pilot of a International medivac 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 medivac 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.
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 medivac 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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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 Medivac/Jet Charter and the MIL Ops out of Nowra.