Norfolk Island Ditching ATSB Report - ?
The decision not to depart APW with full tanks was certainly wrong, unless payload prevented it. Most of us agree that, regardless of any management desire to save a buck on fuel, we would have gone full tanks, or stopped in Fiji for a top-up. Maybe management prohibited that or would not pay for it, or had no fuel credit in Fiji? The report glosses over commercial pressures.
Earlier I mentioned a Bae 146 crew that gave themselves a good fright at NLK. Back then the rules did not require an alternate if the weather forecast met the usual mainland criteria. It was usual to go to a PNR which was normally about top of descent. Subject to what the unicom operator had to say, the decision was then made to divert or descend. Once the descent started it was a total commit to a landing.
On this occasion the weather outsmarted both the unicom and the crew and they did bust minima by heading out to sea, letting down until visual then clawing their way back up to the runway. It cost the Captain his command for a while. A bit harsh in the circumstances, but typical of the blame game that authorities and managements play to cover up their own inadequacies and poor policies.
Earlier I mentioned a Bae 146 crew that gave themselves a good fright at NLK. Back then the rules did not require an alternate if the weather forecast met the usual mainland criteria. It was usual to go to a PNR which was normally about top of descent. Subject to what the unicom operator had to say, the decision was then made to divert or descend. Once the descent started it was a total commit to a landing.
On this occasion the weather outsmarted both the unicom and the crew and they did bust minima by heading out to sea, letting down until visual then clawing their way back up to the runway. It cost the Captain his command for a while. A bit harsh in the circumstances, but typical of the blame game that authorities and managements play to cover up their own inadequacies and poor policies.
Bottums Up
Saving a few $$ on fuel, or reducing fuel burn by not carrying more than requiredis a good commercial practice. I mean a dollar saved is a dollar saved.
Just because the airframe can't be used again, who cares!
Just because the airframe can't be used again, who cares!
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Ben Sandilands sums up this incident perfectly;
The Pel-Air incident ought to be a lightning rod for immediate action by federal parliament, with some remedial action in terms of transparency as a legislative priority followed by an appropriate committee hearing and ministerial intervention at the top of CASA, the air safety regulator, and the ATSB, the air safety investigator.
CASA and the ATSB ought not be responding to this report, but to a parliament seized with the seriousness of these failings in the public administration of air safety.
Pel-Air and CASA damned by safety audit documents | Plane Talking
Bring on the Senate Inquiry.
The Pel-Air incident ought to be a lightning rod for immediate action by federal parliament, with some remedial action in terms of transparency as a legislative priority followed by an appropriate committee hearing and ministerial intervention at the top of CASA, the air safety regulator, and the ATSB, the air safety investigator.
CASA and the ATSB ought not be responding to this report, but to a parliament seized with the seriousness of these failings in the public administration of air safety.
Pel-Air and CASA damned by safety audit documents | Plane Talking
Bring on the Senate Inquiry.
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Like I said last night, read the audit report. Ben is on to it, Pel-air should have been grounded based on that audit report. I've been Chief Pilot for regional airline and a large turboprop charter company and if we got that many RCA's they would have grounded us.
Pel-air had RCA's for training, operational control, maintance issues etc. And it appears the MIL ops had/have their own culture and don't really care about civil regs although they operate under a civil AOC.
Pel-air had RCA's for training, operational control, maintance issues etc. And it appears the MIL ops had/have their own culture and don't really care about civil regs although they operate under a civil AOC.
There are many, many factors at work here, but a few things stand out for me:
The comment was made:
GEOFF THOMSON: With six people safely on board, they take off from Samoa just before dark.
Captain Dominic James had flown patients to Australia from islands in the South Pacific about 50 times in the two years he'd been a Medevac pilot.
So in two years in the South Pacific, he never picked up that weather at Norfolk was dodgy / changeable at the best of times? If he hadn't flown it personally, surely it would've come up in the pre-flight briefing with the CP, or at some point over hangar beers (don't know Pel Air's culture, so I'm guessing here).
Yes, there are many factors contributing that can be blamed which have been listed in other posts but at the end of the day, there is only one bum in the left hand seat.
As Richard de Crespigny (QF32) points out - a flight deck is not a committee.
I was reminded of a comment by the late, great, Gordon Smith who said (or quoted) - a superior pilot uses his superior intellect to keep out of situations where his superior flying skills are required.
The true heroes (for me) are the blokes who took their boat out through a narrow gap in the reef, at night, in crap weather, with no information but guesswork, and came back in again safely. And the bloke who went and stood on the lookout, and looked all around, to see the torch. Quite scary to consider that survival came down to a bloke, on a hill, who used his eyes (no radar, no Spiderwatch, no Flight Tracker) to look in the wrong direction (West, not South, as assumed).
The comment was made:
GEOFF THOMSON: With six people safely on board, they take off from Samoa just before dark.
Captain Dominic James had flown patients to Australia from islands in the South Pacific about 50 times in the two years he'd been a Medevac pilot.
So in two years in the South Pacific, he never picked up that weather at Norfolk was dodgy / changeable at the best of times? If he hadn't flown it personally, surely it would've come up in the pre-flight briefing with the CP, or at some point over hangar beers (don't know Pel Air's culture, so I'm guessing here).
Yes, there are many factors contributing that can be blamed which have been listed in other posts but at the end of the day, there is only one bum in the left hand seat.
As Richard de Crespigny (QF32) points out - a flight deck is not a committee.
I was reminded of a comment by the late, great, Gordon Smith who said (or quoted) - a superior pilot uses his superior intellect to keep out of situations where his superior flying skills are required.
The true heroes (for me) are the blokes who took their boat out through a narrow gap in the reef, at night, in crap weather, with no information but guesswork, and came back in again safely. And the bloke who went and stood on the lookout, and looked all around, to see the torch. Quite scary to consider that survival came down to a bloke, on a hill, who used his eyes (no radar, no Spiderwatch, no Flight Tracker) to look in the wrong direction (West, not South, as assumed).
And another thing.....
The CASA Pel-Air audits should both be made public. Then we can play "spot the difference".
That the "Safety" agency should hide behind keeping these off the record, should be of very serious concern of the Minister. There is one ??
"Government (and its agencies) efforts to manipulate or block information should be presumed to be anabuse of power" .
CASA has the power. And they sure hell know how to use it and abuse it.
As we know.
Senate Enquiry desperately needed.
That the "Safety" agency should hide behind keeping these off the record, should be of very serious concern of the Minister. There is one ??
"Government (and its agencies) efforts to manipulate or block information should be presumed to be anabuse of power" .
CASA has the power. And they sure hell know how to use it and abuse it.
As we know.
Senate Enquiry desperately needed.
Yes I find it incredible that he didn't keep close contact with the CAGRO during the ditching telling exactly where they were all the time basically up until contact with the water. There were 2 Pilots for gods same!!
They were extremely lucky to have been found that night.
They were extremely lucky to have been found that night.
Last edited by nitpicker330; 4th Sep 2012 at 03:02.
Albo it's time for "heads on a stick"!!
The transcript and the extended interviews for skull and ..dddoollan are worth the time to read, view and absorb!!
Transcript link:Crash Landing - Four Corners
Extended interview link: Crash Landing - Four Corners
Me thinks its past time for a top down culling!
ps anyone with the know how to copy and upload to utube be much appreciated??
Transcript link:Crash Landing - Four Corners
Extended interview link: Crash Landing - Four Corners
Me thinks its past time for a top down culling!
ps anyone with the know how to copy and upload to utube be much appreciated??
Last edited by Sarcs; 4th Sep 2012 at 03:38.
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Personally, I see this as two separate issues. Firstly, the PIC put the aircraft into a situation where he and his pax were at risk. Pure and simple. He stuffed up and he deserves to face the consequences.
The second issue is CASA surveillance combined with an operator who were bereft in their duty of care. But their derelict behaviour did not lead to this occurrence.
Mr James was not cognisant of the risk of an isolated aerodrome. And that came with consequences.
The second issue is CASA surveillance combined with an operator who were bereft in their duty of care. But their derelict behaviour did not lead to this occurrence.
Mr James was not cognisant of the risk of an isolated aerodrome. And that came with consequences.
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Conga line of suckholes
It is time that a royal commission into Australia's aviation decline was held.
CASA doesn't know how to regulate, ATSB no longer know how to investigate, and ASA no longer know how to navigate.
The past 10 years has seen a massive trend upwards in incidents, not to mention crashing Westwinds, Brasillia's and not far off our shoreline Dash 8's. This excludes the ongoing issues with a number of Australian Operators which is simply overlooked, dismissed due to potential political fallout or simply because the oversighting bodies are incompetent and incapable of recognizing risk.
How much is enough? How big must the smoking hole be?
As an absolute beginning there should be an immediate 'plank walking exercise' initiated that should include the removal of the CASA Director, Deputy Director, Associate Director, CASA Board, ASA Board, ATSB Commisioner and his two sidekicks, and Minister Fumblenese.This group has lost it's direction if it ever existed. Has nothing been learned from Lockhart and Seaview for Christ sake?
The systemic issues highlighted in the Norfolk 'special audit' are unbelievable. How the hell did CASA and the ATSB overlook this generated report? The Skull and Co are always talking the talk about safety systems, company cultures, the 'Swiss cheese' model etc, yet The Skull can only manage to get on TV and ramble on about the Captain James and overlook all the other evidence? What more proof do you need that the regulator is being run by out of touch and outdated pensioners. Time to put them to pasture. The ATSB has become an embarrassment. I feel for the last few 'old timers', the decent investigators being hamstrung and 'softened' by a spin spewing **** machine more concerned about playing hide the sausage with Government bureaucrats. And as for ASA, well at least Russell is gone, ran away like a spineless lamb but at least he went, but that doesn't alleviate the systemic issues at ASA. Then you have in politicians lingo 'the overarching' mucous that binds all this dross together in one tightly packed parcel of pony pooh - The Minister. What an embarrassment. No wonder the FAA wanted to downgrade Australia's safety level. This country's aviation ability to enforce, oversight and adjust safety, standards and systems is now probably worse than bloody China, Africa, Russia and Indonesia......Shame shame shame.
Tick tock
CASA doesn't know how to regulate, ATSB no longer know how to investigate, and ASA no longer know how to navigate.
The past 10 years has seen a massive trend upwards in incidents, not to mention crashing Westwinds, Brasillia's and not far off our shoreline Dash 8's. This excludes the ongoing issues with a number of Australian Operators which is simply overlooked, dismissed due to potential political fallout or simply because the oversighting bodies are incompetent and incapable of recognizing risk.
How much is enough? How big must the smoking hole be?
As an absolute beginning there should be an immediate 'plank walking exercise' initiated that should include the removal of the CASA Director, Deputy Director, Associate Director, CASA Board, ASA Board, ATSB Commisioner and his two sidekicks, and Minister Fumblenese.This group has lost it's direction if it ever existed. Has nothing been learned from Lockhart and Seaview for Christ sake?
The systemic issues highlighted in the Norfolk 'special audit' are unbelievable. How the hell did CASA and the ATSB overlook this generated report? The Skull and Co are always talking the talk about safety systems, company cultures, the 'Swiss cheese' model etc, yet The Skull can only manage to get on TV and ramble on about the Captain James and overlook all the other evidence? What more proof do you need that the regulator is being run by out of touch and outdated pensioners. Time to put them to pasture. The ATSB has become an embarrassment. I feel for the last few 'old timers', the decent investigators being hamstrung and 'softened' by a spin spewing **** machine more concerned about playing hide the sausage with Government bureaucrats. And as for ASA, well at least Russell is gone, ran away like a spineless lamb but at least he went, but that doesn't alleviate the systemic issues at ASA. Then you have in politicians lingo 'the overarching' mucous that binds all this dross together in one tightly packed parcel of pony pooh - The Minister. What an embarrassment. No wonder the FAA wanted to downgrade Australia's safety level. This country's aviation ability to enforce, oversight and adjust safety, standards and systems is now probably worse than bloody China, Africa, Russia and Indonesia......Shame shame shame.
Tick tock
Last edited by gobbledock; 4th Sep 2012 at 04:52. Reason: Walked head on into the biggest god damn elephant in the room I have ever seen!
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The state of Australian medical air transport:
If you have an accident and need urgent medical extraction, you will be sent a shiny new PC12, King Air or similar to pick you up.
If your injuries are non-life threatening and only need patient transport, you will most likely be sent a 30 or 40 year old Chieftain, Navajo, Westwind, etc.
Why? Because the charter companies engaged by the govt and insurance companies to contract such services are driven by the lowest common denominator: price.
The parameters for the tendering of medical transport services need to be widened to include age of fleet and operational standards, not just the cheapest price...
If you have an accident and need urgent medical extraction, you will be sent a shiny new PC12, King Air or similar to pick you up.
If your injuries are non-life threatening and only need patient transport, you will most likely be sent a 30 or 40 year old Chieftain, Navajo, Westwind, etc.
Why? Because the charter companies engaged by the govt and insurance companies to contract such services are driven by the lowest common denominator: price.
The parameters for the tendering of medical transport services need to be widened to include age of fleet and operational standards, not just the cheapest price...
KLN94 - not quite sure how the age of the aircraft played a part in this accident. Can you assist?
PS: In NT & SA, all medical transfers - whether emergency evac or patient transfer between hospitals or clinic runs with non-RFDS health staff - is done in shiny new PC12s.
PS: In NT & SA, all medical transfers - whether emergency evac or patient transfer between hospitals or clinic runs with non-RFDS health staff - is done in shiny new PC12s.
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Because the charter companies engaged by the govt and insurance companies to contract such services are driven by the lowest common denominator: price.
The parameters for the tendering of medical transport services
need to be widened to include age of fleet and operational standards, not just
the cheapest price...
The parameters for the tendering of medical transport services
need to be widened to include age of fleet and operational standards, not just
the cheapest price...
Last edited by my oleo is extended; 4th Sep 2012 at 05:45.
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outnaboutKLN94 - not quite sure how the age of the aircraft played a part in this accident. Can you assist?
Just to clarify, I am not suggesting the age of this particular Westwind was a contributing factor in this incident.
I am however suggesting that typically, charter companies that also provide medical transport services, generally have a fleet with an older average age rather than a younger fleet like RFD etc.
This is because they are a commercial operation and subject to ruthless commercial pressures in order to stay afloat, and the insurance companies and government agencies that contract such services [generally] pick the charter company that has the cheapest price rather than youngest fleet.
Just to clarify, I am not suggesting the age of this particular Westwind was a contributing factor in this incident.
I am however suggesting that typically, charter companies that also provide medical transport services, generally have a fleet with an older average age rather than a younger fleet like RFD etc.
This is because they are a commercial operation and subject to ruthless commercial pressures in order to stay afloat, and the insurance companies and government agencies that contract such services [generally] pick the charter company that has the cheapest price rather than youngest fleet.
Last edited by KLN94; 4th Sep 2012 at 05:57.
I don't think age was a factor at all, the Pelair Westwind 1 & 2's are some of, if not the highest time Westwinds in the world.
There have been a few incidents and failures directly related to age in the past few yrs. 1 was a roof outer skin panel blowing out and causing a rapid decompression, I think that was due to age and corrosion/stress fractures from memory.
There have been a few incidents and failures directly related to age in the past few yrs. 1 was a roof outer skin panel blowing out and causing a rapid decompression, I think that was due to age and corrosion/stress fractures from memory.
Gobbles mate there is no doubt about it you really know how to cut through the pony pooh and lay it out for everyone to see...but it still seems like individuals want to pussyfoot around and continue to ignore the couple of elephants in the corner!!
This bit Gobbles is oh so true..
Probably best summed up by this bit in the transcript..
What gets me is it takes three years to complete a report (not even Lockhart took that long!) and even then they still couldn't get it right
.....nah mass top down culling is what's needed here!
This bit Gobbles is oh so true..
The ATSB has become an embarrassment. I feel for the last few 'old timers', the decent investigators being hamstrung and 'softened' by a spin spewing **** machine more concerned about playing hide the sausage with Government bureaucrats.
GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.
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.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.
The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.
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.
Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.
.....nah mass top down culling is what's needed here!
----probably worse than bloody China,
Go easy on China, CAAC is a seriously competent organisation these days, with a set of rules based on the FARs, with some JAA/EASA influence evident in the maintenance area.
CAAC is also a damned sight easier to deal with than CASA.
Tootle pip!!
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Pilots group wants new investigation into Norfolk Island crash
Start listening from 19 min 25 second mark
The World Today - Pilots group wants new investigation into Norfolk Island crash 04/09/2012
Start listening from 19 min 25 second mark
The World Today - Pilots group wants new investigation into Norfolk Island crash 04/09/2012
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The special audit is damning.
One thing I noticed is that it seems like a tale of 2 airlines. Rex was compliant and safe PelAir was a problem.
It does make sense that they left existing management in charge at PelAir when they merged some years ago. However the net effect is that Rex appears very well insulated. I guess Rex is where the real revenue is.
Someone is always left looking for a chair when the music stops. Dom is one. Wally didn't fare to well either. Anyone heard what he is doing now?
One thing I noticed is that it seems like a tale of 2 airlines. Rex was compliant and safe PelAir was a problem.
It does make sense that they left existing management in charge at PelAir when they merged some years ago. However the net effect is that Rex appears very well insulated. I guess Rex is where the real revenue is.
Someone is always left looking for a chair when the music stops. Dom is one. Wally didn't fare to well either. Anyone heard what he is doing now?