Norfolk Island Ditching ATSB Report - ?
LB, I was going to make an offer to ratwood to fluff his pillows, refill his brandy and light his cigar. Keyboard warriors do lead such a draining existence they need all the tender care we mere mortals can provide. The lessons seem to be lost on zanthrus as well. Such an expensive lesson lost on the bystanders. Reading reports can make for an education. Did you ever hear zanthrus about the airliner that arrived in Adelaide and found unforecast fog had rolled in, and they had no fuel to go any where else? The crew carried out a successful autoland, something they had not been trained for. PIC at fault of course I guess for not having enough fuel. 
Interesting that those with experience in the aeromedical field and those who have flown Westwinds get torn down by desk drivers who don't agree that the PIC did a poor job! I will pick up on one comment however by kelly kelpie. He (or she) states that because the flight nurse continues to support the PIC then
So the fact that the F/O, whose role in the event becomes clearer and that she was left seriously injured in the flight deck, has said nothing in support of her Captain suggests that the analysis of the PICs performance is valid. Surely if he had done what was expected of any PIC and then looked after his passengers and crew in the aftermath then she would be defending him in the court of public opinion? The fact that she hasn't, in any the media or even the Senate, to me speaks volumes.
Let me ask one question of the desk drivers, would you be happy to board, or let your family board an aircraft under the command of this bloke? No if's or buts just a simple yes or no.
that says more than those character assasins.
Let me ask one question of the desk drivers, would you be happy to board, or let your family board an aircraft under the command of this bloke? No if's or buts just a simple yes or no.
desk drivers who don't agree that the PIC did a poor job
Whenever I see someone taking a whip to an individual who has erred, I always wonder what errors the whip holder has made in their life. There but for the grace of God applies to we all. You're only as good as your last flight, a NASA investigation found crews make errors on every flight, most times you get away with them, sometimes you don't.
Personally I wouldn't have a clue how to calculate a PNR or CP without getting the books out, not something that had relevance in the flying career I had.
I’m not quite sure why Lookleft has me pegged as sitting behind a desk. I am interested in how he/she thinks PIC should have responded once at Norfolk Island without fuel to divert. I think the pressure to fly lower and lower on the approach would have been huge. Having flown RPT jets in and out of Norfolk I know both how hilly and remote it is. I don’t think that having flown for Aeromedical or a Westwind makes you anymore qualified to comment on the actions of the PIC being first out. Maybe some survival instinct kicked in and he didn’t think that the doctor could open the door. We can all only hope that we would respond in a certain way, but unless you were there, with water gushing in and lives relying on you - you have no credibility in criticising his actions.
Last edited by kellykelpie; 30th Nov 2017 at 02:30.
you have no credibility in criticising his actions
I am interested in how he/she thinks PIC should have responded once at Norfolk Island without fuel to divert.
I don’t think that having flown for Aeromedical or a Westwind makes you anymore qualified to comment on the actions of the PIC being first out.
The answer to that is clearly spelled out in the report, company ethos and training being but two. If you've not had adequate training you don't know what you don't know, as Rumsfeld famously put it (known knowns, known unknowns, and unknown unknowns). If you can't get past laying it all at the PIC's door then you haven't learnt anything.
Personally I wouldn't have a clue how to calculate a PNR or CP without getting the books out, not something that had relevance in the flying career I had.
Megan and KK, you both failed to answer the question I asked. Would you allow your family to step on board an aircraft with this particular PIC?
Ditto, otherwise I'd have to have grave doubts about the abilities of the people and process that gave him the necessary bit of paper. Our domestic airlines have shown they are quite capable of giving pax an exciting ride, though the pax may not have been aware of the fact at the time - Bangkok over run, Mildura, autoland at Adelaide with untrained crew and ILS not certified, running wing tanks dry, level busts on descent. No one can take a high and mighty stance.
I'm reminded of the corporate story where an employee made a decision that cost the owner a bucket of money. A snivelling underling sidled up to the owner asking, "well I suppose that's him for the high jump". "What, after all I've just spent on his education" he replied. Dominic is no doubt now the countries expert on remote island operations. I wish him all the very best.
I'm reminded of the corporate story where an employee made a decision that cost the owner a bucket of money. A snivelling underling sidled up to the owner asking, "well I suppose that's him for the high jump". "What, after all I've just spent on his education" he replied. Dominic is no doubt now the countries expert on remote island operations. I wish him all the very best.
megan:
......and if CASA was a just organisation and a learning one, Dominic's "punishment" would have been to help build a program on the subject and star in a lecture series, roadshow and video for pilots on what not to do and how to do it right.
As it is the only lesson learnt from Norfolk island is a totally negative one about punishment. Talk about an opportunity missed.
Dominic is no doubt now the countries expert on remote island operations. I wish him all the very best.
As it is the only lesson learnt from Norfolk island is a totally negative one about punishment. Talk about an opportunity missed.
The fact that the NTSB questioned Sullenberger‘s decision-making around what he might be able to achieve with his powerless aeroplane and that he had to go to the effort of ‘proving’ himself is a matter of record. But Sullenberger has also criticised the derisive manner in which the NTSB were portrayed in the movie. We might have expected such sensationalist portrayal from Hollywood, but who is going to stand up for the ATSB? Are they so much the enemy that no-one cares?
First, we need to dispense with the inevitable (and understandable) wave of sympathy for the captain of VH-NGA, and I think that’s been dealt with in the incident thread. Then we have to process the concomitant and ever-so-slightly guilty ‘there but for the grace of God go I’ declarations from other pilots (slightly worrisome, because they tend to sound like ‘If I ever got myself into a similar position (and I think I easily could) I would hope to get the benefit of the doubt and plenty of slack too’ confessions), we might take a dispassionate look at the material the film-maker has available.
This story revolves around the professional performance of a flight crew (most especially the captain), relevant aviation legislation of the time, and the methodology employed by the independent investigating agency. Three principal dimensions, plus the connected matter of two ATC agencies forgetting or not bothering to pass on weather information.
The performance of the flight crew/captain—as in most investigations—is what it is… it always is. Actions and activities of personnel who are, thankfully, still around to be interviewed are relatively easy to examine and document against relevant proscription (regulatory and company requirements). So the captain’s role and performance was recorded by the ATSB’s original investigation and not much about that has changed with the release of the second report.
On the other hand, the original report was considered by commentators to have placed an unfair burden of blame on the pilot, who—although he made errors—was determined to have acted within CASA guidelines that were considered less-than-robust. It was also revealed that his employer had been examined by the regulator and been judged seriously deficient in numerous respects a fact on which the original report had been silent.
So, the captain was operating within existing regulations which—if we take account of his plea for fairness—apparently excused him from having to uplift maximum fuel if he so judged. Except that of course it did not. The new report also says the pilot was operating within rules set by Pel-Air which were inadequate and have been addressed since the first report was released. The new ATSB report expresses surprise that CASA has indicated it intends to address some of the deficiencies in its regulations governing long distance air ambulance flights, but has not yet done so.
After considering the pilot’s professional performance, these two aspects—an inadequate regulatory environment and an employer’s administrative deficiencies—constitute the other two dimensions of the saga. These latter have been somewhat addressed, however scantly. But most importantly, they have been more meaningfully deliberated in the second report than they were in the first. So the fairness demanded by the media and politicians has been accorded belatedly and it is left to observers to decide how much difference this has made to the outcome for the implied victim.
But the fundamental issue with this incident is that the captain always had choice. None of the CASA or Pel-Air deficiencies precluded him from proceeding with prudence and circumspection. What CASA and Pel-Air did or didn’t do is summarised above and we might hope that the investigation(s) of this incident and associated outcomes will result in a stronger ‘system’.
Now to examine the captain’s actions. The captain of this passenger-carrying jet aircraft;
• decided not to uplift full fuel for the flight. Company policy did not require or demand that he decide thus
• did not discuss, or think to discuss, flight planning aspects with his FO. His company didn’t require him to; does that mean he didn’t have to?
• asserted he made a phone call to the company from Apia for which there is no record. The ATSB extended him the benefit of the doubt
• asserted that he truncated his call to the Brisbane ASA briefing officer because he (the pilot) thought he was beginning to irritate him (the officer). The audio of this conversation does not support the pilot’s contention
• does not recall a weather forecast upgrade having been provided to him although the CVR reveals him acknowledging it
• did not calculate a viable PNR while enroute
• did not proactively seek enroute weather information for his destination
• forgot the fuel gauge anomaly at a time when he desperately needed reliable knowledge of fuel remaining, (and did not seek an alternative indication via the fuel status indicator), as a result of which he…
• ditched the aircraft before he needed to and deprived the flight of the possible benefits of another couple of approach attempts
• neglected to use the ditching checklist even though it could be reasonably argued that there was adequate time to have done so
• did not transmit or instruct his FO to transmit a Mayday call
• forgot his landing gear was down until reminded of it by his FO
• landed the aeroplane too slowly with the result that it impacted the water harder than it needed to (this VERY possibly being what initiated the structural breakup that might otherwise not have happened)
• did not manoeuvre the aircraft optimally for the run-of-swell. The ‘slow-down’ pitched-up attitude meant the crew had no view of and could not gauge the state of the sea they were about to land on
• did not ensure his FO provided correct and useful information to the cabin occupants regarding the liferafts and use of lifejackets
• did not discuss the conduct of the ditching manoeuvre with his FO and could not recall what the checklist said about the airspeed for a ditching
• did not provide advice to outside agents on the intended location for the ditching
• landed in a direction away from land and at a greater distance from it than he needed to
• evacuated the aircraft ahead of all other occupants without providing assistance either to them or to his FO.
This is a litany, not a lashing. As I stated at the beginning, the pilot’s actions (or not) were what they were. No amount of human concern for him can change that, and although one can acknowledge that it’s easy to be critical, if we take that reality as meaning we therefore shouldn’t criticise, then the performance of individuals in an accident is somewhat concealed, is it not, and our opportunity to learn positive lessons is diminished?
As well as acknowledging what environmental conditions might have been wrong to begin with (the systemic weaknesses and failures), the process of determining what went wrong in these incidents, what was DONE wrongly, and what choices were made that were sub-optimum, requires dispassionate scrutiny of everyone’s actions. It is a burdensome responsibility that every pilot accepts that they will inevitably be subject to the most acute focus in the event of any accident investigation. It goes with the territory, and regulatory and instructional deficiencies do not remove the pilot’s obligation to make prudent decisions. Pilots tend to receive the lion’s share of blame for ‘error’, that has been their lot. But statistics surely reveal that pilots are more likely to be in error than is any other party to an aeroplane prang. This is simply because of the confoundedly exposed position in which pilots place themselves just by accepting their role. Any ordinary human emotional proclivity towards feeling empathy for such a person—utterly understandable and utterly appropriate in human terms—simply clouds the issue when dispassionate examination is required.
Investigations will always look at a person’s past for any evidence of a clue to their behaviour at the time of an incident. That is normal, it is expected, and it’s sensible. In this case, the records of both crew members showed past deficiencies in meeting operational competency standards at one time or another. The reader is left to surmise about whether there might be any connection between these incidents and the state-of-mind (or default behaviours) that contributed to this ditching.
This crew did have some luck. They were flying what must be one of the better aeroplanes in which to have to ditch. Mid-wing, no under-wing engines, clean belly presented to the water. Almost an amphibian.
Will the film-makers take reasonable account of all of these matters? Probably not, since that might tend to make the project look like a documentary. And only Mike Moore makes money from documentaries… right?
The captain is back at that exposed sharp end (albeit ICUS) and the FO has a ‘real’ airline job. One wishes them all the best.
The actual victims in this incident were the cabin occupants. Ruined health and—in some cases, prospects… in one case terminally—and no meaningful financial compensation. Hereat lies the pathos the film-makers will be searching for.
I will await the film with bated breath…. and a largish popcorn tub to vomit in.
Lookleft's statement 'Would you let yr family step on board an aircraft with this PIC'.
This is a typical CAsA-ist derogatory comment, that I have heard and had similar comment used against myself before.
Its to help discredit the target in the eyes of any potential clients.
As you should know with CAsA and its ilk...any old BS will do to make the case
eg.. "what happens if he crashes into a kindergarten". What indeed.
Does CAsA pose the question to QANTAS..what happens if you drop a 380 into a high school ?
I would have thought after all the check flights, sims, exams and whatever that CAsA keep throwing at him, he's the most up to date and tested guy in town.
Which begs the question...do you and yr family step on board a Jumbo...and have NO idea who the PIC is.!
And he/she could be like the Silkair driver and go supersonic into the river.!!
Best stick to the safety of the roads.
This is a typical CAsA-ist derogatory comment, that I have heard and had similar comment used against myself before.
Its to help discredit the target in the eyes of any potential clients.
As you should know with CAsA and its ilk...any old BS will do to make the case
eg.. "what happens if he crashes into a kindergarten". What indeed.
Does CAsA pose the question to QANTAS..what happens if you drop a 380 into a high school ?
I would have thought after all the check flights, sims, exams and whatever that CAsA keep throwing at him, he's the most up to date and tested guy in town.
Which begs the question...do you and yr family step on board a Jumbo...and have NO idea who the PIC is.!
And he/she could be like the Silkair driver and go supersonic into the river.!!
Best stick to the safety of the roads.
Down and welded, I am not qualified to judge the pilots actions. What sickens me are two things:
- that the pilot was shafted by ATSB and continues to be shafted by CASA.
- The learning opportunities presented by this accident have been absolutely and totally squandered by both CASA and ATSB. The only "meta lesson" (the lesson you are teaching when you don't think you are teaching anything) is that there is no justice for pilots if you are caught making a mistake.
Here is the thought that keeps me awake; suppose Dominic had got in and landed on his fourth approach. Would we have heard about it? Not likely, Now considering Dominic James treatment since the accident, how likely is it that other pilots are going to report incidents if they can get away without it? That is the problem with the CASA (RAAF?) punitive culture - it prevents active learning.
- that the pilot was shafted by ATSB and continues to be shafted by CASA.
- The learning opportunities presented by this accident have been absolutely and totally squandered by both CASA and ATSB. The only "meta lesson" (the lesson you are teaching when you don't think you are teaching anything) is that there is no justice for pilots if you are caught making a mistake.
Here is the thought that keeps me awake; suppose Dominic had got in and landed on his fourth approach. Would we have heard about it? Not likely, Now considering Dominic James treatment since the accident, how likely is it that other pilots are going to report incidents if they can get away without it? That is the problem with the CASA (RAAF?) punitive culture - it prevents active learning.
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Down and welded, I am not qualified to judge the pilots actions. What sickens me are two things:
- that the pilot was shafted by ATSB and continues to be shafted by CASA.
- The learning opportunities presented by this accident have been absolutely and totally squandered by both CASA and ATSB. The only "meta lesson" (the lesson you are teaching when you don't think you are teaching anything) is that there is no justice for pilots if you are caught making a mistake.
Here is the thought that keeps me awake; suppose Dominic had got in and landed on his fourth approach. Would we have heard about it? Not likely, Now considering Dominic James treatment since the accident, how likely is it that other pilots are going to report incidents if they can get away without it? That is the problem with the CASA (RAAF?) punitive culture - it prevents active learning.
- that the pilot was shafted by ATSB and continues to be shafted by CASA.
- The learning opportunities presented by this accident have been absolutely and totally squandered by both CASA and ATSB. The only "meta lesson" (the lesson you are teaching when you don't think you are teaching anything) is that there is no justice for pilots if you are caught making a mistake.
Here is the thought that keeps me awake; suppose Dominic had got in and landed on his fourth approach. Would we have heard about it? Not likely, Now considering Dominic James treatment since the accident, how likely is it that other pilots are going to report incidents if they can get away without it? That is the problem with the CASA (RAAF?) punitive culture - it prevents active learning.
Most accidents / incidences happen and we get a second chance to review and take the apporiate actions to insure they dont happen again. Re dc10
Sometimes the lesons learnt are not learnt. I hope tnis dosent happen.
The same is happening in engineering. Poeple arnt doing mdr because of the reactions from casa and tbe need to blame someone at all cost.
The millitary way or the hwyway.
We living in dangerous times brought apone us from the regulator with lies decite and crouption. Until we get fines and goal terms for these poeple a royal commission or higher aviation as we know it is done and dusted
Then we have to process the concomitant and ever-so-slightly guilty ‘there but for the grace of God go I’ declarations from other pilots (slightly worrisome, because they tend to sound like ‘If I ever got myself into a similar position (and I think I easily could) I would hope to get the benefit of the doubt and plenty of slack too’ confessions)...
If you are a pilot, have you ever made a mistake that could have resulted in a bad outcome, but luckily didn’t?
If your answer is ‘no’, you don’t have much aeronautical experience.
If your answer is ‘yes’, how would “we” like to be treated by other pilots, the ATSB and CASA if your mistake had instead resulted in a bad outcome?
Well done Down and Welded you have summed up the situation quite succinctly. There is a lot of talk about lessons learnt. One reason I asked the question about getting into an aircraft commanded by DJ is that I don't think he has learnt from the experience and I am not talking about how to do a PNR. This is one reason why I think this:
I have known of quite a few pilots over my career who have either lost their command, failed to be upgraded or been sacked because of their attitude to the requirements of PIC. What I see in the response to the latest report is more that it is others at fault. I don't doubt that he lacks the knowledge but I doubt that he has the right attitude to regain a command. A very subjective assessment I accept but in my experience an attitude of, it being every one elses fault, does not change readily and DJ's own words, as quoted in the SMH,reinforce that. If it was all about punishment then the crew of the MIA incident would also be going through the same process. As far as I am aware they are not.
But Mr James said a larger tank of fuel would not have changed the outcome that day – he would still have had to ditch the plane in the ocean.
Instead, he said a lack of information about the rapidly deteriorating weather that day was a major factor glossed over.
"For two-and-a-half hours of that flight, there were about four significant opportunities for air traffic control to look at the information in front of them and pass it onto me. All of these opportunities were missed," he said.
Instead, he said a lack of information about the rapidly deteriorating weather that day was a major factor glossed over.
"For two-and-a-half hours of that flight, there were about four significant opportunities for air traffic control to look at the information in front of them and pass it onto me. All of these opportunities were missed," he said.
How about you, LL? Have you ever made a mistake that could have resulted in a bad outcome, but luckily didn’t? (I've made plenty.)
How would you like to be treated by other pilots, the ATSB and CASA if your mistake had instead resulted in a bad outcome?
As has been pointed out, if there'd been a lucky break in the weather during one of the attempted approaches, no one - other than the crew - would have known what a close run thing it was. No lucky break in the weather and there's a different outcome, even though exactly the same systemic problems and poor decision-making lead to either outcome.
If there had been a lucky break in the weather the crew should have been able to report the near miss to the ATSB and expect the ATSB to do an objective analysis of, among other things, the systemic issues that led to the 'near miss', and expect CASA not to punish them for any poor decision-making.
Instead we got an attempted quick and dirty cover up and pilot scapegoating, and the consequent trashing of the ATSB's already-dwindling reputation. My "learning" from this episode is never to volunteer anything to ATSB. What a great outcome for aviation safety.
How would you like to be treated by other pilots, the ATSB and CASA if your mistake had instead resulted in a bad outcome?
As has been pointed out, if there'd been a lucky break in the weather during one of the attempted approaches, no one - other than the crew - would have known what a close run thing it was. No lucky break in the weather and there's a different outcome, even though exactly the same systemic problems and poor decision-making lead to either outcome.
If there had been a lucky break in the weather the crew should have been able to report the near miss to the ATSB and expect the ATSB to do an objective analysis of, among other things, the systemic issues that led to the 'near miss', and expect CASA not to punish them for any poor decision-making.
Instead we got an attempted quick and dirty cover up and pilot scapegoating, and the consequent trashing of the ATSB's already-dwindling reputation. My "learning" from this episode is never to volunteer anything to ATSB. What a great outcome for aviation safety.
he would still have had to ditch the plane in the ocean
Then we have to process the concomitant and ever-so-slightly guilty ‘there but for the grace of God go I’ declarations from other pilots (slightly worrisome, because they tend to sound like ‘If I ever got myself into a similar position (and I think I easily could) I would hope to get the benefit of the doubt and plenty of slack too’ confessions)
As to the would you let your family with this man question, I would ask Lookleft would you let your family fly with Bob Hoover?
The Mildura incident has been mentioned elsewhere as having similarities. Would the crews have been held at fault, responsible (chose your term) had the weather turned out to be zero/zero and a 737 was left spread across the grapevines/saltbush?