Norfolk Island Ditching ATSB Report - ?
I have been patiently reading these posts and, more importantly reading the report. The time has come when I have to question the opinions of those who seem to suggest that the PIC made the sort of mistakes which are only to be expected in a flying career.
Have they actually read the section of the report on the PIC's fuel planning? How he ended up with less fuel on board for the flight to Norfolk Island (a rather remote place) than he intended to take on his next leg to Melbourne (which is not remote at all) despite that leg being the shorter of the two. How he did not involve his FO in any fuel planning? How he didn't calculate an accurate PNR? How he claimed that cost considerations were a factor in him not taking full fuel with him on departure?
I could go on, but anyone who has read the entire report would know that there were many more issues than those with the PIC's fuel management.
Have they actually read the section of the report on the PIC's fuel planning? How he ended up with less fuel on board for the flight to Norfolk Island (a rather remote place) than he intended to take on his next leg to Melbourne (which is not remote at all) despite that leg being the shorter of the two. How he did not involve his FO in any fuel planning? How he didn't calculate an accurate PNR? How he claimed that cost considerations were a factor in him not taking full fuel with him on departure?
I could go on, but anyone who has read the entire report would know that there were many more issues than those with the PIC's fuel management.
Lead Balloon, it's nothing to do with industrial relations. Sigh. It's a management imposed structure to centralise the holding of SARTIMEs in a single location to remove that workload from ATC. We used to hold them but TAAATS really wasn't designed for providing anything but a control service and the process we used to hold SARTIMES was not robust.
As a controller I don't have time to go looking for random information on the off chance that you may need it. It's nothing to do with stovepipes and things being hungrily protected. What you're asking for is the reinstitution of ops which was devolved to the pilot many years ago.
As a controller I don't have time to go looking for random information on the off chance that you may need it. It's nothing to do with stovepipes and things being hungrily protected. What you're asking for is the reinstitution of ops which was devolved to the pilot many years ago.
LB Airservices/ CASA/ATSB/DoTRS etc. aren't to blame for the current system. The changes came in as a result of what industry decided they were and weren’t prepared to pay for. The days of the mantras "User Pays", Affordable Safety" etc.
They weren’t prepared to pay for people in Ops. Control providing an overwatch service & FPA to all IFR aircraft, nor Flight Service, nor people providing VFR a FULLSAR service, nor a handful of briefing offices around the country, nor sundry other stuff.
Personally I’ve always thought that’s about when the standard of pilot training and knowledge/smarts etc. started to go down the tubes for a variety of reasons. Perhaps education suffered, with instructors not knowing too much more than their students, those students becoming instructors and so it goes on.
They weren’t prepared to pay for people in Ops. Control providing an overwatch service & FPA to all IFR aircraft, nor Flight Service, nor people providing VFR a FULLSAR service, nor a handful of briefing offices around the country, nor sundry other stuff.
Personally I’ve always thought that’s about when the standard of pilot training and knowledge/smarts etc. started to go down the tubes for a variety of reasons. Perhaps education suffered, with instructors not knowing too much more than their students, those students becoming instructors and so it goes on.
Lead Balloon, it's nothing to do with industrial relations. Sigh. It's a management imposed structure to centralise the holding of SARTIMEs in a single location to remove that workload from ATC. We used to hold them but TAAATS really wasn't designed for providing anything but a control service and the process we used to hold SARTIMES was not robust.
As a controller I don't have time to go looking for random information on the off chance that you may need it. It's nothing to do with stovepipes and things being hungrily protected. What you're asking for is the reinstitution of ops which was devolved to the pilot many years ago.
As a controller I don't have time to go looking for random information on the off chance that you may need it. It's nothing to do with stovepipes and things being hungrily protected. What you're asking for is the reinstitution of ops which was devolved to the pilot many years ago.
Absolutely! In the olden days, DCA/CAA/Dotas/CASA had Operational Control. Someone in a building had overall management of a flight ,rated higher than the PIC. They would call you up via enroute comms and tell you things that might be helpful to you. The downside was that they would also call you up and tell you that airports were closed to you, and other unhelpful things like imposing unexpected holding time on you etc. Then Operational control was abolished and control reverted to the PIC and the operator. A good thing. But they stopped calling you up with things you didn’t need and didn’t like. However you the PIC were in control of your destiny. You had to manage your flight. You had to make sure you had the info you needed/ wanted. If you couldn’t get it by method A you got it by method B and if method B wasn’t possible you used method C.
IMHO the abolition of Operational control was a good thing but you had to understand that there was no one ther3 to chang3 you nappy any longer.
Last edited by JamieMaree; 4th Dec 2017 at 09:07.
Let us not forget that when a certain enthusiast became Chairman of the Board of the predecessor to CASA, such items as the mandatory 2 hours Island Holding for Lord Howe and Norfolk Islands were also dispensed with.
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Ah Ah, we finally know who is responsible for the WestWind ditching, it was none other than old mate chairman of the board way back when.
I cannot comment on the professional aviation issues here. What concerns me is that despite the detailed conclusions and observations of the report, neither ATSB or CASA has distilled the event into a simple safety message(s) to pilots.
This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.
Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.
Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
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I cannot comment on the professional aviation issues here. What concerns me is that despite the detailed conclusions and observations of the report, neither ATSB or CASA has distilled the event into a simple safety message(s) to pilots.
This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.
Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
This HAS to mean that despite claims of the PIC having an "attitude" problem and transgressing some regulations, that the situation he faced was far from clear and that the regulations, his employers training and procedures and Air services provided insufficient guidance to someone in his situation.
Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
This leaves all of us vulnerable to a repeat performance because there are no "lessons learnt" from this.
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Likewise, although most I know learnt from the original report.
I don't see a need for a safety alert or "lessons learned", but I guess something will appear in FSA sometime.
Conspiracy theorists and ATSB/CASA bashers on this forum will never be happy though.
You seem to be the one unable to move on.
I don't see a need for a safety alert or "lessons learned", but I guess something will appear in FSA sometime.
Conspiracy theorists and ATSB/CASA bashers on this forum will never be happy though.
CASA and ATSB seem unable to draw a line here, close the event off and move on.
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Were that NOT the case then he would have been prosecuted by now and no doubt convicted.
Maybe you could assist CASA by showing which particular transgression warrants prosecution by the DPP.
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Do you understand how referral for prosecution works in Australia? CASA and ATSB are not involved, other than CASA referring the proposed case to DPP for them (DPP) to take the case further if they (DPP) consider it (the Case) has merit.
Maybe you could assist CASA by showing which particular transgression warrants prosecution by the DPP.
Maybe you could assist CASA by showing which particular transgression warrants prosecution by the DPP.
Certainly ATSB will not be involved in any prosecution. It is not in their mandate to prosecute and besides much of the evidence they collect would be inadmissible in court.
I think the roles of the regulator (CASA) and the investigator (ATSB) are sometimes misunderstood and conflated by some. It is not the ATSB's remit to 'point a finger' at a person and state the need for prosecution. They set out the facts and they are (usually) careful to look for systemic issues (as well as personal contributory actions). The report itself cannot be used in a court of law.
In this incident, they were criticised for not making enough of some of the systemic issues so they went back, with a different group of investigators, and redid it. The aircraft was recovered and the recorders interrogated. They added quite a bit (I thought) to the context but not much to the story. The newly-added recorder data did little to help the outcome for the captain. He might have been better-served if NGV had remained on the seabed.
The ATSB's investigations are intended to illuminate both failings and failures, and their reports highlight 'What we found' and include recommendations that are predicated on preventing a recurrence. They try to keep emotion and emotive content out of it. It is not their job to ruminate on the hurt feelings or egos of individuals or corporations.
I acknowledge they sometimes take a long time to finish a report, but it has to be understood that in recent years they have had the devil's own job securing a sufficient budget to retain personnel numbers.
Their draft reports go out to all who were involved and they consider all feedback in an effort to ensure factual accuracy in the final report.
CASA may be another story. It is a matter of personal concern to me that in the transport accident investigation space in Australia (various modalities) there is excessive staff cross-pollination between regulators and investigators. Senior bureaucrats inevitably become 'politicians' and I believe political networks have a lot to answer to in the organisational performance that we might be inclined to criticise. The troops, I suspect, work hard to do the job effectively and professionally. It's too bad that public service salaries (at the investigator level) can't match those for experienced airline pilots. Having to live in Canberra probably holds them back too.
In this incident, they were criticised for not making enough of some of the systemic issues so they went back, with a different group of investigators, and redid it. The aircraft was recovered and the recorders interrogated. They added quite a bit (I thought) to the context but not much to the story. The newly-added recorder data did little to help the outcome for the captain. He might have been better-served if NGV had remained on the seabed.
The ATSB's investigations are intended to illuminate both failings and failures, and their reports highlight 'What we found' and include recommendations that are predicated on preventing a recurrence. They try to keep emotion and emotive content out of it. It is not their job to ruminate on the hurt feelings or egos of individuals or corporations.
I acknowledge they sometimes take a long time to finish a report, but it has to be understood that in recent years they have had the devil's own job securing a sufficient budget to retain personnel numbers.
Their draft reports go out to all who were involved and they consider all feedback in an effort to ensure factual accuracy in the final report.
CASA may be another story. It is a matter of personal concern to me that in the transport accident investigation space in Australia (various modalities) there is excessive staff cross-pollination between regulators and investigators. Senior bureaucrats inevitably become 'politicians' and I believe political networks have a lot to answer to in the organisational performance that we might be inclined to criticise. The troops, I suspect, work hard to do the job effectively and professionally. It's too bad that public service salaries (at the investigator level) can't match those for experienced airline pilots. Having to live in Canberra probably holds them back too.
Plovett...not quite right there.
The CDPP dont do investigations. (and I have that in writing)
CAsA decides on a prosecution using whatever reg suits their fancy, "investigates" for the evidence, with a view to gaining a prosecution, ( criminal, strict liability etc) and produces material / evidence 'brief' for the for the CDPP to look at.
If CDPP like what they see and reckon a successful prosecution is the go, they'll run with it.
The cruncher is of course the CDPP, in aviation ignorance, doesnt know whether the material presented by CaSA is the gospel truth or a crock of doggy doo.
Just ask three AWIs, namely Retski Larard and Clark, who with brilliant observational skill and professional acumen, all saw and swore, to something that technically and physically could never occur. Not who you would want to be checking your aircraft !
Once advised as to the truth of the matter, the CDPP bolted, and CAsA's 'easy bash'/ "there are those in Canberra who think they can make this stick" (statement of short career "investigator" Cremerius), went tits up. Charge Struck Out
CAsA have been in denial ever since and CYA 101 to protect the guilty ...and they're still at it.
I've even had a 3 page "thesis" since from the good Doctor from LSD (very appropriate) explaining that outrageous sworn falsehoods are not lies or untruths but just discrepancies in the wording !!
I kid you not.!! It caused great mirth among the legal profession, not surprisingly.
The surviving AWI still in CAsA employ, is still pissed off and continues to get his rocks off writing/or causing to be written on toilet walls, my private mobile no.
That is no joke either. We're working towards a legal outcome.
As Carmody spouts... CAsA has culture of Just Arse.
The CDPP dont do investigations. (and I have that in writing)
CAsA decides on a prosecution using whatever reg suits their fancy, "investigates" for the evidence, with a view to gaining a prosecution, ( criminal, strict liability etc) and produces material / evidence 'brief' for the for the CDPP to look at.
If CDPP like what they see and reckon a successful prosecution is the go, they'll run with it.
The cruncher is of course the CDPP, in aviation ignorance, doesnt know whether the material presented by CaSA is the gospel truth or a crock of doggy doo.
Just ask three AWIs, namely Retski Larard and Clark, who with brilliant observational skill and professional acumen, all saw and swore, to something that technically and physically could never occur. Not who you would want to be checking your aircraft !
Once advised as to the truth of the matter, the CDPP bolted, and CAsA's 'easy bash'/ "there are those in Canberra who think they can make this stick" (statement of short career "investigator" Cremerius), went tits up. Charge Struck Out
CAsA have been in denial ever since and CYA 101 to protect the guilty ...and they're still at it.
I've even had a 3 page "thesis" since from the good Doctor from LSD (very appropriate) explaining that outrageous sworn falsehoods are not lies or untruths but just discrepancies in the wording !!
I kid you not.!! It caused great mirth among the legal profession, not surprisingly.
The surviving AWI still in CAsA employ, is still pissed off and continues to get his rocks off writing/or causing to be written on toilet walls, my private mobile no.
That is no joke either. We're working towards a legal outcome.
As Carmody spouts... CAsA has culture of Just Arse.
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I am not sure that the DPP gets involved in CASA prosecutions as CASA is a government agency and not a government department. It is one of the reasons CASA has a legal department. However, someone may have a better knowledge of this than I.
And I was very surprised that Mr Retski allowed himself to become involved in that bit of stupidity, for goodness sake the tailplane was one piece.
He might have been better-served if NGV had remained on the seabed.
More spin.
The point of FDRs and CVRs is to assist in determining the facts.
We used to think the ATSB’s job was to do the same.
The calls for recovery of the recorders were, in effect, calls for the ATSB to do its job properly.
If the ATSB had done its job properly in the first place, there would have been no speculation as to what the recorders may have revealed. The ATSB’s reputation might be a little less trashed.
I would still prefer to hear the actual recording from the CVR (and from flight services), rather than relying on the ATSB’s paraphrasing.
The point of FDRs and CVRs is to assist in determining the facts.
We used to think the ATSB’s job was to do the same.
The calls for recovery of the recorders were, in effect, calls for the ATSB to do its job properly.
If the ATSB had done its job properly in the first place, there would have been no speculation as to what the recorders may have revealed. The ATSB’s reputation might be a little less trashed.
I would still prefer to hear the actual recording from the CVR (and from flight services), rather than relying on the ATSB’s paraphrasing.
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I would still prefer to hear the actual recording from the CVR (and from flight services), rather than relying on the ATSB’s paraphrasing.
I am now re-reading the ATSB report, and imagining myself in Dom's position during the varous stages of flight. I cannot for the life of me(and it would have been my life) understand his refusal to take full fuel from Apia - does anyone have a reason why he might have believed 7200lbs was sufficient for the flight?
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Eddie, the problem is that by not releasing the exact transcripts it leads to suspicion that perhaps things could have been altered/distorted/omitted/added. Not saying that's what was done, but its all about perception. Have things been twisted to suit a certain agenda..? Who knows. But if you print the exact transcripts then it removes any doubt or room for speculation.
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"Eddie, the problem is that by not releasing the exact transcripts it leads to suspicion that perhaps things could have been altered/distorted/omitted/added."
According to the pilot concerned thats exactly what happened
"I cannot for the life of me(and it would have been my life) understand his refusal to take full fuel from Apia"
The fuel he took was what was legally required to complete the flight under the rules that applied at the time and in accordance with Pelair's fuel policy. The same fuel others had taken before him, including the Chief Pilot.
It costs fuel to carry fuel, Mr Davies analysis showed even if he took full fuel he would more than likely ended up at Norfolk with the same residual fuel as he had.
There is also the likelihood that he would have been descended to a level outside RVSM airspace due to being to heavy to climb, in which case we wouldn't be having the conversation as he would have had to divert to Nadi to take on more fuel.
To my mind his biggest mistake was leaving Samoa in the first place. A wiser and perhaps more experienced mind would have deduced, I aint had proper rest,
the patient aint critical, its the middle of the night, bugger it, I'll go in the morning.
But then just how much commercial pressure was there to complete the mission?
According to the pilot concerned thats exactly what happened
"I cannot for the life of me(and it would have been my life) understand his refusal to take full fuel from Apia"
The fuel he took was what was legally required to complete the flight under the rules that applied at the time and in accordance with Pelair's fuel policy. The same fuel others had taken before him, including the Chief Pilot.
It costs fuel to carry fuel, Mr Davies analysis showed even if he took full fuel he would more than likely ended up at Norfolk with the same residual fuel as he had.
There is also the likelihood that he would have been descended to a level outside RVSM airspace due to being to heavy to climb, in which case we wouldn't be having the conversation as he would have had to divert to Nadi to take on more fuel.
To my mind his biggest mistake was leaving Samoa in the first place. A wiser and perhaps more experienced mind would have deduced, I aint had proper rest,
the patient aint critical, its the middle of the night, bugger it, I'll go in the morning.
But then just how much commercial pressure was there to complete the mission?
