Norfolk Island Ditching ATSB Report - ?

[PLovett]

Originally Posted by aroa

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.

Thanks aroa, I was basing my opinion on a case that occurred in Tassie, where local counsel was briefed for the prosecution. I thought it was CASA who briefed but on reflection perhaps it was the CDPP.

No wonder CASA lives in fantasy land if they believe that a sworn affidavit containing falsehoods is merely a discrepancy. There really will be no change short of a root and branch cleansing of the place, especially at the deputy level.

[Checkboard]

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.

Not quite. The fuel he took was insufficient to cater for depressurisation or engine failure en-route, as required by regulations. It wasn't planned in accordance with current wind charts. The Pelair fuel policy didn't cater for engine out/depress either, though.

The same fuel others had taken before him, including the Chief Pilot.

Untrue:

Originally Posted by Westwind report

Of the operator’s 185 flights to remote aerodromes during the period 1 January 2002 to 17 November 2009:

• 158 (85 per cent) departed with full fuel (1.80–4.77 hours flight time)
• 12 (6 per cent) departed with 8,000–8,400 lb (1.85–3.80 hours)
• 5 (3 per cent) departed with 7,400–7,800 lb (1.80–3.00 hours)
• 10 (5 per cent) departed with full main tanks or just less than full main tanks (1.80–2.50 hours).

...


In terms of the fuel on board for different flight times:

• All 8 flights with a flight time of 4.25 hours or more departed with full fuel.
• Almost all (29) of the 30 flights with a flight time of 3.75–4.24 hours departed with full fuel. A 3.80-hour freight flight during the day from Darwin to Christmas Island departed with 8,000 lb.
• All 19 flights with a flight time of 3.25–3.74 hours departed with full fuel.
• Most (33) of the 38 flights with a flight time of 2.75–3.24 hours departed with full fuel.

It costs fuel to carry fuel,

The fuel in Samoa was half the cost of the fuel at Norfolk. It would have paid to carry on this sector.

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.

That's ridiculous.

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.

As a MED1 priority - probably not. As he never mentioned that priority on the radio, however, he appeared to be unaware of this. In any case, if you have to divert, you have to divert - still not a reason not to carry fuel.

[Lead Balloon]

Checkboard: I’d be interested to know if you’ve read Mr Davies’ submission (and supplements) here: https://www.aph.gov.au/Parliamentary...12/submissions and to understand where you consider his reasoning to go astray.

[get_over_it]

I've seen some media reports and articles around the internet comparing Mr James's actions to that of 'Sully' Sullenberger. Does anyone know if Sully has voiced his opinion on the event? I would love to hear it.

[Ethel the Aardvark]

https://independentaustralia.net/bus...ng-lives,11000

Not agreeable on all the statements

[Checkboard]

Checkboard: I’d be interested to know if you’ve read Mr Davies’ submission (and supplements) here: https://www.aph.gov.au/Parliamentary...12/submissions and to understand where you consider his reasoning to go astray.

I looked through them at the time. My "That's ridiculous" comment was purely on the statement that loading 8670 lbs (full fuel) would result in arriving at Norfolk with about the same amount of fuel as loading 7200 lbs (full mains) did.

Having said that, the ATSB seem to have addresssed most of Mr Davies points in their reopened report. The fuel calculations they have made for different scenarios and at different points of the flight are more comprehensive than in the original report.

[Lead Balloon]

That wasn’t my second question Checkboard (although you are, of course, under no obligation to answer my questions).

“More comprehensive” doesn’t mean correct. “Seem to address” doesn’t mean categorically answer.

I’d still be interested, if you get the time, to set out your thoughts on where Mr Davies’ analysis goes astray.

CAR 234(3) specifically required that contingencies such as a loss of pressurisation or engine failure be considered when determining the amount of fuel required for a flight. CAR 220 also required the operator to provide specific instructions for situations such as an engine failure. CAAP 234-1 provided additional guidance for these abnormal situations.

CAR 234(3) does not impose an obligation on a pilot.

In any event, if the PIC breached 234(1), he should be prosecuted for the breach. It automatically follows that the operator should be prosecuted under 234(2).

234 Fuel requirements

(1) The pilot in command of an aircraft must not commence a flight within Australian territory, or to or from Australian territory, if he or she has not taken reasonable steps to ensure that the aircraft carries sufficient fuel and oil to enable the proposed flight to be undertaken in safety.

Penalty: 50 penalty units.

(2) An operator of an aircraft must take reasonable steps to ensure that an aircraft does not commence a flight as part of the operator’s operations if the aircraft is not carrying sufficient fuel and oil to enable the proposed flight to be undertaken in safety.

Penalty: 50 penalty units.

(3) For the purposes of these Regulations, in determining whether fuel and oil carried on an aircraft in respect of a particular flight was sufficient within the meaning of subregulations (1) and (2), a court must, in addition to any other matters, take into account the following matters:

(a) the distance to be travelled by the aircraft on the flight to reach the proposed destination;

(b) the meteorological conditions in which the aircraft is, or may be required, to fly;

(c) the possibility of:

(i) a forced diversion to an alternative aerodrome; and
(ii) a delay pending landing clearance; and
(iii) air traffic control re‑routing the flight after commencement of the flight; and
(iv) a loss of pressurisation in the aircraft; and
(v) where the aircraft is a multi‑engined aircraft—an engine failure;
(d) any guidelines issued from time to time by CASA for the purposes of this regulation.

(4) An offence against subregulation (1) or (2) is an offence of strict liability.

Note: For strict liability, see section 6.1 of the Criminal Code.

Note that (1) and (2) require “reasonable steps”, not an “absolute guarantee”. Note also the test is at a point in time: The commencement of the flight.

We all know why the PIC wasn’t prosecuted under 234(1).

[Checkboard]

234(1) requires a pilot to plan "sufficient fuel and oil to enable the proposed flight to be undertaken in safety.", and 234(3) gives instruction to the court, specifically, to consider those reasonable other items to be included in the "in safety" claus. That's pretty definitive for the pilot to also consider those elements.

In any case that quote was cut & paste from the new report.

At no point did I suggest Mr Davies was in error in his submissions - I don't know where you got that idea? I have simply not examined his submissions to that depth. Did he calculate for depressurisation & engine out scenarios?

The new report does include figures for those - and they came to (from memory) about 300 lbs above the main tank fuel that was loaded on the flight in question.

I have no idea why the pilot wasn't proscecuted under 234(1), by the way. Care to enlighten me? Are you privvy to CASA's deliberations on the matter?

[Lead Balloon]

Originally Posted by Checkboard

234(1) requires a pilot to plan "sufficient fuel and oil to enable the proposed flight to be undertaken in safety.", and 234(3) gives instruction to the court, specifically, to consider those reasonable other items to be included in the "in safety" claus. That's pretty definitive for the pilot to also consider those elements.

In any case that quote was cut & paste from the new report.

At no point did I suggest Mr Davies was in error in his submissions - I don't know where you got that idea? I have simply not examined his submissions to that depth. Did he calculate for depressurisation & engine out scenarios?

The new report does include figures for those - and they came to (from memory) about 300 lbs above the main tank fuel that was loaded on the flight in question.

I have no idea why the pilot wasn't proscecuted under 234(1), by the way. Care to enlighten me? Are you privvy to CASA's deliberations on the matter?

No, I’m not privy to CASA’s deliberations.

I don’t need to be.

The facts speak for themselves.

The pilot didn’t breach 234(1). Even if he did, it follows that the operator breached 234(2).

You will note, from the operator’s submission to the Senate Inquiry, that the operator did not ‘throw the PIC under the bus’. The operator did not say that the PIC was off on a frolic of his own, having suffered a brain fart, in breach of the rules and procedures put in place by the operator and accepted by CASA:

Pel-Air offers the following comments in relation to the findings of ATSB report AO-2009-072.

FINDINGS

At the time of flight planning, there were no weather or other requirements that required the nomination of an alternate aerodrome, or the carriage of additional fuel to reach an alternate.

Pel-Air agrees with this finding.

The aircraft carried sufficient fuel for the flight in the case of normal operations.

Pel-Air agrees with this finding.

The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.

The crew did request actual weather reports (either METARs or SPECIs).

WEATHER PROVIDED BY NADI:

The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. This was the first indication to the crew that the weather at Norfolk Island was becoming marginal.

WEATHER PROVIDED BY AUCKLAND:

The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with Auckland would have alerted the crew to the true situation with time enough to divert. At 0839 the aircraft was still around 32 min away from the last diversion point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew. [NOTE: In the Pelair submission, the bolded text in the quote above is in red font.]

While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.

The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with their incomplete flight planning to influence their decision to continue to the island, rather than divert to a suitable alternate.

Pel-Air agrees with the first part of the finding on delayed awareness but disagrees with the second part. As explained in the preceding section, the accident would have been averted if weather information was obtained in a timely manner as there was more than enough time and fuel to divert had the up-to-date information been communicated.

The flight crew’s advice to Norfolk Island Unicom of the intention to ditch did not include the intended location, resulting in the rescue services initially proceeding to an incorrect search datum and potentially delaying the recovery of any survivors.

Pel-Air agrees that the crew did not make a proper mayday call as per the regulations. While this may be understandable in the circumstances, the failure to even provide the approximate ditching location meant additional delay to the rescue.

The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands.

Pel-Air disagrees with the second part of this finding and maintains that its procedures, compliant with CASA regulations at the time, are effective for minimising risks for remote island operations. Pel-Air supports the proposed rule changes by CASA to bring passenger carrying aerial work operations in line with regular public transport operations to remote islands including the requirement to always carry an alternate.

...

[Lookleft]

Just a couple of questions. Who is Richard James Davies and why are his fuel calculations and the assumptions made any better or have any more credibility than anyone else? I note in his submission that he became involved at the request of parties involved in the accident. So why is his motive not tainted with self-interest and to be considered above reproach.

I also note that from his fuel calculations that the estimated fuel at NFI was 709lbs! The recently released report has the fuel at ToD NFI as 1360lb. So much for Mr Richard J Davies assumptions.

The facts speak for themselves.

Indeed they do Lead Balloon but for some the facts do not fit the narrative so are therefore to be rejected.

[Checkboard]

As Pelair are tied to the pilot by 234, their response is pretty much what I would expect. I don't even disagree with it.

The 0830 SPECI was neither passed, nor sought - and that is the shame of this accident. While that time was before a diversion point no one knows wether it would have triggered a diversion or not, though (no diversion airport weather had been requested, and I personally doubt a PNR was calculated).

That the loaded fuel was sufficient for normal operations was more luck than skill as no enroute winds had been obtained to accurately calculate it, though. The other pilots loaded generous (full, on this route) fuel to mitigate that type of innacuracy, and he didn't.

Yes - I understand that even with full fuel he would have arrived without an alternate option (but more holding). Yes, giving him the benefit of doubt, he would have diverted immediately if given the 0830 - and would have been lucky to have enough just fuel to do so (as he hadn't calculated a diversion).

Don't get me wrong. I don't want to see anything more happen to the pilot. I think he performed perhaps a little (not a lot) below average for GA jet pilots at that time. I think he has to be better now.

That CASA make the ATPL nav exams so complex that no one expects to be able to use the exam techniques in real life - and the exams are sat so early in a career that they are a distant memory by the time a person commands a two crew aircraft - is a problem. The operators also don't have easily used techniques in their manuals or training. Both of those are STILL issues.

Something I wrote in 1999:
PNR usage

[Lead Balloon]

Originally Posted by Lookleft

Just a couple of questions. Who is Richard James Davies and why are his fuel calculations and the assumptions made any better or have any more credibility than anyone else? I note in his submission that he became involved at the request of parties involved in the accident. So why is his motive not tainted with self-interest and to be considered above reproach.

I also note that from his fuel calculations that the estimated fuel at NFI was 709lbs! The recently released report has the fuel at ToD NFI as 1360lb. So much for Mr Richard J Davies assumptions.



Indeed they do Lead Balloon but for some the facts do not fit the narrative so are therefore to be rejected.

So ATSB’s calculations are an objective truth, and it therefore automatically follows that Mr Davies is incorrect? That’s what’s called a mere “appeal to authority”.

All of the parties, including the ATSB, were tainted by interests other than those of safety. Everybody knows why.

[Lookleft]

So you have no idea who he is then? You and Thorn Bird were exhorting CB to look at them as they, for some reason, had a greater authenticity. CB has actually flown the Westwind and has suggested that his calculations were not reliable. CB doesn't consider the new reports figures to be inaccurate.

All of the parties, including the ATSB, were tainted by interests other than those of safety. Everybody knows why.

You should have finished your statement at the full stop because all you have done is highlight your particular bias.

[slats11]

With all this talk about diversions, my understanding is that Noumea may not have been an option. The French authorities had earlier that year (Feb 2009) banned the operator from flying into Noumea due to non-compliance with the EU regulations - no TCAS II, no EGPWS. The operator was in the process of addressing this and had updated the aircraft systems, but the pilots had not yet completed training in its use.

Sure he could (? should) have diverted there prior to PNR. With full fuel he may have even been able to reach Noumea at TOD Norfolk - when he definitely knew weather was below landing minima.

However I wonder if the operators difficult history at Noumea played a role in the pilot's decision making. Did he press on to Norfolk and descend into Norfolk thinking there would be trouble if he went to Noumea?

[Lookleft]

He already knew or should have known that the weather was below the alternate minima when he got the 0800 SPECI.

At 0756, the captain requested the latest METAR for Norfolk Island from the Nadi IFISO. At 0801, the IFISO provided the 0630 METAR, and at 0802 he provided the 0800 SPECI. Whereas the 0630 METAR was broadly consistent with the current TAF (issued at 0437), the 0800 SPECI indicated the cloud had deteriorated to be overcast at 1,100 ft. These cloud conditions were below the published alternate minima for planning a flight to Norfolk Island, but it was above the landing minima.

He wasn't in the habit of talking about fuel with the F/O so I can only assume he ignored the alternate minima and continued on because he thought that they would get in off the approach. I doubt the issues with the French authorities were even a consideration.

[Lead Balloon]

Originally Posted by Lookleft

So you have no idea who he is then? You and Thorn Bird were exhorting CB to look at them as they, for some reason, had a greater authenticity. CB has actually flown the Westwind and has suggested that his calculations were not reliable. CB doesn't consider the new reports figures to be inaccurate.



You should have finished your statement at the full stop because all you have done is highlight your particular bias.

Please identify the flaws and errors in Mr Davies’ reasoning and calculations.

The reasoning and calculations are what they are, whether Mr Davies is the PICs lover or arch enemy.

Saying that the ATSB and CB came to different conclusions merely begs the question.

[kellykelpie]

For me there is a much bigger issue at play on PPRuNe. Did the pilot deliberately proceed knowing he would not get in? Were his actions wilful? Did he have a history of unsafe acts? His actions or inactions under discussion here were errors not violations. As pilots (in some cases highly trained airline pilots), I would hope that we wouldn’t eat our own. I’m not sure of the motivation of those that publicly condemn this man. Be careful because one day you may share a flight deck with him - I hope it’s your check flight and he’s sitting behind, because I’m sure that he would have gained the compassion that many of you lack and the experience of this to boot. Merry Christmas 🎄

[Lead Balloon]

Not sure of their motivation? Speaking in the royal “we”, Down and Welded provided a good insight:

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)...

You see, if you aren’t prepared to dispassionately condemn the pilot of NGA, you’re confessing that you could easily make mistakes. Shame on you!

[kellykelpie]

I feel that Down and Welded isn’t a professional pilot - his comments are not written by someone with skin in the game, someone that deals with risk and risk assessments daily in a high hazard environment. He’s an observer.

If he is a pilot and doesn't think that something like this can happen to him, then he is are wrong. Fatigue, circumstance and lack of relevant experience/training can catch us all out on a bad day. To quote Reason “Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors.”

[megan]

You see, if you aren’t prepared to dispassionately condemn the pilot of NGA, you’re confessing that you could easily make mistakes. Shame on you!

You must be a unique aviator LB, not making ANY mistakes, despite NASA finding that EVERY crew makes mistakes on EVERY flight. You must be a Skygod, along with Lookleft.