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Norfolk Island Ditching ATSB Report - ?

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Norfolk Island Ditching ATSB Report - ?

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Old 7th Nov 2011, 02:56
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Norfolk Island Ditching ATSB Report - ?

Its been almost 2 years and still no report...
When do you think it might be issued?

I tried looking for the old thread, but guess it might have been removed.
Just wondering when the report might be issued, not wanting to speculate or re-invent past discussions.
Cheers,
PD
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Old 7th Nov 2011, 03:14
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"PD"............Shzzzzzzzz, be quiet, the report along with the plane has gone to the bottom, it sleeps with the fishes as the Sicilians would say

The guy ran out of gas, it ain't rocket science! (or was about to depending on which version of the evnets you believe)


Wmk2
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Old 7th Nov 2011, 03:27
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Given how quick the head honcho was to praise the actions of the pilot, it's almost like he's got something to hide.

My money is that they didn't top up before departure because a) fuel was more expensive deeper into the pacific and b) you burn more when you haul more.

Yeah, it was probably (barely) legal, but it'd be fun to know if that was unwritten company policy to save some bucks...
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Old 7th Nov 2011, 04:09
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Seems odd that its shrouded in silence
Can the ATSB squash and hide an investigation report
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Old 7th Nov 2011, 04:52
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Looks like it may be a NZ run investigation for some reason. Or else they are just helping: http://taic.org.nz/Currentinquiries/tabid/89/Page/2/language/en-US/Default.aspx. It's on page 3 - #09-008
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Old 7th Nov 2011, 05:47
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I tried looking for the old thread, but guess it might have been removed.
Might be this one or this one

Looks like it may be a NZ run investigation for some reason
ATSB has a file - but no report as yet

Last edited by bentleg; 7th Nov 2011 at 06:56.
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Old 7th Nov 2011, 11:20
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My suspicion on this is that the flight was legal, right up to the point where the pilot decided to continue the planned flight rather than divert due to weather. However, it was only legal because of dispensations or approvals granted by CASA and was certainly not prudent.

So, given that affected persons and organisations have the opportunity to review an ATSB report, I suspect that they are taking the opportunity to delay the publication by suggesting changes while they boiler-plate their back-sides for the inevitable kicking that is going to come their way.
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Old 7th Nov 2011, 11:50
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Gunna hafta debate that suspicion Plovett - it was a Charter, not Airwork, so the CHTR regs on fuel did apply.... ergo he shoulda had more go-juice on board.
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Old 7th Nov 2011, 13:17
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Hmm,
did this pilot make a bad decision? I think not. If it were so we'd be talking about in another thread here.

Strikes me as good planning gone to sh*t by the things we cannot control.

Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed

Just my half cent

Jas
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Old 7th Nov 2011, 19:40
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Strikes me as good planning gone to sh*t by the things we cannot control.
I just coughed on my weetbix when I read that comment.
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Old 7th Nov 2011, 19:51
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Strikes me as good planning gone to sh*t by the things we cannot control.
There was nothing out of control on that flight except the decision making process BUT subject to the right combination of organisational culture and operational pressures I fear many of us could have ended up in the same spot.

How many times had he done the same or similar trips?
How many times had he managed to get in when the wx was marginal?
Had he ever received a butt-kicking for making a precautionary diversion for fuel that turned out to be unnecessary?

He didn't go past that CP for diversion knowing they would end up in the drink. He would have been confident that he could get in.

....right up to the point where he wasn't.

Personally, I would love to know how this event has changed the HF culture and the training accross the Rex group
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Old 7th Nov 2011, 21:27
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As far as the report goes I think QF32 has probably soaked up a lot of resources so this report just gets put on hold until the investigator can get back to it. The only reason an investigation would be terminated would be if the accident was caused by terroism or a deliberately illegal act e.g. the Kingair barrel role over Mt Hotham.
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Old 7th Nov 2011, 21:38
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Jamair, you may be right but I was under the impression that aeromedical work was AWK and not CHTR.

Even if it was CHTR I believe that a CASA dispensation is possible (and I think in this case probable) from the fuel requirements for flights to islands. If this was granted then it was a very poor decision from our regulators.

IIRC this point was debated at some length on one of the previous threads on the topic.
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Old 7th Nov 2011, 23:22
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Hmm,
did this pilot make a bad decision? I think not. If it were so we'd be talking about in another thread here.

Strikes me as good planning gone to sh*t by the things we cannot control.

Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed

Just my half cent

Jas
You have got to be kidding me.

- He departed underfuelled - refer Jamairs post, and regardless of whether or not there was an exemption, he still did not carry prudent fuel.
- He could have diverted to New Cal after he received WX advising that he was now below the alternate minima. Had he been departing that point in space with that WX it would have required an alternate or suitable holding fuel. He had neither the fuel nor the brains to divert.
- He arrived with WX that was even worse still, and knowing he was low on fuel he never declared it or an emergency.
- He flew several VOR approaches which are not runway aligned by a mile or two from memory and require a circle to land.
- After a couple of them he tried yet again.
- He had a F/O that was not endorsed on GPS approaches, yet he was, but they never tried one. The RNAV for RWY 11 IS RUNWAY ALIGNED.
- He could have had the the FO call the numbers for distance and height to the SNFWM and flown a 3 degree profile watching the Radar Alt which it should have had, and flown the RNAV as a sudo ILS, and landed the thing on the runway. Might have been hard work and scary but should work.
- Some folk will argue "but that is descending below the MDA why would I be encouraging busting the minima, well he went well below the minima when he crashed it on the water .

Bloody lucky of the highest order that anyone lived, let alone the patient. Lucky the bloke who spotted them stopped where he did, by rights he had no reason to belive he should have.

So......poor planning, poor in flight monitoring, poor decission making in the cruise and poor decission making once it all turned to sh!t .

So show me one area of this guys flight operation where you can honestly cut him some slack? Maybe commercial pressure prior to departure? If so then he should have diverted in the first instance, and that extra cost would have shoved it right up the ar$e of the company for being so stingy. Of course he did sink a perfectly servicable jet on the bottom of the sea in return.

I too think the ATSB will be getting all manner of requests to distort the facts to minimise the arse covering required for the obvious.
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Old 7th Nov 2011, 23:37
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Gunna hafta debate that suspicion Plovett - it was a Charter, not Airwork, so the CHTR regs on fuel did apply.... ergo he shoulda had more go-juice on board.
Shouldn't matter if the company ops manual specifies adhereance to CAAP 234-1.
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Old 8th Nov 2011, 00:39
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Kudos to the pilot for a safe touchdown.....most of us would get spinchter strain doing it in daylight, let alone with out eyes closed
As I understand it, the bath came as a bit of a surprise for all concerned!

Dr
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Old 8th Nov 2011, 00:42
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Kudos to the pilot for a safe touchdown
Can only agree. However, I cannot help but harbour a slight suspicion that this particular successful touchdown might bear some strong parallels with the story (told, I think, by EK Gann in one of his books [FITH?]) of the Catalina that 'landed' in IMC on a snow-covered Greenland hillside during WW2 - much to the surprise of the Catalina's crew.

Edited to add: I hadn't seen the post immediately above until after posting this observation.
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Old 8th Nov 2011, 01:34
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'Jaba' I have to agree with you here pretty much on this one with what you wrote.

Going below any min is justifiable when under emerg conditions so all bets are off by this stage. Not declaring an Emerg means I believe one of two things he either was more concerned of the ramifications if he did declare an Emerg due paperwork retribution etc (which is plausible) or he simply believed that he was going to get in & say nothing chalking it up latter to sh!t I'll never do that again !, one way humans tend to learn.
There would have to have been some commercial pressure on this guy as apart from total ignorance nobody would intentionally put themselves or others in harms way by going skinny on the gas.
I personally will be very keen to see/read the outcome of this one as it's somewhat close to my heart ( done Pacific Aer-Med B4) as it can be very challenging out there over the Pacific with limited options flying wise.

They where damned lucky that is was a Westy jet as you couldn't pick a better small jet airframe to land on water if you tried. Mid wing, eng's out of the way & even with the gear down (likely to be the case here) a water landing would be doable due to bugger all of the wheel protrudes blw the fuse.


Wmk2
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Old 8th Nov 2011, 05:04
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WM2 - re the commercial pressures - I hope the ATSB report discusses the medical decision making as well, to proceed on an overwater flight of some several thousand km by night to collect what can only be described as a non-urgent patient who subsequently trod water for 90 min then took a commercial flight the next day....

Plovett, the air ambulance / AWK criteria do not apply because the operator (Pelair) was not the medical provider. The aircraft was chartered by Careflight from Pelair.

Jaba - you forgot leaving the FO behind unconscious in her seat while making his escape over the top of all the other occupants.

Were the CVR & FDR recovered?

Should be interesting reading, IF we ever see it.
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Old 8th Nov 2011, 05:54
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'Jamair' that's a valid point you make re the nature of the med condition etc.

That being the case(low priority) there would still be an element of commercial pressure as with any med retrieval, time= money.You keep the team (med & tech crew) on the ground for another day or so for say better wx or daylight Ops & the costs start to escalate.
The tech crew where not in a position to access the condition of the patient as the very fact that it's a long distant costly transfer done outside of normal commercial ops alone means some level of urgency so making ops decisions based on that alone means commercial pressure.
The insurance Co's couldn't care less about details of any particular flight (delays etc due WX) they just want it done quickly to keep costs down.

Commercial reality is very real in that part of aviation.


Wmk2
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