Legal Responsibility of Pilot in Command. Thoughtful article
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PA_RCA.
For those who remain firmly convinced that DJ is the sole perpetrator of these events, consider a short reading session, commencing at page 39 of the "very special audit" CASA audit ending at page 103.
The CASA signed confession begins at p.39; the items discussed did not occur overnight. If CASA can identify these problem areas after the event; it follows that they could have done so before. These issues, identified and addressed may have prevented the infamous 'group cluster' now referred to as the Norfolk ditching.
Pages 40 – 41 : CASA identifies experience and cultural 'contributing factors' which had been in effect long before DJ decided to ditch the aircraft. Once again, if CASA can define these issues, so very clearly identified after the event, why were they not identified beforehand by CASA and corrected. It is amusing that the issues are laid at the company's door due to a lack of internal audit, what were CASA auditing, the biscuit tin or the lunch menu ?
Then we come to the RCA section, no page numbers but start at PDF 45 – through 78:-
RCA 321058 – it's a bit difficult to blame DJ for dodgy evacuation procedures when the company had not provided the training.
RCA 321059 – training, including V1 cuts conducted by 'non approved' supervisory pilots.
RCA 321060 – more 'non training', this time for ACAS.
RCA 321061 - more 'non training', this time for CRM.
RCA 321062 – operations conducted with no DGA certificate
RCA 321063 – operations without medical certificate.
RCA 321064 – Deficient Fuel policy.
RCA 321065 – Deficient flight preparation documentation and procedures.
RCA 321066 – Deficient/ non existent navigation log and audit procedures.
RCA 321067 – No RTOW or OC charts or procedure.
RCA 321068 – Westwind fleet pilots with out of date of no COM.
RCA 321069 – No formal training for international operations.
RCA 321071 – Systemic failure to report defects.
RCA 321072 – Pre fight passenger and crew briefing deficiencies.
RCA 321073 – Multiple deficiencies notes related to training not provided.
There are a further 22 pages of the same thing to be analysed, but the above certainly gives an idea of the background and culture DJ was in. The company failed to correct the issues, CASA failed in previous audit and surveillance to either identify or correct any of these post accident 'discoveries'. Airtex was raped, pillaged, burned and buried for a whole lot less than this, by the same manager I might add. Polar was a stellar exemplar in comparison and poor old Tiger, their administrative policy dispute pales to insignificance. Yet PA survives.
This is the audit that did not merit the attention of the ATSB. This is the audit that still has not been presented to the Senate. This audit page count is growing daily, firstly we have a humble 45 pages, then a solid 103 pages; I hear there is more of this audit to come under the FOI, unless 'I'm a star see' can find a way to avoid it by skimming around the edges of the Act without actually, technically breeching it, we shall see.
But that's OK it was all the pilot's fault. Right Blackie, but do try to remember who issues operational approvals, who oversights operations and who signs it all off as 'acceptable'. Give you a clue, it is not Dominic James.
The CASA signed confession begins at p.39; the items discussed did not occur overnight. If CASA can identify these problem areas after the event; it follows that they could have done so before. These issues, identified and addressed may have prevented the infamous 'group cluster' now referred to as the Norfolk ditching.
Pages 40 – 41 : CASA identifies experience and cultural 'contributing factors' which had been in effect long before DJ decided to ditch the aircraft. Once again, if CASA can define these issues, so very clearly identified after the event, why were they not identified beforehand by CASA and corrected. It is amusing that the issues are laid at the company's door due to a lack of internal audit, what were CASA auditing, the biscuit tin or the lunch menu ?
Then we come to the RCA section, no page numbers but start at PDF 45 – through 78:-
RCA 321058 – it's a bit difficult to blame DJ for dodgy evacuation procedures when the company had not provided the training.
RCA 321059 – training, including V1 cuts conducted by 'non approved' supervisory pilots.
RCA 321060 – more 'non training', this time for ACAS.
RCA 321061 - more 'non training', this time for CRM.
RCA 321062 – operations conducted with no DGA certificate
RCA 321063 – operations without medical certificate.
RCA 321064 – Deficient Fuel policy.
RCA 321065 – Deficient flight preparation documentation and procedures.
RCA 321066 – Deficient/ non existent navigation log and audit procedures.
RCA 321067 – No RTOW or OC charts or procedure.
RCA 321068 – Westwind fleet pilots with out of date of no COM.
RCA 321069 – No formal training for international operations.
RCA 321071 – Systemic failure to report defects.
RCA 321072 – Pre fight passenger and crew briefing deficiencies.
RCA 321073 – Multiple deficiencies notes related to training not provided.
There are a further 22 pages of the same thing to be analysed, but the above certainly gives an idea of the background and culture DJ was in. The company failed to correct the issues, CASA failed in previous audit and surveillance to either identify or correct any of these post accident 'discoveries'. Airtex was raped, pillaged, burned and buried for a whole lot less than this, by the same manager I might add. Polar was a stellar exemplar in comparison and poor old Tiger, their administrative policy dispute pales to insignificance. Yet PA survives.
This is the audit that did not merit the attention of the ATSB. This is the audit that still has not been presented to the Senate. This audit page count is growing daily, firstly we have a humble 45 pages, then a solid 103 pages; I hear there is more of this audit to come under the FOI, unless 'I'm a star see' can find a way to avoid it by skimming around the edges of the Act without actually, technically breeching it, we shall see.
But that's OK it was all the pilot's fault. Right Blackie, but do try to remember who issues operational approvals, who oversights operations and who signs it all off as 'acceptable'. Give you a clue, it is not Dominic James.
Last edited by Kharon; 5th Nov 2012 at 19:30.
Just had a read of the SAR that PAIN has made available and as you point out K it is really the smoking gun in the failure of CASA to do its job and the failure of the ATSB to independently investigate. I find the scyophantic opening statements about how wonderful all the staff at PA and the organisation itself has been in cooperating truly self-serving. Hopefully the Senate Inquiry will generate enough interest beyond the small group of interested parties that have been following events to get real change, but the Senate on its own cannot. I am also hopeful that the ATSB can learn some hard lessons from this and distance itself from CASA so that it regains its voice. That will however require a complete rethink on who leads the organisation and as long as the Minister is being shielded I can't see that happening.
On the topic of the thread all this highlights is that the PIC is not only the last link in the chain but he/she needs to have a good look and take interest in the rest of the links as well.
On the topic of the thread all this highlights is that the PIC is not only the last link in the chain but he/she needs to have a good look and take interest in the rest of the links as well.
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On the topic of the thread all this highlights is that the PIC is not only the last link in the chain but he/she needs to have a good look and take interest in the rest of the links as well.
A real world case.
Management produced a aerodrome analysis detailing the V1 speeds in tabulated form, and it was SOP to refer to said chart post engine start and set the bugs. The only trouble was, in drawing up the chart they had only considered the abort case, and not the fly away if the failure was post V1. What position would the PIC be in if he had a failure post V1 that put him in the scrub, all because of the charts incorrect data?
If management, on being made aware of the issue, refuses to correct the chart, does the PIC then make his own chart drawing on flight manual data, and not comply with SOP?
The ops manual did have a clause saying compliance with its content was mandatory, and failure to comply would meet with disciplinary action, including termination. It also had a get out clause that CASA regs took precedence if there was any conflict.
it may be very difficult for a line pilot to know what is going on behind the chief pilots, and all those other managers, doors.
A bit like the application of water-meths on the Metro11 at places like Mildura or Cooma on a hot day. No idea what to expect with the performance if we lost an engine as the vspeeds did not take the water-meths into account. What we did pay attention to was what would happen if only one side fired and we were going to depart the runway, we briefed where the best escape path was (or where the worst one was). You can only prepare yourself as best you can but you have to prepare yourself. What is becoming more obvious is that the traps in the system extend a lot further than just the flying side of the operation.
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I got told a story once by a young pilot that took off knowing he had a flat tyre. I asked WTF he was thinking and he said the boss approved it so it was ok! Yep there are pilots out there that have no idea of their responsibilities.
