Decomp C441 Broome
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Decomp C441 Broome
OPEN LETTER TO GEOFF THOMAS
This has been sent to CASA and the ATSB - lets see if the Regulator or the Investigator has the back bone to stick upto the orgasnisation.
Hi Geoff,
On the 22 of July 2020 a Cessna 441, VH-LBY, operated by Skippers Aviation suffered an explosive decompression at 27,000 while approx 80mn from Broome enroute to Brown's Range on behalf of a major mining client. The PIC, who had only recently been checked to line on the aircraft and had less than 600 total flying time, requested a descent to 12,000ft. When asked by ATC if he was "ops normal" he said "we have had a decompression problem but are ops are normal" it has been suggested that the radio call was made while the pilot was not wearing oxygen equipment. It is worth noting that the pilot has been given a Cessna 441 endorsement from an external provider - a cost cutting measure by the aircraft operator. When ATC asked if he wished to return to Broome, he responded with "no we will continue to Brown's Range at 10,000ft". ATC recordings confirm a similar turn of events. The aircraft subsequently landed at Browns Range without further incident.
The aircraft's Continuing Airworthiness Maintenance Organisation, owned by Skippers CEO Stan Quinlevin, and the acting maintenance manager, who had repeatedly come under question by CASA, requested that the pilot apply a MEL (minimum equipment list) for the pressurisation system and that the aircraft should be fly back to Broome via Halls Creek for fuel without an engineering inspection. The passengers have been reported as telling the pilot in flight that there was an "air leak" coming from the wing level emergency exit and that metal was "flexing in the wind" and that there was a loud "sucking noise". The aircraft in question has exceeded it's manufactures total airframe life limit and is only able to fly after modifications from an engineering facility in Adelaide, a modification which has been accepted by CASA. CASA, the only regulatory body in the world to extend the life of this aircraft type has come under question for allowing such a life extension to be approved - it is reported that the ASTB is investigating the matter.
One of the four passengers is seeking treatmentment for PTSD as he is unable to continue working as a FIFO worker because of the incident. He claims that stress he has encountered while flying to work in 35yo+ aircraft which often have defects and flown by a pilot with less than a year's experience is unsafe. It has also been noted that within the last two years the same aircraft has landed on a road near Broome due to running out of fuel. CASA has as yet failed to impose any regulatory action on the operator.
The aircraft's drop down oxygen system reportedly activated during the rapid decompression and subsequent emergency descent but that the pilot failed to check on the welfare of the passengers while conducting the emergency descent to 10,000ft. One of the passengers, who has subsequently been contacted by both the ATSB and CASA for comment has reported that the aircraft "appeared old and in poor condition" and that the pilot was nervous and appeared upset. He also said that the Skippers failed to contact him to check on his welfare and that there was no medical follow up. At 27,000ft without oxygen it is suggested that a person has less than 2 minutes before becoming unconscious.
It has subsequently been observed that since that day the aircraft has not flown apart from a short test flight during which the aircraft was seen departing from Broome with an emergency exit on the right hand side clearly from another aircraft. The test flight, according to flightaware, was conducted on the 24 july 2020 and failed to get above 16,000 ft and has not flown since.
CASA and the ATSB have become interested in the matter and are investigating. Skippers has a long history of "flying close to the wire" due to its CEO, owner's and responsible manager's political clout.
CASA is reported to be sending investigative personnel to Broome to review the matter. Skippers is also under consideration by "Fairwork" and a peak pilot's union body for apparently reducing the hours of a pilot operating out of the Broome base under the job keeper scheme for apparently citing unsafe maintenance practices to the regulatory body.
Happy to answer any questions if offered confidentiality. I hope this is not received with too much bitterness - but i dont wish to be summoned by the coroner's court.
regards
This has been sent to CASA and the ATSB - lets see if the Regulator or the Investigator has the back bone to stick upto the orgasnisation.
Hi Geoff,
On the 22 of July 2020 a Cessna 441, VH-LBY, operated by Skippers Aviation suffered an explosive decompression at 27,000 while approx 80mn from Broome enroute to Brown's Range on behalf of a major mining client. The PIC, who had only recently been checked to line on the aircraft and had less than 600 total flying time, requested a descent to 12,000ft. When asked by ATC if he was "ops normal" he said "we have had a decompression problem but are ops are normal" it has been suggested that the radio call was made while the pilot was not wearing oxygen equipment. It is worth noting that the pilot has been given a Cessna 441 endorsement from an external provider - a cost cutting measure by the aircraft operator. When ATC asked if he wished to return to Broome, he responded with "no we will continue to Brown's Range at 10,000ft". ATC recordings confirm a similar turn of events. The aircraft subsequently landed at Browns Range without further incident.
The aircraft's Continuing Airworthiness Maintenance Organisation, owned by Skippers CEO Stan Quinlevin, and the acting maintenance manager, who had repeatedly come under question by CASA, requested that the pilot apply a MEL (minimum equipment list) for the pressurisation system and that the aircraft should be fly back to Broome via Halls Creek for fuel without an engineering inspection. The passengers have been reported as telling the pilot in flight that there was an "air leak" coming from the wing level emergency exit and that metal was "flexing in the wind" and that there was a loud "sucking noise". The aircraft in question has exceeded it's manufactures total airframe life limit and is only able to fly after modifications from an engineering facility in Adelaide, a modification which has been accepted by CASA. CASA, the only regulatory body in the world to extend the life of this aircraft type has come under question for allowing such a life extension to be approved - it is reported that the ASTB is investigating the matter.
One of the four passengers is seeking treatmentment for PTSD as he is unable to continue working as a FIFO worker because of the incident. He claims that stress he has encountered while flying to work in 35yo+ aircraft which often have defects and flown by a pilot with less than a year's experience is unsafe. It has also been noted that within the last two years the same aircraft has landed on a road near Broome due to running out of fuel. CASA has as yet failed to impose any regulatory action on the operator.
The aircraft's drop down oxygen system reportedly activated during the rapid decompression and subsequent emergency descent but that the pilot failed to check on the welfare of the passengers while conducting the emergency descent to 10,000ft. One of the passengers, who has subsequently been contacted by both the ATSB and CASA for comment has reported that the aircraft "appeared old and in poor condition" and that the pilot was nervous and appeared upset. He also said that the Skippers failed to contact him to check on his welfare and that there was no medical follow up. At 27,000ft without oxygen it is suggested that a person has less than 2 minutes before becoming unconscious.
It has subsequently been observed that since that day the aircraft has not flown apart from a short test flight during which the aircraft was seen departing from Broome with an emergency exit on the right hand side clearly from another aircraft. The test flight, according to flightaware, was conducted on the 24 july 2020 and failed to get above 16,000 ft and has not flown since.
CASA and the ATSB have become interested in the matter and are investigating. Skippers has a long history of "flying close to the wire" due to its CEO, owner's and responsible manager's political clout.
CASA is reported to be sending investigative personnel to Broome to review the matter. Skippers is also under consideration by "Fairwork" and a peak pilot's union body for apparently reducing the hours of a pilot operating out of the Broome base under the job keeper scheme for apparently citing unsafe maintenance practices to the regulatory body.
Happy to answer any questions if offered confidentiality. I hope this is not received with too much bitterness - but i dont wish to be summoned by the coroner's court.
regards
What in the name of common sense was a 600 hour total time pilot, flying single pilot with FIFO workers.
I thought the mining industry required two pilots for such operations.
What I can tell you is that LBY was a crappy heap of **** back in early years 2000 when owned and operated by a questionable Essendon operator at the time.
I thought the mining industry required two pilots for such operations.
What I can tell you is that LBY was a crappy heap of **** back in early years 2000 when owned and operated by a questionable Essendon operator at the time.
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Same aircraft, different incident, landing on a highway in 2018. This aircraft has more lives than a cat!
https://www.google.com.au/amp/s/www....b88764636z.amp
https://www.google.com.au/amp/s/www....b88764636z.amp
"It is worth noting that the pilot has been given a Cessna 441 endorsement from an external provider - a cost cutting measure by the aircraft operator."
Slight point of order... the operator engaged external training organisations to provide training that they had no qualifications or expertise to deliver themselves - in the pre-COVID world, not an uncommon practice amongst such operators & to be honest - a reasonable way for them to gain some external input to value-add to their operation, if they had a generative / proactive safety culture... Though I imagine now, with the current state of industry, that they have no shortage of options to provide that training in-house, if they have ended up employing pilots displaced from the majors who have previous experience on these types of aircraft. The decision by that operator to disengagewith established external training providers would more likely be the cost-cutting measure insinuated by the OP...
"What in the name of common sense was a 600 hour total time pilot, flying single pilot with FIFO workers."
Not sure about the single-pilot thing - I thought all this FIFO stuff was done "multi-crew". But - there should be no real issue with a 600 hr pilot in the seat, especially two pilot, provided the training, mentoring & oversight is present - but once again, other factors are possibly in play...
"...LBY was a crappy heap of **** back in early years 2000"
Can't argue with that. However, the C441 life extension concept has been adopted for a few airframes around the country & these machines have operated without issue for quite a while - I'm not sure how what appears to possibly be a failed emergency exit causes the modification itself to come into question - but perhaps the operator's maintenance practices are possibly lacking - let's wait & see.
What I'd really be interested to know is how one draws a potentially compromised airframe down to a pressurisation system failure that can be MEL'ed?? I would suggest that the pressurisation worked just fine (that's why the frame split!), as did the auto-deploy oxygen system - possibly it is the emergency exit / airframe that failed & the aircraft probably should not have been operated on further sectors without detailed inspection. Perhaps it is the operational decisions / organisational culture to "MEL" & operate without engineering inspection (which delegate actually gave that instruction?) that is the heart of this issue. Maybe the aircraft should have returned to Broome (80 nm away at time of failure, according to OP) rather than continuing some 300 nm further on to a remote site without any real resources / support? After the emergency descent that the POH calls for, I imagine the pax had a wonderful time sitting there wondering what was going on for the next 1.5 hrs... especially if the pilot was unable / not inclined to engage with them as the OP has suggested. If the pilot was by himself, with only 600 hrs, I'd imagine that a DP event as described above would be a fairly significant challenge & it's (somewhat) to his credit that the aircraft returned at all - more experienced pilots have mishandled DP events to far more tragic outcomes. Hopefully now that this incident has been brought into the light, we might get to learn how all this came about without the sense of apparent disgruntled-ness of the OP's comments above - it's quite possibly more about culture, oversight & operational decision making than a "simple" aircraft defect / failure.
But as Rookie said - definitely an interesting read - and possibly fiction (at least to some extent), but given previous well publicised events involving this operator (and aircraft) I wouldn't be surprised to hear that this is another classic case study in operational culture & the influence of management in the safety of operations.
Slight point of order... the operator engaged external training organisations to provide training that they had no qualifications or expertise to deliver themselves - in the pre-COVID world, not an uncommon practice amongst such operators & to be honest - a reasonable way for them to gain some external input to value-add to their operation, if they had a generative / proactive safety culture... Though I imagine now, with the current state of industry, that they have no shortage of options to provide that training in-house, if they have ended up employing pilots displaced from the majors who have previous experience on these types of aircraft. The decision by that operator to disengagewith established external training providers would more likely be the cost-cutting measure insinuated by the OP...
"What in the name of common sense was a 600 hour total time pilot, flying single pilot with FIFO workers."
Not sure about the single-pilot thing - I thought all this FIFO stuff was done "multi-crew". But - there should be no real issue with a 600 hr pilot in the seat, especially two pilot, provided the training, mentoring & oversight is present - but once again, other factors are possibly in play...
"...LBY was a crappy heap of **** back in early years 2000"
Can't argue with that. However, the C441 life extension concept has been adopted for a few airframes around the country & these machines have operated without issue for quite a while - I'm not sure how what appears to possibly be a failed emergency exit causes the modification itself to come into question - but perhaps the operator's maintenance practices are possibly lacking - let's wait & see.
What I'd really be interested to know is how one draws a potentially compromised airframe down to a pressurisation system failure that can be MEL'ed?? I would suggest that the pressurisation worked just fine (that's why the frame split!), as did the auto-deploy oxygen system - possibly it is the emergency exit / airframe that failed & the aircraft probably should not have been operated on further sectors without detailed inspection. Perhaps it is the operational decisions / organisational culture to "MEL" & operate without engineering inspection (which delegate actually gave that instruction?) that is the heart of this issue. Maybe the aircraft should have returned to Broome (80 nm away at time of failure, according to OP) rather than continuing some 300 nm further on to a remote site without any real resources / support? After the emergency descent that the POH calls for, I imagine the pax had a wonderful time sitting there wondering what was going on for the next 1.5 hrs... especially if the pilot was unable / not inclined to engage with them as the OP has suggested. If the pilot was by himself, with only 600 hrs, I'd imagine that a DP event as described above would be a fairly significant challenge & it's (somewhat) to his credit that the aircraft returned at all - more experienced pilots have mishandled DP events to far more tragic outcomes. Hopefully now that this incident has been brought into the light, we might get to learn how all this came about without the sense of apparent disgruntled-ness of the OP's comments above - it's quite possibly more about culture, oversight & operational decision making than a "simple" aircraft defect / failure.
But as Rookie said - definitely an interesting read - and possibly fiction (at least to some extent), but given previous well publicised events involving this operator (and aircraft) I wouldn't be surprised to hear that this is another classic case study in operational culture & the influence of management in the safety of operations.
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"It is worth noting that the pilot has been given a Cessna 441 endorsement from an external provider - a cost cutting measure by the aircraft operator."
Slight point of order... the operator engaged external training organisations to provide training that they had no qualifications or expertise to deliver themselves - in the pre-COVID world, not an uncommon practice amongst such operators & to be honest - a reasonable way for them to gain some external input to value-add to their operation, if they had a generative / proactive safety culture... Though I imagine now, with the current state of industry, that they have no shortage of options to provide that training in-house, if they have ended up employing pilots displaced from the majors who have previous experience on these types of aircraft. The decision by that operator to disengagewith established external training providers would more likely be the cost-cutting measure insinuated by the OP...
"What in the name of common sense was a 600 hour total time pilot, flying single pilot with FIFO workers."
Not sure about the single-pilot thing - I thought all this FIFO stuff was done "multi-crew". But - there should be no real issue with a 600 hr pilot in the seat, especially two pilot, provided the training, mentoring & oversight is present - but once again, other factors are possibly in play...
"...LBY was a crappy heap of **** back in early years 2000"
Can't argue with that. However, the C441 life extension concept has been adopted for a few airframes around the country & these machines have operated without issue for quite a while - I'm not sure how what appears to possibly be a failed emergency exit causes the modification itself to come into question - but perhaps the operator's maintenance practices are possibly lacking - let's wait & see.
What I'd really be interested to know is how one draws a potentially compromised airframe down to a pressurisation system failure that can be MEL'ed?? I would suggest that the pressurisation worked just fine (that's why the frame split!), as did the auto-deploy oxygen system - possibly it is the emergency exit / airframe that failed & the aircraft probably should not have been operated on further sectors without detailed inspection. Perhaps it is the operational decisions / organisational culture to "MEL" & operate without engineering inspection (which delegate actually gave that instruction?) that is the heart of this issue. Maybe the aircraft should have returned to Broome (80 nm away at time of failure, according to OP) rather than continuing some 300 nm further on to a remote site without any real resources / support? After the emergency descent that the POH calls for, I imagine the pax had a wonderful time sitting there wondering what was going on for the next 1.5 hrs... especially if the pilot was unable / not inclined to engage with them as the OP has suggested. If the pilot was by himself, with only 600 hrs, I'd imagine that a DP event as described above would be a fairly significant challenge & it's (somewhat) to his credit that the aircraft returned at all - more experienced pilots have mishandled DP events to far more tragic outcomes. Hopefully now that this incident has been brought into the light, we might get to learn how all this came about without the sense of apparent disgruntled-ness of the OP's comments above - it's quite possibly more about culture, oversight & operational decision making than a "simple" aircraft defect / failure.
But as Rookie said - definitely an interesting read - and possibly fiction (at least to some extent), but given previous well publicised events involving this operator (and aircraft) I wouldn't be surprised to hear that this is another classic case study in operational culture & the influence of management in the safety of operations.
Slight point of order... the operator engaged external training organisations to provide training that they had no qualifications or expertise to deliver themselves - in the pre-COVID world, not an uncommon practice amongst such operators & to be honest - a reasonable way for them to gain some external input to value-add to their operation, if they had a generative / proactive safety culture... Though I imagine now, with the current state of industry, that they have no shortage of options to provide that training in-house, if they have ended up employing pilots displaced from the majors who have previous experience on these types of aircraft. The decision by that operator to disengagewith established external training providers would more likely be the cost-cutting measure insinuated by the OP...
"What in the name of common sense was a 600 hour total time pilot, flying single pilot with FIFO workers."
Not sure about the single-pilot thing - I thought all this FIFO stuff was done "multi-crew". But - there should be no real issue with a 600 hr pilot in the seat, especially two pilot, provided the training, mentoring & oversight is present - but once again, other factors are possibly in play...
"...LBY was a crappy heap of **** back in early years 2000"
Can't argue with that. However, the C441 life extension concept has been adopted for a few airframes around the country & these machines have operated without issue for quite a while - I'm not sure how what appears to possibly be a failed emergency exit causes the modification itself to come into question - but perhaps the operator's maintenance practices are possibly lacking - let's wait & see.
What I'd really be interested to know is how one draws a potentially compromised airframe down to a pressurisation system failure that can be MEL'ed?? I would suggest that the pressurisation worked just fine (that's why the frame split!), as did the auto-deploy oxygen system - possibly it is the emergency exit / airframe that failed & the aircraft probably should not have been operated on further sectors without detailed inspection. Perhaps it is the operational decisions / organisational culture to "MEL" & operate without engineering inspection (which delegate actually gave that instruction?) that is the heart of this issue. Maybe the aircraft should have returned to Broome (80 nm away at time of failure, according to OP) rather than continuing some 300 nm further on to a remote site without any real resources / support? After the emergency descent that the POH calls for, I imagine the pax had a wonderful time sitting there wondering what was going on for the next 1.5 hrs... especially if the pilot was unable / not inclined to engage with them as the OP has suggested. If the pilot was by himself, with only 600 hrs, I'd imagine that a DP event as described above would be a fairly significant challenge & it's (somewhat) to his credit that the aircraft returned at all - more experienced pilots have mishandled DP events to far more tragic outcomes. Hopefully now that this incident has been brought into the light, we might get to learn how all this came about without the sense of apparent disgruntled-ness of the OP's comments above - it's quite possibly more about culture, oversight & operational decision making than a "simple" aircraft defect / failure.
But as Rookie said - definitely an interesting read - and possibly fiction (at least to some extent), but given previous well publicised events involving this operator (and aircraft) I wouldn't be surprised to hear that this is another classic case study in operational culture & the influence of management in the safety of operations.
Let’s all jump and down about how the pilot should of had 4000 hours to be in twin turbo prop.
It doesn’t appear to be a new inspection, rather one that needs to be carried out more regularly.
Conquests are such a wonderful aeroplane. Far better than the competition in terms of range, payload, performance. But they are getting on in age now. You can’t flog them forever. I’ve never heard someone who flew one complain about it. Although it’s pretty lonely single pilot at FL350 in a 40 year old frame.
It’s probably time to get some new king airs in and be done with it.
It’s probably time to get some new king airs in and be done with it.
"It is worth noting that the pilot has been given a Cessna 441 endorsement from an external provider - a cost cutting measure by the aircraft operator."
Trouble is, in human equivalent years, they're probably older than me and I suspect many are showing it like me too!
Last edited by C441; 7th Aug 2020 at 04:09.
Not so sure that age is the whole problem - with pressurized aircraft, cycles do tend to wear out lots of"stationary" bits and pieces.
As for a 600 hr TT pilot flying single pilot? Good grief. That's less than 6 months of actual flying experience (600 minus the 250 hours of CPL training). Not even one cycle of the climate. With so many unemployed, and experienced GA pilot, why oh why would they hire a 600 hour ace.? Daddy made the call can be the only answer.
And yes, 4000 hours is a good minimum number for single pilot operations in a complex turboprop because you cannot always guarantee the near perfect benign weather of W.A. in winter.
As for a 600 hr TT pilot flying single pilot? Good grief. That's less than 6 months of actual flying experience (600 minus the 250 hours of CPL training). Not even one cycle of the climate. With so many unemployed, and experienced GA pilot, why oh why would they hire a 600 hour ace.? Daddy made the call can be the only answer.
And yes, 4000 hours is a good minimum number for single pilot operations in a complex turboprop because you cannot always guarantee the near perfect benign weather of W.A. in winter.
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And yes, 4000 hours is a good minimum number for single pilot operations in a complex turboprop because you cannot always guarantee the near perfect benign weather of W.A. in winter.
Well that grounds all RAAF fighter and bomber pilots.
And yes, 4000 hours is a good minimum number for single pilot operations in a complex turboprop because you cannot always guarantee the near perfect benign weather of W.A. in winter.
The Conquest was somewhat quicker than our previous aircraft but most managed the transition comfortably including regular operations from ASP to ADL & MEL all year round and the usual wet season adventures in the Top End.
What on earth is anyone doing involving GT about anything to do with aviation? He has zero credibility among professionals in this industry.
He once published a story about me that was completely made up. Only ignorant people believe his nonsense.
It's a bad idea to feed trolls.
Looks familiar?
The Lazy Journalists Plane Story Generator
He once published a story about me that was completely made up. Only ignorant people believe his nonsense.
It's a bad idea to feed trolls.
Looks familiar?
The Lazy Journalists Plane Story Generator
Last edited by Clare Prop; 8th Aug 2020 at 01:21.
The mob I worked for in the Territory in the early to mid 80's had 3 Conquests. Most of us had around 2000 hours when we first got to fly the Conquest, usually about half of which were in 310's and 402's, the rest in 210's.
The Conquest was somewhat quicker than our previous aircraft but most managed the transition comfortably including regular operations from ASP to ADL & MEL all year round and the usual wet season adventures in the Top End.
The Conquest was somewhat quicker than our previous aircraft but most managed the transition comfortably including regular operations from ASP to ADL & MEL all year round and the usual wet season adventures in the Top End.
Sooo...NOT Single Pilot and with probably far more intense training for someone that was already well above the standard of your average Pilot in the first place to even get in? On Aircraft that are maintained by some of the best in the world with some of the best equipment in the world... are you seeing any differences here between the two?