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They refer to HUET (helo underwater escape training) in the report. As the helicopter will sink very quickly & most likely roll with all the weight above the roofline. The drill is to crack whatever door you can & get out. Maybe the captain was following that drill ??
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Unlike the ATSB report planetalking has no problem heaping it on to one and all of the various stakeholders that were party to this incident::ok:
Which also means CASA’s rules, contrary to the posturing of the safety regulator after the accident, were so weak that Pel-Air wasn’t obliged to carry enough fuel for a diversion caused by weather or other circumstances right up to the point where it overflew its intended destination. But three years later, CASA ‘intends’ to fix the problem. This triumph of prompt regulatory intervention, follows an incident in which poor pilot decision making by an apparently fatigued Pel-Air employee, resulted in six people, comprising two pilots, a nurse, an attendant, a patient, and her companion, flying four missed approaches to the Norfolk Island airstrips, and then making a controlled water landing at around 160 kmh after which the jet broke into two parts and sank 48 metres to the sea bed, leaving those on board to tread water or cling to wreckage before being found by a boat that had been looking in the wrong area when its skipper fortuitously glimpsed the pilot’s torch from afar. It also confirms the truth of the astonishing comment by Pel-Air chairman, John Sharp, the morning after the near disaster, that the pilot, Dominic James, had set off from Apia with no plan B in the event that the flight couldn’t land on the island where it was to refuel. There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia. There are parts of the developed world where this level of regulatory and operational performance would offend aviation law. But not in Australia. Pel-Air ditching report hurts the more as it sinks in | Plane Talking There is also more evidence of the ATSB's 'softly, softly' approach in accident/incident reports over the last few years: The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisations. In addressing those issues, the ATSB prefers to encourage relevant organisations to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices. |
Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia?
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Interesting that there is no weight analysis to assess what extra fuel may have been loaded, if any. ie Was the aircraft at max all up weight on departure Apia? |
...or a more suitable aircraft should have been contracted for the job......or a fuel stop made at Nadi.
While not wishing to become an armchair umpire after this sad event, it is all too common for aircraft operators to enter into deals with unsuitable equipment simply because they already have it. And clients all too keen to accept such equipment on the basis of price alone. |
Bits missing
It is also interesting that they refer to the conversation between the pilots and the Unicom operator however they didn't release the tape. They released their own video so why not the tape. Also they refer to the briefing and flight planning conversation for the return trip but no transcript or actual recording.
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And clients all too keen to accept such equipment on the basis of price alone. Different operators will have different price structures and different profit margins. Is the client really expected to determine the underlying reason for the lowest price? After all, it is a more significant decision that brand name versus no name brand at the supermarket. The client may well expect that the regulator and operator will ensure that the operator will conduct operations in a safe and appropriate manner. |
Soft pedal – (una corda pedal).
Plane Talking - Instead the report, which is a master class in how to write commercially inoffensive copy that will avoid raising public concerns, notes only that CASA has “advised of their intent to regulate Air Ambulance/Patient transfer operations in proposed Civil Aviation Safety Regulations …. to safety standards that are similar to those for passenger operations.” Bit tragic to see the integrity of the once modestly proud, fearless, independent BASI become a cats paw for spin and dross. I wonder what the NTSB would have made of this, not a three year meal. That's siccar. |
K, do you ask for more regulation, surely not:eek:
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Reading the report, the crew did have fuel for a diversion to Noumea between approx 0905 and 0930.
They had 3 Speci reports (2 in this 25 minute period), each getting worse. Once the first Speci was received at 0800 indicating that the weather at LHI was not as forecast, the process to assess the actual weather at Nandi and Noumea should have started. This should have been the main focus of the crew for the next 90 minutes up to the PNR for Noumea. As the weather at YNSF was deteriorating from the Specis received during this period, 90 minutes is more than enough time to determine the time and fuel required for a diversion to Noumea. The crew state that they were not sure of the winds to Noumea. They were in the position of flying in the actual wind. This was probably more accurate than the Grid Wind forecast, if they had it. It appears no request for the weather at Noumea was made. Why? This would be the first thing asked for once the first Speci for YNSF was issued. As we are not informed of the weight at departure, we do not know how much extra fuel may have been carried and if that extra fuel would have allowed an approach at YNSF and a diversion to Noumea. One thing that was not raised is the need for a Company to require an alternate when planning to a single runway airport, especially a remote destination. The Westwind is above the weight allowed for 04/22. |
ATSB have determined it was AWK, fair enough (despite the obvious issue of there being non-essential passengers aboard). I was surprised however to see no mention of the Careflight task management, where the aircrew and medical crew elected to undertake a couple thousand km over-water flight with no alternate nominated, at night, when the patient condition allowed for the flight to be undertaken in daylight. As AWK, the medical crew form part of the operating crew so come under the ATSB scope of examination. A significant contributor to the outcome I would have thought.
On reading the report I formed the opinion that it was somewhat vanilla froth. |
4 Corners on September 3rd features this incident.
From my brief glimpse of the promo last night, I thought the aircraft shown was a Lear. |
It may have been covered in the previous pages, so sorry for the double up but...
Does anyone else think that the landing gear looks down and locked? Would a lack of hydraulic pressure cause the gear to fall that straight? If the gear was up, should the fuselage have broken like it did? Not suggesting it was down, just curious. |
GN,
If the gear was down on landing the force of impact with the water would have torn it off. Nowhere really spells: Now. Here. |
Thankfully no fatalities resulted from this unfortunate incident.
I would suggest it is probably not over for Pel -Air you would think that the ATSB report provides some ammunition for a Civil Claim. Or has this already commenced? Is there are valid reason why the Captain would exit the Aircraft first. That seems a bit odd or has the report left some detail out. |
Nowhere really spells: Now. Here. |
You would have to imagine the legals were waiting for this report before doing anything. The report states that care flight had not done a audit for a long time. That seems a bit out of line and could also be significant
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GN, I doubt the gear was down for the ditching. Well hopefully it wasn't.
1 line of thought tho for off field Emerg landings on LAND tho is to lower the gear as it is a very strong component and will help absorb impact forces as it is possibly torn off by the impact. This means, hopefully, less forces to be absorbed by the fuselage/cabin area thus a greater chance of survival. Obviously every situation is different and requires a judgement call at the time. |
Thanks for the replies, like you said Aus, one would HOPE the gear was up. It does look pretty well locked down though! :confused:
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Going Nowhere,
If you read the report you would know it says in part: The wreckage came to rest on a sandy seabed. Video footage showed that the two parts of the fuselage remained connected by the strong underfloor cables that normally controlled the aircraft’s control surfaces. The landing gear was extended, likely in consequence of the impact forces and the weight of the landing gear. The flaps appeared to have been forced upwards from the pre-impact fully extended selection reported by the PIC. |
Casa as Irresponsible in surveilance
From the ATSB report:
The decision to continue to Norfolk Island Under conditions of increased stress or workload, working memory can be constrained and may limit the development of alternative choices and the evaluation of options. Depending on whether the available options are framed in a positive (lives saved) or negative way (injuries and damage), a decision maker can be influenced by how they perceive the risks associated with each option when making a decision. When decision-makers are confronted with options that are considered as a choice between two different benefits, decision makers tend to be more risk averse. They tend to prefer a guaranteed small benefit, compared with just the chance of a larger benefit. On the other hand, when decision makers are faced with a choice between two options that are considered as two separate losses, they tend to be more likely to accept risk. In this instance, the flight crew described the choice when they first comprehended the deteriorating weather conditions at Norfolk Island as being between diverting to Noumea and continuing to the island in terms of assessing competing risks. Given the weather and other information held by the crew at that time, including their not having information on any possible alternates, their perception that the higher risk lay in a diversion was consistent with the greater number of unknown variables had they diverted. Is this another "SeaView" ??? in failed procedures and surveillance?? |
I have difficulty in criticizing the captain for being first out of the exit. Just imagine - he's gone back to the cabin to open the exit and get his pax out, his primary responsibility - now there is an open exit. Can you imagine his trying to fight his way back forward in the cabin when the pax REALLY want to exit? I imagine that he was fired out of the exit almost like toothpaste out of a tube.
His other decisions might well have been questionable though IMHO. Real men don't divert!! |
I was surprised however to see no mention of the Careflight task management |
Reading the report, I was surprised:
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Let dead dogs lie!
The Aviation Advertiser, in its article 'CASA revives a dead dog', makes mention of the ELT (fixed), which apparently gave one squawk and then quit, hmm that far overwater (if it was me) I'd be carrying, or have very close to me, one of those PLBs!
The ATSB’s report on the Norfolk Island ditching accident adds a real-time account that puts the realities of ELTs into further perspective: The aircraft was fitted with a 406 MHz emergency locator transmitter (ELT), which was designed to transmit a distress signal that could be received by a satellite. The ELT could be manually activated by a switch in the cockpit, and it would also activate automatically if the aircraft was subjected to g-forces consistent with an aircraft accident. The aircraft was also equipped with four personal locator beacons (PLBs) that could be carried separately and manually activated. Two of these beacons were installed in the life rafts, and one of the remaining beacons was equipped with Global Positioning System (GPS) equipment, which would enable it to transmit its position when it was activated. The aircraft occupants were unable to retrieve any of the PLBs before they exited the aircraft after the ditching. The aircraft-mounted ELT was not GPS-equipped. A geostationary satellite received one transmission from that ELT and the information associated with that transmission was received by Australian Search and Rescue (AusSAR) 38 8 minutes after the aircraft ditched. AusSAR was able to identify the owner of the ELT, but was not able to assess its location from the one transmission. Obviously the single transmission was impact-activated; however it seems probable that the airframe damage caused the antenna or its connecting lead to fail after that first transmission. CASA revives a dead dog – opinion – aviationadvertiser.com.au |
The careflight document mentioned above states:
EPIRBs – Personal issue EPIRBs / strobes were not carried by our crew at the time – but now are! • Crew also now carry their own life‐jackets equipped with appropriate survival aids Edit: I might also add, that I am surprised that in this computer day and age a contracted jet aircraft is still relying on manual flight planning for an international overwater flight! The industry standard is to pay the reasonable fees of a professional third party planning company, such as Universal Weather & Aviation Inc, or Jeppesen. In that way, the plan could simply have been faxed to the pilot's hotel - and you are not relying on a tired pilot not making an arithmetic error (or a simple inability to correctly determine the critical contingency point). |
casa and surveillance
From page 29 of the ATSB report:
Part A Section 9.11.2 of the operations manual titled Critical Point required pilots to calculate a CP on ‘appropriate’ flights over water that were greater than 200 NM (371 km) from land and on all other flights for which the availability of an ‘adequate aerodrome’52 was critical. There was some disparity between that section and Part B section 6.1.2 of the operations manual titled Calculation of Critical Point, which omitted the need for an available adequate aerodrome, instead stating that a CP was to be calculated for flights where no ‘intermediate aerodromes’ were available. Smell like Lockhart River?? And then at page 35: Five different operators were interviewed and provided relevant sections of their operations manuals for review. Those manuals generally reflected the requirements of CAAP 234-1 but also had individual operational requirements appended. However, they either had no guidance, or did not provide consistent guidance on the process to be used when deciding whether to continue to a destination in circumstances similar to those affecting the flight to Norfolk Island. When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided. Now, as I read on, is there any SR to be found on the topic??? |
This Monday's Four Corners on ABC TV is all about this incident. Should make for interesting viewing.
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Bloody Nanny state.
UIA- When questioned on how they expected their flight crews would act in this situation, the operators generally answered that they expected flight crews to base their decisions on past experience and a conservative approach to flight planning to ensure their flight remained safe at all times. The concept of ‘good airmanship’ was frequently used, but consistent methods for implementing good airmanship to address this situation were not provided. I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against. The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office. No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations. BH - K, do you ask for more regulation, surely not. |
This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors).
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John62 - This particular operator is rumoured to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors). The stuff not written which carries the full weight of 'company' rules and a bollocking. Don't buy fuel at ABCD – to expensive; don't land at EFGH – we barred; don't ask for RTOW charts, etc. etc. We all have heard or seen it. Minimising uplift at 'expensive' ports and tankering fuel at 'cheap' ports is a game often and well played. It's called operating a service, as is saving a ton of fuel or finding the best flight level, or any of that unwritten, command type stuff. But, even if the rumours related to Noumea were true, I'd pick a night in French pokey over a swim in dark, any old day of the month. |
Agree "K" you can't regulate for sheer stupidity or a severe case of 'pushonitis', although the philosophy is very much akin to the regulator's i.e. 'flying with the blinkers on'!:E
However one does wonder why it took so long to complete? Political correctness, sense and sensibilities, who knows? Also what's with the wishy, washy soft cock approach by the bureau??:ugh: |
Also what's with the wishy, washy soft cock approach by the bureau?? OR they may learn from their mistakes - we could not have that now, could we. |
This particular operator is rumored to have had a difficult history at Noumea, which may be relevant to the decisions concerning flight planning and alternates (both sectors). |
Kharon
Neither should there be; it only leads to more prescriptive, draconian, criminal based law being produced and misinterpreted, by all. Command discretion is an essential given; in theory, it's why you get paid the big bucks. It would be grossly unfair and harsh to criticise CASA in this case. I doubt there a pilot in command Australia who when faced with 1440 nms of open water, to a remote island, famed for fast changing weather, with a front approaching, in the middle of the night; would amble off with less than maximum fuel and at least 3 assessment points to base divert decisions against. The fuel was there, the alternates were there, the weather reports were there; South Abeam Fiji (Nausori), fuel status check, PNR/ETP back to Nadi fuel status, TOD weather and fuel check – divert to La Tontouta. Just another day in the office. No, not the company, CASA or the BoM, have a look at page 1; the Alternate on the way out was Brisbane 736 nms the wrong way against the wind. LA Tontouta is 432 nms in the right direction with the wind. You cannot legislate for that type of thinking, it would bring aviation to a standstill. It's even a bit rich wanting the "Company" to specify where, when and with what weather an aircraft 'must' divert. Command discretion (or lack thereof) is the key, not more bloody half arsed regulations. have a long hard look at the report from a purely operational viewpoint; no amount of regulation would, or could have helped ? |
I had wondered this particular point a while back, perhaps also the same applied at Nadi? I had missed this point in the report. Good catch Kharon. |
Didn't pull the tabs down on the tip tanks?
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Is strict compliance the problem?
This is the bit vexes me. Long, complex, subjective, prescriptive, variable interpretation regulation.
ATSB - CAO 82.0 expanded on a number of the CAR 234 requirements for application in specified circumstances, including passenger-carrying charter operations to defined remote islands, such as Norfolk Island. As an aerial work flight, the aeromedical flight to Norfolk Island was not subject to these CAO 82.0 requirements, but they nevertheless provide useful context. ATSB - Although not assessed as part of the study, the importance of the PIC as a risk mitigator in the case of un forecast deteriorated weather at the destination was discussed in the conclusion to ATSB Research Report B2004/0246 titled Destination Weather Assurance – Risks associated with the Australian operational rules for weather alternate weather (available at Australian Transport Safety Bureau Homepage). ATSB report - here. Chapter 3 is the one you want – sure, it's a little tedious (nature of the beast) but I'd like to see a copy in every technical library. The ATSB can and do put some great educational tucker on the table, it's just that it's so hard to find. Food for thought – you betcha.http://images.ibsrv.net/ibsrv/res/sr...ies/thumbs.gif More real life education – less micro managed compliance bollocks. :ugh: |
In the good old days one had an option to declare a "mercy flight" and not many suffered the chopping block for working outside the required minimas. Unless it all went tits up of course. Anyone using the two way communicative device would assist to help make the flight a success.
How many would dare attempt such a thing today? Operating an EMS service with an AOC pertaining to same is a different thing I guess? |
When the 'game' is compliance and only compliance, this sort of incident results. Fact - it's a small island in a lonely corner of the world. It's a bloody long march to the nearest friendly place (fully equipped with dancing girls and cold beer). What experience did the P in C have on this sort of Op? Did he have a a good understanding of the vagaries the the weather at Norfolk? Even if he didn't, I still don't understand the decision not to divert while there was still time. |
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