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A fuel policy that pushed things to the very edge of the legal limit with no thought whether this was sensible (aerial work so no alternate). A pilot who pushed things even further (no OEI). A sense of complacency (not getting en route weather and not monitoring a deteriorating situation). Possible difficulties at Noumea. Poor CRM (not asking FO to check calculations).
How else was this going to end up. This all reads like a recipe for disaster. In the end they got themselves backed into a tight corner. There is more than enough blame to go around. The crew did the wrong thing, but they were not the only ones. |
why no mention of the decision to not fill the tip tanks?
Also, why were they made to climb/descend when surely as an aero med flight it would have had a STS? As for not having current weather/notams for possible diverts enroute.:ugh: Is there no fax machine on Norfolk? We can get by without the net. Seems to me he called up with the flight plan then said by the way whats the TAF? No need for that trend from 1500 best be on my way. |
Four Corners Monday - Norfolk Ditching
Just noticed it on my Internet TV guide. Should be interesting.
DB |
Two Hours Island Holding:
Was always standard operating procedure for our company, in fitting with a favorable TAF! add into that any TEMPO, and it had to be re-thought:
Even with a favorable TAF, We got caught out going into Funifuti, 5 missed, and we got in on the 6th! power back at minimum, M-Apps, at lowish power, was not a very nice feeling! And before you ask, 10 minutes before the PNR, Nadi had given us via HF a suitable Metar, and TAF! so anything can happen especially when the CTZ gets down below 15 Sth: When I asked the F/O what he thought of bringing one to Idle power and Feather, he nearly choked. ::eek::sad::ooh::suspect::{ H/Snort: |
Given that the crew had put themselves between a rock and a hard place, would it have been possible to set up a v/s of 800'/min on the A/P, keep vor/loc coupled and come down to 200' to try and get visual? Given the performance of a Westwind I imagine that a go-around would have been successful from a low altitude. They seemed to have persisted with VOR approaches to the minimum even though they had been told that the cloud base was 200'.
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What? A 200 Ft base:
I am not prepared to say what I went down to, get into Funifuti, BUT! 200 Ft while not being legal, in a circumstance such as this? is ample!:=:=
H/Snort: |
There's a line in the report stating that on the last approach they went below the minima to try to get visual, but it doesn't detail how they did so, nor how far below they went.
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4 corners preview
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I tell ya what being down at 200 ft at night doing an NPA (well Blw the Min) very close to the AD with minimal fwd vis virtually zero room left to maneuver & with rain pelting against the screen, the fuel gauges showing 'E' & you know that going around from this means possible death or ta least career ending actions would have any pilot almost at their maximum level of capability.
Like I've said b4 on this subject I bet my left one (the right one I lost in a bet years ago!:E) that commercial pressure was the main criteria that found Dom in this ugly mess.That along with possibly not enough experience & poor flight planning in these Ops means a LOT of young pilots can & will find themselves in similar situations maybe not as drastic as this one but still life changing. As has been said it's got zip to do with what's legal here (AWK PVT Etc) there's still flesh & blood being carried regardless of the regs. A good Capt Commands:ok: Most of these light jets are capable of carrying full fuel (or close to it) in an average Aero-Med config. Taking off with less than full fuel on such missions means there's some external force making that decision. They survived & lets hope that something good can or has come good of this. At the very least this accident might make some young buck one day think twice about going skinny on the gas due Commercial pressure! As for the final report on this?............well that's just a waste of time to even be put together. Too much legal jargon & ass protecting to be of any benefit really. Wmk2 |
Impossible on any form of TV journalism to get the nitty gritty out in the open, in house lawyers will be controlling every word.
CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! |
Spooky spooky
CASA will go free !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! http://t3.gstatic.com/images?q=tbn:A...q6uHGlE_8i&t=1 |
You mean 4 Mourners don't ya. Three years in the making, oh roll up, roll up.
The stats are interesting, CASA reports to the Minister, the ATSB reports to Minister, the ABC depend on the Gummint for Dollars, (if not sense); and we cannot have the Minister' s wee boat rocked. Yup, the 4 Mourners show should be worth the cost of the carbon rich electricity. Tony the Tiler - Smoke and mirrors is the new act, normally reserved for the corporate management thug types, but now adapted for the Elephant hiding act. Now, as everyone knows, elephants are very hard to hide. But, in a light bulb moment, the elephant hiding ringmasters have decided that the next best thing to hiding an elephant is making it disappear. Wow, the crowd is silent in anticipation, a disappearing elephant act, can it really get any better. Sadly, the act is only part way through and my source is unable to report on the outcome of this new and daring act. But so far there is a lot of smoke and distraction and something called unity. Unity is mentioned by the ringmasters at every opportunity, what can it mean and where will it end? |
A month later, the Civil Aviation Authority (CASA) took away James' pilot license and his reputation was all but destroyed I wonder what else they will get wrong. |
The cause distilled
At the risk of being accused of harping on about professionalism (or the lack of) and over simplifying the analysis of the accident you need only look at the writing between the lines in the "Celebrate the professional pilot" thread, now closed.
Of over 2000 views only one pilot had the testicular fortitude to admit that he was coerced into "non compliance". Even on this forum that thrives on anonymity, nobody else could put their hand up and say that they had stood up to coercion from their employer. Either too afraid speak up or just plain had never exercised command judgement. Hopefully it is not the latter. Combine that GA upbringing and an organisation culture where blind obedience to a figure that had and exercised the power to make or break a career then you set the stage for this sort of accident. You only have to wait for the players to walk on stage. Even worse you condition the pilots to replicate the same behavior in the cockpit. |
Four Corners
Ben Sandilands seems to know what angle Four Corners is taking, so we can assume that Ben was a source interviewed for tonight's episode.
He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report. Pel-Air exposé on ABC 4 Corners tonight is a must view report | Plane Talking Pel-Air exposé on ABC 4 Corners tonight is a must view The ABC TV show 4 Corner’s exposé on the Pel-Air ditching near Norfolk Island that airs tonight goes directly to the honesty and candor with which aviation safety regulation is pursued and discussed in Australia. It is a must see program. The issues of transparent and fearless public administration of air safety regulation and investigation have been central to Plane Talking for five years but their pursuit by a well resourced national television program is an important breakthrough. Tonight’s program is more evidence that the flawed regulatory performance of CASA, the air safety regulator, and the supposedly independent safety investigator the ATSB, include a systemic failure to fully and unambiguously keep the public informed about substandard operations. 4 Corners will disclose matters arising from a CASA audit of Pel-Air, conducted immediately after the Norfolk Island incident, that ought to have been included in the ATSB final report into the crash. The non disclosure of such matters raises the question as to whether CASA, the ATSB and by association, the responsible minister, are deliberately acting to protect the airlines or aviation services providers and their regulator from better informed scrutiny of their respective capacities to follow or draft effective safety regulations. |
The reason I mentioned the lack of a weight analysis in an earlier post is this taken from another 1124A accident.
Because of the Westwind II design, a small change to the aircraft's load can result in a relatively large shift to the aircraft's centre-of-gravity (C of G) position. The aircraft's C of G envelope is published in Section VIII-21 of the Westwind II Airplane Flight Manual . The lower portion of that envelope identifies two separate zones. The manual indicates that, if the aircraft's zero fuel weight falls within zone 1, then fuel may be loaded up to the maximum ramp weight without exceeding the C of G limits. However, in order to maximize the aircraft's payload, the aircraft's C of G at its zero fuel weight is normally adjusted to the aft-most limit of zone 1. As passengers, baggage, and fuel are then added, the C of G will move progressively ahead, toward the forward limit of the operating C of G range. This adjustment to the zero fuel weight C of G position is accomplished through the use of removable ballast. Prior to departing from the Edmonton Municipal Airport, the flight crew had positioned 100 pounds of removable ballast (four 25-pound bags of lead shot) into the aft baggage compartment in order to configure the aircraft's C of G to allow for the loading of eight passengers at Meadow Lake. The aircraft's weight and balance for the re-positioning flight to Meadow Lake were within prescribed limits. Its weight for the time of the accident was estimated to be 18,138 pounds, and the distribution of that load would have placed the aircraft's C of G at the aft limit of the aircraft's C of G operating range. |
The two comments (so far) from Ben's blog article are interesting...
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What are the pilot (Dominic?) and the Co-Pilot doing now?
Are their careers in aviation over??? (Presumably) taking a Westwind for a swim is not good for your cv and job prospects. |
Originally Posted by PaulDamian
(Post 7393196)
What are the pilot (Dominic?) and the Co-Pilot doing now?
Are their careers in aviation over??? (Presumably) taking a Westwind for a swim is not good for your cv and job prospects. |
It was mentioned earlier in the thread that the FO who was conveniently having a sleep during the weather update is in the RHS at virgin. That kinda got my attention, but I did wonder at the relevance! Dr :8 |
He seems to be suggesting the CASA audit into Pelair found deficiencies, but did not find its way into the ATSB report. I wonder what sort of mark CASA will get. |
I believe Dominic will achieve immortality as this accident becomes the centre of many future CRM courses.
Hogsnortrupert, there is a big difference descending to 200ft at Funafuti where the highest point is a coconut tree, to 200ft at Norfolk with higher ground in the vicinity. |
Looking at the plates for the vor 29 and 11 the inbound tracks are displaced along way from the rwy centreline. This would not be ideal in weather below the minima.
Perhaps the rwy 04 approach would have been worth a shot. Although its shorter, the rwy is lit and the inbound track is only 2 degrees off meaning the threshold at least would have been straight ahead. I'm sure 4700ft would have been long enough for a very light Westwind in the wet. Maybe that approach was not available at that time. |
In an emergency low fuel situation coming down to 200 ft at Funafuti would be no biggie if flown accurately, because the highest tree is only about 50ft. Cyclones usually knock them over if they try to grow any higher.
Groping around at 200 ft at Norfolk, at night, would probably be terminal for the occupants of any aeroplane so foolishly flown. For all that he got so wrong, finally coming to the conclusion that he had to ditch (even if it was in the wrong place) was proper. All on board owe their lives to that decision rather than the alternative of attempting a landing with no visual contact with the runway. The weather at NLK is tricky. They can be calling it below minima from the ground yet sometimes the approach and landing can be completed without busting any limits. On other occasions - and sometimes even within a few minutes of being OK - it is just impossible to see anything at the minima - or even a bee's dick below minima (altimeter error, honest it was). Given the way the weather was coming through in waves on this occasion, I certainly would have tried as many approaches as I had fuel for - up to the point of being able to divert to NOU. But being at NLK with no diversion fuel - not done that since the Bae 146 did the run, when PNR was at top of descent. But then we had to be absolutely sure it was OK to continue. One crew nearly got caught out once and gave themselves a good fright, and I am sure there were others less publicised. Then, praise be, the rules changed to require an alternate for RPT and charter. Obviously paying passengers' lives are more important than patients flying courtesy of insurance (don't get me started on double standards in aviation!) This ditching appears to be the direct result of inexperience being exploited by a loophole in the regulations. Poor judgement being the by-product of inexperience. Loophole in the regulations being the by-product of an incompetent regulator. |
what a crock
kharon, spot on the money...
pathetic :yuk: |
Four Corners Report
The really interesting part of the whole saga is that a fair chunk of evidence can't be produced unless there's a senate enquiry. Even with what was produced tonight though should be enough to get people asking questions as to the relationship between CASA the ATSB.......and the clowns that run Pelair and Rex.
Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case. |
After that incompetent perfrance, the Screaming Skull should be cleaning out his desk. Even his former right and man turned on him.
What's misleading performance , yes Skull 40 years ago when you began your legendary career etc etc, something's never change, the regulator is never wrong, and yes CASA had no problems with the Captain retaining his license for six weeks, but pulled it on Christmas Eve, reprehensible scum |
I think the skull had make-up.:*
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Just maybe now, some of the drooling no name fools that that lurk these pages may sit down and have a think about the way they went at Dom James...one could hope in any case. I didn't operate in a vacuum. I operated as a pilot that belonged to a company that was overseen by a regulator. You can't isolate one thing from all the others and say that's a fair appreciation of what took place. |
What really hit me from tonight's Four Corners programme:
The Head of CASA denigrates the pilot for not demonstrating an ability to plan a flight ex Samoa without software. He's clearly angered by this. Its almost as if he's found the smoking gun. Pretty much a 'gotcha' moment from the CASA head. He seemed argumentative, defensive & abrasive. This guy appears to be a guy who makes his mind up and locks on to a belief when clearly there are contributing factors way beyond simple pilot error. To say none of the Pel-Air breaches would have contributed to this accident is simply wrong. When CASA identified PA as failing to comply with fatigue management systems, THEY CONTRIBUTED TO THE ACCIDENT. How does CASA repeatedly fail to find these breaches in time? |
MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet. That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed. MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ... GEOFF THOMPSON: So it might be a mistake. MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that. GEOFF THOMSON: And he did. |
The program was an opportunity lost to explore the mess that CASA and the ATSB has become under commercial pressure and the compromises it is producing. It did, however, reveal the problems surrounding obtaining weather information and the complete shambles that Pel Air had for flight planning.
Fair doos to Mr James for being prepared to face questioning. I would have liked more information on the differing fuel calculations as to fuel remaining had they diverted to Noumea. From the pilot's perspective I can understand why 8 minutes is not inviting based on their figures. |
The story should have placed a far greater spotlight on CASA and the ATSB. This poor standard in regulatory oversight has happened before and logic says it will happen again.
Tonight I will write to the minister and ask for the Head of CASA to be removed. |
GADRIVR
I am as critical of CASA as the next guy, the oversight, the company, the lack of sleep, the bad planning, the conflicting weather, and everything in-between is just not kosha with most people who read this stuff. I see your point about Dominic being the soft target, and yeah I feel for the guy, but at the beginning of the day, he had the ability to pull the pin. And should have. PelAir should have had all his planning done for him, just like a good supportive company operating into these places should do. But clearly the did not. Back of a beer coaster planning is fine for Mudgee to Dubbo, but not across the oceans of the south pacific. No way! At several points, the lack of sleep. The lack of wx and planning. The fuelling choices. The wether reports and conflicts, all should have been triggers something does not add up. Three strikes you are OUT principle applies when bush flying, local flying and when the company, the systems etc are letting you down, the 3-strikes rule could well save the day. I understand, the circumstances all conspired against him, but what he did with them was poor, and you could easily blame fatigue etc, but he himself did not believe that was a factor. There were options, and 4 corners did not explore them at all. Hate to say it, but criticising JMAC over his comment is a bit lame. As T28D has pointed out there are other choices that are more runway aligned, and none used. The ones tried are nowhere near the runway, and were futile really. One thing is for sure, I bet Dominic never makes that mistake again! |
Unsafe skies for all
There was a lot in this interview to be disected, no doubt. But 3 things were extremely disturbing;
a) The fact that the ATSB's reputation for unbiased, clear and concise investigation reports has absolutely hit '**** bottom'. CASA has been a bureaucracy for decades so there is nothing new or shocking there, however the ATSB in the past few years under Dolan's direction has become a complete joke. He was caught off guard, looked awkward, stumbled and looked like Beaker off the Muppets. Reports containing piffle and bollocks are now the norm. Investigations are absolute light weight ****e. The same methodology is employed at the ATSB and ASA and it sure as hell stands out. At least Russell got the heave ho from ASA, but it might be time to get some of the old ATSB gang back on deck? b) The return of Herr Quinn! We wondered where the wiley old rascal had been hiding. After being pineappled by the Skull a few years back (at least the Skull had the balls to do it unlike Byron) and he has been waiting to fire a bullet. So for Quinn I imagine it was more an act of sour grapes and payback. The same applies for his 'sidekick' who also featured on the show, he is most certainly a former CASA employee who lasted just over a year, and has many chips on his shoulder against the authority also. There is a lot more to the Quinn/Aherne stage show but best let sleeping dogs lay. c) The Skulls make-up. Fair dinkum, he looked like a dolled up Ladyboy! 4 Corners should sack its make-up artist immediately. When the angry man watches the replay tomorrow he will be reaching for the stoogies and going nuts over his poor performance (he sounded very nervous and didnt even look like cutting loose and throwing some office furniture). Heaven help the first Inspector or operator to screw up Tuesday morning as the Skull will be raining down fire and brimstone, not to mention the phone calls that he and Dolan will be receiving from the Minister for Mascot. Which one is Beaker???? http://t1.gstatic.com/images?q=tbn:A...D9XE_1_qPQ&t=1 http://www.itsasafety.org/images/upl..._Australia.jpg Mememememememememe. |
What a shambles that whole saga was & totally unnecessary!!
The extensive footage of the LE 35 on the program (same one I used to drive) brought back memories of crappy nights out there over the Pacific in a tiny 2 eng plane. A place where there was no decision on how much fuel you took you simply filled it to the gunnels & made sure that you had an escape at every point along the intended route. SE or Depress Ops usually meant max fuel anyway. At least I had great support from a great Company. I'd like to think that something good might come from all this by way of strong directions & rules from the regulator so that young pilots can learn from Dom's life changing event. Wmk2 |
It most certainly was an interesting watch! :ugh:
Tonight I will write to the minister and ask for the Head of CASA to be removed. Quick question, Should the passengers be compensated? |
Quick question, Should the passengers be compensated? Also, for the head of CASA to be so black and white about where the blame lies when any layperson watching 4 corners could see the issue is complex and multi faceted, in my opinion makes him completely unsuitable to hold that position. My girl didn't know whether to be amused or concerned when I told her he was the head of the 'safety' regulator. "THAT guy's keeping you safe?!?!" |
As a former Chief Pilot of a International medivac operation (Falcon 200) I would offer the following insight.
1/. You're typically operating under the 'guidance' of a CASA FOI who doesn't know $hit about jet operations let alone corporate jet operations...never mind medivac operations across international borders, to the middle of nowhere, in the middle of the night. 2/. But he wants an endorsement on your aircraft for free. 3/. Companies doing this sort of work invariably have the wrong aircraft for the job - they get the cheapest jet they can find whether its the right aircraft or not. That is why you have LR31/35s and Jew Canoes running around the Pacific in the middle of the night - just because you get away with it for a few years doesn't make it the right aircraft. That corporate imperative eventually killed off the operation I was in charge of. 4/. A jet is a jet. In my operation we never, EVER went anywhere without an alternate...period. What the rules say is irrelevant. 5/. Fatigue management systems are a sick joke. CASA tried to make us have one. We spent large $ on getting the program software - ran a bunch of scenarios through it and found it would allow us to do trips with 2 pilots we currently did with 3 (Singapore- Kathmandu-Singapore) and not even come close to flagging us as fatigued - but we arrived back shattered even with heavy crew. I rang CASA and literally told them the fatigue software was "fcking dangerous and anyone pushing its use is a moron" - then the fella I was talking to allowed as how HE was one of the fellas from Uni of SA who designed it...before becoming a consultant to CASA. "So? - we will be staying on CAO48 - there is NO WAY I or my pilots will be operating under your FMS" It instantly went from being a 'requirement for renewal or your AOC' to "Ok you can keep using CAO48". I think this young pilot made some very basic mistakes that night - why was the gear down when he ditched? We wasn't he more proactive getting weathers for a place he MUST have known could be dodgy? He was clearly impaired by fatigue. I have been as tired as he was...only difference was I wasn't backed into a corner when that tired. Our operation had FAA trained dispatchers (ex SingAF navigators) and our flight plans/wx/notams were faxed to the hotel we were staying at and picked up by the crew at checkout (already lodged by our dispatchers of course). We had a satphone. One of our dispatchers (there were 3) was on duty for the entire time we were away from base keeping an eye on us. Contacting them from ANYWHERE/24hrs a day, via satphone, was as complicated as ringing your mother on mother's day. This young pilot fcked up - but CASA/PA fcked up more. I bet young Dom would be the first to admit his mistakes (he virtually did on 4C) CASA and PA NEVER will. It seems more and more obvious that ATSB doesn't have the staff/resources to carry out its statutory role at any level that could be deemed effective. After the Falcon operation ended I flew a C441 casual out of SEQ for a few months before getting back into airlines - I did one trip out east of Fiji in it. I arrived in Nadi to find my employer hadn't even bothered to inform the Fijian immigration people I was coming - no accom booked etc. I rang the boss from Nadi in the middle of the night just to wake him up. I managed to smooth things over with the Fijians, find accom, get suitable rest and complete the task safely. When I got back I just looked the boss in the eye and said "That won't happen again". It didn't. Looks to me like that was the level of backup young Dom got. I hope this doesn't permanently effect his career. After that night he will be the safest pilot around - and the first to tell his employer "That won't be happening" and mean it. Good luck to him.:ok: |
Have a read of the CASA audit document the ABC have on the 4 corners site. The only good part of Pelair back then appears to be the Saab/Metro operation. Can't say the same or the Medivac/Jet Charter and the MIL Ops out of Nowra.
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