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-   -   Norfolk Island Ditching ATSB Report - ? (https://www.pprune.org/pacific-general-aviation-questions/468378-norfolk-island-ditching-atsb-report.html)

outnabout 22nd Nov 2017 02:24

Oh, Slats, you are such a tease....

Eddie Dean 22nd Nov 2017 06:41


Originally Posted by slats11 (Post 9965253)
The much awaited report of the re-opened investigation will be released tomorrow. It has been a very long time coming.

During a recent heated discussion about this incident, someone who may or may not be a DIP, who may or may not have perused the "new" report, opined that some senior pilots contributing to Pprune will be vindicated in their thoughts, and some that Big Mac referred to as vexatious bloggers will be embarrassed.
I await with baited breath.
I must add, that the person refused to discuss any part of the report and told us to wait.

zanzibar 22nd Nov 2017 08:08


Originally Posted by Eddie Dean (Post 9965350)
During a recent heated discussion about this incident, someone who may or may not be a DIP, who may or may not have perused the "new" report, opined that some senior pilots contributing to Pprune will be vindicated in their thoughts, and some that Big Mac referred to as vexatious bloggers will be embarrassed.
I await with baited breath.
I must add, that the person refused to discuss any part of the report and told us to wait.

What's your breath been baited with? Hope it doesn't smell too bad when you're in close company.

alphacentauri 22nd Nov 2017 08:09

27/09 and Leadsled,

Where do you guys come up with this cr&p? You both have over active imaginations....

27/09 this may be hard to believe but SBAS technology has moved on, it has been around for quite sometime. The SBAS service being offered to Australia is the most up to date version of the technology. The problem is that aviation avionics are still using the SBAS legacy technology. Its the new technology that GeoscienceAus and other industry sectors want, the aviation sector are trying mount a strong case to ensure that what ever SBAS is chosen, that it will support legacy aviation avionics....but yeah its a conspiracy. Make no mistake that if your aviation colleagues are unsuccessful in convincing the department to consider legacy SBAS......then it will be largely useless for aviation until next gen avionics catch up....thats a loooooong way off. Also consider that aviation is the only industry sector that requires the legacy signal.....all other sectors are happy with SBAS II.

Leadsled, your first paragraph is correct. But you do need to clarify that it was the Australian Gov't that specifically rejected it because the Dept is anti SBAS....not AsA. Aviation will be a minor user of SBAS.
Your second paragraph is bollocks. Spreading unsubstantiated rumour does not help the cause.

Sunfish 22nd Nov 2017 20:48

The Department was anti - SBAS most likely because someones career was heavily invested in GBAS. CASA probably couldn't have cared less. The drivers for aviation regulation in Australia are plainly the career prospects of the regulators.

Here is a prediction: Avmed has jumped on the sleep apnoea bandwagon which is making millions for doctors. The AMA (american) has just redefined "high blood pressure" ten points lower then the current definition. Watch CASA Avmed grab that new definition with both hands and ram it down our throats at more expense.

Car RAMROD 22nd Nov 2017 20:55

I wonder if the ATSB site will handle the flood of downloads?

Bit over an hour and a half to go.

VH-MLE 22nd Nov 2017 22:31

It's been like waiting for Santa to come...

TWT 22nd Nov 2017 22:39

Santa has arrived !

https://www.atsb.gov.au/publications...r/ao-2009-072/

531 page report

Lookleft 23rd Nov 2017 00:14

That can't possibly be right. Sunfish said that it would be released at Christmas or the Melbourne Cup or the anniversary of JFK's assassination. I trusted his wisdom because he has been a consultant, and worked for various Governments and has numerous relatives and acquaintances whose inside knowledge is infallible. Oh well.:8

Sunfish 23rd Nov 2017 00:34

only out by 34 days over 2 years

Old Akro 23rd Nov 2017 00:47

The methodology outlined in the press release looks good. We'll see if they followed it!

Cloudee 23rd Nov 2017 07:33

ATSB have started using his and her again instead of the gender neutral rubbish! Much easier to read.

Slezy9 23rd Nov 2017 09:40

PICs response...

Norfolk Island ditching pilot returns fire on investigators 'without a backbone'

Checkboard 23rd Nov 2017 14:25

I've read about half of the report. This one is pretty comprehensive, at least.

Answers quite a few questions missed in the first report.

  • Different fuel planning methodologies, and the results of each.
  • The history of why Australia in the only country to classify air ambulance as "aerial work".
  • Why the flight was "aerial work" even though it carried a person not strictly connected to the operation (the patient's husband).
  • The legal position on taking off without an alternate, then on being advised en-route of a new TAF with weather below the alternate minima, whether there is a legal requirement to divert.
  • The TAF relaibility at remote aerodromes like Norfolk
  • The general industry lack of advice on PNR and CP planning methodologies.


etc. etc.


But Mr James said a larger tank of fuel would not have changed the outcome that day – he would still have had to ditch the plane in the ocean. ...

"If you put anyone else in the pilot's seat that night, it is more than likely that they would find themselves in the same situation...
Well, that's stretching things a bit far. A full tank of gas would have gone a long way that night.

Marauder 23rd Nov 2017 16:14

Patients husband on board under Australian law, it is still a medical flight, likewise if a spouse travels with their partner in an ambulance it doesn’t become a taxi.


The guts of it again, is inaccurate forecasting, passing incorrect met information, 6000 feet instead of 600, failure to pass deteriorations in weather in a timely faction, gloss over all the organisational short comings, still blame the PIC.

According to ATSB the crew should have joined the dots, but how was that possible when too many dots were missing.

The Qantas\ Virgin Mildura incident should have been a wake up call, ATSB need to grow a set.

Slippery_Pete 23rd Nov 2017 19:23

Haven’t read the entire thing but have made a start.

In the original report, the CVR/FDR supposedly weren’t recovered because the CVR was only going to have the last 30 mins... not enough to cover when the PNR fuel calculations and discussions should have occurred.

Interestingly, the new report shows that the CVR was actually a newer model which held over 2 hours of audio.

Apparently the serial number in the maintenance documentation matched the CVR.

So what was the reason it wasn’t pulled the first time? Was it political pressure to not have it removed (involving strong ties to an ex-politician), or was it a case of the operator deliberately didn’t supply the correct paperwork with regard to the CVR model fitted?

I want to know why the ATSB didn’t know it was a two hour CVR.

Checklist Charlie 23rd Nov 2017 20:04


I want to know why the ATSB didn’t know it was a two hour CVR.
Perhaps they did.

CC

Sunfish 23rd Nov 2017 20:29

There is at least one factual mistake by the ATSB associated with an extremely unconvincing excuse for not initially recovering the CVR/FDR. On page 62, the ATSB states that it didn't initially recover the CVR/FDR because the wreck was 'beyond conventional diving range" (ie depth) at 48 metres.

Either the ATSB is a flat out liar (or playing very fast and loose with the truth) or very, very, badly advised. I think it is the former because all ATSB would have needed to do is pick up the phone and ask the Navy who have their own diving staff.

The depth limit for recreational diving on breathing air is 38 - 42 metres, depending whether you were certified by PADI or SSI. "Technical" recreational divers (the nerds of the sport diving world) go to 60 metres and commercial divers routinely work at much greater depths - the record commercial dive is over 500 metres breathing a mixture of gases, not air. Trimix gas certificate holders have a depth limit of 100 metres. DAN (divers alert network) provides insurance on trimix users to 130 metres. This is routine stuff for oil industry divers, there is nothing "unconventional", to reflect ATSB use of words, about diving to 48 metres..

From what I saw, the recovery of the CVR/FDR would have been a doddle. The evidence for this is that the contract was awarded in October 2015 and the diving contractor recovered them in November 2015 by lifting the tail section of the wreck. In my opinion this was probably done with one dive to position lifting slings.

To put that another way, a young stupid sports diver could have reached the wreck. My deepest dive was the "Blackjack" B17 at 42 metres off new Guinea.


As a follow up question, exactly who in ATSB made the decision not to recover the CVR and who advised them about diving?

Checkboard 23rd Nov 2017 20:45

It was a bit more than that, because a wing was buried under sand after 6 years on the floor - so they had to dig the wing out.

Sunfish 23rd Nov 2017 21:43

correct - 6 years later, but at the time of the accident?


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