PelAir & Beyond: A: “cover-up or a balls-up”..?

28 Jan

It is absolutely staggering how the more we discover with the PelAir duck-up of the cover-up the more entrenched the Mandarins & the Pollywaffles become in obfuscating the issue – in other words they are flat out in denial… And this is despite the rest of the world acknowledging a long..long time ago that the game was up and the stench emanating from Aviation House and the surrounding precinct was positively rancid…

An excellent example of this was captured in Hansard – from the 24 Feb ’14 Senate Estimates – where the Chair Senator Heffernan said this (in bold) in reply to Dolan’s weasel words…:

Quote:

Mr Dolan : I and my fellow commissioners very carefully went through the contents of the committee’s report and tested it against the information we had available to us in the course of our investigation. There was nothing, in our view, that constituted new and significant information that would lead to a need to reopen the investigation.

CHAIR: How did it go from a critical incident to a ‘don’t worry about it’ incident?

Mr Dolan : That is a matter we did rehearse with the references committee. In short, our initial assessment of the issue of guidance as to dealing with the situation, weather deterioration and what was planned, we overassessed it as critical at an early stage and by applying our methodologies we concluded by the end of the process that it constituted a minor safety issue.

CHAIR: Can I commend you. You look really well. You look less stressed than you used to for some reason.

Mr Dolan : It is probably the lack of the beard.

CHAIR: With that particular incident of which I just spoke no thinking person would believe that bureaucratic answer. You cannot go from a critical incident to a minor one or whatever it was without something happening on the journey. Anyway, we will not go back there. To any sensible person it sounds like either a cover-up or a balls-up.
And slats11 does not shirk the issues in his excellent contribution the Peeler, CASA, and ATSB – the movie which goes some of the way to chronologically explaining the whole corrupt, sordid tale.

Despite the many twists and turns since the farcical, BASR ATSB final report was released – what is amazing is how the slats11 script has not deviated that much.

Perhaps to highlight this here is a blog piece from the popular US Avweb online publication..:

Quote:
Norfolk Island Ditching: Still Many Questions

By Paul Bertorelli | September 16, 2012

If you talk to someone who’s been involved in a serious aircraft accident long enough, they’ll eventually get around to two things: The accident constantly intrudes in the daily thought process and any external description of it—an official accident report or news reports—won’t ring quite true. Experiencing something so traumatic isn’t the same as reading someone reporting it.

I thought of that when I interviewed Dominic James over the weekend. James was the Captain on that Westwind that ditched off Norfolk Island on November 18, 2009. At the time, I blogged that the accident report on this one is going to be interesting. Now that the report is complete, I got what I wished for. It’s interesting alright, but for the wrong reasons. This accident appears to be a classic example of the linked chain, but the ATSB’s report simply ignores many of the links, speeding apace to its conclusion: The crew was responsible.

And so it was. The flight crew—James and First Officer Zoe Cupit—had the final vote and sole ability to sunder the accident chain. They failed to do that, but the report itself fails to explain that in some ways, the company, the system and CASA set James up for an accident and left him to his command authority to avoid it. When a perfectly competent pilot throws away a perfectly good airplane, it’s often the result of a mindset patterned by past success and both external and internal pressures. This accident seemed to have all of that. As we reported in today’s news, James is challenging the ATSB report and an Australian Senate hearing on it is planned for early next month. He says he’s not ducking fault or responsibility, but believes the report simply doesn’t give an accurate picture of all the factors involved in the accident.

To refresh, the flight was a Westwind medevac mission with a stable patient from Apia, Samoa to Melbourne, Australia. To save you the trouble of hauling out your atlas, that’s some 2800-nautical miles, almost all of it over water. It’s the distance from New York to Los Angeles, plus another 700 miles. Norfolk Island was the planned fuel stop, a distance of 1600 miles. James said the Westwind had the legs for trips like this, but only if everything went to plan.

For James and Cupit, it didn’t. With good VFR forecast for Norfolk, neither the company’s policy nor Australian regulation required a named alternate, so none was contemplated. In any event, it’s doubtful that one could have been reached. The closest was Noumea in New Caledonia, 400 miles north of Norfolk Island. The Westwind departed with 83 percent of full fuel; mains full, tips empty. Even with the tip fuel, Noumea was unlikely, given the fuel required for climb. When the weather tanked at Norfolk, the crew had no option other than to land there. It couldn’t and ditching was the only survivable option other than a desperation, homemade, below-minimums approach. The airplane simply lacked the capability to do the trip with contingency fuel.

The number of links in this accident chain not covered in the ATSB report are too numerous to cover here. But as James explains it, they’re obvious to him in retrospect. In hindsight, it is clear how this chain of events led him to the decisions he made. On a previous trip, James had been told Norfolk’s automated weather reports were notoriously pessimistic and forecasts for the island were iffy. Other similar aircraft routinely made such trips with no drama, despite Norfolk’s exceptional remoteness. Pel-Air seemed to have a loose relationship with regulatory adherence and CASA failed to oversee the company aggressively, as evidenced by an internal report only recently made public. ATSB never mentioned this report.

Pel-Air airplanes routinely operated in or through RVSM airspace, but the Westwind wasn’t RVSM equipped, according to James. Controllers would give the flight a bye on RVSM if they could climb to FL390, which the Westwind could do only if light, thus the decision to leave tip fuel behind.

Noumea was potentially a paper alternate, but James said the local authorities there didn’t want Pel-Air airplanes arriving because they lacked TCAS II and GPWS, not to mention RVSM. The accident airplane had just had TCAS and GPWS installed, but James and Cupit had never seen it and hadn’t been trained in its use.

The ATSB made a great deal of discussing James’ fuel planning, especially the oceanic technique that routinely requires points of no return and/or critical points, which are continuation decision thresholds when few or no alternates are available. The ATSB conceded that based on the forecast, an alternate wasn’t required and that the crew had enough fuel for a flight that proceeded normally, but no contingency for a de-pressurization event that would force the airplane to lower, less fuel-efficient altitudes. If the drift down happens in the wrong place, the range can dwindle to the point of neither being able to return to the departure nor reach an alternate. James insists his fuel load covered this and when he asked the ATSB for its fuel calcs, they declined the request. He had the data reviewed independently to confirm his calculations.

Even with the good forecast, James got an updated METAR for Norfolk from Fiji ATC. The controller misstated the ceiling as 6000 feet rather than 600 feet. A later corrected METAR relayed via HF was garbled in poor atmospherics at dusk. James couldn’t explain why he didn’t receive it, but he knows he didn’t. Fiji refused to release the audio tape of the transmission. “There’s no way you sit on your hands for an hour after getting a METAR like that,” James said. “You’d have to be a suicidal maniac.”

That missed METAR may have been the final or most critical link in the accident chain. Once the Westwind passed Fiji, it was committed to Norfolk, save for a brief diversionary window to Noumea. I like to think if I’d been in that cockpit, I’d have surely had the threat and error management thing going on and would have diverted sooner, just as any competent pilot should. Maybe you think the same thing. The reality is that given the circumstances, I can imagine myself being sucked down the same dark hole James and Cupit found themselves in. For me, personally, that’s a creepy truth, but a truth nonetheless.

Later in the week, I’ll take a look at another accident that is eerily similar to this one. It occurred 42 years ago in the Caribbean.
See what I mean a few more dots & scenes for the movie script but the basic plot remains the same.

While on the Avweb it is worth going to the PAIN comment at the bottom of the page as it is extremely pertinent in light of the Ferryman’s Cui Bono? piece on Flight Nurse Karen Casey’s upcoming court case…:

Quote:
Flight Nurse comment from Planetalking blog:

· Karen Casey Posted November 4, 2012 at 3:49 am

When will truth trump cover-ups that are with laced with selfish intent to save ones posterior? How ridiculous to have so many broken rules in an- audit, yet almost get away with it. There is a reason for the truth that is emerging, it’s for air safety & the failure of our regulator & investigative bodies results. It has been the survivors that have been the seekers of the real deal. What a disgrace. With both our Chief Commissioners under the microscope now, the amplification of this ordeal is finally happening. CASA & ATSB have a lot to answer for, dragging this on for selfish intent is criminal & at the least cruel to all on board. The coverup is surfacing and all will be revealed about the incompetencies of all parties involved. How unprofessional this has all been. How disappointing in the treatment of the people who have experienced hell from impact till now with our own government bodies involved. Does our government have enough integrity to investigate the individuals involved and actually DO something about this rather than just go around in circles. To add insult, let’s just throw in the fact that the ex-Pel-Air chief pilot at the time of the incident now works as an investigator for CASA…please!

“Just stop the B.S & tell the truth.”

PAIN comment: Puts a human face to this sordid tale!

 

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