[P1_aka_P1]

Opinion x 2.

I have slightly edited the following which is an extract from a submission provided to the Senate Standing Committee inquiry into Pel-Air.  The Canley Vale accident and subsequent ATSB and CASA management of the case left much to be desired, particularly when a comparison of the ‘differences’ are made.  Part of the submission provided an independent appraisal of the accident and ATSB report which draws attention to the many flaws and much bias.  The ATSB report is, in our opinion, influenced by CASA to the point where we believe an inquiry, similar in nature to the Pel-Air inquiry would reveal another aberration.  Please note CASA were aware of and dismissed this report a full 12 months before the accident.

This report extract is published without prejudice in hope of preventing future accidents which could occur due to flawed safety analysis and reporting.

a) Gentlemen; please be aware that the report presented is "anecdotal", based on information provided to me by the individuals concerned, and from my own investigation into the facts.  It is, to the best of my knowledge accurate.

b) Having held a Chief Pilot approval for almost 25 of the 35 years I have been a professional pilot; and having spent many of those years associated with General Aviation (GA) in that capacity and as Check and Training pilot, I feel obliged to bring the following reports to your attention.  Had, as I initially believed, the reports were "Pilot gossip" or "Junior pilot speak" I would not have taken the trouble of writing and editing this report.  I have attempted to recreate the spirit, intent, humour and manner in which the information was delivered.  Although there is nothing remotely humorous here.

c) Regrettably, this is not so. I cannot, in good conscience, allow the existing situation to continue.  It is inevitable that sooner or later, the current Sky Master operating standards are going to be the root cause of an accident or serious incident.

d) I accept that on an individual basis the items may seem, at first glance, trivial. However, Individually, each item provides concern, collectively, I believe there is real cause for alarm.

Preamble.
a) The holes in that famous cheese are slowly, but inevitably lining up.   It is no longer a matter of if there will be an accident, but when.  

b) For the record, one day (or night) a junior pilot is going to get trapped in bad weather, or bad situation.  The procedures and methodology employed to mitigate risk will be directly reflected by the end result.  

c) I have noted that a lack of respect within the pilot body for the edicts of the individual mentioned has had a serious, negative impact on SOP.  Essentially this individual has lost control of the pilot body.

d) The pilots are, to all intents and purposes, now "making it up" as they go along in the absence of creditable guidance .  They are informing each other, through the "drums" of how they do things. SOP is circumvented, replaced by normalised deviance.    

e) Some of the junior pilots will (i) do exactly as they are told, to impress and (ii) are highly susceptible to "senior" pilot influence, for right or wrong.

f) The amount of time and money wasted are serious.  For example, ESIR pilots are arbitrarily grounded, no remedial training is offered and then a "Check flight" is conducted.   There have been 4 events this week.   Serious ESIR require deep briefing and training; but for minor infractions, a "chat" would achieve a far more useful outcome than an aircraft and pilots out of the system for a period of time.

1) Hand slapping.
a) I have now been informed by three individual company pilots that their hands have been slapped during "training" operations, conducted by the XXXX.

b) Quite apart from the legal aspects of "assaulting" and interfering with a pilot in flight.   The humiliation of being treated like a 3 year old and the potential for distraction both physical and mental during a critical flight period is dangerous. The practice is not an approved (or documented) training procedure.

c) The most alarming thing is, I believe that the events are occurring during landing, which in itself is alarming, however, the reasons for the procedure are even more so. Pilots are "slapped" for maintaining contact with the throttles during the last 50 feet of a landing.   They are instructed to close the throttles at 50 and await contact with runway.

d) Recently a very Junior pilot was instructed to ensure that every landing was made on the "piano keys", literally at the very beginning of the runway.  He is the only pilot to be so instructed.  During the tirade against his poor landing technique, he was also informed that "Navajo fuel gauges are 100% accurate, all of the time".

f) I have been reliably informed that pilots are "slapped" for placing the propeller levers at "Climb" RPM prior to landing.   In short, the aircraft is not being configured, as per the AFM checklist for a missed approach.

g) I will not elaborate here the sheer, purblind folly of these practices, the disregard for AFM procedures or the requirements of sensible operating practice.   This has all been demonstrated, with serious consequences, on several occasions in the past.

2) Unsafe practices.

a) I have personally heard once, and been informed several times of pilots being instructed to perform operations in a manner which defies most of the sensible and legitimate tenets of sound practice.

b) The most recent was a serious lecture, given, thankfully, post flight to one of the most sensible, intelligent pilots we have on staff.   The pilot requested a meeting with me and, told me of the event.  It is one of three similar stories.

c) In short; the pilot was tasked to Lismore NSW, after a second attempt at the instrument approach, the aircraft was visual at the minima, but, on top of a very low deck of Stratus (lifting fog) which obscured the aerodrome and prevented a landing.  The aircraft was diverted to Ballina.

d) This individual later responded to a general question related to the days operation with a sketch of the days events.  He was then taken aside and briefed on how it should be done, not to labour the issue the essential points where:-

(i) Slow the aircraft (PA 31-350) to less than 120 knots,
(ii) Stooge about until you identify a roadway which leads toward the aerodrome,
(iii) Get below the cloud and follow the road through the hills until the runway is sighted.   Enough said.

3) Fuel system questions.

a) Apparently, during a supposed "check flight", pilots have been seriously chastised (not slapped) because, they had no idea that PA 31 series aircraft engines could, (despite AFM prohibition), be cross fed whilst both engines are operational.

(i) The question runs like this, " OK mate, you look out of the window and notice fuel leaking (how ??) from the right main (which "main" tank is a mystery).    Question ?.   How can you recover (and use) this fuel.  
b) The sensible answer is land at the nearest suitable.   WRONG !!. (Hand smack following).

c) The right answer, apparently, is some unbelievable rubbish, not related to the actual fuel system, by which, despite the manufacturer AFM warnings, this can be achieved.

d) When a sensible pilot was asked this question, he diplomatically ventured the idea that if fuel was sighted, then the leak is severe, and the source indefinable.  The best answer is to close down the engine, and land at the nearest suitable, (engine and/or wing fires etc).  WRONG !!.

e) When the pilot produced a fuel schematic and illustrated why the manufacturer disallowed the practice, and further pointed out the complex series of circuits to be managed (from the aircraft schematic) and stated that all control was behind the cross feed line, only then, reluctantly, was it was acknowledged that, well perhaps the question "could" be rephrased; but it is still achievable.  QED.

f) Could be !.   Could be a junior pilot, in trouble one day does exactly what the correct answer is (according to the "training pilot") and bursts into flames, 10, 000 feet above a suitable airport).

4) Engine Failure.

a) Currently under investigation (CASA/ATSB) is a series of turbo charger failures, traced to a manufacturing fault.

b) What is not being examined is the inconsistent response and the total absence of any training material, course or general discussion relating to the incidents.  There have been at least eight (8) return to land and a couple of unscheduled occurrences.

c) The unbelievable part is that despite correct technique and, a couple of very level headed decisions being made, several pilots have been the recipient of a serious dressing down, for doing the right thing.  I know this because, it's usually me that gets asked the questions afterwards, by confused, offended pilots.

d) On one occasion, a LAME pilot had a partial failure on take off with a full load of passengers.   During the verifying procedure it was noted that when the throttle was retarded, the yaw increased.   He surmised that by not securing the engine, and leaning the mixture, he could retain 60% power on the engine.  The return to land was made safely.  The pilot almost resigned after being told that he was "basically useless".

5) Check flights.

a) The most recent horror story occurred very recently.  It is the latest in a long litany of similar events.  Please keep in mind the following points.

(i) this occurred during a commercial operation, with a flight nurse and patient in the back.

(ii) the 'check' pilot has no formal training or qualification to act as either a training pilot or check airman.

(iii) the pilot involved is a 'journey man' pilot, although well respected and capable, for the experience level.

b) The pilot was informed that there was to be a "Check flight" to qualify him to conduct patient transport operations.   There is no formal statement in the Operations Manual relating to this, no formal training procedure set down and no "pass/fail' benchmarks.

c) Pre flight the pilot was asked if he could conduct a DGA approach, the correct answer was offered.  WRONG.  The check pilot clearly has some confused ideas about the use of GPS as DME.

d) The pre take off (ground time) for briefing with engines running was spent in a lecture, delivered by the "Check pilot" of approximately a 30 minutes.  The talk went on during runway entry, take off clearance delivery, line up and take off role, ("non stop natter") the pilot, distracted, in an unfamiliar aircraft type omitted to turn the transponder on.  

e) The route was KAT – ORG, at top of descent the pilot still being chastised for the transponder, was instructed to conduct a DGA arrival.   Half way through the GPS was turned OFF, the pilot was informed that he was a fool, acting illegally and told to overshoot (despite being visual) and join the NDB approach.  No problem until an opposite direction Citation informed them that he was entering the overshoot procedure and was climbing to holding altitude.

(i) Imagine, the radio is taken over, there is no distance guidance and suddenly you need to find 1000 feet to avoid a mid air, no clear briefing, no instruction and absolutely no idea of who has command of the flight.

f) The remainder of the flight was similar, no clear definition of whether it was training or checking.  Needless to say the kid has been completely grounded, severely chastised and is completely demoralised.

g) The number of real live serious safety issues raised in this matter alone should at least be grounds for CASA investigation.  This gentleman should not be allowed to conduct training or checking until he has at least a rough ides of how to set about the task safely and consistently.

6) Maintenance Issues.

a) I have now confirmed that XXXX has, on two occasions, failed to report aircraft un serviceability's.

b) On one occasion, the follow on pilot grounded the aircraft, pre departure, recorded 10 separate items, of which 4 were MEL covered, but not noted.   The previous pilot had completed 5 sectors, one of which was a purported "line check + ICUS", services were all commercial, over approximately 7 hours of flying.  The aircraft was returned to and signed off as being serviceable.

7) Useable Fuel.

a) Two individual pilots report that the flight planning data for the PA 31 series aircraft has been altered to reflect that the capacity (fuel calibration card) indicated for each individual aircraft has now become the fuel useable for flight planning.  

b) Insanity, when it was pointed out that the AFM is clear and specific as to the amount of useable fuel, the CP then declared that engineering had incorrectly conducted the calibration checks and it was still acceptable to plan a flight against the placard capacity.  CAO 108 was referred to, it took a meeting of the GM, HAM and CE to attempt a correction.  To date, the flight planning data still reflects the total capacity as useable fuel.

c) This is as good an indication of absolute incompetence as I have ever witnessed.   A few seconds of thought produces several lethal practices and identifies complete and utter incompetence.


8) A last word.
a) Lately, simulating engine failure has become part of the regime, the latest was, as usual not briefed, and conducted at Tumut with a junior pilot at the controls, at high speed during the take off roll.  

Just slightly short of criminal.   What next I wonder.

There is, as you can imagine, a lot more contained within the report.  PAIN believes that the family and friends of both Kathy and Andrew deserve the very best from the aviation oversight organisations.