[Peetwo]

 

18 November 2016 the 7th anniversary of VH-NGA ditching - UDB!

In three days time we will pass the 7th anniversary of the Norfolk Island ditching of VH-NGA and what have we learnt from that attempted bureaucratic cover-up? - Nada, zilch, zero...

Have we forgotten? Not bloody likely...

Have the Senators involved in the PelAir cover-up inquiry forgotten? Not bloody likely...

Here is a written QON listed for the Sup Estimates to the ATSB from NX ...

QON 206./Australian Transport Safety Bureau/ Xenophon /Pel-Air


Please provide an update on the Pel-Air report.

Written 28/10/2016

So as we approach 7 years of repeated government(s) attempted obfuscation of the PelAir (cover-up) investigation, I thought it appropriate to reflect on what safety lessons might have been learnt if certain government agencies and private entities hadn't gone into CYA mode..

To perhaps best illustrate the irony of the situation where we are now approaching the 2 year mark of the 2nd ATSB PelAir investigation, the following excerpts are taken from the PelAir (REX) submission to the Senate AAI inquiry:

EXECUTIVE SUMMARY

ATSB INVESTIGATION INTO THE DITCHING OF VH-NGA ON 18 NOVEMBER 2009.
Pelair agrees with the conclusion of the investigation that:
- The aircraft carried enough fuel at departure for normal operations as required under
the regulations;
- The essential cause of the ditching was the change of the weather enroute;
- Timely notification of the change of weather by ATC would have averted the accident;
Pelair feels that the role of ATC could be examined in this respect to see if any systemic
improvements can be made to provide an additional layer of safety buffer.

---

&..
The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.

The crew did request actual weather reports (either METARs or SPECIs).

WEATHER PROVIDED BY NADI:
The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. This was the first indication to the crew that the weather at Norfolk Island was becoming marginal.

WEATHER PROVIDED BY AUCKLAND:
The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with Auckland would have alerted the crew to the true situation with time enough to divert. At 0839 the aircraft was still around 32 min away from the last diversion point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew.

While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.

The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with their incomplete flight planning to influence their decision to continue to the island, rather than divert to a suitable alternate.

Pel-Air agrees with the first part of the finding on delayed awareness but disagrees with the second part. As explained in the preceding section, the accident would have been averted if weather information was obtained in a timely manner as there was more than enough time and fuel to divert had the up-to-date information been communicated. 

Does anyone else see the passing strange absurdity of the situation where we have the 'offending' operator pointing out contributory factors and identified safety issues to the investigative and regulatory authorities...

 The PelAir submission went on to say:

The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands.

Pel-Air disagrees with the second part of this finding and maintains that its procedures, compliant with CASA regulations at the time, are effective for minimising risks for remote island operations.

Pel-Air supports the proposed rule changes by CASA to bring passenger carrying aerial work operations in line with regular public transport operations to remote islands including the requirement to always carry an alternate. (P2 comment: Although since actioned by CASA, I note that this amendment is way too little and way too late for Kaz Casey - )

The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

Pel-Air agrees that more information can be provided in this area and notes that CASA is proposing a review of CAAP 234-1 and the relevant regulations to take into account amendments to ICAO Annex 6 with new Standards and Recommended Practices (SARPs) regarding to fuel planning, inflight fuel management and the selection of alternates becoming effective in November 2012. Pel-Air has also instituted a range of improvements to provide more guidance to pilots in this respect.

That having been said, by the nature of their profession the pilot-in-command is trained to exercise the ultimate authority with regard to the safety of their aircraft and the conduct of their flight . (P2 comment - Keep the above in mind when you consider the sanitised & Pc'd outcome of the Mildura Fog duck-up ATSB investigation final report - UFB! )

 
 Rewinding just a tad..

 "..say they were not required to do so by international agreement.." 

Q/ Has this identified safety issue, which has significant international ramifications, been satisfactorily addressed?

A/ Well who'd know when the ATSB can't even see the wood for the trees domestically with their typically PC'd Mildura Fog duck-up investigation. Meanwhile Harfwit has his head so far up his own arse with promoting his beloved 'accelerate program', that he is simply too distracted to realise it is actually ASA's responsibility to block that particular Swiss cheese hole...

Watch & weep...

MTF...P2