[Peetwo]

Media coverage Part II.

Beginning with Hitch via Oz Flying & the Yaffa:

  Read more
ATSB releases Second Norfolk Island Report
23 Nov 2017
The ATSB has today released the much-awaited second investigation report into the Norfolk Island ditching in 2009. Read more

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ATSB Commissioner Chris Manning. (Steve Hitchen)

ATSB needed to Address Issues in Original Pel-Air Report: Manning
23 November 2017

Australian Transport Safety Bureau Commissioner Chris Manning has said that the final report into the re-opened Norfolk Island ditching investigation had to address issues in the original report earmarked by both the Canadian Transportation Safety Bureau (TSB) review and a senate inquiry.

The resulting 531-page second investigation report was released today.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” Manning said. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.

“The ATSB recognises the importance of being able to demonstrate that the re-opened investigation addressed identified areas for improvement with the original investigation. A main focus of the re-opened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

The final report found 36 safety factors, including 16 safety issues. According to the ATSB, many of these stemmed in part from the amount of information obtained by the re-opened investigation and the depth of analysis.

“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Manning. “The ATSB was mindful at all times that the people and organisations involved in this accident have been intently waiting for the results of the reopened investigation and acknowledges the time that it has taken to complete the final report.”

The original report provoked controversy because it seemingly laid blame at the feet of the flight crew. After a senate inquiry resulted in 26 recommendations and the TSB review found that the ATSB had not followed its normal procedures, the ATSB agreed to re-open the investigation, which included recovering the flight data recorder.

According to the ATSB, special measures were taken to distance the re-opened investigation from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, the investigation was conducted by investigators and overseen by managers who had not been involved in the original.
ATSB’s current Chief Commissioner, Greg Hood, was also not involved in any part of the investigation because he had been in a senior role at CASA at the time of the accident.

The depth of the report document and the greater scrutiny have failed to impress the pilot involved in the ditching, Dominic James, who says the ATSB has missed an opportunity to make a real improvement to aviation safety by including reams of irrelevant information.

"They've incrementally improved their understanding of what happened," he told Australian Flying, "but given how much attention has been poured into this and what resources were given to them, the fact that they haven't come up with a landmark document that could be given out as a paragon of accident investigation is a total cock-up.

"There's about 200 pages there that should hit the cutting-room floor straight away.They don't help anyone do anything. It's quite simplistic: if I am given the right weather on the night before I leave Samoa, or I get the correct weather handed to me in flight, the accident doesn't happen; it's a weather accident.

"To talk about thing like pressurisation fuel when no de-pressurisation took place is a total red herring. It would be like having a whole expose on my pre-flight technique, but if nothing I did in the pre-flight had an impact on the accident, why go chapter-and-verse about my pre-flight technique?"

The full ATSB statement that accompanied the release of the investigation report is available on the ATSB website.

Read more at http://www.australianflying.com.au/lates...wb0KHCH.99

& the latest from 'that man' in the Oz:

Lax aviation rules still in place

12:00amEAN HIGGINS

The aviation safety watchdog has still not changed lax rules that contributed to an extraordinary air accident eight years ago.

Eight years after crash-landing, ATSB lashes CASA’s inaction

The aviation safety watchdog has still not changed lax rules that contributed to an extraordinary air accident eight years ago in which the flight crew of a medical evacuation aircraft had to ditch in the sea off Norfolk Island as it ran out of fuel.

In a rare admonishment by one federal government aviation agency of another, the Australian Transport Safety Bureau has expressed a series of “concerns” about the Civil Aviation Safety Authority’s failure to fully address recognised deficiencies in its regulations governing such long-­distance air ambulance flights over remote areas and oceans.

The criticism comes in a report released yesterday of the ATSB’s re-investigation of the accident, which also spreads the blame beyond the flight’s captain, Dominic James, determining he made errors but acted within the inadequate guidelines set by CASA and his employer.

Mr James yesterday said he believed the report was still unfair and inaccurate when it came to criticism of his actions, but went some way towards a fairer balance than the original report.

While the ATSB report released yesterday agrees CASA has taken a number of steps to address the problems of its regulations governing air ambulance and similar non-airline flights, it lists many areas where it has not.

“There are still limited Australian regulatory requirements that specifically address the hazards associated with such flights,” the report says. The ATSB identifies as a more general concern that “the available regulatory guidance on in-flight fuel management 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.”

It says although CASA has undertaken some work in this regard, “the ATSB is concerned that, as yet, this work has not resulted in many actual changes to the requirements and guidance”.

Mr James said: “You have had eight years to make everything better and safer for those who travel, and nothing has been accomplished. That is just a gross failure of CASA to regulate.”

The unprecedented fresh investigation, ordered three years ago by then transport minister Warren Truss, followed a Senate inquiry that found grievous failures in both the ATSB investigation and CASA’s handling of the Pel-Air matter.

The Pel-Air flight in November 2009 was returning to Australia after picking up a critically ill Australian woman in Samoa when severe weather on Norfolk Island prevented the pilots landing for a planned refuelling stop.

With fuel running out, Mr James put the Israel Aircraft Industries Westwind twin-engined jet down in a stormy sea in total darkness, with all six people on board including the patient surviving the ditching and being picked up by a Norfolk Island vessel.

The ATSB took almost three years to produce a report that identified mistakes by the flight crew relating to fuel planning and weather checks as contributing safety factors and to a lesser extent criticised the available guidance on these issues from the company.

An ABC Four Corners investigation, which sparked the Senate inquiry, revealed a CASA audit after the crash — but not mentioned in the ATSB report — uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

A CASA spokesman said the agency already had made a range of improvements and changes to safety requirements and activities as a result of the earlier report. “CASA has already announced the intention to finalise the development of remaining new regulatory parts in 2018,” he said.

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Blame the pilot or praise the pilot three matters are shining clear. 


One :- Anyone who has any General Aviation commercial flying experience will think to themselves “glad that wasn’t me”.  In other words there always can be traps and no one is totally invulnerable. 

Two :- The independent, pretend corporation and unaccountable regulators have degenerated into wasteful and inept Can’tberra salary and make work factories with easily the worst aviation industry reputation in the developed world. 

Three:- The Captain of the ill fated flight will never fall for the trap of expecting “the rules” to assist him, ie timely weather advice from a  Government body, ever again;  and having had blame shifting penalties imposed on his licence by CASA is a nine year old scandal and travesty of justice. Alex in the Rises. 

& an update from Matt O with a more balanced 2 page spread in today's SMH:

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


 
Matt O'Sullivan

To some he remains Australia's equivalent of Chelsey "Sully" Sullenberger, the captain who landed a passenger plane on New York's Hudson River.

While Dominic James was initially hailed a hero for successfully ditching a Pel-Air jet in rough seas and pitch darkness off Norfolk Island without the loss of life, he quickly came under fire for his role in the incident.

Almost eight years to the day after the accident, the Australian Transport Safety Bureau has released a 531-page final report, the second it has issued on the crash that left two people badly injured.

In it, the bureau's investigators are again critical of Mr James but also raise concerns about inadequacies with the country's aviation regulations and the risk-control measures of Pel-Air, a subsidiary of NSW airline Regional Express which was operating the air-ambulance flight on November 18, 2009.

The ATSB reopened the investigation several years ago into what has been one of the most miraculous – yet equally controversial – incidents in modern Australian aviation history, following a senate inquiry thatcastigated both the bureau and the Civil Aviation Safety Authority for their handling of the matter.

And Nick Xenophon, who instigated that senate inquiry, said on Thursday that it remained a "deeply flawed and conflicted process".

"Dominic James is a scapegoat for the regulatory failures and nothing short of a fully independent inquiry will bring the truth out," he said.

Remarkably, air ambulance flights remain classified as "aerial work" rather than charter, which means they are not subject to the same rigors as other passenger planes. This is despite CASA looking to change their classification five years ago.

Dominic James  Photo: Louie Douvis


The Westwind jet he was piloting was carrying a seriously ill patient, Bernie Currall, husband Gary, doctor David Helm and nurse Karen Casey from Samoa to Melbourne, when bad weather disrupted a planned fuel stop at Norfolk Island.

After four aborted attempts to land at Norfolk Island due to low cloud, Mr James and co-pilot Zoe Culpit ditched the plane into the ocean, where it broke into pieces and rapidly sunk to the sea floor 48 metres below.

Wreckage of the sunken plane off Norfolk Island 

Mr James, who is still an air-ambulance pilot and has had the backing of a senior aviation safety expert, told Fairfax Media that the latest report "doesn't solve anything" in making the skies safer.

"I flew to Norfolk Island four months ago for the first time and several people that were there at the time [of the accident in 2009] greeted me," he said.

The Pel-Air plane that ditched into the ocean off Norfolk Island in 2009.  

"I asked them what has changed, and they said nothing. There is not a single regulation that has changed that would stop this – that is a gigantic failure."

The report found Mr James's pre-flight planning lacked many elements needed to lower the risk of a long-distance flight to a remote island, including miscalculating the total amount of fuel required.

But Mr James, who lives on Sydney's north shore, said the ATSB had slammed his conduct but did not "want to rock the boat" when it came to criticising the system and parts of the aviation bureaucracy.

"They have lost their nerve – they are not courageous," he said.

"They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result.

"If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a senate inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

The report explains at length failures in the pre-flight planning needed to ensure the plane had adequate amounts of fuel in its tanks

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.

Instead, he said a lack of information about the rapidly deteriorating weather that day was a major factor glossed over.

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MTF...P2