[Peetwo]

Manning says next month for PelAir report MKII -

Via Oz Flying:

ATSB Commissioner Chris Manning. (Steve Hitchen)

Norfolk Island Report due Next Month
26 October 2017

The second Australian Transport Safety Bureau (ATSB) investigation report into the 2009 crash of a Pel-Air Westwind off Norfolk Island is due to be released in the next two weeks.

ATSB Commissioner Chris Manning today told the Regional Aviation Association convention that he had approved the report, which is expected to stretch to 500 pages.

Westwind VH-NGA with six people on board was on an aeromedical flight from Samoa to Melbourne on 18 November 2009, when it ditched off Norfolk Island because it was low on fuel, and had been unable to land after four VOR approaches had to be aborted.

All on board survived the accident.

The initial ATSB report published in August 2012 indicated shortcomings in the pre-flight and en route planning, and the crew not properly assessing the situation before it was too late to divert to an alternate to refuel.

The report became controversial because it appeared to ignore systemic issues and focused too much on the crew, and was referred to the Senate Standing Committee on Rural and Regional Affairs and Transport two weeks later. Then ATSB Chief Commissioner Martin Dolan later admitted the report was not one he was proud of.

In 2014, a Canadian Transportation Safety Bureau review of the ATSB singled out the report as an example where the ATSB did not stick to "sound investigation procedures", prompting the ATSB to re-open the investigation.

The ATSB returned to the crash site and recovered the flight data recorder in 2015

Updated 7.30 pm 27 October 2017.

Read more at http://www.australianflying.com.au/lates...7KvOjXM.99

MTF...P2

[Peetwo]

'Precious' Hoody sanctions DJ embuggerance -

Dear DJ...

---

..Thank you for your email regarding correspondence within CASA concerning the draft report from the reopened investigation into the ‘Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009’.  The ATSB will confirm with CASA its practices for disclosure of the draft report in this matter in the context of section 26 of the Transport Safety Investigation Act 2003.  Please note that section 26 of the Act does permit disclosure and copying of the draft report necessary for:

                   (a)  preparing submissions on the draft report; or
                   (b)  taking steps to remedy safety issues that are identified in the draft report.

Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.  The email you have provided does not establish, prima facie, a breach of the Act with respect to copying or disclosure of the draft report.  The ATSB will make enquiries with CASA.

I note that you have included the ATSB’s Chief Commissioner, Mr Greg Hood, in the recipients list for your email.  As you may be aware, Mr Hood has recused himself from this investigation acknowledging his employment at CASA at the time of the accident.  Mr Hood is not involved in the ATSB’s decision making with respect to this investigation.  You may send any future correspondence on this particular matter to either myself or Colin McNamara, Chief Operating Officer.  Mr McNamara’s email address is colin.mcnamara@atsb.gov.au.

Regards..

---

Before beginning to dissect the (CYA) weasel words from the ATSB Legal & Governance manager Patrick Hornby, here is a couple of what I believe are relevant quotes off two of my CASA embuggerance thread posts.

First from: The Leopard (Carmody) reveals it's spots  

DAS Carmody:"..I will not make a decision till after the ATSB report is finalised.."

Just think about that comment for a second..

Now although the intent by the DAS is to indicate that he will...be not making any references or revealing any part of the DRAFT report...he does appear to be indicating that he will be referencing the ATSB Final Report to inform his decision making process on DJ's request for the conditions on his ATPL be dropped...

Does this indicate that the DAS is contemplating breaching the spirit and intent of section 12AA of the TSI Act?

 
P2 Q/ In light of the Hornby comment..
 "..Decisions around the content of submissions and deciding what steps to be taken to remedy safety issues are matters for CASA.."

...one wonders why Carmody has to wait for the final report to be released in order to be (ill-)informed for his decision on the continued embuggerance (CEP) case of DJ?   

Next from: The 0904 from Auckland.

P9: ...The use of a ‘general term’ i.e. ‘weather forecast’ is not nearly good enough. I wonder has the ‘second’ Pel-Air report provided an in depth analysis of the legal/technical information conveyed to James (and his FO) or the application of that information to his decision process.


IMO - P7 nailed it – the 0803 from Nadi was pivotal. Auckland wouldn’t think to confirm that the flight had an update issued an hour ago – and so another strand of the safety net was broken. I digress...

---

P2: ...the 0803 amended Terminal Area Forecast (TAF) was never actually relayed to the flight crew; or that the 0904 from Auckland...




was not actually a 'weather forecast' but was really an auto METAR/SPECI and not a TAF (forecast) at all...

The 'passing strange' omissions in paragraph 6 in Hood's original (   Yesterday, 12:15 PM">Letter to Mr Dominic John ~ NOTICE OF SUSPENSION OF COMMERCIAL PILOT (AEROPLANE) LICENCE dated 24 December 2009.pdf (Size: 561.88 KB / Downloads: 1)) notice of suspension; of the 0803 amended TAF or indeed the 0801 Nadi relayed Norfolk island METAR can partly be explained by the fact that the CASA investigators & FOI's involved were yet to receive the transcript from the Fijian ATC.

This begs the question to how it was possible for the delegate Hood to make a fully informed decision when such critical information, which included a amended TAF that if received by the VH-NGA flightcrew would have automatically placed a legal operational requirement on the conduct of the rest of the flight.

From that post & my previous post - Pelair dots, dashes & the DJ TOE - coupled with the highlighted conflict of interest sensitivity 'Precious' Hood has on the matter; IMO the whole veracity of the appointment of Greg Hood as CC of the ATSB needs to be independently reviewed and I would question whether Hood's continued employment as Chief Commissioner is in fact tenable?
 

MTF...P2

[Kharon]

Did hoody miss the 0803 from Nadi?

He certainly was not on it when it arrived at Embuggerance Junction. Fact (or is it)?

The thing which amazes most is the Hood elevation to ‘top-dog’ ATSB – how, FDS can that be? When the Norfolk ditching is unresolved and don’t, not for a moment think that Manning’s little effort (a 500 page re-hash,-sans all facts) will answer all the questions. It simply will not. It dare not -

OK, for once I shall try to be crystal clear. An ‘informed, balanced decision’ is what a ‘decision maker’ is required, by law, to make. Now it seems the Hood could not – as an alleged ‘pilot’ and ‘the man’ at CASA HQ differentiate between the type of forecast which is actually legally binding and one that is not. Yet ‘he’ is ‘the’ decision maker. Making sweeping decisions based on only partial facts – in a hurry, based on Wodger ( the load master) say so. WTD?

I can understand that in the first rush of information, he could – as an inexperienced sausage – err on the side of safety. Because of the 0801 from Nadi, not the un-relayed 0803. Once the Nadi transcript was in hand though - different matter; entirely, completely and utterly.  

Consider; there you sit reading Playboy and Nadi pops up with a ‘report’:-

A) (0801) - Cloud base 6000 feet: write it down and return to Playboy. A 6000 foot cloud base for an IFR pilot is ‘seventh heaven’ stuff, a stroll in the park.

B) 0803 - Cloud base 600 feet – the Playboy is put aside and the skinny pencil appears – it's time to go to work.

Hood knows this (or) as ‘the’ decision maker should at least be aware of this. As an alleged pilot, there should have been no worries in making the decisions he made until the omitted 0803 report turns up (or doesn’t as the case maybe).

Once it became abundantly clear that Chambers was relying on Hood to sign off McConvicts edicts, that the Captain was ‘negligent’ and ignored fair warning, the stich up was complete. Except the late arrival (Fiji time) of the 0803 TAFOR, which was never delivered. Certainly not to the flight crew and, perhaps, not to Hood. Delayed decisions everywhere.

Once this ‘small’ detail was revealed, Hood weaselled out. Refused to sign anymore of Chambers little ‘gotcha’s’. Old fat Terry had to do it – although; how the hell they got him out of bed before 0630, without a glass of ‘Chardy’ and his meds, to sign off on a ‘thing’ is a matter of mystery. No matter, Terry signed that from which Hood ran away from. We must ask why?

No matter how you look at this whole sorry episode – Hood comes out as (i) gutless; (ii) brainless; (iii) ignorant or; (iv) in a position he should never, not ever been allowed to occupy. A real decision maker would have knocked this imbroglio on the head, right about the time the 0803 turned up ‘in evidence’. A real pilot would have known and realised the implications; alas, Hood is neither.

Hood is however ‘in charge’ of the nations ultimate transport safety agency. That would be the one drafting the report which; odds on bet: never mentions the 0803 from Nadi. Now I ask you, how can all this be so and have Hood in charge. It’s BOLLOCKS.

The moment Hood realised that he’d missed the train – he should have told Wodger to bugger off. HE DID NOT – he took a sickie; or, missed the bus; or, his cowboy chaps had given him a rash; or, the power was out. Anything, any lame excuse, rather than as a decision maker look and look hard at ALL ‘the facts’ and then make a balanced, cold blooded, sensible decision. But, he reneged (chickened out) instead, opting to use  any flimsy excuse he could dream up (close to being credible, that is) not  to do so and retain his  position. Dolan was a straight arrow compared to this creature - and that, boys and girls is saying a lot.  

This man lied – several times. John McConvicts pet odalisque ain’t fit, nor proper to be making sanction ‘decisions’ let alone running the nations principal safety agency.



So why is he minister?  If that question is too hard for you to answer – I can, at length, explain it and provide the answer. Your problem then becomes simple; do you really want all of this in the public purview. Yes or No will suffice – we will wait until Sunday. Then, the gloves will come off. That minister, is a promise you can take to the bank.

Selah…(Look it up – Muppet).

[Peetwo]

One for the Flight Safety textbooks - err maybe??

Slight thread dread but finally a good news story on an aviation occurrence and it involves another survived ditching at sea....

Via the Daily Mercury:

Pilot set off 'mayday' signal
10th Nov 2017 6:00 AM



The helicopter which crashed off Hayman Island with four people on board. RACQ CQ Rescue



by Tara Cassidy

THE pilot involved in the helicopter incident north of Hayman Island did well to land safely in such choppy conditions, according to the president of a local aviation club.
Stan Wright, of the Airlie Beach Aero Club, said this sort of incident only occurred "once every 10 years”.

There were four people on board the helicopter that was forced into an emergency landing off Hayman Island Wednesday afternoon, all of them believed to be Australian tourists visiting the Whitsundays for a holiday.

About 3.40pm the pilot of the Hamilton Island, Robinson R44 helicopter made a mayday call and set off the aircraft's distress beacon, alerting AMSAR who then initiated a rescue effort.

An AMSAR spokesperson said a passenger vessel called Sea Odyssey, a local cruise boat, was then diverted by AMSAR to go and assist the four passengers who were floating in the water holding on to the aircraft.

When it landed, the helicopter activated its emergency flotation devices, allowing it to land safely upright in the water near Hook Reef.

None of the people aboard were injured in the landing.

RACQ CQ Rescue were called to the incident about 3.50pm, which occurred 25km north east of Hayman Island, however were stood down once the rescue vessel reached the passengers in the water and transported them to safety on Hamilton Island.



Four people that were aboard a helicopter forced into emergency landing, floating in the ocean awaiting emergency crews. Seven News

Whitsundays VMR were also on standby with a paramedic aboard, in case back up was needed, but it was not required in the end.

Water police notified the Australian Transport Safety Bureau of the incident soon after it took place, and said the owner of the aircraft would be responsible for salvaging the helicopter in the coming days, now that they were safe on shore.

With stormy weather hitting the region overnight, it is not known what the condition of the helicopter is in, or if it is still afloat.

Peter Gibson from the Civil Aviation Safety Authority said any further investigations into the incident would be run by the safety bureau, while they would review a report from the operator about the process the pilot took on the day.

"We will review that and make sure all the appropriate regulatory standards were being met,” he said.

"We need to make sure the air operator that operated that flight was meeting all the applicable safety standards so we get a report from them on that flight, what happened, how the flight was conducted and so on.

"It is stock standard for us just to make sure the right processes were followed.”

It is not yet known what caused the incident.

Pinocchio Gobson: "We will review that and make sure all the appropriate regulatory standards were being met,” he said.
Code for we'll make sure our (CASA's) ass is covered before exploring whether it will be worth embuggering either the operator or the pilot. This will depend on whether the overseeing (cross out appropriate) FOI/Middle manager/Executive Manager has some personal 'bent' against said operator and/or pilot -    

"We need to make sure the air operator that operated that flight was meeting all the applicable safety standards so we get a report from them on that flight, what happened, how the flight was conducted and so on.

"It is stock standard for us just to make sure the right processes were followed.” "Stock Standard" when it may be possible to get any sort of bad press (ala PelAir) from the wash up of this unfortunate pilot survived occurrence...


MTF...P2  

[Peetwo]

 The 0803 lost in White rabbit obfuscation.

From the highly suspect, possibly illegally extracted, 16 December 2009 CASA interview of DJ:

As a reminder this was the weather update that Auckland broadcasted to VH-NGA at 09:02:

SPECI YSNF 180902Z AUTO 20007KT 7000 SCT005 BKN011 OVC015 20/19 Q1013 RMK RF00.0/000.0

However on reviewing the whole unrecorded interview Q&A session between MALIU Richard White & co for CASA vs DJ and his legal counsel, I note that there was never any question asked of DJ regarding whether he had received the 0803 AMD TAF or the 0739 SPECI.

This was despite there being factual evidence that Richard White was aware of the 0803 AMD TAF and the operational requirement alarm bells that should have rung if the flightcrew had received and disseminated that wx forecast.

T6 extract from CASA v DJ T documents (note date at the top of the page):

& from T5 page 7 of the T-documents listed as a 'document from audit conducted':

 Note that this investigative summary and update was completed before the Hood 24 December 2009 suspension decision notice. Therefore we can only presume that Hoody was not privy to this additional information, otherwise it would have been included in the notice correspondence and by rights DJ would have had his licence cancelled rather than suspended.

This non-inclusion of this critical factual information and the fact that it wasn't a featured question in the 16 December DJ Q&A, would suggest to me that White, Chambers, Campbell and Co. were either totally inept; or already fully cognisant of the fact that the flightcrew of VH-NGA never received either the 0803 AMD TAF or the 0739 SPECI ...

MTF...P2

[Kharon]

A thumbnail, dipped in tar.

"And an answer came directed in a writing unexpected,

  (And I think the same was written in a thumbnail dipped in tar)

'Twas his shearing mate who wrote it, and verbatim I will quote it:

  "Clancy's gone to Queensland droving, and we don't know where he are."

This post is definitely not for the purist or the professional. However, I get asked, a lot, to explain the ‘fuss’ about fuel and ‘critical’ points along the James flight path. Operationally, the matter is not too complex – legally, when CASA get determined to prove a point, it’s a bloody nightmare. Putting aside the twisted Chambers logic and the ‘niceties’ of flight planning I shall endeavour to explain why most thinking pilots are calling bollocks’ on most of the CASA assumptions and ridiculing the Walker attempts to foist yet another flawed report on the ditching. Why Walker is determined to do this and why CASA is happy to assist is a question we cannot answer – yet. The ‘T’ documents and other supporting ‘paperwork’ read properly, with a time/date line analysis almost completely exonerate James; but more of that later. Lets take a layman’s quick guided tour through a practical examination of the flight, it may shed some light.

Fuel – a must have. There is a finite amount of fuel which may be loaded onto an aircraft and it is ‘heavy’. There is a finite amount of power which may be extracted from the engines. The eternal problem is one of aircraft weight, the amount of fuel needed to move that weight and the rate at which the fuel is consumed. Jet aircraft fuel consumption benefits from altitude; high is good; but, the engine power available must be equal to supporting the aircraft at its weight at the optimum altitude. This is why a ‘Stepped’ climb profile may be used; climb to 36,000 is acceptable, cruise for an hour, weight reduces and a climb to 38,000 may be possible; this reduces the overall fuel burn off and, has the effect of ‘making’ fuel, which may be used to calculate the ‘critical’ gateways along the route. It is standard operating practice, legal and safe to operate in this fashion – Qantas would hardly get a long haul flight completed if the crew were not skilled in managing the ‘weight/fuel/distance/ weather at destination equation.

But we need to consider the ‘en-route’ gateways. Release points if you will; each gateway is a decision point; crew are always aware of an approaching ‘gate’ they do the sums, weigh up the ‘ifs and buts’ and are prepared to make a decision at that gate. So lets place ourselves in cruise at 36, 000 feet (F360) half way between the departure aerodrome and our first gate; two items for consideration. Item one; the weight for a climb is calculated and the approximate time for initiating the climb is jotted down. Item two: action in the event of abnormal or emergency conditions arising This is a no brainer; each of the ‘standard’ scenarios is predetermined; the only variables are the wind, temperature and weather’ (which may not be exactly as forecast at the planning stage) which call for minor adjustments to the time at which the aircraft will arrive at the gateway and the actual amount of fuel available to meet the requirements. As we approach gate ‘A’ the calculations are complete; provided we do not have a failed engine; or, have not lost cabin pressure and the weather at the destination is still acceptable – there is no decision, other than to continue which needs to be made. Should any of the ‘critical’ elements change in a manner which affects the amount of fuel we have to use then the decision is simplicity itself. We divert to an alternate; this is pre planned, fuel is allocated to complete the diversion, the time taken to reach an alternate is known and – with a little luck – apart from the expense and inconvenience – all should be well. Thus, we proceed past our ‘gateways’ toward our destination; each gateway has it’s own ‘limitations’ and decision making prerequisites which influence that decision. We, finally, arrive at gateway ‘X’ and find that due to the wind conditions we have insufficient fuel to meet the requirements – we divert. Once past gate ‘X’ provided the destination weather remains acceptable we toddle along to the top of our descent; once we have passed gate ‘X’ there is no spare fuel to divert anywhere – there is fuel for the depressurised situation; for the engine fail situation; fuel to meet any holding requirements, fuel to complete at least one instrument approach; there is even enough fuel for a missed approach and a second whack at landing. But that’s all she wrote. Well, it is unless you happen to be operating under any other rule set bar the Australian ones; it is mandatory [FAA for e.g.] (and most sensible) to carry enough fuel to divert from the intended destination to an alternate airfield; with acceptable weather conditions.

It is a ramble, I know, but if we must dive into the Pel-Air debacle then it is important (IMO) that ‘muggles’ understand at least the basics. So lets look at the Pel-Air flight, from a practical standpoint.

If you grab a clean sheet of A4 the draw a line from top right to bottom left it will assist. Put a dot for Apia in the top right; a third of the way along the line put a dot for Fiji; two thirds the way a dot for Noumea and in the bottom left a dot for Norfolk Island.

James ‘radius of action’ was, on departure Apia somewhere about 180 miles past Norfolk Island, toward the mainland – assuming normal operations. The single engine ‘radius of action’ and the ‘depressurised’ radius are a good way down the line. The Point of No Return to Apia becomes academic and of no interest. Connect our flight path line to Fiji; there are two perfectly serviceable airports available there; ‘South abeam Fiji’ James could reset all his calculations; his critical gates would now be return to Fiji or divert the Noumea; he had plenty of fuel to do either until he passed the point where Noumea was the closest option. So far so good. Now, connect our flight path with Noumea; once again two suitable airports. South abeam Noumea James could reset his calculations; divert if things started to go wrong with the aircraft or, continue on toward Norfolk until he passed the point where a return to Noumea was ‘impractical’.

The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

I do, most sincerely, apologise to the purists; but unless the muggles get at least a mud map of the core issues, to explain what we’re banging on about; then, the pony-pooh from ATSB and CASA is just going to accepted as correct – well it ain’t..

Phew; wish I’d never started this post; second coffee just became a mandatory requirement.

Toot toot.

[Peetwo]

Above: ATSB Chief Commissioner Hood impersonating Buzz Lightyear -   

---

PelAir MKII countdown: Redemption or oblivion?

With 2 days to go before the 500+ page PelAir MK II Final Report is released the BRB punters corner is running hot with speculative bets on how the Senate RRAT committee, collectively and individually will interpret and react to this latest ATSB reiteration??



Therefore IMO now is the perfect time to reflect (in this case posthumously) on how Ben Sandilands, in company with many IOS/BRB members, was moved by a typical clinically informative Senator Fawcett summary speech in the Senate a month after the report was officially tabled on 23 May 2013:

Pel-Air air safety issues spelt out by pilot and Senator, David Fawcett

A parliamentary speech that everyone concerned about the safety of the flying
public, and the competency and integrity of CASA and the ATSB should read

Ben Sandilands

Earlier this week Senator David Fawcett (Liberal, South Australia) urged the upper house of Australia’s federal parliament to ‘take note’ of the Senate committee inquiry into the ATSB’s final report into the 2009 Pel-Air crash and related matters.

Senator Fawcett was a military helicopter pilot, and was the Commanding Officer, RAAF Aircraft Research and Development Unit, Edinburgh, SA, and an experimental test pilot, before being elected to public office.

He played a very measured and penetrating role in the air accident investigation committee hearings which were were instigated by fellow SA independent Senator Nick Xenophon.

This is Senator Fawcett’s address to the motion that the Senate take note of the committee’s findings. Whatever the attitude of the government and opposition benches to the Pel-Air matters, the disgrace they brought on CASA and the ATSB will neither be forgiven nor go away.

This is about the safety of the Australian public, and the functioning of the bodies charged to regulate air safety (CASA) and investigate safety issues to further air safety (ATSB). In the Hansard of Senator Fawcell’s speech some emphasis has been added by Plane Talking.

Senator FAWCETT  I move:
 That the Senate take note of the report: 
The final report of the Rural and Regional Affairs and Transport References Committee into aviation accident investigations was tabled in May this year.

It followed a long period of investigation into the inquiry by the ATSB into the accident in which a Pel-Air aircraft ditched off Norfolk Island in 2009.

The Senate report highlighted that the performance of the two government agencies that were primarily involved, the Australian Transport Safety Bureau and the Civil Aviation Safety Authority, came far short of the expectations that the Australian taxpayer, this parliament and the aviation community should have.


In 2010 a review was done into the operations of those two agencies.

Of the eight desired outcomes of that review, the committee found that actions by ATSB and CASA failed to deliver against six of the main areas.

I will list them and then talk in more detail about them.

They failed to maximise the beneficial aviation safety outcomes that could have been derived from the investigation into this incident.

They failed to enhance public confidence in aviation safety.

I think we saw that in the controversy in the aviation industry and the media around the report when it was finally released.

They failed to support the adoption of a systemic approach to aviation safety.
They failed to promote and conduct ATSB independent no-blame safety investigations and CASA regulatory activities in a manner that assured a clear and publicly perceived distinction between each agency’s complementary safety related objectives, as well as CASA’s specialised enforcement related obligations; they also failed to avoid to the extent practicable any impediments in the performance of each other’s functions.

They also failed to acknowledge errors and to be committed in practice to seeking constant improvement.

The committee made 26 recommendations to address a number of systemic deficiencies that were identified in both the investigative and regulatory processes but also in funding and reporting.

Safety outcomes is one area that I would like to touch on.

[i]Accident investigations are an opportunity for an informed and expert body to sit back and take a considered look at why an incident occurred.

That body may be expert but they are not necessarily the best judges of how the lessons from that incident may be applied to other sectors of the aviation industry.

The committee found that for various reasons and over time the ATSB processes have got to the point where much evidence can be excluded if it does not fall into the categories that they consider will impact on high-risk future operations. So we have a situation where they are making an arbitrary decision to exclude evidence, and without evidence they are not then investigating or reporting on what actually occurred.

That means that other aviation operations are not the beneficiaries of an explanation of occurrences and failures in a system safety approach and what defences failed such that the accident occurred. It has been the traditional approach to identify each of those factors and let the stakeholders make their own assessment. But the safety outcomes are no longer optimised because of this approach of trying to make that arbitrary decision at the front.

That is a significant flaw in the current approach which the committee has recommended be revisited.

The report and CASA’s statements in name supported the concept of a systemic approach to aviation safety.

But what we found very clearly was that the investigation focused very quickly on the pilot in command on the night, as opposed to looking at the raft of other factors.
Looking at the James Reason model of system safety, one sees that there are a number of defences which are in place, which include the operating company, the regulator and a raft of things—training et cetera—as well as the pilot. But many of those factors were given, at best, lip-service. They were mentioned in the report so a box could be ticked to say that they were considered, without a detailed consideration of them.
For that reason, the report was quite flawed.


What made the matter worse was that, having required both CASA and ATSB to produce documents for the inquiry, which initially they were reluctant to do, we spent some considerable time going through literally boxes and boxes of documents to find information, emails, reports and things that were relevant to the report and, having seen a report that said that the company was applying all of its regulatory requirements and CASA was auditing it and so there were no organisational factors to consider, we found that CASA in fact had done a special audit.

Not only had they done a special audit that found a range of problems within the company; they had done their own internal report about CASA’s performance of their oversight of the company and found that, in their own words, that was deficient.

So we have a situation where CASA—who have an obligation, under the memorandum of understanding, to disclose to the ATSB when they are aware of or hold, information relevant to an accident investigation—withheld the information of the Chambers report, which is their internal document, and when, as a directly interested party, they were given a draft of the report and the opportunity to say, ‘No, this is not correct; there are organisational factors both with the company and the regulator that you should be aware of,’ they chose not to do that.

That comes very close to breaching, if it does not actually breach, the transport safety act. It certainly does nothing to boost public confidence and it does nothing to enhance the safety outcomes that could have been achieved through this investigation.


It is telling that there were many organisational and systemic measures put in place by the company in order to resume operations.

That says that, in their assessment and in the assessment of those people who were auditing the company, clearly the pilot alone was not at fault for the original accident or there would be nothing else they had to change.

So the ATSB, in its approach to its report,  and CASA, by withholding that information, have done the aviation industry in Australia a great disservice.

The aviation industry relies on open, transparent and accurate reporting from the regulator and from the safety investigation agency to make sure that the organisations concerned can be ongoing learning organisations that maximise the safety outcomes for the travelling public and for people operating aircraft.

The regulatory reform process is another thing that came through from this.

The air ambulance operation, like the RFDS operation—which also has some emergency aspect to it, certainly for the helicopter emergency services—highlights that we have a category of operation here which has traditionally been put into the air work category, and that is clearly not adequate for all operations in terms of either their planning requirements or the aircraft equipment.

To put them into a higher category such as regular public transport or even charter would unnecessarily, in fact prohibitively, restrict their ability to respond and operate in emergency situations to unprepared airfields.

There is a very clear case here for industry to have a voice and a role to work with the regulator to establish a new category of operation that provides the guidance required around equipment standards and configuration of the aircraft but also provides the flexibility the operators need to perform their mission in a structured manner.

The last point I would raise is that the Chambers report indicated that CASA felt they were under resourced and their people, in many cases, did not have the requisite insight and, in some cases, skills, knowledge or background to do the auditing.

From subsequent discussions, I would argue that, in some cases, they did not have the background to be writing the regulations or standards in the first place.

I believe there is a strong requirement to look at the regulatory reform process and the role that industry should have, not just with token consultation but with a powerful voice, even to the point of veto, where they can work with the regulator to highlight what is industry best practice, and that should form the basis of regulation unless there is a very clear safety case to not go down that path.

Australia’s travelling public and our aviation industries deserve better.

I look forward to the reforms that either this government or the next will bring.

---

Just as a reminder here is a link - HERE - for the original AAI report and here is a list of the 26 recommendations:
[/i]

List of Recommendations

Recommendation 1
3.68      The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay.

Recommendation 2
4.41      The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification.

Recommendation 3
4.43      The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.

Recommendation 4
4.69      The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.

Recommendation 5
4.78      The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.

Recommendation 6
4.79      The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in training/competence must be advised to the minister and the Parliament.

Recommendation 7
4.87      The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.

Recommendation 8
4.101      The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Recommendation 9
4.103      The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.

Recommendation 10
6.41      The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

Recommendation 11
6.52      The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.

Recommendation 12
6.55      The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.

Recommendation 13
6.58      The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.

Recommendation 14
7.15      The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:

• advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
  
• provide the ATSB with the relevant review report as soon as it is available.
  

Recommendation 15
7.16      The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.

Recommendation 16
8.35      The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.

Recommendation 17
9.18      The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

Recommendation 18
9.40      The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

Recommendation 19
9.42      The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.

Recommendation 20
9.44      The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.

Recommendation 21
9.45      The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.

Recommendation 22
9.77      The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.

Recommendation 23
9.104      The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer.

Recommendation 24
9.106      The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.

Recommendation 25
9.108      The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.

Recommendation 26
10.35      The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

TICK..TOCK Hoody - "To infinity and beyond"


MTF...P2

[Kharon]

The whirligig of time.

“I wish it need not have happened in my time," said Frodo.

"So do I," said Gandalf, "and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.” (Tolkien).

And we do, live in such times; for nothing has influenced change; not the Senate inquiry, not the ASRR, not stirring rhetoric, not evidence, not logic, not even the will of ‘reasonable men’. ATSB, CASA and only the gods know who else is relying on ‘time’ to heal the mortal wounds inflicted on aviation The Pel-Air incident revealed the tip of an ugly, dangerous iceberg, which, to this day remains immobile, untouched and determinedly whole.

The Senate recommendations should have brought about an immediate change in the regulator; the sins exposed would have a supplicant penitent for a good long while – the crimes committed should have seen a criminal penalty extracted, the complete lack of morality revealed demanded an immediate apology to the Australian people. Anyone notice that happening?

The grotesque pantomime continues, the ridiculous law sets become the norm, the fools and charlatans who inflict these outrages on the industry are still comfortably ensconced within the protection of the ivory towers.  

Clearly, neither ATSB or CASA have any intention of changing and why should they. They have everything set up just so and it works for them. So we must look to our politicians to enforce the changes demanded by industry. It’s all well and good for Senators to make stirring ‘speeches’ after exposing a small part of the horrors which reside deep within Sleepy Hollow; but, did they follow through. The very short answer is a long, loud ‘NO- they did not’.

Did the minister follow through – once again a resounding NO. The ministerial solution was to throw the whole thing back to the ‘accused’ to sort it out. Go figure, remember - this covers a three minister flush.

So ask not why the situation remains critical – ask why nothing, absolutely nothing, has changed since the rhetoric stopped. Is the same travesty to be repeated and will the Senate committee allow the Chimera to escape – again?

Toot – toot…;

[Peetwo]

PelAir coverup MKII - Final report released.

Media release

Title
Media statement: AO-2009-072 (reopened)
 
Date: 23 November 2017

The Australian Transport Safety Bureau (ATSB) has today released its final report into the reopened investigation of the 18 November 2009 accident involving Israel Aircraft Industries Westwind 1124A aircraft, VH-NGA, near Norfolk Island.

The flight, which was conducting an air ambulance flight, took off from Apia, Samoa, bound for Australia, via Norfolk Island for a fuel stop. On arrival at Norfolk Island, low cloud prevented the crew from making a safe landing. After four unsuccessful approaches, and with insufficient fuel to divert to another airport, the aircraft was ditched into waters 6.4 km west-south-west of the airport. All six occupants evacuated from the aircraft and were rescued by boat.

The ATSB formally reopened its investigation on 4 December 2014 following criticism of its original investigation by the aviation industry and was subject to an inquiry by the Australian Senate’s Rural and Regional Affairs and Transport References Committee.

Prior to commencing the reopened investigation, the ATSB requested the Transportation Safety Board of Canada (TSB) conduct an independent peer review of its investigation methodologies and processes. Its review, which included an examination of two previous aviation investigations along with the original investigation involving VH-NGA, stated that “The TSB Review compared the two organisations’ methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization (ICAO) Convention on International Civil Aviation, and found they met or exceeded the intent and spirit of those prescribed.”

However, the review also found deficiencies in how the ATSB’s methodologies were applied in the case of the Norfolk Island investigation and identified 14 recommendations for the ATSB to enhance the quality and the way in which it conducts future safety investigations.

Special measures were taken to ensure the reopened investigation remained distinct from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, it was conducted by investigators and overseen by managers who had not been involved in the original investigation. Additionally, the ATSB’s current Chief Commissioner, Greg Hood, was not involved in any part of the investigation, as he had been in a senior role at the aviation regulator, the Civil Aviation Safety Authority (CASA), at the time of the accident.

The new investigation team reviewed evidence obtained during the original investigation and acquired a substantial amount of additional information that was not obtained or available to the original investigation team. This new material included data from the aircraft’s recovered flight recorders and over 30 additional interviews with a range of people, including a number of other Westwind pilots from the operator, inspectors from CASA, as well as re-interviewing the flight crew and medical crew who were on board the aircraft.

The Commission review and approval process of the final investigation report was led by the ATSB’s aviation-experienced Commissioner, Chris Manning.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “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 significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened 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.”

Commissioner Manning added the thoroughness and level of detail in the final report was substantially more than would normally be the case for a safety investigation of this nature. The final report found 36 safety factors, including 16 safety issues. This large number of safety issues and factors was due in part to the amount of information obtained by the reopened investigation and the depth to which it was analysed.

“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Commissioner 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.”

Commissioner Manning said the most fundamental lesson from this reopened investigation for the regulator, operators and flight crews is to recognise that unforecast weather can occur at any aerodrome and can be especially challenging at remote islands and isolated locations.

“Consequently, there is a need for robust and conservative fuel policies, planning and in-flight management procedures for passenger-carrying transport flights to these types of destinations” said Commissioner Manning.

The final investigation report, AO-2009-072 (reopened), ‘Fuel planning event, weather-related event and ditching involving Israel Aircraft Westwind 1124A aircraft, VH-NGA, 6.4 km WSW of Norfolk Island Airport on 18 November 2009’, has been published on the ATSB’s website.

Editor’s note: Broadcast video and audio grabs of Commissioner Manning are available to media outlets on request by emailing: media@atsb.gov.au
 


Last update 23 November 2017

The following investigation crumbs IMO highlights clearly why the ATSB should be disbanded for at least the Aviation accident investigation ASAP:

ATC weather updates?

Given the huge missed opportunity by ATC to inform the co-pilot and myself of the new TAF which changed the fuel requirements for Norfolk, and that exemptions from ICAO policy have been granted in this regard re informing crew in international operations of such changes, why is a lengthy discussion on this topic missing?

ATSB IIC Dr Walker's nasty and arrogant reply to the above Captain DIP comment:
  

No change required

In addition to the content in The occurrence section, the draft report discusses the provision of flight service in the Nadi and Auckland Oceanic FIRs in detail (about 5 pages). The topic is also discussed in the Safety analysis (2 pages), and findings are included in relation to the Nadi IFISO and Auckland air/ground operator’s actions.

It is not clear what ‘exemptions from ICAO policy’ the captain is referring to. In relation to amended TAFs, ICAO guidance (in document 7030 for most regions) stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination. However, this did not apply to the Nadi FIR (although it did apply to the Auckland Oceanic FIR and the Australian FIRs). Overall, the Fijian and New Zealand flight information service providers’ procedures were consistent with ICAO standards and recommended practices.

Limited information about the reasons for the actions of the Nadi IFISO and Auckland air/ground controller regarding VH-NGA on 18 November 2009 were available to the ATSB reopened investigation. The ATSB discussed the topic in as much relevant detail as it could, given the available information. The importance of the meteorological information that was not passed by ATS to the flight crew has also been highlighted in the draft report.

Overall, further discussion of the topic was not considered warranted.

The dismissal by Walker of what essentially is IMO an ATSB identified significant safety issue...

ICAO guidance..(sic)..stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination

...is extremely problematic and disturbing in an international perspective.

How hard would it have been for the ATSB to issue a safety recommendation or notice to ICAO suggesting that maybe the document 7030 guidance should be revisited and possibly amended.  

Now from the MKII report some relevant quotes from the Dr Walker referred pages.

From Pg 97:

CAAF also reported:

- The Nadi Air Traffic Management Centre normally received METARs/SPECIs and TAFs within a few minutes of them being sent by the disseminating station.
 - METARs/SPECIs and TAFs were delivered automatically to two printers, including one at the IFISO’s workstation.
 - The IFISO’s workstation was enclosed in a soundproof booth.
 - When SPECIs were received, they were displayed to both the IFISO and the controller.

On 20 November 2009, the ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI.

P2 - Note the non-inclusion of the 0739 SPECI & 0803 AMD TAF. However this was explained in the next paragraph where the timeline of investigation bizarrely seems to jump from the original investigation back to the present reiteration:

CAAF advised it was not aware of the 0739 SPECI and the 0803 amended TAF until it received the ATSB’s investigation report in 2012. CAAF contacted the ATS provider, who advised it had provided CAAF with all the weather reports it had received at the time (in 2009). The ATS provider advised CAAF it no longer held the hard copy print outs and therefore CAAF could not verify whether the 0739 SPECI or the 0803 amended TAF had been received.

Q/ We now know that the ATSB and CASA in their parallel investigation activities were both aware of the existence of at least the 0803 AMD TAF by 23 November 2009. Therefore why did the ATSB in the course of their investigations - especially after receiving the Auckland & Nadi ATC transcripts -  not query the CAAF on why it was they didn't have copies of the 0739 wx report & the 0803 amended forecast?  

Quote from "K" post above - A thumbnail, dipped in tar. - once again the significance of the non-relayed wx report and AMD TAF in the context of this 531 page re-hashed 'the pilot did it' bollocks report...

...The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

MTF? MUCH!..P2

[ventus45]

8 years and 5 days for Mk2, and now, a long read.

[Peetwo]

PelAir MKII report - MSM coverage...

Via 'that man' & the Oz:

Pel-Air pilot who ditched plane in sea acted ‘within lax guidelines’
The 2009 Pel-Air Westwindafter being ditched in the sea off Norfolk Island. Picture: ATSB

• Ean Higgins
  
• The Australian
  
• 1:34PM November 23, 2017
  
• Ean Higgins
  
  Reporter
  Sydney
  https://plus.google.com/116716661262546957732
  @EanHiggins
  
  

A reinvestigation of 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 has found the pilot made errors but acted within the lax guidelines set by the aviation watchdog and his employer.

The new report, by the Australian Transport Safety Bureau, also expresses concern that the Civil Aviation Safety Authority, which sets aviation regulations, has failed to implement many recommendations that could help prevent similar accidents in future.

The unprecedented fresh inquiry, ordered three years ago by then Transport Minister Warren Truss, followed media revelations about the first report by the ATSB which placed almost all the blame on pilot Dominic James.

The disclosures by the ABC’s Four Corners program led to a Senate inquiry, which found grievous failures in both the ATSB investigation and CASA’s handling of the affair.

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

With fuel running out, Mr James put the Israel Aircraft Industries Westwind 1124A 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.

The Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

The CASA handling of the case was done by then CASA officer Greg Hood, who is now chief commissioner of the ATSB, and who issued the letter suspending Mr James’ licence to be captain on jets which have two pilots.

The new investigation, conducted by a different group of ATSB investigators, still finds the flight crew made errors.

But it says Mr James was operating within the existing regulations set by CASA, including not having to load enough fuel to reach an alternate airport if the weather turned bad.
It also says Mr James was operating within the rules set by Pel-Air, which the ATSB says were inadequate but have since been addressed.

The ATSB report expresses surprise that CASA has indicated it intends to address some of the deficiencies found in its regulations governing long distance air ambulance flights, but has not implemented changes.

“In 2014, CASA modified the requirements for operations to Australian remote islands, so that all passenger-carrying transport flights, including air ambulance flights, were required to depart with alternate fuel,” the ATSB says in the report released today.

“In addition, in 2012 CASA initiated action to change the regulatory classification of air ambulance (or medical transport) flights from aerial work to air transport,” which would mean ambulance flights would be governed by the stronger regulations applying to regular passenger airline flights.

“However, although CASA released a Notice of Proposed Rule Making about this issue in 2013, no changes have yet occurred.”

The ATSB says it has now issued a safety recommendation to CASA to continue reviewing the requirements for air ambulance operations.

& via the SMH:

Pilot error and lack of safety oversight led to Norfolk Island ditching

• [/url]Matt O'Sullivan
  
  • Contact via Email
    
  • Follow on Twitter
    

The ditching of a Pel-Air rescue flight in rough seas at night off Norfolk Island was the result of a series of errors by the pilots, insufficient risk-control by the airline and limits to this country's aviation regulations, air-crash investigators have found.

Almost eight years to the day after the Westwind jet ran out of fuel and ditched, the Australian Transport Safety Bureau has released the outcome of an investigation it reopened following pressure from a senate inquiry.
   
Play Video


Video duration00:26

What cost surviving a plane crash?
[url=http://www.smh.com.au/video/video-news/video-national-news/what-cost-surviving-a-plane-crash-20170309-4rh6p.html]
What cost surviving a plane crash?

In 2015, Four Corners investigated the shocking tale of nurse Karen Casey, who was on an air ambulance flight when the plane crash-landed into the ocean. She saved the life of her patient but sustained crippling injuries. Vision courtesy ABC.

In 2015, Four Corners investigated the shocking tale of nurse Karen Casey, who was on an air ambulance flight when the plane crash-landed into the ocean. She saved the life of her patient but sustained crippling injuries. Vision courtesy ABC.

The plane was carrying a seriously ill patient, Bernie Currall, husband Gary, doctor David Helm and nurse Karen Casey from Samoa to Melbourne on November 18, 2009, when bad weather disrupted a planned fuel stop at Norfolk Island.

After four aborted attempts to land at Norfolk Island due to low cloud, captain Dominic 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.

Related Articles

• Norfolk Island crash nurse wins damages claim against Pel-Air
  
  
• The crash that goes on forever
  
  

While the six on board miraculously survived the ditching, two were left with lasting injuries including Ms Casey, a nurse educator with CareFlight.

She suffered serious long-term injuries including complex pain syndrome, major depression, anxiety and PTSD, as well as multiple physical injuries.


While the captain was hailed a hero in the immediate aftermath of the crash, the 531-page report – one of the longest the ATSB has ever produced – released on Thursday is again highly critical of him.

It found that his pre-flight planning did not include many elements needed to lower the risk of a long-distance flight to a remote island.

Pilot Dominic James who ditched plane at Norfolk Island in 2009.  Photo: Louie Douvis
 
These included miscalculating the total fuel required, not calculating the extra fuel needed for aircraft system failures, not obtaining relevant forecasts for upper-level winds, and not obtaining the latest information about potential alternate airports.

While the report is critical of Mr James, it found the risk controls of Pel-Air, a subsidiary of Sydney airline Regional Express, did not give assurances there would be sufficient fuel on board flights to remote islands or isolated airports.
 
Nurse Karen Casey. Photo: Jon Reid  

The list of Pel-Air's lack of risk-control measures included "no explicit fuel planning requirements" or formal training for planning such flights, no procedure for a captain's calculation of the total fuel required to be checked by another pilot, and "little if any assessment during proficiency checks of a pilot's ability to conduct fuel planning".

The report also lists shortcomings in Australia's regulations including a lack of "explicit requirements" for planning flights to remote airports.

The Pel-Air Westwind plane that ditched into the ocean off Norfolk Island in 2009. 
 
And, because air ambulance flights were deemed "aerial work" rather than charter, they were subject to a lower level of requirements than other passenger flights.

It also notes that air traffic controllers in Fiji and New Zealand "did not provide the flight crew with all the information that should have been provided".
 
Wreckage of the sunken plane off Norfolk Island   

However, it said the pilots did not request enough information before they passed the point of no return, which meant they had no option but to land at Norfolk Island or, as it turned out, were forced to ditch the plane in the ocean.

Mr James did not use the right method for calculating the point of no return, the report added.

The aviation regulator, the Civil Aviation Safety Authority, also had made limited information available about in-flight fuel management.

While the pilots did indeed ditch the plane without the loss of life, the investigators said they did not effectively discuss approach options, review their fuel situation or consider other emergency options.

However, the investigators said a range of local conditions affected the pilots' performance towards the end of the flight "including workload, stress, time pressure and dark night conditions".

A lack of formal procedures and limited training also hampered the evacuation of the plane.

"In very difficult circumstances, the nurse and doctor did an excellent job evacuating the patient, and then assisting the injured first officer and the patient in the water, both of whom did not have life jackets," it said.

The ocean ditching, and ensuring investigation, has been one of the most controversial in modern Australian aviation history.

A federal senate inquiry in 2013 castigated the ATSB for its handling of the investigation into the ditching and demanded it reopen the case.

That inquiry also took a "dim view" of the failure by the Civil Aviation Safety Authority to provide the ATSB with "critical documents".

MTF...P2  


Ps Yes "V" a long and at times pointless read - yet again the ATSB prove that they are without peer the premier Government top cover agency...

Pps Should be the ATCB not the ATSB...

[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

---

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.

---

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.

[*]
MTF...P2

[Peetwo]

'That man Higgins' today, via the Oz : 

A pilot’s act of heroism, then lives destroyed over eight years of hell

Pilot Dominic James at Mosman in Sydney. Picture: John Feder..

• Ean Higgins
  
• The Australian
  
• 12:00AM November 27, 2017
  

Whatever he did or failed to do earlier in the flight, the way pilot Dominic James brought it to an end is regarded by aviation buffs as an extraordinary feat of airmanship, the stuff of legend.

It was during the night of ­November 18, 2009, and James was at the controls of a Westwind two-engine jet owned by Pel-Air. He was in command in the left-hand seat, co-pilot Zoe Cupit in the other. In the rear, on a stretcher, lay the very ill Melbourne woman who was the purpose of his CareFlight mission from Australia to Samoa and back: Bernie Currall, who had contracted a severe infection from a botched hysterectomy and needed intensive care in an Australian hospital.

Also in the passenger section were Currall’s husband, Gary, and the flying doctor and nurse sent to look after her during the flight, David Helm and Karen Casey.

James had set off with enough fuel to fly from Samoa to Norfolk Island, where he intended to take on more; he left the tip tanks unfilled to keep the aircraft light enough to get to high altitude where jets get best endurance.

The CareFlight Pel-Air Westwind plane that was forced to ditch in the sea off Norfolk Island.

He did not have enough fuel to fly to an alternative airport in the vast spaces of the Pacific if the weather at Norfolk Island turned bad at the end. But that was allowed for his type of flight under Civil Aviation Safety Authority regulations, it fitted Pel-Air’s operational guidelines, and the weather report for Norfolk Island when he set off was good. When the plane approached Norfolk ­Island, however, the weather wasn’t good. In fact, it was just about the worst it could be, the rain torrential, the clouds low.

James and Cupit attempted to get the plane down on Norfolk Island four times, trying different approaches. Fuel was about to run out, and there was nothing for it: James had to try to ditch the aircraft in the sea, in a storm with big seas, in the dead of night.

James lowered the flaps and slowed the aircraft, but it was too dark to see the direction of the swell. The plane hit the water hard, and Casey suffered a severe jolt which tore her neck and shoulder muscles.

“It broke underneath me,” Casey told The Australian. “The impact smashed all my teeth. I was knocked out very briefly.”

Karen Casey was a nurse on the Careflight plane.

The water started pouring in, and Bernie Currall was helpless on the stretcher. “She was absolutely terrified,” Casey said. “She was strapped in, relying on us. It was a rough ocean, and it was coming in over her head.”

Helm and Casey worked to get Currall unstrapped, and they ­escaped the sinking plane. James marshalled everyone in the ocean. Some had life jackets, some didn’t. James got his pocket pen light out and shone it into the night.

Incredibly, a fireman saw the light from shore, and was able to relay directions to a rescue boat, which picked up all six souls.

Businessman and aviator Dick Smith, who has flown similar twin-engined light jets over oceans, described James’s actions as “an incredibly talented feat”.

“Being able to get that plane down at night and all the passengers out alive was great,” Smith said.

Eight years on, the toll of the accident is still being played out. Casey has not been able to work again, the physical pain from her injuries persisting, and she still struggles with post-traumatic stress disorder. While she got a large compensation payout for the physical injuries, Pel-Air and its insurers fought her claim for PTSD, arguing it was not a “bodily injury” as required under the Civil Aviation Act. Casey won the PTSD part of the case initially, but the airline successfully reversed it on appeal earlier this year.

Helm, who suffered a debilitating back injury, returned to his ­native England and works as an emergency doctor near Brighton.

The greatest tragedy involves the woman for whom the flight was made: Bernie Currall. Having survived the ditching, being pulled naked from the sea after 90 minutes in the water, and then a long time in an Australian hospital, she developed chronic PTSD and had to spend periodic stretches in mental wards.

“She was one of those people who smoke a lot and seem permanently spooked,” James said of Bernie Currall’s mental state.

She, too, battled Pel-Air and its insurers for years. In February 2015, she committed suicide.

“She put up a brave fight, but the insurers were brutal,” James said. All the survivors have stayed in touch, and they are close.

“We were up against three sets of giants,” Casey said. One was Pel-Air, the second was an “insurance company that was just massive”, and the third was “a federal government that wasn’t going to help”.


The 2009 Pel-Air Westwind on the sea bed. Picture: ATSB

Left a widower, Gary Currall is understood to be trying to put the terrible affair behind him.

Cupit went on to fly with Virgin. But James is still battling two government agencies: CASA and the Australian Transport Safety Bureau, which investigates air ­accidents. In what James says remains “the worst thing that happened to me in my life”, after the accident CASA suspended his ­licence to captain jets that have two pilots. CASA has revoked the suspension, but the flyer and aviation watchdog are still locked in a dispute about how and when an ­“observation” flight can be flown to confirm it.

James now flies as co-pilot, or in command but under the supervision of a captain, for another charter and air ambulance company, Falcon Air.

After the accident, the ATSB took almost three years to produce a report that focused on what it said were mistakes by James relating to fuel planning and weather checks.
But an ABC Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

The disclosures led to a Senate inquiry, which found grievous failures in the ATSB investigation and CASA’s handling of the affair.

In its wake, the then transport minister, Warren Truss, ordered an unprecedented fresh inquiry, and last week, after another three years, the ATSB brought down its second investigation report.

The second report placed considerably more emphasis on failures in CASA’s regulations governing long-distance flights in remote areas — of which it says many have still not been resolved — and Pel-Air’s poor guidelines.

While it confirmed James had operated within the rules and regulations, it still found he made a number of errors related to fuel management and keeping abreast of weather updates. It also found he did not put the aircraft down at optimal speed and failed to report his final location.

James says the report still leaves a stain on his reputation as a pilot despite the fact he has had a flawless professional flying record over the past eight years.

He says the investigators did not appreciate the circumstances at the end of the flight.

“The whole world is burning down around our ears,” James said of those final minutes.

“We have the radio, the passengers to manage, and I have to control the aircraft.”

Casey thinks James’s treatment by the ATSB “stinks”, and misses the fundamental point as far as she is concerned: “I’m hurt, but I’m alive. I have nothing but praise for Dominic.”

James has had a longstanding ally in former independent senator Nick Xenophon, who helped get the Senate inquiry going. Xenophon’s replacement, Rex Patrick, told The Australian he was dissatisfied with the second ATSB report and was taking steps to have the organisation reappear before a Senate committee for a further grilling.

The second report comes at a time when the bureau is under ­attack for repeatedly failing to bring out investigation reports on schedule, and for suppressing critical information related to its failed search for Malaysia Airlines flight MH370. Senior ATSB officer Colin McNamara refused an FOI request from The Australian for the MH370 documents because their release “would, or could reasonably be expected to, cause damage to the international relations of the commonwealth”, a decision supported on review by ATSB chief commissioner Greg Hood.

According to Smith, a former chairman of CASA, it all goes to a toxic culture in the ATSB, which he describes as secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals.

Relatives of those killed in air accidents point to broken promises. Felicity Davis’s husband, John, a prominent environmentalist and documentary-maker, was killed in a helicopter crash in ­November 2015, and at the time the ATSB said it would complete an investigation in a year. It has now been two years, and the ATSB keeps saying it will produce a report, but doesn’t.

“I just feel we are getting fobbed off,” Davis said.

The Australian put questions about Davis’s concerns to the ATSB and sought comment from the investigator involved. There were no answers to the questions and no comment from the investigator, but McNamara took a dislike to the fact that the request had been made in the first place, and sent a menacing email back. Unless The Australian changed its behaviour, McNamara warned, “We will exercise our right not to engage with you on future requests”.

According to Smith, such behaviour is “outrageous”. “They are basically a secret, secret organisation. They are so insecure.”

Smith believes it’s time for Transport Minister Darren Chester to take charge and demand the ATSB bring itself up to the levels of efficiency, timeliness and transparency that Australians expect for their taxpayer dollars, and in a fashion consistent with a democracy that values free speech and freedom of the press.

And some comments...

Michael

Look at PelAir history from the time it phoenixed out of Wings Australia in the early 1980s. Three Westwinds destroyed and four pilots dead. Dominic and many other living victims.

---

Peter

The ATSB is a national disgrace! Vastly experienced pilots like Byron Bailey and hundreds of others, plus experienced air crash investigators have continually voiced their opinions that MH 380 was flown by the pilot deliberately into the sea, and there is sufficient physical and other evidence to support this view.

The ATSB officer MacNamara has given the game away by stating that to release documents to the Australian would, quote: "would have the expectation to cause damage to the international relations of the Commonwealth"!

That sentence says it all, and has revealed what this whole appalling fiasco for the last two years has been about!

They have been looking in the wrong place, they know they have been looking in the wrong place, have spent 2 years and $200 million doing it, all to appease the sensibilities of the Malaysian Government.

If the minister doesn't put the cleaners through this disgraceful body he too should be fired.

---

David

Bring CASA to heel as well.

---

pmac

ATSB and the APVMA must be trained by the same obfuscation college

---

graham

After coloring themselves into a corner, it was a pretty good effort by Dominic James and crew including the Doctor and Nurse who didn't wilt under pressure; pretty rare to have a 100% survival rate in such a situation.

---

Peter

Who do these "supervisors of flying bus drivers" think they are. Shades of 1950's Qantas pilots who exuded a "God Like" air. Time for public servants to be just that "Public Servants"

MTF...P2  

[Peetwo]

'That man Higgins' today, via the Oz : 

A pilot’s act of heroism, then lives destroyed over eight years of hell

Pilot Dominic James at Mosman in Sydney. Picture: John Feder..

• Ean Higgins
  
• The Australian
  
• 12:00AM November 27, 2017
  

Whatever he did or failed to do earlier in the flight, the way pilot Dominic James brought it to an end is regarded by aviation buffs as an extraordinary feat of airmanship, the stuff of legend.

It was during the night of ­November 18, 2009, and James was at the controls of a Westwind two-engine jet owned by Pel-Air. He was in command in the left-hand seat, co-pilot Zoe Cupit in the other. In the rear, on a stretcher, lay the very ill Melbourne woman who was the purpose of his CareFlight mission from Australia to Samoa and back: Bernie Currall, who had contracted a severe infection from a botched hysterectomy and needed intensive care in an Australian hospital.

Also in the passenger section were Currall’s husband, Gary, and the flying doctor and nurse sent to look after her during the flight, David Helm and Karen Casey.

James had set off with enough fuel to fly from Samoa to Norfolk Island, where he intended to take on more; he left the tip tanks unfilled to keep the aircraft light enough to get to high altitude where jets get best endurance.

The CareFlight Pel-Air Westwind plane that was forced to ditch in the sea off Norfolk Island.

He did not have enough fuel to fly to an alternative airport in the vast spaces of the Pacific if the weather at Norfolk Island turned bad at the end. But that was allowed for his type of flight under Civil Aviation Safety Authority regulations, it fitted Pel-Air’s operational guidelines, and the weather report for Norfolk Island when he set off was good. When the plane approached Norfolk ­Island, however, the weather wasn’t good. In fact, it was just about the worst it could be, the rain torrential, the clouds low.

James and Cupit attempted to get the plane down on Norfolk Island four times, trying different approaches. Fuel was about to run out, and there was nothing for it: James had to try to ditch the aircraft in the sea, in a storm with big seas, in the dead of night.

James lowered the flaps and slowed the aircraft, but it was too dark to see the direction of the swell. The plane hit the water hard, and Casey suffered a severe jolt which tore her neck and shoulder muscles.

“It broke underneath me,” Casey told The Australian. “The impact smashed all my teeth. I was knocked out very briefly.”

Karen Casey was a nurse on the Careflight plane.

The water started pouring in, and Bernie Currall was helpless on the stretcher. “She was absolutely terrified,” Casey said. “She was strapped in, relying on us. It was a rough ocean, and it was coming in over her head.”

Helm and Casey worked to get Currall unstrapped, and they ­escaped the sinking plane. James marshalled everyone in the ocean. Some had life jackets, some didn’t. James got his pocket pen light out and shone it into the night.

Incredibly, a fireman saw the light from shore, and was able to relay directions to a rescue boat, which picked up all six souls.

Businessman and aviator Dick Smith, who has flown similar twin-engined light jets over oceans, described James’s actions as “an incredibly talented feat”.

“Being able to get that plane down at night and all the passengers out alive was great,” Smith said.

Eight years on, the toll of the accident is still being played out. Casey has not been able to work again, the physical pain from her injuries persisting, and she still struggles with post-traumatic stress disorder. While she got a large compensation payout for the physical injuries, Pel-Air and its insurers fought her claim for PTSD, arguing it was not a “bodily injury” as required under the Civil Aviation Act. Casey won the PTSD part of the case initially, but the airline successfully reversed it on appeal earlier this year.

Helm, who suffered a debilitating back injury, returned to his ­native England and works as an emergency doctor near Brighton.

The greatest tragedy involves the woman for whom the flight was made: Bernie Currall. Having survived the ditching, being pulled naked from the sea after 90 minutes in the water, and then a long time in an Australian hospital, she developed chronic PTSD and had to spend periodic stretches in mental wards.

“She was one of those people who smoke a lot and seem permanently spooked,” James said of Bernie Currall’s mental state.

She, too, battled Pel-Air and its insurers for years. In February 2015, she committed suicide.

“She put up a brave fight, but the insurers were brutal,” James said. All the survivors have stayed in touch, and they are close.

“We were up against three sets of giants,” Casey said. One was Pel-Air, the second was an “insurance company that was just massive”, and the third was “a federal government that wasn’t going to help”.


The 2009 Pel-Air Westwind on the sea bed. Picture: ATSB

Left a widower, Gary Currall is understood to be trying to put the terrible affair behind him.

Cupit went on to fly with Virgin. But James is still battling two government agencies: CASA and the Australian Transport Safety Bureau, which investigates air ­accidents. In what James says remains “the worst thing that happened to me in my life”, after the accident CASA suspended his ­licence to captain jets that have two pilots. CASA has revoked the suspension, but the flyer and aviation watchdog are still locked in a dispute about how and when an ­“observation” flight can be flown to confirm it.

James now flies as co-pilot, or in command but under the supervision of a captain, for another charter and air ambulance company, Falcon Air.

After the accident, the ATSB took almost three years to produce a report that focused on what it said were mistakes by James relating to fuel planning and weather checks.
But an ABC Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

The disclosures led to a Senate inquiry, which found grievous failures in the ATSB investigation and CASA’s handling of the affair.

In its wake, the then transport minister, Warren Truss, ordered an unprecedented fresh inquiry, and last week, after another three years, the ATSB brought down its second investigation report.

The second report placed considerably more emphasis on failures in CASA’s regulations governing long-distance flights in remote areas — of which it says many have still not been resolved — and Pel-Air’s poor guidelines.

While it confirmed James had operated within the rules and regulations, it still found he made a number of errors related to fuel management and keeping abreast of weather updates. It also found he did not put the aircraft down at optimal speed and failed to report his final location.

James says the report still leaves a stain on his reputation as a pilot despite the fact he has had a flawless professional flying record over the past eight years.

He says the investigators did not appreciate the circumstances at the end of the flight.

“The whole world is burning down around our ears,” James said of those final minutes.

“We have the radio, the passengers to manage, and I have to control the aircraft.”

Casey thinks James’s treatment by the ATSB “stinks”, and misses the fundamental point as far as she is concerned: “I’m hurt, but I’m alive. I have nothing but praise for Dominic.”

James has had a longstanding ally in former independent senator Nick Xenophon, who helped get the Senate inquiry going. Xenophon’s replacement, Rex Patrick, told The Australian he was dissatisfied with the second ATSB report and was taking steps to have the organisation reappear before a Senate committee for a further grilling.

The second report comes at a time when the bureau is under ­attack for repeatedly failing to bring out investigation reports on schedule, and for suppressing critical information related to its failed search for Malaysia Airlines flight MH370. Senior ATSB officer Colin McNamara refused an FOI request from The Australian for the MH370 documents because their release “would, or could reasonably be expected to, cause damage to the international relations of the commonwealth”, a decision supported on review by ATSB chief commissioner Greg Hood.

According to Smith, a former chairman of CASA, it all goes to a toxic culture in the ATSB, which he describes as secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals.

Relatives of those killed in air accidents point to broken promises. Felicity Davis’s husband, John, a prominent environmentalist and documentary-maker, was killed in a helicopter crash in ­November 2015, and at the time the ATSB said it would complete an investigation in a year. It has now been two years, and the ATSB keeps saying it will produce a report, but doesn’t.

“I just feel we are getting fobbed off,” Davis said.

The Australian put questions about Davis’s concerns to the ATSB and sought comment from the investigator involved. There were no answers to the questions and no comment from the investigator, but McNamara took a dislike to the fact that the request had been made in the first place, and sent a menacing email back. Unless The Australian changed its behaviour, McNamara warned, “We will exercise our right not to engage with you on future requests”.

According to Smith, such behaviour is “outrageous”. “They are basically a secret, secret organisation. They are so insecure.”

Smith believes it’s time for Transport Minister Darren Chester to take charge and demand the ATSB bring itself up to the levels of efficiency, timeliness and transparency that Australians expect for their taxpayer dollars, and in a fashion consistent with a democracy that values free speech and freedom of the press.

And some comments...

Michael

Look at PelAir history from the time it phoenixed out of Wings Australia in the early 1980s. Three Westwinds destroyed and four pilots dead. Dominic and many other living victims.

---

Peter

The ATSB is a national disgrace! Vastly experienced pilots like Byron Bailey and hundreds of others, plus experienced air crash investigators have continually voiced their opinions that MH 380 was flown by the pilot deliberately into the sea, and there is sufficient physical and other evidence to support this view.

The ATSB officer MacNamara has given the game away by stating that to release documents to the Australian would, quote: "would have the expectation to cause damage to the international relations of the Commonwealth"!

That sentence says it all, and has revealed what this whole appalling fiasco for the last two years has been about!

They have been looking in the wrong place, they know they have been looking in the wrong place, have spent 2 years and $200 million doing it, all to appease the sensibilities of the Malaysian Government.

If the minister doesn't put the cleaners through this disgraceful body he too should be fired.

---

David

Bring CASA to heel as well.

---

pmac

ATSB   and the APVMA   must be trained by the same obfuscation college

---

graham

After coloring themselves into a corner, it was a pretty good effort by Dominic James and crew including the Doctor and Nurse who didn't wilt under pressure; pretty rare to have a 100% survival rate in  such a situation.

---

Peter

Who do these "supervisors of flying bus drivers" think they are. Shades of 1950's Qantas pilots who exuded a "God Like" air. Time for public servants to be just that "Public Servants"

---

Alexander

Thank you Ean for keeping the spotlight on our disgraceful regulator CASA and its sycophant ATSB. It’s high time Australia realised the extraordinarily poor return its reaping from the failed experiment of the ‘independent umpire,’ a 30 yo concept of ‘user pays’ and an excuse for removing Ministerial responsibility. ATSB is shown up as completely inept and incapable of making a timely or objective finding. The (Un) Civil Aviation Safety Authority has progressively turned itself into a fee gouging regulation and salary factory with no regard to having destroyed General Aviation. 30 years rewriting the aviation rules, still not finished $300 million down the drain. Incapable of admitting it might improve, instead prefers to scapegoat the pilot. Alex in the Rises

MTF...P2

[Peetwo]

'That man Higgins' today, via the Oz : 

A pilot’s act of heroism, then lives destroyed over eight years of hell

Pilot Dominic James at Mosman in Sydney. Picture: John Feder..

• Ean Higgins
  
• The Australian
  
• 12:00AM November 27, 2017
  

Whatever he did or failed to do earlier in the flight, the way pilot Dominic James brought it to an end is regarded by aviation buffs as an extraordinary feat of airmanship, the stuff of legend.

It was during the night of ­November 18, 2009, and James was at the controls of a Westwind two-engine jet owned by Pel-Air. He was in command in the left-hand seat, co-pilot Zoe Cupit in the other. In the rear, on a stretcher, lay the very ill Melbourne woman who was the purpose of his CareFlight mission from Australia to Samoa and back: Bernie Currall, who had contracted a severe infection from a botched hysterectomy and needed intensive care in an Australian hospital.

Also in the passenger section were Currall’s husband, Gary, and the flying doctor and nurse sent to look after her during the flight, David Helm and Karen Casey.

James had set off with enough fuel to fly from Samoa to Norfolk Island, where he intended to take on more; he left the tip tanks unfilled to keep the aircraft light enough to get to high altitude where jets get best endurance.

The CareFlight Pel-Air Westwind plane that was forced to ditch in the sea off Norfolk Island.

He did not have enough fuel to fly to an alternative airport in the vast spaces of the Pacific if the weather at Norfolk Island turned bad at the end. But that was allowed for his type of flight under Civil Aviation Safety Authority regulations, it fitted Pel-Air’s operational guidelines, and the weather report for Norfolk Island when he set off was good. When the plane approached Norfolk ­Island, however, the weather wasn’t good. In fact, it was just about the worst it could be, the rain torrential, the clouds low.

James and Cupit attempted to get the plane down on Norfolk Island four times, trying different approaches. Fuel was about to run out, and there was nothing for it: James had to try to ditch the aircraft in the sea, in a storm with big seas, in the dead of night.

James lowered the flaps and slowed the aircraft, but it was too dark to see the direction of the swell. The plane hit the water hard, and Casey suffered a severe jolt which tore her neck and shoulder muscles.

“It broke underneath me,” Casey told The Australian. “The impact smashed all my teeth. I was knocked out very briefly.”

Karen Casey was a nurse on the Careflight plane.

The water started pouring in, and Bernie Currall was helpless on the stretcher. “She was absolutely terrified,” Casey said. “She was strapped in, relying on us. It was a rough ocean, and it was coming in over her head.”

Helm and Casey worked to get Currall unstrapped, and they ­escaped the sinking plane. James marshalled everyone in the ocean. Some had life jackets, some didn’t. James got his pocket pen light out and shone it into the night.

Incredibly, a fireman saw the light from shore, and was able to relay directions to a rescue boat, which picked up all six souls.

Businessman and aviator Dick Smith, who has flown similar twin-engined light jets over oceans, described James’s actions as “an incredibly talented feat”.

“Being able to get that plane down at night and all the passengers out alive was great,” Smith said.

Eight years on, the toll of the accident is still being played out. Casey has not been able to work again, the physical pain from her injuries persisting, and she still struggles with post-traumatic stress disorder. While she got a large compensation payout for the physical injuries, Pel-Air and its insurers fought her claim for PTSD, arguing it was not a “bodily injury” as required under the Civil Aviation Act. Casey won the PTSD part of the case initially, but the airline successfully reversed it on appeal earlier this year.

Helm, who suffered a debilitating back injury, returned to his ­native England and works as an emergency doctor near Brighton.

The greatest tragedy involves the woman for whom the flight was made: Bernie Currall. Having survived the ditching, being pulled naked from the sea after 90 minutes in the water, and then a long time in an Australian hospital, she developed chronic PTSD and had to spend periodic stretches in mental wards.

“She was one of those people who smoke a lot and seem permanently spooked,” James said of Bernie Currall’s mental state.

She, too, battled Pel-Air and its insurers for years. In February 2015, she committed suicide.

“She put up a brave fight, but the insurers were brutal,” James said. All the survivors have stayed in touch, and they are close.

“We were up against three sets of giants,” Casey said. One was Pel-Air, the second was an “insurance company that was just massive”, and the third was “a federal government that wasn’t going to help”.


The 2009 Pel-Air Westwind on the sea bed. Picture: ATSB

Left a widower, Gary Currall is understood to be trying to put the terrible affair behind him.

Cupit went on to fly with Virgin. But James is still battling two government agencies: CASA and the Australian Transport Safety Bureau, which investigates air ­accidents. In what James says remains “the worst thing that happened to me in my life”, after the accident CASA suspended his ­licence to captain jets that have two pilots. CASA has revoked the suspension, but the flyer and aviation watchdog are still locked in a dispute about how and when an ­“observation” flight can be flown to confirm it.

James now flies as co-pilot, or in command but under the supervision of a captain, for another charter and air ambulance company, Falcon Air.

After the accident, the ATSB took almost three years to produce a report that focused on what it said were mistakes by James relating to fuel planning and weather checks.
But an ABC Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

The disclosures led to a Senate inquiry, which found grievous failures in the ATSB investigation and CASA’s handling of the affair.

In its wake, the then transport minister, Warren Truss, ordered an unprecedented fresh inquiry, and last week, after another three years, the ATSB brought down its second investigation report.

The second report placed considerably more emphasis on failures in CASA’s regulations governing long-distance flights in remote areas — of which it says many have still not been resolved — and Pel-Air’s poor guidelines.

While it confirmed James had operated within the rules and regulations, it still found he made a number of errors related to fuel management and keeping abreast of weather updates. It also found he did not put the aircraft down at optimal speed and failed to report his final location.

James says the report still leaves a stain on his reputation as a pilot despite the fact he has had a flawless professional flying record over the past eight years.

He says the investigators did not appreciate the circumstances at the end of the flight.

“The whole world is burning down around our ears,” James said of those final minutes.

“We have the radio, the passengers to manage, and I have to control the aircraft.”

Casey thinks James’s treatment by the ATSB “stinks”, and misses the fundamental point as far as she is concerned: “I’m hurt, but I’m alive. I have nothing but praise for Dominic.”

James has had a longstanding ally in former independent senator Nick Xenophon, who helped get the Senate inquiry going. Xenophon’s replacement, Rex Patrick, told The Australian he was dissatisfied with the second ATSB report and was taking steps to have the organisation reappear before a Senate committee for a further grilling.

The second report comes at a time when the bureau is under ­attack for repeatedly failing to bring out investigation reports on schedule, and for suppressing critical information related to its failed search for Malaysia Airlines flight MH370. Senior ATSB officer Colin McNamara refused an FOI request from The Australian for the MH370 documents because their release “would, or could reasonably be expected to, cause damage to the international relations of the commonwealth”, a decision supported on review by ATSB chief commissioner Greg Hood.

According to Smith, a former chairman of CASA, it all goes to a toxic culture in the ATSB, which he describes as secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals.

Relatives of those killed in air accidents point to broken promises. Felicity Davis’s husband, John, a prominent environmentalist and documentary-maker, was killed in a helicopter crash in ­November 2015, and at the time the ATSB said it would complete an investigation in a year. It has now been two years, and the ATSB keeps saying it will produce a report, but doesn’t.

“I just feel we are getting fobbed off,” Davis said.

The Australian put questions about Davis’s concerns to the ATSB and sought comment from the investigator involved. There were no answers to the questions and no comment from the investigator, but McNamara took a dislike to the fact that the request had been made in the first place, and sent a menacing email back. Unless The Australian changed its behaviour, McNamara warned, “We will exercise our right not to engage with you on future requests”.

According to Smith, such behaviour is “outrageous”. “They are basically a secret, secret organisation. They are so insecure.”

Smith believes it’s time for Transport Minister Darren Chester to take charge and demand the ATSB bring itself up to the levels of efficiency, timeliness and transparency that Australians expect for their taxpayer dollars, and in a fashion consistent with a democracy that values free speech and freedom of the press.

And some comments...

Michael

Look at PelAir history from the time it phoenixed out of Wings Australia in the early 1980s. Three Westwinds destroyed and four pilots dead. Dominic and many other living victims.

---

Peter

The ATSB is a national disgrace! Vastly experienced pilots like Byron Bailey and hundreds of others, plus experienced air crash investigators have continually voiced their opinions that MH 380 was flown by the pilot deliberately into the sea, and there is sufficient physical and other evidence to support this view.

The ATSB officer MacNamara has given the game away by stating that to release documents to the Australian would, quote: "would have the expectation to cause damage to the international relations of the Commonwealth"!

That sentence says it all, and has revealed what this whole appalling fiasco for the last two years has been about!

They have been looking in the wrong place, they know they have been looking in the wrong place, have spent 2 years and $200 million doing it, all to appease the sensibilities of the Malaysian Government.

If the minister doesn't put the cleaners through this disgraceful body he too should be fired.

---

David

Bring CASA to heel as well.

---

pmac

ATSB   and the APVMA   must be trained by the same obfuscation college

---

graham

After coloring themselves into a corner, it was a pretty good effort by Dominic James and crew including the Doctor and Nurse who didn't wilt under pressure; pretty rare to have a 100% survival rate in  such a situation.

---

Peter

Who do these "supervisors of flying bus drivers" think they are. Shades of 1950's Qantas pilots who exuded a "God Like" air. Time for public servants to be just that "Public Servants"

---

Alexander

Thank you Ean for keeping the spotlight on our disgraceful regulator CASA and its sycophant ATSB. It’s high time Australia realised the extraordinarily poor return its reaping from the failed experiment of the ‘independent umpire,’ a 30 yo concept of ‘user pays’ and an excuse for removing Ministerial responsibility. ATSB is shown up as completely inept and incapable of making a timely or objective finding. The (Un) Civil Aviation Safety Authority has progressively turned itself into a fee gouging regulation and salary factory with no regard to having destroyed General Aviation. 30 years rewriting the aviation rules, still not finished $300 million down the drain. Incapable of admitting it might improve, instead prefers to scapegoat the pilot. Alex in the Rises

---

Botswana O'Hooligan

@Terence  When you do a medivac there are huge pressures brought to bear on you, the company (Care Flight) is in the business to make money and if you knock back a flight they will get all upset and the people who use their services will look askance, the family will bring pressure on you in various ways if they can, the medical staff are only interested in saving the life of the patient and most nearly always don't think about their own lives because that is their natural tendency, so it is up to you. When you do an organ retrieval for instance, a heart is only good for about four hours and you think to yourself that someone has died so that someone may live so you leave no stone unturned to facilitate that operation, and ATC shine in instances like that for they too open all the taps for you. Some people can handle that pressure, others can't.

---

Botswana O'Hooligan

@arlys  20/20 vision in hindsight is a wonderful thing and one wonders if that young man would do the same or something similar again. I really do doubt if skill and daring played a part, lady luck did for she sometimes smiles down upon aviators, and the tragedy didn't happen. If that young man had skill he would have demonstrated it by carrying a bit more fuel for "mum and the kids," would have got the latest Taf's issued for Norfolk and even Tontuta 430 odd miles from Norfolk. Most of all that accident proves that the person occupying the left hand seat must have maturity, be able to make a decision if prudence dictates that the company is in error, and be right on top of the game as well has having the necessary licences. Samoa to Brisbane is 2100 odd nautical miles, that aeroplane is supposed to be able to do 2300 which is close but doesn't earn a cigar so you must ask yourself prior to departure, what happens if we depressurise and thus burn more fuel at a lower level on the way to Norfolk, what happens if we lose an engine for we are going to lose airspeed, where can we go, what about Noumea, what is the weather like there, what about Lord Howe even if it is a bit short, all the "whatevers"because that is exactly what a captain does. A captain must also have the strength of character if things are crook, even if it is a medivac, to weigh the lives of he and his crew against the life of a single person, do I possibly sacrifice the life of my crew and the company aeroplane to save one person when I might kill the lot of us?

And for the top comment so far...

Karen

Some facts about the incompetencies of our Aviation Safety regulator & investigative authorities, in particular, the behaviour of the band of brothers in management/director positions. There are some great people who work for them with good intentions. Unfortunately, good intentions have not been forthcoming with this hell of a saga.

* The CASA officer who suspended James's license was basically promoted to the position of ASTB Commissioner on a very healthy salary. Conflict of interest, you bet. (says he's removed, but really?)

* There are no Air Ambulance regulations to adhere to. Not then, not now. Safety you say? Eight years with no safety lessons learnt or much need regulations written is a direct insult on their own aviation philosophies.

* The ditching was not reported correctly to the ICAO. Not until 2015 when I called the Operational Safety Manager. Not on any statistics when presentations are given internationally, zero learning. It's like it never happened. Misleading? You decide.

* What did not happen was a crucial weather communication. What's a pilot to do, conjure clairvoyance powers?

* Pel-Air's 2008 Audit found that there were major insufficiencies with the operator. Regarding FRMS, International training, it's a public document, have a read. Quite sickening to know that this company was given the thumbs up from CASA to fly high risk Air Ambulance missions. This is why robust regulations are so important to have just in case a pilot needs to know what the hell he's suppose to follow. Their bread & butter was freight. How dare they allowed such flimsy guidelines to have continued for so long. Shame on them.

* The arrogant audacity of the airline and our government agencies has been beyond disgraceful regarding this matter. The connections are questionable.

* All must remember, the CEO of Pel-Air was an ex transport minister. Large political donations from Pel-Air at the time of the Senate. Prior to this was in 2003 for 3k. At the time of the Senate, over 300k.

The whole thing stinks to high hell and back again.

Yeah, Dom may have changed a few things if he could have, but he landed that Jet in pitch black, with a rolling ocean and we ALL lived.

The ones that need to be taken to task if real change is desired to enhance safety, are the players at the top of the Pel-Air matter. Starting from the Minister of Tpt at the time, Mr Albanese & his white aviation safety paper, all the bureaucrats that have been aware & Mr Chester who has done nothing!

Pel-Air is the tip of the iceberg when it comes to controversy within the Australian Aviation portfolio.

We were not protected by the safety agencies as there were no rules. What Dom did or didn't do is a very small part.

It is the Safety Agencies that need to be critiqued, investigated and taken to task.

MTF...P2

[Peetwo]

PelAir coverup goes to the big screen -

Pel-Air saga for big screen
12:00amEAN HIGGINS

The saga of the Pel-Air air ambulance flight that ditched in the sea off Norfolk Island is to be made into a feature film.

---

MTF...P2

[Peetwo]

PelAir coverup goes to the big screen -

Pel-Air saga for big screen
12:00amEAN HIGGINS

The saga of the Pel-Air air ambulance flight that ditched in the sea off Norfolk Island is to be made into a feature film.

---

A twitter retweet/comment from Christine Negroni: 

Christine Negroni@cnegroni


Christine Negroni Retweeted PAIN_NET
Very good explanation of a botched investigation that even on its 3rd attempt still fails to meet the goals of air accident probes; to prevent re-occurrence.
Christine Negroni added,
@PAIN_NET1
Replying to @PAIN_NET1 @ATSBnews and 9 others
@EanHiggins @australian 'That man Higgins' today, via the Oz http://www.auntypru.com/forum/showthread.php?tid=149&pid=8015#pid8015 … + http://www.theaustralian.com.au/news/a-pilots-act-of-heroism-then-lives-destroyed-over-eight-years-of-hell/news-story/a9690e9a7ca80bec0fff763b3ab8efea … & http://www.auntypru.com/forum/showthread.php?tid=57&pid=8010#pid8010 … &
http://www.auntypru.com/forum/showthread.php?tid=57&pid=8010#pid8010 … & Pirate code: "..more guidelines than actual…
2:01 AM - 1 Dec 2017

MTF...P2

[Peetwo]

PelAir coverup goes to the big screen -

Pel-Air saga for big screen
12:00amEAN HIGGINS

The saga of the Pel-Air air ambulance flight that ditched in the sea off Norfolk Island is to be made into a feature film.

---

A twitter retweet/comment from Christine Negroni: 

Christine Negroni@cnegroni


Christine Negroni Retweeted PAIN_NET
Very good explanation of a botched investigation that even on its 3rd attempt still fails to meet the goals of air accident probes; to prevent re-occurrence.
Christine Negroni added,
@PAIN_NET1
Replying to @PAIN_NET1 @ATSBnews and 9 others
@EanHiggins @australian 'That man Higgins' today, via the Oz http://www.auntypru.com/forum/showthread.php?tid=149&pid=8015#pid8015 … + http://www.theaustralian.com.au/news/a-pilots-act-of-heroism-then-lives-destroyed-over-eight-years-of-hell/news-story/a9690e9a7ca80bec0fff763b3ab8efea … & http://www.auntypru.com/forum/showthread.php?tid=57&pid=8010#pid8010 … &
http://www.auntypru.com/forum/showthread.php?tid=57&pid=8010#pid8010 … & Pirate code: "..more guidelines than actual…
2:01 AM - 1 Dec 2017

Sandy comment in reply to Oz article...

...Australian General Aviation (GA) will hope for a fair and balanced account apart from the entertainment value. The stupendous waste and mismanagement of aviation in Australia, especially the treatment of GA, by the (Un) Civil Aviation Safety Authority might well be the “story behind the story.” Thousands of GA people that have watched this flying industry’s death by a thousand bureaucratic cuts leading to job and business losses all the while the independent Commonwealth corporate grows fat and lazy, full of hubris. CASA is an out of control make work and salary factory that was commissioned thirty years ago to rewrite the aviation rules. After spending at least $300 million to produce the worst, most costly and unworkable strict liability criminal sanction rules (latest tranche), this fee gouging monstrosity still hasn’t finished. Perhaps this movie will shame a do nothing Minister Darren Chester into action... 

MTF...P2

[Peetwo]

Via Independent Australia:

Plane crash review: Are Australia's aviation bureaucrats endangering lives?

 [b]Norm Sanders[/b] 5 December 2017, 3:30pm 

Norfolk Island crash pilot Dominic James (screen shot via abc.net.au).

Aviation would be safer if the regulators realised pilots aren't suicidal and acted as partners rather traffic cops, says pilot Dr Norm Sanders.


THREE GOVERNMENT BODIES are tasked with keeping Australian aviation safe: CASA(Civil Aviation Safety Authority), ATSB (Air Transport Safety Bureau) and Airservices. 

CASA deals with regulations and pilot qualifications, the ATSB investigates crashes, and Air Services operates the radio facilities to control air traffic.

Of the three, Airservices has the best reputation among Australian pilots. Airservices operates within a strict regulatory framework, but the safety of pilots and passengers is foremost and getting planes back safely on the runway takes priority over the multitude of rules.

CASA is just the opposite. Rules are paramount. Pilots trust Airservices but universally hold CASA in low esteem.

I flew for years as a commercial pilot and flight instructor in the U.S. before coming to Australia. I had two in-flight emergencies in that time — one involving an engine fire, which required an emergency landing at busy Santa Monica Airport, near LA. Once safely on the ground, there were smiles and congratulations from the firemen and the airport manager. No recriminations.

I found a completely different attitude in Australia. Ask pilots in this country if they would declare an emergency in a dangerous situation and many would say, “Only if a wing had just fallen off". They are all fearful of the punitive action CASA would take.

Some time ago in Tasmania, a pilot took off from Strahan on the West Coast. He got lost and asked for assistance from Launceston Flight Service. They had no radar and could not give him his position. The pilot managed to find his way back to the field and took off for Hobart in better weather a few days later. When he contacted Hobart Tower, he was told to tie his plane down securely and wait in the area. The bureaucrats had decided to take away his licence — for getting lost and admitting it! The message here? Don't ask for help.
That things haven't changed much over the years is shown by the recent Aviation Safety Regulation Review into CASA and the ATSB.

The final report found: 

'A significant disconnect between the Industry and CASA, which, if left unchecked, could put both the safety and reputation of the industry at risk.' 

[size=undefined]
The report, also known as the Forsyth Report, made 37 recommendations for reform. (About half have been implemented so far.) The Review Panel found that CASA’s hard-line attitiude has distanced it from the industry — contrary to the approach taken by many leading aviation regulators around the world.
In the U.S., the FAA (Federal Aviation Administration) has a much better reputation. The FAA is charged with the promotion and regulation of aviation. CASA sees its role as the creation and enforcement of laws.E DITCH O E SEAILOTS PRAISED FOR SAFE LANDING(SEE IMATION)!!
lay Video



An inquiry was instituted by former Senator Nick Xenophon after the Norfolk Island Crash of a CareFlight medical evacuation aircraft on the night of 18 November, 2009. Dominic James was piloting a two-engine jet owned by a firm called Pel-Air. His copilot was Zoe Cupit. A Melbourne woman was on a stretcher, being tended by a flying doctor and a nurse. The woman's husband was also on board. The flight had originated at Samoa and was heading for Australia, planning to stop at Norfolk Island for fuel. 

The weather reports for Norfolk Island were good on departure, but a storm moved in while the plane was in the air. Air traffic services in Nadi and Auckland did not radio the flight crew all the revised information that should have been provided so that the pilot could head for an alternative airport.
 
There was torrential rain at Norfolk Island that night and the clouds were down to the surface. James made four attempts to land but couldn't see the runway. Fuel was running out and James had to try to ditch at sea, which he considered to be a better option than crashing on land. It was dark and raining so heavily that he couldn't see the direction of the swell in order to land parallel to the wave tops. The plane hit hard, but everybody miraculously got out of the aircraft and into the water. James had a small pocket flashlight which he pointed at the shore. A fireman saw the light and alerted the rescue crew. All survived the crash, but some were injured.

Businessman and aviator Dick Smith described James’ actions as[/size]

“ ... an incredibly talented feat. Being able to get that plane down at night and all the passengers out alive was great.” 

[size=undefined]
James was hailed as a hero, like Sully Sullenberger who landed on the Hudson. 

But the bureaucracy didn't agree. CASA downgraded Jame's licence. The ATSB stated that he did not put the aircraft down at optimal speed and failed to report his intended landing position on the radio. (Pilots have a saying: "Aviate, Navigate, Communicate". Jame's priority was to make a successful landing. He was too busy to “communicate.”)[/size]

ABC News

✔@abcnews

Senate Committee releases damning report into Australia's aviation authorities http://bit.ly/10NmlxP 
4:46 PM - May 23, 2013
[/url]
Report raises concerns over aviation bodies' competency
A Senate Committee casts doubt on the standard of Australia's air safety regulators, warning of systemic failures. abc.net.au

[size=undefined]
A subsequent Senate Inquiry found that the ATSB accident report was “deeply flawed” and unfairly blamed the pilot wholly for the accident. They recommended the report be redone. The Inquiry also found evidence of collusion between agencies and that the heads of both agencies gave evidence that “wasn't credible”.

The second ATSB report was released last week, almost eight years to the day after the accident. In the 531 page report, the ATSB 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.
   
Senator Nick Xenophon said the process remained a “deeply flawed and conflicted”. The pilot, Dominic James, commented that the ATSB did not “want to rock the boat” when it came to criticising the system and the aviation bureaucracy.[/size]

WorldNews_net@worldnews_net

Norfolk Island ditching pilot returns fire on investigators 'without a backbone' http://ift.tt/2hXrMR0  #Sydney #News
5:45 PM - Nov 23, 2017

Norfolk Island ditching pilot returns fire on investigators 'without a backbone'
To some he remains Australia's equivalent of Chesley "Sully" Sullenberger, the captain who landed a passenger plane on New York's Hudson River.
smh.com.au

James said:

"They have lost their nerve — they are not courageous. 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."

[size=undefined]
Another common criticism of the ATSB is the length of time taken to publish findings of crash investigations.

Dick Smith ascribes it to a "toxic culture" in the ATSB:[/size]

According to Smith, a former chairman of CASA, it all goes to a toxic culture in the ATSB, which he describes as secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals.

[size=undefined]
(The same could be said of CASA.)
These individuals include relatives of those killed in air accidents who understandably want closure. Environmentalist John Davis was killed in a helicopter crash in November 2015. The ATSB promised his wife, Felicity, a report in a year, but it is now two years since the crash and she still has heard nothing.[/size]

PAIN_NET@PAIN_NET1

A pilot's act of heroism, then lives destroyed over eight years of hell - http://www.theaustralian.com.au/news/a-pilots-act-of-heroism-then-lives-destroyed-over-eight-years-of-hell/news-story/a9690e9a7ca80bec0fff763b3ab8efea … via http://news.google.com 
7:00 AM - Nov 29, 2017

[url=https://t.co/TTO7mPaWeC]Heroism, then lives destroyed
theaustralian.com.au

[size=undefined]
With regard to CASA, the Aviation Safety Regulation Review noted:[/size]

'Foreign regulators adopt a performance based system with a focus on a "just culture", and an approach that places more trust in the operators to carry out their activities in compliance with the applicable regulatory scheme. The regulator monitors and takes appropriate action on any breaches of that system. In comparison, many in the industry would argue CASA’s approach requires the operator to proactively prove that they have not done anything wrong. The proponents of a performance based regulatory system argue that it supports a more open discourse between the regulator and the industry, leading to better safety outcomes.'

[size=undefined]
CASA has to realise that pilots aren't suicidal. We have a vested interest in our own survival and that of our passengers. We WANT to do the right thing. Aviation would be much safer if we could consider CASA as a partner rather than a traffic cop. Then maybe we wouldn't be afraid to declare emergencies. l-Air Aviation criticised by pilots' union Play Video



Dr Norm Sanders is a former Tasmanian MP and Australian Federal Senator. He is also a qualified commercial pilot and flight Instructor.[/size]

[Peetwo]

The hidden agenda of PelAir MKII IIC Dr Walker -

Remember this? Ghost who walks & talks beyond Reason 

&..

Hiatus; after the storm.

I quite enjoy a full head of steam, most refreshing, but I do however like to know the root cause. When I got the whole story from Kaz; the blue touch paper started to fizz; certainly the Walker insulting, demeaning behaviour and unbelievable ‘attitude’ created the spark, but I was surprised at the level of fury it generated. Time to think it through; so I did.  Ala P2, I put on the research hat, fired up the trusty box, grabbed a fresh ale and went back to the very beginning.  From Seaview to Lockhart through to Pel-Air; Mildura, Albury, Melbourne etc.  The midnight oil bill took a beating, I finally understood the radicals, but not the Walker trigger. A second ale helped sooth the curiosity bump and the little light came on. The Pel-Air review, the itch I couldn’t scratch.

Totally and completely unnecessary. The Senators (bless) allowed a second chance; with which I have no quarrel; they could hardly take an axe to the entire structure of aviation administration, much as they may like to. So, as an act of grace and forbearance, a second chance was gifted. A chance for both the ATSB and CASA of redemption, an escape from the pit.  Furry muff, I can, as a practical man accept that. What I cannot accept is that both agencies have continued, despite a very close shave, to thumb their collective noses at government and industry alike. That attitude clearly reflected in the Walker diatribe against Karen Casey. In a few short moments, he revealed the true attitude of the agency he represents.  Karen, like industry, is an irritant and may be treated with open contempt. There is not a hint of ‘humble-pie’ or apology, not a scrap of remorse, not a glimmer of real change to be seen. In short, despite Pel-Air there is no hope of a real attitude change, in fact quite the reverse. They are coming out swinging, not in a mans way, but with snide, smug, self satisfied work round’s, of which they are ‘proud’.

The concerns PAIN raised in supplementary comments, provided to the SSC on the re-investigation of the Pel-Air incident are proving to be founded in reality. Walker’s attitude indicative of fact.

FWIW – the Supplementary comments are available from the AP library – HERE -.

P7 is correct. A weasel worded apology will not serve, the under pinning structure is deeply flawed and an attitude change is necessary. Anything else is simply window dressing, designed to keep the ministerial arse out the public sling.  Warning – that will not be allowed to happen; not a second time.

Toot – toot.

Well in the course of reviewing the ATSB (Dr Walker) reply summary to two of the DIP DRAFT report comments, coupled with the many glossed over organisational safety issues in the MKII FR (example ref - Pirate code: "..more guidelines than actual rules");  I am firmly of the opinion that the Walker appointment, as the 2nd IIC, was based on purely political (top-cover) expedience and not any sense of conducting the re-investigation in accordance with the ICAO principles and guidelines for proper Aviation Accident Investigation, safety risk mitigation and the essential preservation of safety information (as per ICAO Annex 13 & 19).

"..Karen, like industry, is an irritant and may be treated with open contempt. There is not a hint of ‘humble-pie’ or apology, not a scrap of remorse, not a glimmer of real change to be seen. In short, despite Pel-Air there is no hope of a real attitude change, in fact quite the reverse. They are coming out swinging, not in a mans way, but with snide, smug, self satisfied work round’s, of which they are ‘proud’..."

Keeping the above "K" observation in mind, the following extracts off the 'work in progress' PelAir MKII chronology - see Post 32 - will lead the reader to the damning and obscene conclusion that Dr Walker continued with his 'snide', 'smug', belittling contempt for the DIPs KC and DJ:

15 February 2010: ATSB create a PDF of the Preliminary Report to forward to ICAO ADREP database office. However it would appear that this PDF copy was not forwarded to ICAO until 10 November 2015. (ref link - #149 & ICAO1 ) Ps The original VH-NGA Final Report was never forwarded to ICAO.

---

10 November 2015: PDF copy of 2010 AO-2009-072 Preliminary report ( Aus_Isreal_VH-NGA_18Nov2009_prelim.pdf) is bizarrely modified and added (2126 days after it was created) to the ICAO iSTAR/ADREP database by the ATSB REPCON Manager Elaine Hargreaves. (ref links - 15 February 2010 entry & #56 + https://blogs.crikey.com.au/planetalking.../17/52003/) 

Now note the Walker reply to the KC DIP comment on this identified, albeit administrative, safety issue:

KC (DIP) comment - ATSB Non-compliance with ICAO reporting of the incident. No further information supplied to ICAO about VH-NGA since Feb 2010. Zero learning. The ditching not on any stats of global aviation incidents. Full hull loss, jet ditching…no learning. A direct link to the ATSB and the question is: what exactly is the ATSBs job if investigations are flawed and learning from the past is not an outcome?

No change will occur in this far-away land without serious review of current practices.

---

Walker reply   - Ms Casey has had several communications with different ATSB personnel since the release of the draft report (reopened) about this issue, and it has been explained to her that this was an inadvertent administrative oversight. In particular, Ms Casey contacted the ATSB officer responsible for ICAO notifications and that officer explained the situation and that this error was unintentional and inadvertent and probably associated with personal factors at that time.


To summarise this issue:

· The ATSB provided the initial notification to ICAO (November 2009) and the preliminary report to ICAO (January 29010) as required.

· Unfortunately and inadvertently the final report of the original investigation was not sent to ICAO when the report was publicly released in 2012.

· When the ATSB identified this omission in February 2015 it contacted ICAO and advised them of the situation and offered to send them the original report. ICAO said they would wait for the report from the reopened investigation.

· After identifying the problem with the sending of the AO-2009-072 final report, the ATSB also reviewed the status of other reports and found that some other reports had not been sent to ICAO. These were then sent to ICAO.

· Ms Casey has also stated verbally to the IIC that she believed that two other ATSB reports had not been sent to ICAO: AO-2010-043 (Canley Vale) and AO-2013-100 (Mildura). ATSB records show that AO-2010-043 was sent to ICAO as required, and AO-2013-100 was sent to ICAO in early 2017 (although not within the required 30-day period).

The above Walker reply and summary of proactive ATSB inquiries and subsequent administrative actions may sound fair & reasonable, however this attempted downplay by Walker of the seriousness of this DIP identified safety deficiency omits to include some crucial facts.
Here is a link to the posts that record the extensive research that I conducted into this matter, references -  "Out, damned spot!" + PASO, dots, dashes & an unfortunate ditching - Part III :

Still trying to track down what historical and present entries are actually listed on the iSTAR database for VH-NGA and VH-PGW. However as the ICAO ADREP system is now inter connected via the ECCAIRS IT application tool it is now possible to access a worldwide AAI final report archive. Here is a link for that archive: http://applications.icao.int/e5web/default.asp

Doing a search through the 'query' TAB I was able to locate the following entry for VH-NGA:

Reporting form type: Other (Preliminary Report)
Report identification: AO-2009-072
Report: Aus_Isreal_VH-NGA_18Nov2009_prelim.pdf

What this obviously means is that the ATSB (as per the minion statement in the PT article extract) did report to ICAO the ditching occurrence of VH-NGA and subsequently filed the preliminary report. However the question is did this happen in the required (Annex 13) chronological order? And if it was done as per the Annex 13 book, where is the copy/record of the original AO-2009-072 Final Report?

This brings me to VH-PGW - there is no entry that I can find that would indicate that ICAO have been notified; or have had filed either a preliminary or final report on the fatal accident, near Canley vale Sydney NSW, of VH-PGW - can someone please explain??

&..

Dots, dashes & ICAO ADREP aberrations - Part III

..In the course of reviewing the ICAO ADREP/ECCAIRS crumb trail to the original VH-NGA (non-)notification, which would appear to be at odds to Annex 13, ch 7, para 7.7...

Incidents to aircraft over 5 700 kg

7.7 If a State conducts an investigation into an incident to an aircraft of a maximum mass of over 5 700 kg, that State shall send, as soon as is practicable after the investigation, the Incident Data Report to the International Civil Aviation Organization.

 
....but not at odds with paragraphs 7.3 & 7.4...

Language

7.3 The Preliminary Report shall be submitted to appropriate States and to the International Civil Aviation Organization in one of the working languages of ICAO.

Dispatch

7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available.

 
...I happened to notice some strange anomalies with the ICAO/ECCAIRS version of the original preliminary report - Aus_Isreal_VH-NGA_18Nov2009_prelim.

To begin this copy was created two days after the original prelim report was released for public consumption on the 13th of January 2010. From that PDF it would appear that the original report was modified on 10/11/2015 at 8:13:02 am (click 'file' then click 'properties') by 'author' E.Hargreaves (ATSB REPCON Manager & ICAO co-ordinator).

Now remembering that the ECCAIRS IT application is basically a big version of a SMS incident/accident software program and is therefore supposed to be secure from 1st, 2nd and 3rd party modification/amendment after submission. Therefore the question that must be answered is how is it possible for the official ATSB ICAO co-ordinator to go back into 'modify' the original ICAO prelim report??  

The obvious answer is that the original prelim report copy, intended for ICAO, was not sent; or was intercepted before reaching the ICAO ADREP secretariat responsible for inputting all forwarded notifications and/or AAI reports.

Since conducting that research there has, as Walker suggests, been confirmation that the ATSB notified ICAO of the VH-NGA ditching and their intention to investigate that ditching. It is also a fact that a copy of the prelim report was forwarded to the ICAO iSTAR database office. However what Walker omits to say is that prelim report was either; not forwarded until 10 November 2015 by the REPCON Manager E Hargreaves; or it was forwarded but the REPCON Manager has exclusive security access to the ICAO iSTAR database and has made a unexplained modification to the ICAO iSTAR database PDF copy of the original 13 January 2010 prelim report? Of the two options for this administrative glitch. I know which one I would be more inclined to believe.

---

---

· Ms Casey has also stated verbally to the IIC that she believed that two other ATSB reports had not been sent to ICAO: AO-2010-043 (Canley Vale) and AO-2013-100 (Mildura). ATSB records show that AO-2010-043 was sent to ICAO as required, and AO-2013-100 was sent to ICAO in early 2017 (although not within the required 30-day period).

---

& refer: BRB BT: The IR mole & the ADREP cock-up(rort)?

---

[b]FINDING:
[/b]

The ATSB has been reporting accidents and investigated incidents to the ICAO ADREP data system (Preliminary Reports and Data Reports), however, they are incomplete partly due to the differences in the taxonomy format.

---

RECOMMENDATION:

Since the ATSB is in the process of acquiring a new accident and incident data reporting system, it is recommended that this new database system be ADREP-ECCAIRS compatible. It is also recommended that further discussions take place between the ATSB database system personnel and the ICAO ADREP system administrator in order to facilitate the reporting to the ADREP using the ATSB existing system before the new ATSB system becomes operational.

---

CORRECTIVE ACTION PROPOSED BY THE ATSB:

There was some confusion prior to the audit between the ATSB and the ICAO secretariat which meant that the ATSB was not aware of the ADREP reporting problems. The ATSB is currently investigating the feasibility of incorporating an ECCAIRS compatible ADREP into the new accident/incident database. However, a determination is still several months away. As a result of the audit, the ATSB has obtained a copy of the latest ADREP (Form D) and is seeking to create a template that will capture the necessary data applicable. The ATSB is committed to fully meet the ICAO obligation in both the short and longer terms.

---

ACTION TAKEN BY THE ATSB:

The use of ECCAIRS was considered as an option for the occurrence database module of the ATSB's newly developed Safety Investigation Information Management System. Given that most of the aviation data collected by the ATSB is high-volume, low-detail data, the complexity of the ECCAIRS taxonomy was not considered appropriate. A bespoke taxonomy for safety events and safety factors was developed by the ATSB which better suits its needs, particularly for the purposes of safety research and for the application of its investigation safety analysis methodology. However, a mapping exercise was carried out to ensure that there was comparability between the ATSB and ECCAIRS taxonomies. For the purposes of notification, preliminary and final ADREP data reports, the ATSB continues to provide this information in the ECCAIRS format, including the use of the ECCAIRS taxonomies.

P2 comment - In other words the ATSB will continue to forward only those (PDF copied) reports it deems not politically and (big end of town) industry sensitive for the ICAO ADREP Secretariat to input via the ECCAIRS IT application - and it remains so to this day. 

---

---

Whatever the reasons for these ATSB administrative glitches it would also appear that there is some serious issues with the ICAO iSTAR receiving office, remembering that the examples mentioned above were only 3 of many that I was able to identify as not existing/filed on the iSTAR/ECCAIRs databases.

Could it be that there are still 'taxonomy' and/or compatibility issues with the current ATSB SIIMS database and the forwarding of safety and accident reports being sent to the ICAO iSTAR database office? Why wouldn't a State endorsed Annex 13 AAI at least check that there are no issues at the receiving end of some important forwarded Annex 13 compliant reports? After all we are talking about the integrity and security of valuable safety information that deserves to be properly disseminated to the worldwide aviation industry as per the good intent and philosophy of ICAO Annex 19.


MTF? Definitely!...P2