[Peetwo]

Finally some Reason in the ATSB nuthouse -   


Reference the Senate thread on latest bollocks PelAir update:

[quote pid='5471' dateline='1476405150']
..Two days ago DIPs to the 2nd PelAir cover-up/cock-up ATSB investigation were informed by Dr (Beyond-all-Reason) (I've a conflict of interest) Walker that there would be a further public update issued on the progress of the 'RE'-investigation.

Well again without absolutely any recognition (i.e. update to the aviation investigation page, media release or tweep from the twitter guy) the ATSB discretely by stealth released an update eight in what has to be the longest running ICAO Annex 13 AAI in the history of the world??

Updated: 13 October 2016

The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen.  However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry.  The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year.  Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.

    
No further comment required - UDB? No actually totally ducking believable...

Update: Ben Sandilands (Plane Talking) with a summary of the nearly seven year diabolical saga of the VH-NGA Norfolk island ditching:  

After almost 7 years Pel-Air crash scandal lurches toward finality
Oct 14, 2016
Ben Sandilands

How the ATSB expunges the shame of its original and highly unprofessional inquiry into the Pel-Air ditching remains to be seen

The wreckage of the Pel-Air jet which the ATSB originally refused to recover

Comments from Tango onwards -

Tango

Ben: Could you give a short synopsis of what deficiency specifically the regulatory authorities played in this that should have been different?

I know this has been commented on, but I continue to wonder about the Airlines part and not the Australian regulatory end.

But I also wonder about the so called Medevac period. The patient survived a ditching, spent 90 minutes in the water and lived. What condition of the patient required a Medevac?

And I don't care what the regs say or not, you don't fly a one way trip assuming you do not need to be able to divert.

I can't pierce the timeline together enough to figure out if they could have returned to Apia when they found there was an issue with deteriorating weather (it sounds like they would have had a significant tail wind)

I would place the vast majority of the extremely poor judgment on the Pilots head as well as Pel-Air. They did not have it in regs for divert fuel does not cut it with me.

Credit to the pilot that he did an outstandingly good job ditching it. While his judgment was abysmal (and despite that, he also made the right decisions to ditch in time so its some and some) , his flying skills and aircraft knowledge were obviously first rate. If I could get his judgment up to speed I would hire him in a heartbeat.

I have not read the specific detail of evac, but it appears the crew did a good job on getting everyone out of the aircraft as well.

I do find a fault that those actions are not in the report, it should always include what was done right ( even if bad decision led to the situation) as that is a lesson for all about how to go about that part correctly.
 

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James Wilson

Tango,

I agree - operating to a remote island destination without sufficient fuel for an alternate was unwise, even though it was allowed by the regulations. The TAF the crew was issued before departure indicated the weather was expected to be good at their ETA for Norfolk, but the weather in that area is known to be unpredictable and difficult to accurately forecast. I guess inexperience, lack of training and poor operations manual guidance all played a part.

To complicate matters further, the aircraft was only marginally suitable for the route it was operating because it was not RVSM compliant. That meant that ATC could force the aircraft to descend to a level below RVSM airspace in the event of a traffic conflict. The flight in question was asked by ATC to descend to FL270 for that reason, but the crew was able to secure a higher level. Ironically, if they'd been carrying more fuel they would have had to descend because they would have been too heavy for the higher level. They would then have burnt far more fuel and been no better off for carrying the extra fuel.

Regarding the PNR, I think you'll find they were well past the PNR for Apia when the weather deteriorated. The crew didn’t appreciate the deteriorating weather until they were near or possibly past their last point of safe diversion for Noumea, which was the last enroute alternate that was available to them. By that stage, the crew was unsure if they had sufficient fuel for Noumea, so they elected to continue to Norfolk.

The ATSB stated that the carriage of main tank fuel only, as occurred on this flight, meant that if the aircraft had suffered a depressurisation (the most critical scenario) at the least favourable position during the flight, it would not have had sufficient fuel to fly to a suitable alternate. That alone was a significant breach of the rules.

I don't think any information has been released regarding the the medevac patient's condition, probably due to medical privacy issues.

The difference in the regulations for this flight related to the "aerial work" category. Passengers can be carried on aerial work flights such as medevac, but they are not carried for hire or reward. I guess the theory was that you take your chances if you’re not paying a fare. The regulations have since changed.
 

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Ben Sandilands

James and Tango,

I just can't stop working on other things to elaborate on all of those points, although I have covered off on them in the past. (This solo, unpaid game has some limitations.) However the patient passed away some seven to eight years after the crash. In the short term she suffered considerably from the immediate aftermath, and had settled litigation brought against the operator Pel-Air and/or its owner REX.

It is a disgusting reflection on the authorities and Ministers Albanese and Truss that no government made a point of actively pursuing justice for all concerned, and in my opinion, showed no signs of doing anything but taking instructions from civil servants who I think held each of them in total contempt anyhow. As senior civil servants tend to do of Ministers in Canberra. The executive branch has basically been (withheld graphic epithet) by the administrative branch in aviation safety in this country since the latter part of the 90s. 

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Ben Sandilands

Tango,

I should have earlier mentioned that the pilots of large jet airliners aren't require in this country to fly with sufficient fuel to reach an alternative airport if on arrival in the vicinity of their destination they are unable to land because of a deterioration of conditions (and quite possibly a few missed approaches etc). This was the situation in the Mildura fog fiasco in 2013. Neither 737 could have made it to a suitable alternative airport from Adelaide approach airspace, and it was that situation that saw them take advice to divert to Mildura before committing to a descent to the SA airport, only to discover how bad the situation was at that rural airport.

We have in this country an ingrained policy of "she'll be right mate" when it comes to fuel rules, and if it wasn't for the innate conservatism of some pilots in loading extra fuel for domestic flights the risk of a much worse outcome than seen at Mildura would probably have taken a planeload of lives before then. I'm aware of stories of a few mainline jet diversions to country airports, including one where the runway itself was marginal, that could have ended very badly. I do not see any evidence that CASA, or the airline managements, have the slightest intention of introducing or supporting the safer fuel requirements that apply to airline operations in the US and some other wiser jurisdictions when it comes to fuel planning requirements.

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James Wilson 

 Just to clarify that Ben, they're not required to carry fuel for an alternate when the weather is forecast to be above the alternate minima. The alternate minima provides a buffer above the landing minima to cater for unforecast deteriorations in the weather. The problem of course, is when significant deteriorations occur that aren't forecast, as happened at both Norfolk Island and Mildura. On another note, a bunch of previous posts seem to have been deleted. Touchy subject, eh? 

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joe airline pilot October 18, 2016 at 6:57 pm

As James Wilson explains, your point is not quite correct. The rules are clear around requiring an alternate airport any time the weather conditions deteriorate below a defined criteria. Whilst it may be true that a destination does not require an alternate at the time of departure, that doesn't mean that the pilots adopt a cavalier attitude and just blast off hoping for the best. There is an enormous amount of planning that goes into a flight, before and during. That means planning for failures that increase fuel burn, assessing critical points and pnr's for enroute alternates and updating weather during the flight. That's the difference, and the reason why in one case a crew landed a jet safely and the other ended up in the water.The bulk of a pilot's job so threat and error management, this means planning. 

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Ben Sandilands

October 18, 2016 at 8:07 pm

Joe,

That was made perfectly clear in the original posting on the Mildura incident. It was also made clear in the coverage of the cop-out ATSB report and the incidents themselves that your perfect world of professionalism explanation fails to cover when two 737s found themselves with no-where to go but a fog bound country airport. I live in the real world, this was a serious incident, as numerous other pilots made said here and in technical forums, the deficiencies in those rules saw one 737 with almost no fuel left to set down by guesswork or intuition over a runway the pilots couldn't see.

Why are you making such perfect world excuses for the inexcusable? And why have you forgotten what was reported at the time? I don’t think the majority of your colleagues agree with you on this.

Now with all that in mind I was intrigued to find a very much related ATSB news item released today that almost (but not quite - ) mentions the Mildura cock-up and PelAir cover-up in the context of an ATSB Officer's soon to be conducted research paper:

Ground-breaking aviation research to reduce unforecast weather risks

ATSB senior research analyst Dave Wilson is working on a research investigation that will raise awareness of potential weather-related risks among pilots and also examine the effectiveness of rules that have been in place for more than 30 years.



Weather planning rules in Australia are unique compared to countries in Europe and North America. Because weather in Australia is generally good, risks are very low. But when weather is unsuitable for landing, these differences can have a real world effect on aircraft operations. It is these effects that Dave’s research aims to quantify.

A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding and, in some cases, landing below published safe limits. Dave’s research is seeking to understand how the reliability of weather forecasts affects the ability of flight crew to conduct safe landings.

“I want to help decrease the likelihood of pilots being exposed to unexpected and unsuitable conditions for landing,” Dave said. “The likelihood of an accident happening because of conditions unsuitable for landing is low. But in making it even lower, the probability of a major accident happening reduces considerably.

“Initially I’m looking at Mildura and Adelaide airports. At Mildura, 99 per cent of the time, the weather is suitable to land a large aircraft. But based on the data I’ve looked at, there is still a remote possibility you may have an unreliable forecast. With the volume of air traffic, this could affect up to four aircraft per year.

“If you look at Adelaide, the chances of a single flight crew being exposed to an unreliable forecast are lower. However, when you take into account fluctuations in weather reliability, and the aircraft traffic arrival patterns (around 50,000 per year), the potential to result in a catastrophic accident increases. That’s what we want to avoid.

“If you’re in the air and you get to the point of last safe diversion—where you’ll be committed to landing at the planned destination—if the current forecast predicts marginal conditions, questions are raised as to whether continuing to the planned destination or diverting to an alternate destination should be required. This scenario has been a particular focus of this research.”

Dave has a vested interest in his research. Several actually. He’s a pilot who first flew solo when he was a 15-year-old student at Caringbah High in Sydney—well before he could legally drive. The opportunity of subsidised flying with the Australian Air Force Cadets was too good to knock back. He has since flown aerobatics out of Bankstown Airport but has undertaken little flying over past two years while pursuing this research.

Dave also has degrees in Aeronautical Engineering and Physics from Sydney University. It was there he attended a guest lecture by Pierre Blais from the Directorate of Defence Aviation and Air Force Safety (DDAAFS), which set him on a path to the ATSB.

“It was then that I thought investigating aviation safety would provide the ultimate career path for me. I find it both meaningful and challenging,” Dave said.

The research was initially going to secure Dave a Master’s degree. But he is now upping the ante and aiming to pursue a Doctorate. A stumbling block is finding reviewers with sufficient expertise in a related field. When you’re breaking new ground, this is often the case.

After first working at the Department of Infrastructure as a vehicle compliance engineer, Dave came to the ATSB to embrace his love of aircraft, engineering and how things work. Now with six years under his belt, Dave is also considering his future. “I’m happy as long as I’m being challenged,” he said. “But after this research is completed, I wouldn’t mind also undertaking a broader range of transport safety investigations.”

Research on Adelaide and Mildura aerodromes is expected to be published by the end of 2016. Progressive reports for each major aerodrome in Australia and four of our remote island aerodromes (Norfolk, Cocos, Christmas and Lord Howe) will be progressively released over the next year or two.
 



Last update 18 October 2016 

    
No direct criticism of Dave here, however I find it deeply disturbing that it has taken 16+ years with an identified (normalised deficiency) safety issue that has been causal to a number of min fuel occurrences & accidents, and we are just now exploring the regulatory  and BOM contributory factors that are part of the causal chain to these incidents and accidents...


MTF...P2  
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