[Peetwo]

Pirate code: "..more guidelines than actual rules" 

I note that off the UP Lead Balloon (aka Creampuff) gets it but then again from my memory I think he always did...   

I seriously believe someone’s hacked Lookleft’s username. The ‘real’ Lookleft would not have been silly enough to suggest that Table 10 is a ‘transcript’. It’s a paraphrasing and summary by a third party. In any event...


A trap was set for the PIC by the system in which he was variously allowed, encouraged and forced to operate. The ‘tripwire’ on the fateful flight was the incomplete and erroneous weather information about YSNF that misled the PIC.

The PIC’s primary sin was that he did not have ESP.

The controversy around the classification and standards applicable to this kind of operation are merely a manifestation of the broader classification of operation dog’s breakfast that will never be cleaned up by CASA.

While on the typical ill-informed, arrogant and narcissistic Lookleft post, I was intrigued by this almost emotive, strangely biased and complimentary statement in regards to the FO's performance on that fateful night :

..The report finally sheds some light on the F/O's contribution to the event. She was doing a lot of managing upwards. The PIC just seemed to be shutting down to any course of action other than ditching. I'm not sure if the first report stated that she had sustained a serious injury but I am not surprised that she did not want any part of any discussion outside of the ATSB investigation. In my view she did a good job but short of taking over she was restricted by the PIC's performance...

 
P2 comment - Perhaps LL has just given a clue to why he has never been able to holistically look at the PelAir ditching investigation in a systemic top down approach and without what would appear to be a personal grudge against DJ...     

This creates a perfect opportunity to bring up another aspect of the report that IMO seems to have been glossed over through either reckless and arrogant ineptitude by the IIC Dr Walker; or once again through 'malice and aforethought' Walker has attempted to muddy the waters...    

From page 14 of the report (note part in bold):

..The first officer did not recall hearing any weather information provided by the Nadi IFISO. Both of the crew stated that at some stage after reaching FL 390, the first officer had a controlled rest (or ‘cockpit nap’), which was an approved component of the operator’s fatigue risk management system (see Cockpit strategic napping). The first officer believed she had this controlled rest at the time the Nadi IFISO provided the weather reports. The extent to which the first officer was subsequently briefed regarding the 0800 weather report could not be determined...

From the pg 14 part in bold, one gets the impression that the IIC and/or investigators have checked that the FO's 'cockpit nap' was being conducted in accordance with the safety risk mitigation FRMS (i.e. SMS) SOPs - from page 225:

Cockpit strategic napping

The FRMS manual stated that, even though the FRMS was intended to ensure flight crew were well rested:

… the nature of Pel-Air operations can present unique challenges to crew alertness, despite meeting crew rest requirements. Pel-Air scheduled and ad-hoc charter operations tend to involve lengthy sectors at critically fatiguing periods of the night as well as fatiguing tasks in demanding flight scenarios, as such deliberate crew napping is seen as a suitable means of improving crew alertness during more critical portions of the flight.

Accordingly, the manual stated ‘cockpit strategic napping’ was permitted subject to specified conditions. These conditions included:

- only one pilot was able to nap at a time
- napping could only be done during low workload parts of a flight
- naps were limited to 30 minutes maximum (to prevent problems associated with sleep inertia254)
- pilots should be woken 30 minutes before any anticipated high workload event
 the autopilot was engaged
- pilots were not permitted to disconnect their headset or turn down the volume of their radio.

Many Westwind pilots reported cockpit napping was regularly used as a risk mitigator on long flights at night.

---

254 Sleep inertia: a short period of time immediately after awakening associated with poorer task performance and a feeling of mental sluggishness.

   
However after a couple of quick phone calls (ala Barry O) I was able to establish a couple of (unfortunately) hearsay facts:

Q1/ Was the flight crew or medical crew aware of the FRMS conditions for an approved 'cockpit nap'?

A1/ Unfortunately I cannot establish whether the FO or Doctor was aware of these conditions but I can confirm that the Capt & Flight nurse were not aware.

Q2/ Was the FO's approved 'cockpit nap' conducted in compliance with the FRMS (SMS) safety risk mitigation conditions?

A2/ Both replies were no:

1/ The 'nap' went for longer than 30 minutes.

2/ The nap was conducted without headsets on or with volume up and neither was the cockpit speaker selected on and with the volume up.

Note: a) It was also stated to me that this 'normalised deviance' was a regular routine for the FO with other aeromed flights and with different Captains.
b) Surprisingly the EP training for medical crew (although not completed under an approved CAR217 CAO 20.11 course) did not include awareness of the FRMS (SMS) fatigue risk mitigation components - WTD?    
c) Disturbingly the safety risk mitigation conditions as published in the FRMS manual were not published in the FCOM (Flightcrew operating manual) and that would be because apparently PelAir didn't have FCOMs for at least the Westwind operations...  

Quote from page 23:

 ..As the first officer had not flown the leg from Apia to Norfolk Island before, the captain asked her if she would like to be the pilot flying. The first officer agreed...

After contemplating all of the above I have to keep pinching myself that the FO was the PF for this flight. Personally I always saw a FO pilot flying leg as an opportunity to display your aptitude and ability for a future command upgrade. Therefore I find it quite reprehensible that the FO saw fit to make an ICUS decision to take a non-compliant 'cockpit nap'.

The command aptitude aside, just consider that if the FO had of been compliant with the FRMS 'crew nap' conditions that she may just have heard the 0801 exchange and therefore may have questioned and discussed the mixed weather messages received from Nadi. This may have led to Nadi discovering the MIA 0739 SPECI & 0803 AMD TAF and (as they say) all this would be history...

IMO the worst command decision DJ made that fateful day was to allow the FO to be the pilot flying on that leg...



MTF? - Definitely...P2