A journey, through the Swiss cheese.
Do you remember – one of the first things ever taught – apart from Up, Down, Left, Right and ‘it nuffin was – escape. This was lest you required your ‘superior’ skills to extricate your arse from a situation in which your superior talent should never had placed you. The lesson is a simple one – paddock – paddock – paddock; why? Well if the single fan up front quits – over the tiger country – where can you park the beast. It’s a habit, deep ingrained; same-same with weather, engine out in fact, the whole gamut of caution and back door theory, so that when things turn unpleasant – there is a viable alternative.
So discovering the why and the how of the Norfolk ditching becomes essential – if we are to prevent a repeat performance and close up some fairly large holes in the safety net. This, standing alone is one of the reasons for the outrage and Senate inquiry which followed the ATSB report. There is a huge effort, made at considerable risk to shift the responsibility spotlight, which is bad enough but when that manipulation leaves the systematic deficiencies, some of the holes which led to the event wide open, then it is time to plug them. If the ATSB has not the integrity and courage to meet the challenge they become a useless, expensive incubus.
What we have is a very grey piece of cheese with lots of holes that all lined up – resulting in a night ditching due fuel exhaustion. The ATSB report into that event was and remains a disgrace and an insult to the aviation world; we were curious as to why the report became a corrupted, diluted, crippled thing. What was so compelling that both ATSB and CASA would be willing to risk so much should the manipulation become public.
One must begin the journey with the first class research provided by P2 (above). It builds the framework for the structure and suggests why every door was closed and James was to thrown to the wolves. Rather than resolve the outstanding problems and mend the system holes there was a collective, conscious scramble to cover everyman’s arse and leave James out in the cold – vilified, blamed and shamed. Well, IMO there is more then enough blame and shame to go around and everyone should have a fair share.
P2 picked up the 123 ‘clue’; the FAR 91 quote provides an example of the type of rules a pilot can ‘rely’ on when all else fails and the pilot becomes the last line of defence. 1 – 2 – 3 – no ambiguity “I need an Alternate”. The complexity of staying ‘legal’ and getting the job done under the incredibly complex Australian rules is a constant headache for crews. Some of the ‘technical’ discussion around ‘staying legal’ is mindboggling. Always makes me smile to hear the complex machinations and watch the pawing through the AIP to check for legal ‘gotchas’ while the basic operational question is shunted to the rear. It is, in essence a simple enough decision – (Q) “do I need to carry an alternate?” (A) Apply 1,2,3; then select Yes or No. Of course that’s simplistic !– but had James applied that rule along with some other simple but effective maxims that day, then perhaps we would not be having this discussion.
We must set aside the glaringly obvious if we are to discover the real reason behind the ‘obfuscation’ of the report and not be distracted by the event. Just for a while ignore all that came before PNR minus 18 minutes (6 minutes = 40 miles +/-). The PNR has been checked against the current wind and fuel remaining and may be considered ‘fixed’ for the next quarter hour; this creates a ‘release’ point, a gate if you like. It’s time to gather all available information, look at the aircraft status and consider the options. Crews do this what, a million times a day, everyday. It begs a question, was this procedure specified, clearly defined within the company fuel planning policy? Which leads us to is there a rule which requires the calculation of PNR and a company policy regarding decision making at the PNR.
Whatever the crew ultimately decide will depend to a great extent on the weather information provided, the quality, accuracy and timely receipt of the ‘forecast’ quintessential. If the automatics do not provide it, then the PIC should ensure the information is received, how many times do you hear “request latest for Kickatinalong”? The request is never (rarely) made of idle curiosity – it’s nearly always made when approaching a critical gate; top of descent or at PNR, or when diversion options are being considered. The receipt of that information is vital. Interpretation of the different ‘layers’ is an art form of legal and operational skill set, local knowledge a great asset. But what if not one, but two of the stations being depended on failed to provide that information?
The two critical TAFOR highlighted by P2 (above) are food for thought – 0803 and 0958 (z) and the timing of the second begs many questions. Even for the most fatigued, half asleep crew receiving the 0958 TAF the alarm bells would have rang – loud and clear
So the answer to the question, why paper over the cracks instead of plugging the holes becomes crystal clear – ASA, BoM, CASA, Pel-Air were all ‘slices’ with holes and most definitely, IMO, own a large share of the event, as does James.
The conclusion is stark – James acknowledged the errors made and apologised, then set about correcting his part to ensure that a repeat performance was not going happen.
ASA ducked the issue, threw both Nadi and Auckland under bus, and joined in the cover up of systematic failure. Which fooled no one, least of all the Senate committee.
BoM so secure in their latitude to be wrong in forecast and their wriggle room cast in law need make no reparation or apology – their system secure, their hands legally clean. It has always been so, even being asleep at the wheel is forgivable – legally.
CASA realising that they had been partly to blame by not only ‘accepting’ flawed procedure, failing to realise the fuel policy was ‘incomplete’, failing to realise there were serious holes in the check training procedure; and, IMO worst of all, allowing the operation to continue with almost 20 potentially serious ‘events’ on record. Many operations have been closed down for much less. To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence. No apology, no corrections. Just another pilot crucified.
Well, at least this did not occur on the Skidmore watch so it’s all good. Perhaps the much vaunted ‘tiger team’ could find a little time to examine the rather large can of worms which has been mouldering in the basement for a number of years now; you know the one – it has Reform of the Regulator stencilled on the lid. All roads lead to the acknowledged control of all matters aeronautical – CASA.
Selah.
Do you remember – one of the first things ever taught – apart from Up, Down, Left, Right and ‘it nuffin was – escape. This was lest you required your ‘superior’ skills to extricate your arse from a situation in which your superior talent should never had placed you. The lesson is a simple one – paddock – paddock – paddock; why? Well if the single fan up front quits – over the tiger country – where can you park the beast. It’s a habit, deep ingrained; same-same with weather, engine out in fact, the whole gamut of caution and back door theory, so that when things turn unpleasant – there is a viable alternative.
So discovering the why and the how of the Norfolk ditching becomes essential – if we are to prevent a repeat performance and close up some fairly large holes in the safety net. This, standing alone is one of the reasons for the outrage and Senate inquiry which followed the ATSB report. There is a huge effort, made at considerable risk to shift the responsibility spotlight, which is bad enough but when that manipulation leaves the systematic deficiencies, some of the holes which led to the event wide open, then it is time to plug them. If the ATSB has not the integrity and courage to meet the challenge they become a useless, expensive incubus.
What we have is a very grey piece of cheese with lots of holes that all lined up – resulting in a night ditching due fuel exhaustion. The ATSB report into that event was and remains a disgrace and an insult to the aviation world; we were curious as to why the report became a corrupted, diluted, crippled thing. What was so compelling that both ATSB and CASA would be willing to risk so much should the manipulation become public.
One must begin the journey with the first class research provided by P2 (above). It builds the framework for the structure and suggests why every door was closed and James was to thrown to the wolves. Rather than resolve the outstanding problems and mend the system holes there was a collective, conscious scramble to cover everyman’s arse and leave James out in the cold – vilified, blamed and shamed. Well, IMO there is more then enough blame and shame to go around and everyone should have a fair share.
P2 picked up the 123 ‘clue’; the FAR 91 quote provides an example of the type of rules a pilot can ‘rely’ on when all else fails and the pilot becomes the last line of defence. 1 – 2 – 3 – no ambiguity “I need an Alternate”. The complexity of staying ‘legal’ and getting the job done under the incredibly complex Australian rules is a constant headache for crews. Some of the ‘technical’ discussion around ‘staying legal’ is mindboggling. Always makes me smile to hear the complex machinations and watch the pawing through the AIP to check for legal ‘gotchas’ while the basic operational question is shunted to the rear. It is, in essence a simple enough decision – (Q) “do I need to carry an alternate?” (A) Apply 1,2,3; then select Yes or No. Of course that’s simplistic !– but had James applied that rule along with some other simple but effective maxims that day, then perhaps we would not be having this discussion.
We must set aside the glaringly obvious if we are to discover the real reason behind the ‘obfuscation’ of the report and not be distracted by the event. Just for a while ignore all that came before PNR minus 18 minutes (6 minutes = 40 miles +/-). The PNR has been checked against the current wind and fuel remaining and may be considered ‘fixed’ for the next quarter hour; this creates a ‘release’ point, a gate if you like. It’s time to gather all available information, look at the aircraft status and consider the options. Crews do this what, a million times a day, everyday. It begs a question, was this procedure specified, clearly defined within the company fuel planning policy? Which leads us to is there a rule which requires the calculation of PNR and a company policy regarding decision making at the PNR.
Whatever the crew ultimately decide will depend to a great extent on the weather information provided, the quality, accuracy and timely receipt of the ‘forecast’ quintessential. If the automatics do not provide it, then the PIC should ensure the information is received, how many times do you hear “request latest for Kickatinalong”? The request is never (rarely) made of idle curiosity – it’s nearly always made when approaching a critical gate; top of descent or at PNR, or when diversion options are being considered. The receipt of that information is vital. Interpretation of the different ‘layers’ is an art form of legal and operational skill set, local knowledge a great asset. But what if not one, but two of the stations being depended on failed to provide that information?
The two critical TAFOR highlighted by P2 (above) are food for thought – 0803 and 0958 (z) and the timing of the second begs many questions. Even for the most fatigued, half asleep crew receiving the 0958 TAF the alarm bells would have rang – loud and clear
Quote:P2 – “The significance of these omissions was brought fully to the attention of the RRAT Senate Committee PelAir Inquiry on the 19 Nov 2015.
Quote:CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question
Quote:Sen. Fawcett: “So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident.
Quote:CHAIR: How long have you been at Airservices?
Mr Harfield : Nearly 25 years.
CHAIR: I think you need a change of career.
So the answer to the question, why paper over the cracks instead of plugging the holes becomes crystal clear – ASA, BoM, CASA, Pel-Air were all ‘slices’ with holes and most definitely, IMO, own a large share of the event, as does James.
The conclusion is stark – James acknowledged the errors made and apologised, then set about correcting his part to ensure that a repeat performance was not going happen.
ASA ducked the issue, threw both Nadi and Auckland under bus, and joined in the cover up of systematic failure. Which fooled no one, least of all the Senate committee.
BoM so secure in their latitude to be wrong in forecast and their wriggle room cast in law need make no reparation or apology – their system secure, their hands legally clean. It has always been so, even being asleep at the wheel is forgivable – legally.
CASA realising that they had been partly to blame by not only ‘accepting’ flawed procedure, failing to realise the fuel policy was ‘incomplete’, failing to realise there were serious holes in the check training procedure; and, IMO worst of all, allowing the operation to continue with almost 20 potentially serious ‘events’ on record. Many operations have been closed down for much less. To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence. No apology, no corrections. Just another pilot crucified.
Well, at least this did not occur on the Skidmore watch so it’s all good. Perhaps the much vaunted ‘tiger team’ could find a little time to examine the rather large can of worms which has been mouldering in the basement for a number of years now; you know the one – it has Reform of the Regulator stencilled on the lid. All roads lead to the acknowledged control of all matters aeronautical – CASA.
Selah.