ATSB report makes Pel-Air, its pilot and CASA look like fools
It is made graphically clear by the ATSB interim report into the November 18 ditching of a Pel-Air Westwind jet off Norfolk Island that the six people on board variously rushed or struggled for their lives.
Some of the hatches were quickly underwater, one person reports swimming upwards to reach the surface of the sea, the first officer may have been unconscious for a time, the main door was blown inwards by an 180 kmh slam down into the water, people had to feel their way to reach exits in what is a tiny jet, and they all ended up treading water for 90 minutes.
Here is a grab from the report’s pages.
The format doesn’t allow for tidy extracts, but the order in which it describes post impact events would be of intense interest to students of real life emergency evacuations, and the entire report is only seven pages long and definitely in the category of a short but gripping read.
Putting aside who went where and when in the seconds after impact, very big questions arise over the competency of CASA in even approving operational procedures which voided the needs to load alternative airport diversion fuel if a flight from one speck in the ocean to another was conducted when weather conditions were expected to be good at what in this case was Norfolk Island as a refuelling stop.
The report manages to slice down to the critical issues with brevity and hard facts. The time line in relation to what steps the pilot in command, Dominic James, took in terms of getting weather updates on his flight path from Apia are a reflection on the flight standards that the air operator certificate holder, Pel-Air, is legally required to uphold. Even if the fuel policy was flawed but approved by CASA.
James did not bring himself up to date with the specific automated advisory for Norfolk Island’s deteriorated conditions until three hours 19 minutes after leaving Apia with his jet only partly filled with fuel and some 44 minutes from his estimated arrival time at the intermediate stop.
There appears have been timely opportunities for James, who received post crash tabloid exposure as a Cleo bachelor of the year contender and hero, to have established the situation that was deteriorating at Norfolk Island and to have diverted to either Noumea or Auckland instead of arriving in its vicinity with no real option but to land or ditch. The un-timed references to earlier weather advice in the interim report are just that, without a time.
After four missed approaches the jet exhausted its fuel and was deliberately flown flaps extended into contact with the sea at 180 kmh. The pilots did not see the sea before a contact described as two to three large impacts. After the third missed approach preparations for a ditching began.
While the passengers had been briefed on the ditching, only three wore life jackets and it was considered too dangerous to launch the two life rafts on board as water burst into the cabin after the forward door was blown inwards on contact with the sea.
This is what the ATSB says about the fuel situation.
This is what CASA said on November 20, apparently unaware of the procedures it had approved for inclusion in the Pel-Air AOC
The Australian Transport Safety Bureau is investigating the ditching of the Pel-Air Westwind aircraft at Norfolk Island and any comment on the investigation must come from them.
CASA has legal requirements for air operators to carry sufficient fuel to undertake a flight safely. This includes additional fuel to deal with delays caused by weather or other factors and enough fuel to divert to alternate aerodromes.
CASA is examining issues relating to the planning of the flight that ditched at Norfolk Island.
This is the section of the regulations that CASA drew media attention to prior to the above statement.
EXTRACT FROM CAO 82.0:
1.1 This Part applies to Air Operators’ Certificates authorising aerial work operations, charter operations and regular public transport operations and sets out conditions to which such certificates are subject for the purposes of …
remote island means:
(a) Christmas Island; or
(b) Lord Howe Island; or
(c) Norfolk Island.
2.3 The minimum safe fuel for an aeroplane undertaking a flight to a remote island is:
(a) the minimum amount of fuel that the aeroplane should carry on that flight, according to the operations manual of the aeroplane’s operator, revised (if applicable) as directed by CASA to ensure that an adequate amount of fuel is carried on such flights; or
(b) if the operations manual does not make provision for the calculation of that amount or has not been revised as directed by CASA — whichever of the amounts of fuel mentioned in paragraph 2.4 is the greater.
2.4 For the purposes of subparagraph 2.3 (b), the amounts of fuel are:
(a) the minimum amount of fuel that will, whatever the weather conditions, enable the aeroplane to fly, with all its engines operating, to the remote island and then from the remote island to the aerodrome that is, for that flight, the alternate aerodrome for the aircraft, together with any reserve fuel requirements for the aircraft; and
(b) the minimum amount of fuel that would, if the failure of an engine or a loss of pressurisation were to occur during the flight, enable the aeroplane:
(i) to fly to its destination aerodrome or to its alternate aerodrome for the flight; and
(ii) to fly for 15 minutes at holding speed at 1500 feet above that aerodrome under standard temperature conditions; and
(iii) to land at that aerodrome
Which raises the question, what was CASA thinking when it allowed Pel-Air to ever fly to an airstrip as badly affected by changeable weather as Norfolk Island without the reserves consider normal in developed countries?
Three days later CASA announced a special audit of Pel-Air and owner REX.
An audit of CASA competencies wouldn’t be amiss either.