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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.

report 01

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.

fuel detailThis 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 Application

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 …

And:

remote island means:

(a) Christmas Island; or

(b) Lord Howe Island; or

(c) Norfolk Island.

And:

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.

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  • 1
    David Klein
    Posted January 13, 2010 at 7:21 pm | Permalink

    It’s difficult to understand why Rex, which is a combination of former reputable regional airlines Kendall and Hazelton would have contemplated taking over a charter operator such as Pel-Air with it’s chequered operational history. Whatever the results of the ATSB investigation and special audit by CASA into both Pel-Air and Rex, there is little doubt that there will be some negative fall-out for Rex in protecting it’s reputation as a professional regional airline.

  • 2
    Josh
    Posted January 13, 2010 at 9:46 pm | Permalink

    I won’t pass judgement on the pilot’s decision to get the hell out of the aircraft as fast as possible once it ditched. In a real emergency no-one truely knows how they will react until that moment. But I’m going to scream if the media keeps referring to him as a hero.
    Heros don’t leave their potentially injured and unconscious co-pilot in the cockpit whilst they save their own skins. Charles Sullenberger, a real hero, insisted on being the last person to exit his sinking aircraft. Just saying.

  • 3
    737Pilot
    Posted January 13, 2010 at 11:56 pm | Permalink

    CAO82.0 as quoted by “cut and paste” journalist Sandilands applies to Charter, not Airwork.

  • 4
    Ben Sandilands
    Posted January 14, 2010 at 5:06 am | Permalink

    737Pilot,

    Which part of this sentence don’t you understand?

    QUOTE This is the section of the regulations that CASA drew media attention to prior to the above statement. UNQUOTE

    No-one who quoted from CAO82.0 was cutting and pasting anything. They were repeating what CASA told them, that the flight was illegal. Backed up by the CASA statement of November 20. CASA didn’t even know or understand its own regulations when it released the ‘guidance’ to those who asked the question. And you can’t even read.

    So don’t be an inattentive moron. Criticism is fine if it deals with the message rather than the messenger.

  • 5
    john muppet
    Posted January 14, 2010 at 10:20 am | Permalink

    Criticism of the messenger is very acceptable when the message is very wrong. Despite what CASA may or may not have said thus far, this flight when it departed Apia did not require alternate fuel. Simple as that. It was not an illegal flight as you put it. Read it properly Sandilands. Read it in conjunction with all of the other relevant Orders and Reg’s. You are grossly unqualified to make public comment on such issues.

  • 6
    Ben Sandilands
    Posted January 14, 2010 at 10:48 am | Permalink

    John,

    I have published precisely what CASA said. Confusing what I say with what I am reporting is pointless.

    QUOTE 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.UNQUOTE

    Reports elsewhere this morning that the regulator is looking at whether the pilot fuelled the jet in accordance with the company’s operating procedures, or properly monitored the weather situation are correct. The legality of this flight is under continuing examination.

  • 7
    johntillerstudent
    Posted January 14, 2010 at 1:35 pm | Permalink

    No one has look at CASA Alcohol by-laws which are total open to abuse by pilot with alcohol problems. There is no on ramp testing prior to fights, only off ramp testing which is conducted at rendem. E.G. You are to captian a 6 hour fight to a given destination. You can be over the legal limit at take-off and while flying but under the limit if test on a off ramp testing. CASA laws allows a pilot to allow 8 hour from his or her last alcoholic drink before being with-in the law to fly a aircraft. In other word you could have polish off a litre bottle of gin then allow 8 hours before flying again. Before CASA review this they can not discount the influence of Alcohol from any investigations.

  • 8
    robear
    Posted January 14, 2010 at 5:22 pm | Permalink

    737pilot and John Muppet need to do a bit more comprehension here. Don’t shoot the messenger.

    I operated both F27 and F28 services for years to Norfolk Island so I feel I am qualified to pass comment on fuel policy for NLK.

    To go there without an alternate is just not commonsense or good airmanship IMO.
    At night doubly so.

    If you operate on a PNR and its night you are asking for trouble if its not 100% gin clear. Even then the weather can change in minutes.

    I believe in the old days ANSW came close a few times after leaving PNR(usually near TOD) with the WX clear at NLK only to find by the time they got in the circuit it was a vastly different story.

    And this is in the daytime.

    Fortunately both the F27′s and F28′s I flew could always carry Tontouta or Kaitaia so I always had an alternate. I needed it on quite a few occasions too.

  • 9
    737Pilot
    Posted January 15, 2010 at 12:05 am | Permalink

    Oh, but I do pay attention, Sandilands, and I quote from your previous scrawlings:

    “The captain, Dominic James, apparently took off from Apia with inadequate fuel to meet the requirements of the catch-all section of Civil Aviation Order CAO 82.0 (2.4), which relates to fuel reserves. The relevant regulations are appended to this report (after the jump).” and

    “I can also confirm reports that the flight struck the water without having been prepared for a ditching.”

    “Apparently” you jumped to press without understanding the CAO in question or the difference between charter and airwork. “I can also confirm reports” that the ATSB report contradicts garbage you reported as fact.

    NB. Journalism does not = cut and paste from PPRUNE.

  • 10
    Ben Sandilands
    Posted January 15, 2010 at 6:35 am | Permalink

    737 Pilot,

    The error about the ditching occurring without preparation is mine, and I’m not going to share the credit for this with Pprune. My source as to the flight being illegal in terms of being fuelled contrary to the requirements are ‘apparently’ correct.

    This statement was issued by CASA yesterday.

    QUOTE: 1. CASA is continuing to investigate the Pel-Air ditching and as the investigation is continuing it is inappropriate to comment in detail.

    2. One area of investigation is the fuel requirements that applied to the flight and whether these were correctly followed.

    3. The ATSB report is factual and CASA has no issues with it. There is no dispute between CASA and the ATSB, the report in fact makes no mention of CASA. UNQUOTE

    I disagree with point 3, in the light of its statement on November 20. The ATSB report puts pressure on the safety regulator in terms of the purpose of the rules, its approval of the operating procedures, and also, critically, on the performance of the pilot in carrying out those procedures.

    CASA confirmed yesterday that it has proposed removing the particular distinctions between aerial work and charter. The second point in yesterday’s CASA statement merits close attention.

    The dumping of an inadequately fuelled air ambulance in the ocean after it has flown past at least four alternative landings into deteriorating weather is not in my opinion, nor of those I consult, the result of professional piloting or a professional operation. It is a disgrace and a matter that raises broader issues about the competency of aviation oversight and administration in this country.

  • 11
    clivedorman
    Posted January 15, 2010 at 9:44 am | Permalink

    @737 Pilot indicates in his comments that he considers air safety a private matter between pilots and the regulator and that it is none of the public’s business.

  • 12
    robear
    Posted January 15, 2010 at 2:19 pm | Permalink

    From what I hear it appears that CASA approved the fuel policy that allowed this flight to take place.

    Assuming that was the case and the MD of REX has stated when the Westwind left Apia it had sufficient fuel for the flight then its an indictment on the regulator for a start.

    Norfolk at night with no alternate = very bad idea

  • 13
    Frank x-icao
    Posted January 24, 2010 at 12:24 pm | Permalink

    This appears not to have been a medical emergency flight where higher risk may have been justified.

    You are all overlooking that this was not an Australian domestic flight but international. Flight over the “high seas” by aircraft registered in a country that is a Contracting State to the Convention on International Civil Aviation (as is Australia) are also legally obliged to comply with the standards set down by the International Civil Aviation Organization (ICAO) in the Annexes to that Convention. Relevant to the causes of this crash of an aeroplane carring out an international aerial work operation, are the standards and recommended practices (SARPS) of Annex 6, Part 2 – Operation of Aircraft, International General Aviation – Aeroplanes. If you care to read these standards, it is pretty clear that based on the the information in the interim ATSB report that both Pelair and the Pilot in command were, in the case of this flight at least, not complying with the International standards for flight planning an IFR flight with respect to at least the destination weather requirements for the mandating of an alternate aerodrome, the PIC enroute weather watch requirements for a remote destination aerodrome and the fuel requirements for international aerial work flights. Chapter 2.2 of the Annex is particularly relevant.

    It must be recognized that Contracting States do have the privilage of formally registering a non-compliance to ICAO SARPS with ICAO if they wish to publish in their local domestic aviation rules and use, safety standards lower than that in any ICAO Annex. According to the latest ICAO Supplement (the registry of such lesser standards), Australia seems not to have told ICAO that Austraian aerial work aeroplanes will not comply with Annex 6, Part 2, operational SARPS on international flights.

    All this makes for a good read and it must be assumed that the ATSB will consider the international safety standards aspects in this crash investigation in due course. One question arises, does CASA condone non-compliance of Australian aerial work aeroplanes with international standards when on international flights. Note: The much more strict ICAO standards for international commercial air transport operations are in Annex 6, Part 1,

    As a personal note on CASA standards, it is my opinion that this crash was one waiting to happen. Since it’s creation in 1990, CASA has been on a steady path on accepting increasing risks for private and aerial work operations. The removal of the mandatory carriage of alternate aerodromes for aerial work operations when a destination was not forcast to be VMC for a lengthy time before and after the planned arrival time (non-ICAO), is but one example. It was the opinion of many that from the first Chairman of the newly formed CASA having a very personal interest in seeing general aviation standards adopt higher risks and lower standards, the trend seems to have continued.

  • 14
    Frank x-icao
    Posted January 24, 2010 at 4:51 pm | Permalink

    P.S.
    Regarding forecast and actual weather.

    According to the ATSB report, from 0803 when the amended TAF was issued by BOM, which was full two hours before the first missed approach was exicuted at 1004, the cloud base of 1000 ft at Norfolk was below aerodrome alternate minima under both Ausralian and ICAO standards. With the fuel available, the flight should not have coninued to Norfolk from that time and an alternative course of action taken e.g. diverted to another aerodrome or returned to Apia.

  • 15
    Ramatech
    Posted August 27, 2012 at 1:04 pm | Permalink

    Check out four corners on Monday night 3rd September, they are reporting this story.

3 Trackbacks

  1. ...] Read more: ATSB report makes Pel-Air, its pilot and CASA look like fools … [...

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  3. By Full fathom 25-a jet lies – Plane Talking on February 2, 2010 at 1:48 pm

    ...] report contains astonishing factual revelations about the conduct of this flight, and its captain, Dominic James, who exited the jet first at a [...

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