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CASA caught playing the man not the company in ABC TV exposé on Pel-Air ditching

The ABC TV 4 Corners report into the Norfolk Island Pel-Air ditching has this evening  shown CASA’s director of safety, John McCormick, making an attack on the flight’s captain, Dominic James and excusing every single deficiency the regulator uncovered in the company during a safety audit as not being a cause of the accident.

However the program is also posting online the safety audit that CASA tried to keep secret and which materially contradicts McCormick in that the safety regulator he heads found among many things that Pel-Air was in breach of the safety rules and was inadequate in its management of fatigue.

The interview and the audit read side by side support the program’s opening premise that CASA scapegoated James in preference to carrying out its obligations under law to pursue the company.

McCormick would well know, and has insisted before the Senate Inquiry into pilot training and airline safety, that it is the airlines or operators that are responsible for safety outcomes.

As pilot James said near the end of the program, he was the pilot of a company that was being overseen by a regulator. Last night, on national television, the head of CASA unloaded all the blame for the accident on a pilot who had not even slept properly for two nights, and was employed by an operator that was so poorly overseen by CASA that it uncovered massive safety deficiencies, while benefiting from a defective CASA rule that excused it from operating as an air ambulance without sufficient fuel to fly to an alternate airport if for any reason a remote refueling airport in the middle of the ocean was rendered unavailable by bad weather.

McCormick’s performance and statements on air are not only inconsistent with the body of law on airline or operator responsibility for pilot training and standards, but were manifestly unfair to the pilot, even though the pilot undoubtedly made serious mistakes in the preparation of the flight, its fueling, and in dealing with the available weather information as the Westwind jet approached Norfolk Island from Apia.

(The 4 Corners report by Geoff Thompson also uncovered evidence that critical weather information had not been passed on to James at a point where had he known of the real situation at Norfolk Island he would have diverted to Nadi in Fiji rather than passing the point of no return where he had to continue to the intended tech stop.)

A fair question arising from McCormick’s performance is whether or not he is capable of taking direct public action against a high profile airline or operator other than Singapore owned Tiger Airways, given the severity of a series of safety failures at Jetstar that were also declared to be unworthy of investigation by the ‘independent’ safety regulator the ATSB.

Regulatory matters aside, the human suffering caused by the unsafe operation of the air ambulance flight by Pel-Air was movingly documented by the program, as was the vigilance and determination of their rescuers on Norfolk Island that brought all six souls to safety from the wild and dark sea in which they had to tread water for close to 90 minutes.

It is utterly shameful to hear that Pel-Air has not once been in touch with Bernie Currall or her husband Gary since the accident, and to see the ruin and despair that the operator’s unsafe and negligent conduct brought to their lives, as well as to Karen Casey the nurse who has lost her livelihood and suffers continued pain from her injuries.

McCormick heads a safety regulator that approved the removal of special life rafts from Qantaslink turbo-props serving Lord Howe Island, and has been unable to release any safety case or statement as to why it allowed this to happen other than the downwards harmonization of Australian standards to the depths of world’s best practice.

It is also an organization that has never explained the safety case that saw it determine that the sort of aerial work performed by the Pel-Air flight didn’t need to carry enough fuel to make a diversion from an oceanic airstrip in bad weather, although it has only recently expressed an ‘intention’ to change a rule it should never have tolerated in the first instance.

The 4 Corners program is an indictment of shamefully deficient standards and oversight by our safety regulator, as well as its disposition to crucify a pilot rather than the company responsible for the flight and safety standards of its operations.

The program, and the supporting documentation, will be readily found on the ABC site in the near future.

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  • 1
    NeoTheFatCat
    Posted September 3, 2012 at 11:20 pm | Permalink

    I watched the show and largely agree with your points.

    However, the expertise and decisions of the person in charge are always the final link in the chain of causes that lead to disasters. In this case, James must have had some inkling of the management environment at Pel-Air. He knew he was lacking sleep and potentially operating with fatigue. He was responsible for the decisions he made, particularly where they were based on assumptions. There are probably a few more links that relate to his role, but my point is that he could have broken the chain himself at any point (eg. declare himself unfit).

    In the end, the travelling public trusts that the person in charge has prepared themselves as fully as possible for what lies ahead, not just assumed that everyone has told her/him what he needs to know.

    This is not to defame James or criticise him personally, just to point out that there is a chain – and sometimes the person in operational command is best placed to break that chain.

    Finally, I agree that it is downright shameful to see how the people on board were treated. It is completely lacking in the basics of human decency that I would expect of any person, let alone a corporation.

  • 2
    Posted September 4, 2012 at 12:44 am | Permalink

    So should we take this as your apology to the pilot then. It is very easy to run your mouth, write an opinionated blog, go with your “gut” and personal biases like it did happen just after the accident. Everyone’s an armchair captain.

    Four Corners instead chose to do the hard work based on actual research and the truth, to take on figures of authority, questioning a dangerous regulatory climate where businesses always prioritise profit, while pretending to self police.

    Next time you see a sensationalist story in the news about a doctor or nurse in a public hospital or a private retirement home, or a soldier speaking out, a minister’s staffer admitting a lie -for example with “kids overboard”, please report the real story: who is willing to stand up to their boss and say no, who will take on authority and blow the whistle.
    Then, ask why and why not. And please ask why again, and again.
    Once again, great journos and the real hard work from this Four Corners team shows what real Journalismcan be. It puts most of the crap that passes for news these days to shame.
    And quality investigative reporting like this can actually improve safety and make a huge difference to people’s lives. Shame on CASA, so let’s keep the spotlight on this story!
    I do wonder what Albo has to say, he will surely have to act…

  • 3
    ltfisher
    Posted September 4, 2012 at 2:29 am | Permalink

    Fair comment re declaring himself unfit but why no mention of the pressure brought to bear by the fact that this was no ‘regular’ flight…it was a medical evacuation with presumably a little more urgency than usual. In that situation surely it is incumbent on the operator to see that there is proper backup for the flight ie through backup flight crew, rather than risk an evacuation getting to a stage where the rescuers actually need rescuing.

    And by the way congratulations to the ABC for making the program and providing the public with an insight into how some of our aviation regulators think.

  • 4
    CaptCB
    Posted September 4, 2012 at 7:38 am | Permalink

    This was a serious transoceanic flight.

    Pelair dispatched the crew on the mission.

    Would things have been different if they had rostered a much more experienced Co-Pilot; one with an ATPL and the ability to cross check Dom’s flight plan? The challenges of this flight were vastly different to those of a normal flight around Australia and should have warranted a far greater degree of support from Pelair Flight Ops than was actually provided, including a Co Pilot who wasn’t a junior.

    Would things have been different if Pelair planned for pilot fatigue and duty time?

    Would things have been different if the Chief Pilot consulted with Dom in Apia cross checking his flight plan and wx? If Dom didn’t have internet, why didn’t Pelair fax the flight plan and wx to him?

    Would things have been different if Dom had received the correct wx from Nadi (600′, not 6000′) and crucially, that Auckland ATC passed on the actual wx report 300′ ceiling to him when the Unicom operator advised as such?

    After the incident, it was the Chairman of Pelair who immediately hailed the pilot as a hero. Was this a classic spin doctor tactic; to elevate the pilot to the public to deflect attention on where it should have been, so he could then be devoured by a hungry media looking for a hero and for blood, in particular, that ridiculous 60 Minutes report?

    The conduct of CASA and the ATSB borders on criminal.

    As unfortunate as this incident was, it will probably be the catalyst to force much needed change in the way the regulator, accident investigator and the airline operators relate to each other.

    This will no doubt save many lives in the future.

    That is the good thing to come out of this incident.

    Due credit should also be given to Dominic James for electing to remain silent on this matter until now, waiting until the ATSB report was released so he could finally comment on the ‘facts’ as discovered by the ATSB.

    Dominic conducted himself professionally throughout the whole aftermath of this incident. Lesser men would have taken the easy option and succumbed to the media feeding frenzy. He demonstrated patience, professionalism and humility.

  • 5
    Scott
    Posted September 4, 2012 at 10:18 am | Permalink

    I watched the program as well, and it seemed to me that the pilot was expecting a lot more support than he was given, so maybe there were defficiencies in some training areas and company operational support.
    But ultimately, I agree with Neothefactcat.
    Shouldn’t a pilot be proactive in finding out weather conditions at his landing site, rather than just waiting to be informed (especially when they are receiving conflicting reports)? Shouldn’t a pilot plan for the worst in regards to fuel and alternate landing sites, especially when flying in the South Pacific when runways are sparse and weather conditions are notoriously unpredictable?

  • 6
    Glen
    Posted September 4, 2012 at 3:24 pm | Permalink

    Yep, but have you never made a mistake as a professional Scott? It happens. Systems are there to trap that, before it matters. They failed. Seems to me there is still a back story here … something about low-bid cost pressures in contract aviation.

    Carlitos: Haven’t seen you here before, welcome. You can try, but I doubt that any amount of bold type is going to convince us that old Ben is anything but a hard worker. Maybe you should have gone with all caps?

  • 7
    Posted September 4, 2012 at 4:00 pm | Permalink

    Whatever Glen. There’s way too many armchair captains, bureaucrats and accountants having a say in this industry. Ben seems to like to point fingers and pass judgement ACA-style, more real analysis is what we need. Where are the pointy interviews with Albo, Rex and Pel-Air? Why? ;P
    And still no apologies from all those too eager for an easy escape goat.

    My intention was to pay some respect to journos that do their job well. Their efforts will save lives.
    Crucial safety measures are being purposely reduced in efforts to fatten margins, this risk/benefit margin being eroded means accidents will certainly increase. In aviation these cost calculations mean that close shaves will become major incidents and a statistical certainty.

    Such “operational” flexibility and lack of oversight in safety regs is common everywhere. Add the huge commercial pressures on the crews and pilots and we have many more dangerous examples overseas:
    http://www.pprune.org/rumours-news/491559-4-ryanair-aircraft-declare-fuel-emergency-same-time-17.html

    Let’s talk about what systems need to improve, who has systemic responsibility for oversight and licensing: CASA heads must roll.

  • 8
    Lofi
    Posted September 4, 2012 at 5:03 pm | Permalink

    @NeoTheFatCat – I agree, the pilot is ultimately responsible, even though systemic pressures may transpire to inhibit their independence. This is not to redirect blame from CASA and Pel-Air, but re-iterating pilot independence is a point always worth making.
    While the pilot kept his views on the incident to himself, I’d say that was due to legal advice given his performance, not any attempt at professionalism. For an insight into his professionalism, I refer you to the contemperaneous attention he lapped up in his bizarre Cleo Batchelor of the Year nomination. It was tacky, deflective and cynical coming so soon after an event that nearly cost lives.
    Although no more confirmation is required that Albanese is the archetypal egomaniacal, do-nothing, bully-boy politician who has zero to show for his portfolio, he should be watched closely over his response to the Pel-Air incident and CASA’s report, and its own performance. There’s alot wrong here.

  • 9
    Gary Currall
    Posted September 5, 2012 at 5:53 am | Permalink

    the 4 corners programme was a revealing insight inot the performance of the 4 groups that represented by safety on that awful night.

    CASA was represented by Honest john mccormick, the director of safety!!! Someone should remind John that we are now in the 21st century and that really big aircraft have “fly by wire”, cos like, back in the day we didnt need wires or software that would provide a consistent approach to fuel calculations. Honest john seemed incapable of understanding that safety, like technology, is evolving. he needs to move with the times as there is no longer any room for his “back of the fag packet” calculations.

    The second group, Pel Air have according to the 4 Corners website, after 3 years, kindly offered all of the passengers financial assistance, on a without prejudice basis, so I won’t be saying anything nasty about them. Isn’t it funny how commercial interests can interfere with the truth?

    The third group ATSB were represented by Sweaty Martin Dolan, the Chioef Commissioner. i almost felt sorry for poor old Marty. Caught in the headlights of the 4 Cornered juggernaut he seemed incapable of working out which way to go. After almost 3 years and no doubt many revisions marty still couldnt get the facts right. Some 24 hours after the release of the “final” report marty dodged the glare and quietly changed the report. I now have two different versions but don’t know which to believe since Marty hasnt heard of version control. Which version of the “final” report are we now up to Marty? Someone should just put him out of his misery.

    I had hoped that the ATSb would be the investigative superhero, fighting the evil of vested and commercial interests to provide a fair and balanced report. Instead mild mannered Marty Dolan, like Clark Kent fails to quite get the girl. Marty is clearly no Superman.

    On the 4 corners show Dominic James presented as professionsal, calm and cool under pressure; qualities that he also displayed during the accident. Dom was also believeable, in direct contrast to CASA and the ATSB.

    It must be quite frustrating to work within these organisations. The special audit of pel Air, as revealed by 4 corners was conducted by a host of no doubt conscientious professionals who must be embarrassed to find their efforts presented in this shameful way.

    For a long time after the accident i had a recurring nightmare – I could never quite get out of the situation I was in. For the flying public the nightmare continues but the truth will get out.

    apologies for the typos – windows shut down!!!!!

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