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A cautionary tale…
CASA must act now to prosecute over Pel-Air crash
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Some very big issues are now circling the ditching of a very small jet, a Pel-Air Westwind, off Norfolk Island while doing a CareFlight medivac from Apia to Melbourne on Wednesday night. They include failures of public administration in the awarding of state contracts, a prima facie breach of Australian air safety regulations, the future of the Royal Flying Doctor Service, and a clear risk to public safety. Forget the media foolishness about Cleo bachelor hero pilot saves lives, or the former federal transport minister John Sharp making gravely serious admissions of incompetency by the air service he chairs while trying to air-brush the incident to clueless reporters. 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). James and his airline must be prosecuted. The airline must be audited and required to justify continued holding of an air operator certificate or AOC. For an Australian AOC holder to persist with a flight to a refuelling stop at Norfolk Island without adequate reserves or flight planning, if proven, is derelict. John Sharp admits there was no “plan B” and that the plane ditched without a Mayday call in the Tasman Sea in darkness — an example of incomprehensible stupidity and unprofessional conduct. The two pilots, two Care Flight medical staff, the injured person and her spouse, were in the sea for up to 90 minutes. It is unclear if there were enough life jackets for all of them, but only three were worn. Pel-Air is owned by REX, the regional carrier, which is controlled by its major shareholder and chairman Lim Kim Hai. It has won major medical aviation contracts previously held by the Royal Flying Doctor Service in Victoria this year, and is poised to take the NSW contract off the RFDS in the near future, much to the concern of people such as the member for Dubbo, Dawn Fardell. The loss of these contracts has serious implications for the RFDS and the public even before the Norfolk Island ditching. Earlier this month Pel-Air was awarded a three-year ADF contract authorising it to carry personnel and equipment at home and abroad for three years. REX then posted this statement:
In fact, it would have been impossible for the ADF to recognise any of the qualities Davis mentions. It is all about lowest price, and zero diligence on the part of the ADF, as it is with the state medical aviation contracts. There are clear precedents for action in the interests of public safety to be taken by CASA, the most striking of which was its temporary grounding of Ansett’s aged 767 fleet in April 2001 because of its negligence to maintain emergency door slides in working order and failing to correct cracking that was occurring in engine pylon wing joints. At the time CASA feared there would be a major crash of an Ansett airliner because of the wilful neglect of maintenance. CASA and the current minister for tansport, Anthony Albanese, would surely be mindful of the consequences of letting Pel-Air get away with the operational standards implied by Wednesday night’s near disaster. Will they act now, or after the next crash? EXTRACT FROM CAO 82.0:
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24 Comments
Yes, this could get messy, especially since the mainstream press has already elevated Dominic James to Sully Sullenberger status. Whatever the (jaw-dropping, if true) planning screw-ups he does seem to have made some sound calls and done some serviceable pole-work at the nasty end - even if he was a bit modest about it, RT-wise. My vague memory from a decade flying helicopters is that this - not preempting anything specifically, here - is not so uncommon, too: for a pilot to make poor planning and casual chain decisions…but then extract his bum from the inevitable cluster with some useful seat-of-the-pants at the crump. Nothing focuses the mind-hand-eye like the prospect of a cameo on The Wrong Stuff II, I guess. The old aviation prayer: dear Lord, please don’t let me f**k up.
Good post, this. Gutsy. Curious to see what happens next.
Thank you for this information. I work as a rural & remote nurse & depend completely on the RFDS. Will use the information you have provided to discuss the loss of RFDS in NSW with my MPs (does this sound wooosey? Feel powerless). Such a wonderful organisation - even in Saudi Arabia they are respected & a role model of medical evacuations. What has happened to us?
“Forget the media foolishness about Cleo bachelor hero pilot saves lives, or the former federal transport minister John Sharp… trying to air-brush the incident to clueless reporters.”
That’s exactly what I thought when I saw the TV news reports, and I know sod-all about planes. As media fortunes slide, there are fewer journos, fewer experienced journos and less specialist expertise. “Clueless reporters” here reminded me of the ignorance of bushfire that journos showed after Black Sat. Without specialisation, the 4th estate is letting us all down.
Thanks Ben for an informative and objective report. It seems inexcusable to have insufficient fuel for a diversion at any time. As for choosing a cheaper tenderer instead of RFDS, this is unbelievable ignorance on the part of administrators who are happy to deny history in the name of alleged efficiency.
A spokesman for CASA has issued this statement at 4.15 pm.
QUOTE: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. UNQUOTE
Any significant developments in this story will be posted over the weekend on Crikey blog ‘Plane Talking’.
A pilot in Canada was found guilty of criminal negligence causing death. He did one missed approach and then ran out of fuel. Crashed in downtown Winnipeg, killing one of the passengers. A report of the incident can be seen here at the CBC.http://www.cbc.ca/canada/manitoba/story/2007/11/02/winnipeg-crash.html
A spokesman for the ATSB said at 5.15 pm that the jet was in around 30-36 metres of water, but that a decision on whether the data recorders (black boxes) would be recovered would not be made until after the pilots were interviewed next week.
The other four persons on board would also be interviewed.
Ooops. That presser is unusually illuminating; the focus of the investigation is rarely quite so explicitly noted, so early. Hard to see how this is not going to end in tears for some. On the other hand - given that no-one was hurt - maybe it’s exactly the kind of circuit-breaker that’s needed re: some of the really dodgy corner-cutting that government aviation tendering has seen arise.
Nice early eyes on this one, Ben. None of the big mastheads are keen to sniff too closely, still. Watch this space, indeed…
Thanks Ben - a more detailed account of what I commented last night on your post. Hunk Hero? don’t think so - an irresponsible pilot, lack of planning, saving on costs by not carrying sufficient fuel reserves. Pel Air have a lot to answer for. A good friend of mine was a senior Air Services Australia manager when John Sharp was minister and my friend says Sharp was a waste of oxygen. Alex
When will we ever learn?
When Australian Companies ruled our skies our safety reputation was second to none now we are selling years of competence to the cheapest bidder,
I would feel a bit better if that company was flying our Politicians, Senior Public Servants and the CEOs of our larger banks and other VIPs rather than our accident and sickness victims.
Prosecute them, strip them of the contract and return our venerable and reliable RFDS to us.
Carrying enough fuel to divert to another airfield is not always arequirement.
A 30 minute fixed reserve and a 10% variable reserve plus even a 30 minute weather reserve will not last long maneouvring at relatively low altitude as the pilots make THREE instrument approaches. Without the benefit of a RADAR ATC environment to help with track shortening, they would need to fly the full approach, burning even more fuel.
That holding fuel is based on the benign flight path found during a holding pattern and does NOT take into account the constant power adjustments made during an approach to land or the extra drag of landing gear and flap being extended - THREE times.
The VOR approach at Norfolk Is. with the lower operational minima (giving the best chance of success) is the one landing to the west which means they had to start from further away and burn even more fuel.
And that one hour of extra fuel won’t last long when things do not go according to plan. But it may just make the flight LEGAL.
Beyond that, a sensible pilot will not plan to ditch when the tanks are almost empty. Much better to ditch in a controlled condition with the engines still capable of delivering power then in a powerless glide, don’t you think? Anything else is reckless.
As for not making a mayday call - they were all located within (we’re told) approximately 90 minutes. This indicates the people on the ground were fully aware of what was happening and were onto the process of rescuing them in good time. Making a Mayday call when about to die is a complete waste of time and usually only happens in the movies. I can easily forgive this pilot not making a Mayday call because in effect, he had already done so in communication with the ground crew at Norfolk Is.
I hate to burst the bubble for Bakerboy, Liquid Len and others but the PelAir crew kept everyone alive. The RFDS have had TWO fatal accidents in their history. Whilst not intending to malign the RFDS (I used to work for them many years ago) they are pilots just like anyone else and are just as capable of an accident as any other operator. In fact, the RFDS mostly operate into outback locations where the weather is generally fine and nowhere near the state of the weather at Norfolk Is that night.
Bakerboy your post is full of uninformed speculation and a complete disgrace. I trust you’ll issue a retraction if and when this pilot is shown to have carried the legal fuel reserves.
Jim.
“Making a Mayday call when about to die is a complete waste of time and usually only happens in the movies.”
Well, that’s just silly, Jim. It’s called ‘focussing the world’s attention on your plight’, and it changes/expedites the SAR game in multiple ways, for one thing, especially if you are talking about a potential sea recovery. Doing so in this case, for example, would have put your pax on a priority watch-list for every vessel within useful steaming time of Norfolk. Handy, I would have thought, if the locals hadn’t found you and some of you, at least, were still bobbing around in the drink come dawn next day. Declaring an emergency when you’ve got one is, anyway, a legal requirement.
Jim, no-one here is necessarily over-looking what was clearly a very useful effort in the terminal stages. You walk - or float - all your pax away from a ditching and you’re doing at least something right. But it’s a fair bet to suggest that an enormous amount of sheer bloody luck - not to mention the skill and smarts of the local boaties - has played a hefty part here, too.
It’s been fifteen years since I flew professionally and I was single engine helo ops, not so often over water. I was also mostly military - admitting which is usually an invitation to civil operators for a bit of a sneer and a dissing about being mollycoddled, having no commercial pressures, etc. All true. But I did enough SAR, and was flying at the time when civil aviation was taking over much of the military base SAR helo obligation, to see first hand the slightly different approaches to emergency services when the bottom line gets introduced into the equation.
The fact is that shifting what were once publicly-underwritten emergency operations into the contracted commercial realm has introduced a potentially complicating factor that can - CAN, not necessarily automatically does - put additional (non-operational) pressure on crew who are under enough pressure, anyway. It’s no reflection on contracted aircrew simply to ask, in the wake of something like this, whether or not some re-thinking needs to be done on how the tendering arrangements in some areas are stewarded. Anyone who is too touchy about that sort of question might well be protesting-too-much, methinks.
As for the reserves angle, I am not up-to-date enough with the regs to know whether or not this flight will turn out to have been technically legal or not. You’re right to caution us all against pore-judgement. But neither should these pilots be so prematurely lauded, either, as has been happening, because that, too, can skew any subsequent public discussion of the eventual investigation outcomes just as much, and in the end, any changes needed will be up to the pollies. Public perception is important in matters of aviation policy, and our comments here are as much an attempt to nip in the bud any premature canonisation - the ‘gold standard of aviation’ is what the Pel-Air guys are trying to sell it as - of what might well turn out to have been really bad practise. That’s all.
But one thing, Jim: as a matter of general aviation principle I’d put it to you - and anyone else here - that any timea pilot ends up having to throw away a perfectly serviceable aeroplane simply because he’s run it out of fuel - and there being no pax in danger of immediate death on board at the time - has to be at least a bit of a f**k-up, even if one nudged along by some sustained bad luck.
Jim,
Why commit yourself (and take away your chance of diverting) by having three approaches in poor weather.
After just one missed approach and near the minimum divert fuel figure, the sensible option would be to divert to a more suitable airport and refuel - assuming he had the fuel on board as per the “Remote Airport” Regulations.
As an Airline Pilot, I wouldnt be commiting myself, my passengers or Crew to a ditching, thinking I might just get in on the next approach. Expensive gamble.
You’re right, a Mayday call is a requirement. My point is if he forgot to say it in the heat of the moment, maybe that’s understandable. I’m guessing he had the team on the ground on the job and that they were letting the mainland know. Maybe he’d already even told FS he was planning to ditch but never ACTUALLY said Mayday. I guess common sense would have to prevail if an FSO knew he was preparing to ditch but had not heard him use the word “Mayday.” But I take your point.
Dennis, I also see your point about not committing to the destination like that. That’s (arguably) a separate issue which I did not refer to previously. Where I work now our fuel policy would have had an alternate on that flight regardless of weather. Personally, I’d have had tonnes extra, again, for several approaches and mum and the kids and STILL been able to divert.
But I do not fly a Westwind and I certainly wasn’t there so I can’t comment on this guy’s decision making. And neither can anyone else - yet!
So let’s not crucify this pilot OR Pel-Air. I saw some things at RFDS that would make your hair go curly. Everyone is fallible.
Jim.
Jim, I don’t know what RFDS you worked for, or what risks yourself and your colleagues took during that time that would ‘make your hair curl’ as you so eloquently put it, but as a CURRENT employed pilot of the RFDS, I take offence to your comments and can confidently assure the public that not one of our pilots at our base, would ever fly to a destination without the required reserves to retrieve a patient. There is no patient retrieval that would warrant risking the lives of 5 people to enable a patient to travel to a major city for treatment. Ironically in this case, I do believe it’s been documented that the patient walked on the aircraft from Apia. In other words, the patient was hardly on his/her death bed.
As for your holding fuel comment, if you’d looked at the weather reports on the evening of the incident, it is clearly obvious to any professional pilot, that ‘holding’ fuel was NOT an option. The weather at Norfolk Island was never going to improve in 30 minutes/one hour. The only option was an alternate aerodrome and in the event that an alternate aerodrome was not available as could well have been the case with Norfolk Island and it’s remote location, then the obvious fall back would be a point of no return (PNR.) For the non-pilots, when flying to a remote destination, at some point along the track you arrive at the PNR - point of no return- where you either elect to continue to the destination or return to your point of departure (or an alternate if available) if the weather at the destination is forecast to be below the ‘alternate’ weather minimum requirements. Which in this case it most certainly was! The RFDS that I work for pride themselves on their safety culture. Non of my colleagues would ever allow one of their fellow pilots to depart for a remote destination with poor weather and minimal fuel in order to retrieve a patient. Please be careful with your flippant throwaway comments in regard to the safety of the RFDS. Your unprofessional comments at attempting to justify the pilots reasons for not declaring a MAYDAY blatantly show your allegiance to Pelair or the Pilot in question. And lets not even touch on the fact that only 3 of the 5 persons on board were wearing life jackets in the water after the “prepared” ditching…
Would the RFDS you work for allow you to ignore the runway you just landed on in favour of taking off on a highway right next to it? And what if you then hit a road sign with the wingtip during the takeoff roll? And how would they feel if your excuse to CASA was, “The sign wasn’t there the last time I took off on that road…”
Yep that was a RFDS misadventure. I know the pilot. A very professional ex-Mil pilot with loads of experience. But he did all of the above. Doesn’t change my opinion of him OR the RFDS though so take it easy. But please don’t bang on about the safety culture when this and other events HAPPENED.
I don’t know the PelAir pilot and I’ve never worked for them either.
From a press report quoting the locals:
… the crew had not had the opportunity to give the rescuers co-ordinates or even a direction in which they were heading. “Half the island turned out and one guy spotted the lights off the west coast,” Mr Robinson said.
Given the lack of floatation (three without life jackets), the outcome depended on the quick rescue. Yet the report says the rescuers didn’t know where the plane was (they were headed elsewhere). They found them as a result of a fortuitous sighting, on a dark night, in bad weather. And then a weak radar blip off a sinking plane. And a tiny life jacket light.
A “controlled ditching”; but no mayday and no location. Odd.
From Claire Harvey in the Sunday Telegraph today. Great moments in aviation Op Ed/reporting (not):
Pretty fly for a fly guy
Buckle your seatbelts, passengers. The greatest cultural stereotype of our times - the sexy pilot - is about to become even more unbearable than before.
Handsome studmuffin/pilot Dominic James, a former contestant in Cleo’s Bachelor of the Year pageant, is being hailed as a true swashbuckling hero after crash-landing his plane into the sea off Norfolk Island and treading water for 90 minutes, with his co-pilot and passengers, before being rescued. The tale of Captain Dominic is full of intriguing little questions (Did he have enough fuel? Will aviation regulators investigate? Does he prefer girls with Brazilian waxes? He’s already answered that last one: no. “As a pilot, I prefer a landing strip,” Captain D told Cleo.)
But all these questions lead us to one of the greatest unsolved mysteries of modern aviation. Forget the Bermuda Triangle and what happened to Amelia Earhart: what I really want to know is why we allow pilots to get away with wearing military uniforms…
Continues drivelling for another dozen pars. Sure, it’s a throwaway Sunday lifestyle column. And she does squeeze in the (‘intriguing little’) fuel question, sort of. I wonder if CASA investigators will reciprocate, and ask Dom about his celebrity tw*t preferences?
Or then, from the same paper’s Sydney Confidential gossip column, we’re given the (distinctly unwanted) information that:
TV star Simone Jade McKinnon [is] pregnant to hero pilot Dominic James
THE hero pilot who saved the lives of his five passengers including a critically-injured woman is expecting a baby with his former girlfriend, TV favourite Simone Jade McKinnon. Dominic James, the 33-year-old former Cleo Bachelor of the Year who on Wednesday was forced to ditch his aircraft in waters off Norfolk Island, only learned of McKinnon’s pregnancy shortly after they broke up. While sources close to the expectant parents declined to comment on the relationship, McKinnon revealed this month there was no doubt the father of her child would play a role in the baby’s life. She starred in Channel 9’s McLeod’s Daughters and was this year nominated for a Gold Logie.
Australia’s Next Top Model mentor Jonathon Pease said that James - his friend of 20 years - was taking the near-death incident “in his stride”. “When I read about the accident, I thought ‘That’s typical Dom.’ He’s the man I’d want next to me in a crisis. He’s a legend,” Pease said.
Only then do we get into some nitty-gritty:
But as his heroics were being praised yesterday, questions were being asked about how the aircraft ran out of fuel while enroute to Melbourne from Samoa….
Etcetera for a few measured pars, but only buried deep inside all the ‘hero’, ‘studmuffin’, ‘legend in a crisis’, ‘critically-injured pax’ excess. Maybe the sensationalism is not entirely his fault, but to those (rightly) cautioning us against too-premature condemnation, this is hardly what I would call ‘press restraint’ while leaning the other way, in the face of an open investigation(s).
This is the kind of hysterical media silliness that grown-up aviation policy-makers are constantly up against. As Frank Campbell sadly notes above: long gone are the days of the specialist reporter…
Well Jim IF you are or have been a pilot and IF you had flown into Norfolk Island you would hopefully be aware of some extremely well known weather events that occur there around November EVERY year, SEVERE FOG CONDITIONS, so severe that it affects the planting of certain crops.
You would also be aware that the coast of Norfolk Island is so treacherous that there are no boat ramps on the island and those who crane launched the rescue boat were the real heroes not the silly poseur who could not even provide his passengers with the very basic safety equipment that they would have been required to be wearing if on s small boat in a protected bay.
“Norfolk Island has no natural or man made permanent harbours. When they go boating they need to launch the boat every time. Sounds simple, but there are no launching ramps either. Two launching sites are available located at Cascade and Kingston. The procedures are the same at both jetties. The boat is backed under a permanent derrick. The trailer unhooked from the truck. The boat hooked up to a block on the derrick. The truck is then hooked up to the cable. Drive forward until the boat is suspended in the air. Push the boat out over the water. Back up the truck until the boat can be unhooked, load up the passengers and away you go. On return after the trip reverse the procedure to get the boat back on the trailer.
As you are launching into the open ocean, you need to keep an eye out for any swell which can rise unexpectedly. It’s all part of Norfolk’s unique way of doing things, simple but effective if you know how to go about it. And yes, when you come diving you too will be recruited to help with launching and retrieval.”
From http://www.visitnsw.com/Norfolk_Island_p2736.aspx
IF you were or are a pilot you would be aware of the regulations regarding EPIRBs, LIFEJACKETS and the many other safety precautions that should be taken before an over water flight.
Jim your post is an insult to the many wonderful members of the RFDS and the brave folk on Norfolk Island who risked their lives to save the poorly equipped crew and passengers.
An apology is the least you could offer them
Jim you have no idea what you are talking about. It is clear that there was no planned ditching. this was (inadvertent) CFIT.
Ben is right and you are wrong. I don’t believe you have any significant aviation experience( and by significant I mean at least a couple of decades as PIC. OK maybe one depending on what it was).
Len, in over 13,000hrs of flight I’ve operated into Norfolk only about a dozen times (ten years ago) and fortunately I managed to avoid the worst of the weather each time. I remember well the terrain but I don’t recall much about the vagaries of the weather there and couldn’t care much, into the bargain.
Are you saying there was fog restricting visibility at the airfield at the time of the event? I was under the impression it was low cloud as indicated in the SPECI. If it was low cloud, then why is fog (on any other day) relevant to this discussion?
Sorry but you also lost my interest about one line into your irrelevant description of the boat-launching procedures. Whilst time-consuming, it obviously didn’t hamper them too much because they had the people out in 90min. Maybe they had prior warning - from the pilot????
I’m not even sure what your point is anymore but I cast no aspersions on either the RFDS or the people of Norfold Is. Try reading the post.
It appears I’ve mistaken this site for one frequented by the informed and the intelligent. It’s hard to argue with people who proclaim such drivel as this:
“It is clear that there was no planned ditching. this was (inadvertent) CFIT”
Is it a full-moon or something?
Sadly, events such as this ditching always bring out in droves the uninformed, the clueless, the opinionated, the trolls and the raving loonies. Some here are all of the above.
Jim.
CASA has launched a special safety audit of REX and Pel-Air. Documents have been called for. It has also reaffirmed the legal requirement for Pel-Air to carry sufficient fuel to fly to an alternate airport.
I can also confirm reports that the flight struck the water without having been prepared for a ditching.
MAYDAY, MAYDAY, MAYDAY….
Dodgy journalism alert!!!!!!!!!!!!!
Ben, something you may have missed here… the parts of the CAO82.0 you have reproduced are from the interpretation section where the CAO talks about what the CAO means where it later refers to minimum fuel. The application section of the CAO then only talks about remote islands and minimum fuel with respect to passenger carrying CHARTER operations. Here is where the “whoops” kicks in….. it wasn’t a charter! Even if it was, the fuel requirements are preflight requirements only…. you may want to investigate when many operators, including large, iconic ones, allow preflight requirements to be used in flight.
There is another “whoops” here…. don’t know who your dodgy source is, but it is on record that a ditching was briefed.
Very unprofessional and discourteous for so called “professional” pilots are acting as Monday morning quarterbacks on this one while the ATSB is investigating. Even dodgier to report rumour websites as factual info….. oh dear!!!!
My Dear Jim
“Sorry but you also lost my interest about one line into your irrelevant description of the boat-launching procedures. Whilst time-consuming, it obviously didn’t hamper them too much because they had the people out in 90min. Maybe they had prior warning - from the pilot????”
Well Jim I am so sorry to have bored you with such pithy information as the manner of the rescue from the water of this wonderful Pilot and his fortunate passengers.
I see your 13,000 hours and raise you 45 years involved in ocean rescue serving many years as a Lifeboat Coxswain on “All Weather Boats” based in Cornwall for many years not to mention many years in Australian Coastguards since transferring with my company to OZ. I have participated in over 1400 offshore rescues myself and directed many more.
I also am a qualified pilot albeit only having around 4500 flying hours under my belt, many on RN (SAR) Helicopters, Westland and Sea Kings.
I am also well acquainted with Norfolk Island and its waters and weather which I see you are not and I can assure you that a night launching and retrieval at Norfolk Island I have never witnessed, but it would be very hazardous at best.
So I bow to your fixed wing experience but I am way ahead of you when it comes to the matter of saving lives at sea and the dangers it poses to those brave men and women who all too often lose their lives in an effort to save others.