[Peetwo]

PelAir MKII report - MSM coverage...

Via 'that man' & the Oz:

Pel-Air pilot who ditched plane in sea acted ‘within lax guidelines’
The 2009 Pel-Air Westwindafter being ditched in the sea off Norfolk Island. Picture: ATSB

• Ean Higgins
  
• The Australian
  
• 1:34PM November 23, 2017
  
• Ean Higgins
  
  Reporter
  Sydney
  https://plus.google.com/116716661262546957732
  @EanHiggins
  
  

A reinvestigation of an extraordinary air accident eight years ago in which the flight crew of a medical evacuation aircraft had to ditch in the sea off Norfolk Island has found the pilot made errors but acted within the lax guidelines set by the aviation watchdog and his employer.

The new report, by the Australian Transport Safety Bureau, also expresses concern that the Civil Aviation Safety Authority, which sets aviation regulations, has failed to implement many recommendations that could help prevent similar accidents in future.

The unprecedented fresh inquiry, ordered three years ago by then Transport Minister Warren Truss, followed media revelations about the first report by the ATSB which placed almost all the blame on pilot Dominic James.

The disclosures by the ABC’s Four Corners program led to a Senate inquiry, which found grievous failures in both the ATSB investigation and CASA’s handling of the affair.

The Pel-Air flight in November 2009 was returning to Australia after picking up a critically ill Australian woman in Samoa when severe bad weather on Norfolk Island prevented the pilots from landing for a planned refuelling stop on the Australian Pacific territory.

With fuel running out, Mr James put the Israel Aircraft Industries Westwind 1124A twin-engined jet down in a stormy sea in total darkness, with all six people on board including the patient surviving the ditching and being picked up by a Norfolk Island vessel.

The ATSB took almost three years to produce a report that identified mistakes by the flight crew relating to fuel planning and weather checks as contributing safety factors and to a lesser extent criticised the available guidance on these issues from the company.

The Four Corners investigation revealed a CASA audit after the crash, and not mentioned in the ATSB report, uncovered 57 breaches and “serious deficiencies’’ at Pel-Air.

The CASA handling of the case was done by then CASA officer Greg Hood, who is now chief commissioner of the ATSB, and who issued the letter suspending Mr James’ licence to be captain on jets which have two pilots.

The new investigation, conducted by a different group of ATSB investigators, still finds the flight crew made errors.

But it says Mr James was operating within the existing regulations set by CASA, including not having to load enough fuel to reach an alternate airport if the weather turned bad.
It also says Mr James was operating within the rules set by Pel-Air, which the ATSB says were inadequate but have since been addressed.

The ATSB report expresses surprise that CASA has indicated it intends to address some of the deficiencies found in its regulations governing long distance air ambulance flights, but has not implemented changes.

“In 2014, CASA modified the requirements for operations to Australian remote islands, so that all passenger-carrying transport flights, including air ambulance flights, were required to depart with alternate fuel,” the ATSB says in the report released today.

“In addition, in 2012 CASA initiated action to change the regulatory classification of air ambulance (or medical transport) flights from aerial work to air transport,” which would mean ambulance flights would be governed by the stronger regulations applying to regular passenger airline flights.

“However, although CASA released a Notice of Proposed Rule Making about this issue in 2013, no changes have yet occurred.”

The ATSB says it has now issued a safety recommendation to CASA to continue reviewing the requirements for air ambulance operations.

& via the SMH:

Pilot error and lack of safety oversight led to Norfolk Island ditching

• [/url]Matt O'Sullivan
  
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The ditching of a Pel-Air rescue flight in rough seas at night off Norfolk Island was the result of a series of errors by the pilots, insufficient risk-control by the airline and limits to this country's aviation regulations, air-crash investigators have found.

Almost eight years to the day after the Westwind jet ran out of fuel and ditched, the Australian Transport Safety Bureau has released the outcome of an investigation it reopened following pressure from a senate inquiry.
   
Play Video


Video duration00:26

What cost surviving a plane crash?
[url=http://www.smh.com.au/video/video-news/video-national-news/what-cost-surviving-a-plane-crash-20170309-4rh6p.html]
What cost surviving a plane crash?

In 2015, Four Corners investigated the shocking tale of nurse Karen Casey, who was on an air ambulance flight when the plane crash-landed into the ocean. She saved the life of her patient but sustained crippling injuries. Vision courtesy ABC.

In 2015, Four Corners investigated the shocking tale of nurse Karen Casey, who was on an air ambulance flight when the plane crash-landed into the ocean. She saved the life of her patient but sustained crippling injuries. Vision courtesy ABC.

The plane was carrying a seriously ill patient, Bernie Currall, husband Gary, doctor David Helm and nurse Karen Casey from Samoa to Melbourne on November 18, 2009, when bad weather disrupted a planned fuel stop at Norfolk Island.

After four aborted attempts to land at Norfolk Island due to low cloud, captain Dominic James and co-pilot Zoe Culpit ditched the plane into the ocean, where it broke into pieces and rapidly sunk to the sea floor 48 metres below.

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While the six on board miraculously survived the ditching, two were left with lasting injuries including Ms Casey, a nurse educator with CareFlight.

She suffered serious long-term injuries including complex pain syndrome, major depression, anxiety and PTSD, as well as multiple physical injuries.


While the captain was hailed a hero in the immediate aftermath of the crash, the 531-page report – one of the longest the ATSB has ever produced – released on Thursday is again highly critical of him.

It found that his pre-flight planning did not include many elements needed to lower the risk of a long-distance flight to a remote island.

Pilot Dominic James who ditched plane at Norfolk Island in 2009.  Photo: Louie Douvis
 
These included miscalculating the total fuel required, not calculating the extra fuel needed for aircraft system failures, not obtaining relevant forecasts for upper-level winds, and not obtaining the latest information about potential alternate airports.

While the report is critical of Mr James, it found the risk controls of Pel-Air, a subsidiary of Sydney airline Regional Express, did not give assurances there would be sufficient fuel on board flights to remote islands or isolated airports.
 
Nurse Karen Casey. Photo: Jon Reid  

The list of Pel-Air's lack of risk-control measures included "no explicit fuel planning requirements" or formal training for planning such flights, no procedure for a captain's calculation of the total fuel required to be checked by another pilot, and "little if any assessment during proficiency checks of a pilot's ability to conduct fuel planning".

The report also lists shortcomings in Australia's regulations including a lack of "explicit requirements" for planning flights to remote airports.

The Pel-Air Westwind plane that ditched into the ocean off Norfolk Island in 2009. 
 
And, because air ambulance flights were deemed "aerial work" rather than charter, they were subject to a lower level of requirements than other passenger flights.

It also notes that air traffic controllers in Fiji and New Zealand "did not provide the flight crew with all the information that should have been provided".
 
Wreckage of the sunken plane off Norfolk Island   

However, it said the pilots did not request enough information before they passed the point of no return, which meant they had no option but to land at Norfolk Island or, as it turned out, were forced to ditch the plane in the ocean.

Mr James did not use the right method for calculating the point of no return, the report added.

The aviation regulator, the Civil Aviation Safety Authority, also had made limited information available about in-flight fuel management.

While the pilots did indeed ditch the plane without the loss of life, the investigators said they did not effectively discuss approach options, review their fuel situation or consider other emergency options.

However, the investigators said a range of local conditions affected the pilots' performance towards the end of the flight "including workload, stress, time pressure and dark night conditions".

A lack of formal procedures and limited training also hampered the evacuation of the plane.

"In very difficult circumstances, the nurse and doctor did an excellent job evacuating the patient, and then assisting the injured first officer and the patient in the water, both of whom did not have life jackets," it said.

The ocean ditching, and ensuring investigation, has been one of the most controversial in modern Australian aviation history.

A federal senate inquiry in 2013 castigated the ATSB for its handling of the investigation into the ditching and demanded it reopen the case.

That inquiry also took a "dim view" of the failure by the Civil Aviation Safety Authority to provide the ATSB with "critical documents".

MTF...P2  


Ps Yes "V" a long and at times pointless read - yet again the ATSB prove that they are without peer the premier Government top cover agency...

Pps Should be the ATCB not the ATSB...