Sunday, February 17, 2013

Upside Down Air Accident Investigation Down Under

Pel-Air medical evacuation airplane. Photo from ATSB
I am not one to encourage politicians to start sticking their noses into matters of aviation safety. It is WAY too tempting for them to grandstand. But in the case of the Australian Senate and the ditching of a medical transport plane in November of 2009, how could they not?

After all, it is not often that government bureaucrats behave so badly that the politicians wind up looking moderate, but that is just what's happening in Canberra. Worse, the unfolding scandal seems to indicate that the two agencies that should be more attuned than the average Joe to the complexities of causal chains and the futility of blame in accident investigations have been tone deaf. 

Westwind wreckage ATSB photo
Here's the overview. A medical transfer flight departs from Apia, Samoa to refuel en route to Australia, at Norfolk Island, a wee spot of hilly terrain east of Australia's Gold Coast. It is a long, over water flight made more challenging by the fact that en route weather and visibility at the arrival airport are deteriorating as the flight progresses. For a number of reasons, (which you can read about from AvWeb here if you are so inclined) this escapes the notice of the crew until they are past the turn back decision point.  

After four missed approaches with little fuel remaining, the pilot opts to ditch the Israel Aircraft Industries twin jet Westwind 1124A into the ocean and happily, everybody survives and is rescued.

The Australian Transport and Safety Bureau report, which takes nearly 3 years to complete, essentially attributes the accident to inadequate crew planning and decision making. There's a teeny tiny peek up the chain when in what is referred to parenthetically as a "minor safety issue" the report suggests the operator "did not effectively minimise the risks associated with aeromedical operations to remote islands." 

In a nutshell, the ATSB pinned the accident on the pilot. Except in this case the pilot, Dominic James, poked back.

I don't know how politics works in Australia; Capt. James got someone's attention, some questions were asked and darned if two members of Parliament, David Fawcett and Nick Xenophon don't start asking questions, too. Over the past several months the startling answers are beginning to emerge. Turns out Pel-Air, the operator for whom Capt. James was flying that night, had been a subject of concern to the Civil Aviation Safety Authority, specifically for its shortcomings in pilot training and fatigue risk management. Both of which were issues in the air evac flight. 

This is discovered because after the accident, the regulator commissioned an audit of the operator and (Kudos here!) a review of its own oversight. 

"It appears as if there were indicators that could have identified that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention," the report states.  What CASA failed to do was share the results of the audit, called the Chambers Report with the ATSB.  It probably would have broadened the ATSB's narrow conclusions about the accident. 

John McCormick photo from CASA
Confronted with reason to believe the flight crew was only a partial contributor to the accident, the Australian senators called the heads of both agencies into hearings. To John McCormick, director of Aviation Safety for CASA they ask the question, why did you not share with the ATSB, the results of the audit showing serious infractions by the operator of an airplane involved in an accident?

McCormick's astonishing reply - as reported by Australian aviation reporter Ben Sandilands  - was that McCormick did not consider the information relevant since, the accident was entirely the fault of the captain. 

Though you probably don't need them, let me repeat that with italics; entirely the fault of the captain

I was still trying to fathom how anyone with the title "director of aviation safety" could utter those words when I read his further rationale. The information was withheld from the safety board so as "not to contaminate its decision making."  Yup, if you keep information from investigators, it won't affect their decisions, and that's what we call uninformed decisions. Most folks try to avoid them. 

Between the ATSB's skim-the-surface conclusion in its probe, and CASA's retro-style, blame-the-folks at the pointy end of the accident, something very strange is going on in Australia's air safety world. When the guys with the pocket protectors launch in with the double talk and the politicians start to sound reasonable, that's upside down, no matter what side of the equator you're flying on.  


Anonymous said...

"essentially attributes the accident to inadequate crew planning and decision making."

From first reading and looking at the point of departure (Apia, Samoa) and intended destination (Norfolk Island) for refueling, it appears to me that the Safety Board was right.The distance is around 1700 s.miles and the flight would have taken four hours and thirty minutes approximately to complete. So, if the crew were rested prior to departure, the fatigue element is struck out.

Inadequate crew planning and poor decision making it is.

The crew should have made themselves more aware of the weather at destination and what about the alternate(s) here? Four hours plus is a long time to get settled and think clearly, you're flying over water and might lose an engine enroute, what about then?
The operator can be held responsible if adequate weather reporting provisions were not in place and for poor flight following.

Grumpy said...

I'm glad to see the names of the boffins involved in making determinations of relevance beyond their pay grades publicized loud and clear. As John LeCarre wrote in *The Secret Pilgrim*: "For the civil servant, [death] is the moment when his protective walls of privilege collapse around him and he finds himself no safer than the next man, exposed to the gaze of the overt world, answering ... for his laxities and evasions."
I am not aware of Captain Husain's investigation experience, or of the practices in Pakistan. However, in my experience it is accepted practice that determinations of relevance be made only by the duly appointed investigation agency. Withholding of any information, whether subsequently determined relevant or not, should be subject to appropriate legal process.

Anonymous said...

I can exercise my opinion which is anti-sensational. Determination has already been made by the investigative authority, the Australian Transport and Safety Bureau after a study of three years.
Yes pilot training was definitely an issue, the result so demonstrates and the fatigue factor is not relevant to this flight.

Grumpy said...

You are entitled to your own opinion. You are NOT entitled to your own facts.
Your original opinion rests on the assumption "...IF the crew were rested prior to departure...." (emphasis added) You then base subsequent conclusions on that assumption. Unscientific, and illogical.

Ministry of Clouds said...

A report by the Australian ABC Four Corners program indicate that the crew was not adequately rested and also had an inaccurate weather forecast from Fiji earlier in the flight. Due to some policy about certain radio frequencies not being cleared for use on Norfolk (HF as opposed to VHF I think)the crew did not receive updated information about the rapid deterioration of the weather on the island. My apologies, I'm not a pilot so my understanding of the radio issue is patchy but according to the interview with the radio operator on duty that night on Norfolk, it was indeed a mitigating factor and he said he wished he was allowed to use it that night. Transcript of the show here .

Unknown said...

Capt James performed a sensational night ditching. The difficulty in making the decision to ditch whilst the engines were still running would have been immense. So well done there. However, the aircraft was in the drink 25 minutes after arriving at Norfolk. It had insufficient fuel regardless of the weather. I have been low on fuel a number of times in the past 25 years. As yet, I have never been able to trace back the cause of a lack of fuel in my tanks further than myself.

Karen Casey said...

Reality check. There is a current Senate inquiry into NGAs ditching that has alleged collusion between the ATSB and CASA, big no-no for that one. The other disgrace is the covering up of important documents that would have affected the reports' outcome quite remarkedly.Facts are emerging rapidly that suggest the above mentioned and more. For one to state that the ATSB report is accurate is dangerous and ignorant, not smart for air safety.
I survived that ditching. The experience of it all, I will leave to your imagination, threatening, terrified, sharks, freezing.
What has been most disappointing to me in the aftermath besides physical disability, pain and scoring a mental illness, is knowing that the airline I was on were incompetent and sadly two very important Goverment body leaders have lied to me. An extremely bitter pill to swallow.
I owe my life to an exceptionally difficult ditching considering the conditions, pitch black, storm, high swells etc to the skilled, calm pilots. I owe my life to fighting with all my might.
I now fight for the truth to get air safety right here in Australia. I advocate this for the public, my loved ones fly too.
I will not fly again until there is a re-structure of both parties and honest, evaluatioing and implementation of safety are practiced by leaders that are willing to learn.
I am not afraid of dying in a plane crash, I am scared of surviving again and living with the physical, psychological and deceitful amount of grief that I and others have enured over the past three years and four months.
There is a much bigger picture beneth the pieces of the bits of connecting puzzle.

Anonymous said...

The information that has emerged from the Australian senate inquiry supports Karen in her quest to see the regulator answer for it's shortcomings. This is not the first time that an investigation by the Australian national air safety investigator [ATSB] has been queried and seriously found wanting. The following site has collated information, which is growing by the day:

There was Seaview, Whyalla, Lockhart River and others.

Anonymous said...

The pelAir matter will not go away in Australia. The following occurred today in the Australian parliament.