PAIN_NET · @PAIN_NET1
3rd Feb 2015 from TwitLonger
Recent posts from Prune thread - Norfolk Island Ditching ATSB report.
2nd Feb 2015, 09:28 nomorecatering
I can't stand it anymore, I have to speak up. 37 pages of dribble. What ever happened to the concept of PIC...the C meaning Command. One of my first instructors, a WW2 vet, said to me as a 16 year old. " Boy, No damn checklist, ops manual, SOPS, regulations etc" replaces the 2 lbs of grey matter between your ears.
Dispatching to a remote island with only a non precision approach, at night.
An island that is known by anyone with a SPL for changeable weather,
Not carrying every last drop of fuel the tanks can carry.
Poor route selection in the first place, could have gone to Noumea instead, precision approach there.
Not getting a minute by minute update on the weather en route, especially when the weather was worse that forecast on the outbound trip.
Being told the cloud is OVC or BKN at 200agl prior to TOD, yet still chancing an approach. Knowing that to make an approach is likely to paint yourself into a corner with not enough fuel to divert.
Can a patient really be that sick to open up all the above risk factors. Could they not have waited 3 hrs so they had daylight to help with the approach?
You can have all the fancy safety systems, flow charts, ops manuals etc etc and oversight you like. None of this over rules sound judgment and common sense.
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2nd Feb 2015, 09:32 Fantome
sorry nomorecatering but your judgement is hardly that of Solomon
while what your instructor said way back then will always be spot on advice, it is not right to attempt to deliver summary justice
in a complex case like this
It's akin in a way to those diehards over Mount Erebus and Captain Jim Collins who will never admit
to the truth that an always super cautious, highly competent pilot entered a trap not of his own making
It can do your head in having to listen to 'the expert' in the bar telling everyone how "Joe Blow, he busted minimums -
end of story".
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2nd Feb 2015, 10:42 slats11
Nomorecatering, what you say is true - up to a point.
The truth is that DJ exercised poor judgement that night. No one disputes that, including DJ himself.
Equally however, the environment is designed to have multiple lines of defence. The PIC is always the last line of defence as you make clear. But hopefully the PIC is flying for a safe operator, and that operator is kept safe by appropriate regulatory oversight.
Unfortunately these "earlier" lines of defence both failed, leaving DJ horribly exposed to bad judgement and bad luck. The operator and regulator also contributed to the outcome that night. Unlike DJ however, then have sought to minimise their hand in this. And it is disturbing to many that the purported independent investigator seems complicit in this.
FYI, Noumea wasn't an option that night. The operator had been barred from New Caledonia for the previous 12 months because the plane was not fitted with latest generation TCAS as required under French (EU) regulations. So the only ILS runway in that part of the world was off limits. Ironically the operator had just finished putting TCAS into the aircraft, but the pilots had allegedly not been trained in its operation.
Similarly they didn't have RVSM. It has been speculated the reason why full fuel was not uplifted at Apia was the requirement to climb above RVSM airspace upon departure.
Thats how marginal the whole thing was.
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2nd Feb 2015, 11:05 Creampuff
Nomorecatering
You don't know, for sure, what weather information was transmitted to and understood by the crew.
What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.
All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP.
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2nd Feb 2015, 12:26 Jabawocky
Folks, remember that while CASA and PelAir are equally responsible, and my mind swings on what %age that is, in the James Reason model the pilot and his training are the last lines of defence.
Has anyone else here watched the excellent Ansett training video analysing the B743 oops in Sydney. It started with the planned start up date, and folk sticking to it, external contractors pulling the rug out and then all manner of sloppy systemic issues, culminating in the crew being set up and subsequently poorly performing. It was almost a comedy of errors except I am sure nobody thought it was funny.
I am beating myself up for a small error made the other day, no biggie but in my mind I cary the can. 100% me.
In this case there are three parties who have almost equal shares. DJ deserves the whipping he gave himself and the industry has. The sad thing is the other two managed to duck and weave. Then there is the aftermath and the ATSB. Another round of dodgyness involving three parties, two carried over from the original event We know who.
But what happens with them? That is the disgusting part. History repeats. As the gobble dock used to say…tic tock…..
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2nd Feb 2015, 18:49 halfmanhalfbiscuit
Quote:
Creampuff
"You don't know, for sure, what weather information was transmitted to and understood by the crew.
What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.
All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP. "
To answer that question the CVR would go a long way! Just because it was transmitted doesn't mean it was received on board NGA. It has always concerned me that the CVR/FDR were not recovered. Beyond all Reason!!!
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2nd Feb 2015, 22:56 ventus45
halfmanhalfbiscuit
Creampuff
Quote:
"You don't know, for sure, what weather information was transmitted to and understood by the crew.
What we do know, for sure, is that there were patent errors in the weather information transmitted to NGA, and that there are patent errors in the transcription, in the ATSB report, of the broadcasts supposedly made to NGA.
All grey matter has wisdom in 20/20, unfatigued hindsight, but none has yet been discovered with ESP."
To answer that question the CVR would go a long way! Just because it was transmitted doesn't mean it was received on board NGA. It has always concerned me that the CVR/FDR were not recovered. Beyond all Reason!!!
A concern shared by many me thinks.
Perhaps there was a very specific reason.
"There is no evidence your honour".
Consider this "hypothetical".
Suppose, just suppose, hypothetically, that "the investigation authorities (plural)" reaches a certain point, very early on, where they realise, that knowing whether or not NGA got the Nandi info, was cruicial to whether or not they could shaft DJ fully, with the met as the trump card and the fuel as backup, without DJ having a "met based defence".
After all, logic says, if he got the Nandi info, then yes, we have got him cold. Shaft to the max.
But, if he did not get the Nandi info, or if what was received was not entirely readable and understandable, it is not so conclusive, it might not be so easy to shaft him on that. It might leave him some wiggle room on appeal, so we have to do him on the fuel.
Further suppose, just suppose, that "the investigation authorities (plural)", realise that there are only two ways DJ may (or worse - if he gets a good lawyer) wriggle out.
The transmit tape from Nandi and the receive tape from NGA - and of course - subsequent discussion in NGA.
So, two holes to plug.
Suppose, just suppose, that for now, we just leave the box where it is, and make it known, very hush-hush like, in diplomatic circles, that it would be "really helpfull" if a little island nation "declined" to supply their tapes. Given the nature of things - much bigger things - certainly do-able.
Further suppose, just suppose, that, having received advice of such willingness to decline, "the investigation authorities (plural)" now know that only the box could save DJ, so they "concoct" a "rationalle" - beyond all Reason, to "let it rest in peace".
Then, DJ is "done like a dinner" and "the investigation authorities (plural)" slip out into the shadows - and away - scott free.
Eventually, post shafting, DJ and others, like a couple of blokes in a bloody big house with a grass roof, can be given the stock bullshit, fully aware, that they are safe from being implicated in any way, safe in the knowledge that if it ever went to the land of the legal eagles, their defence would be simple - "There is no evidence your honour".
Back to reality.
Question. Can a court demand that a box be retreived ?
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2nd Feb 2015, 23:20 Fantome
Kangaroo court
From Wikipedia
"A kangaroo court is a judicial tribunal or assembly that blatantly disregards recognized standards of law or justice, and often carries little or no official standing in the territory within which it resides. Merriam-Webster defines it as "a mock court in which the principles of law and justice are disregarded or perverted"
The term may also apply to a court held by a legitimate judicial authority who intentionally disregards the court's legal or ethical obligations.
A kangaroo court is often held to give the appearance of a fair and just trial, even though the verdict has in reality already been decided before the trial has begun. Such courts are typically run by authoritarian governments, and can also be found in rural areas where legitimate law enforcement may be limited. In particular, they are still common in rural India, where they are referred to as "Gram Panchayat".
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2nd Feb 2015, 23:55 #724 (permalink)
Creampuff
Quote:
"But, if he did not get the Nandi info, or if what was received was not entirely readable and understandable, it is not so conclusive, it might not be so easy to shaft him on that. It might leave him some wiggle room on appeal, so we have to do him on the fuel.
Let me fix that for you, to make a valid point more strongly:"
Quote:
But if:
(a) the crew did not receive all of the Nandi info; or
(b) some of the info that Nandi transmitted had errors in it that gave a misleading view of the prevailing and likely future weather conditions; or
(c) Nandi refrained from transmitting information that would have given the crew of NGA a better understanding of the prevailing and likely future weather conditions; or
(d) some of the information that was received by the crew was misunderstood due to a combination of fatigue and the usual HF propagation issues; or
(e) a combination of some or all of the above resulted in the crew being misled into believing the prevailing and likely future weather conditions supported the decision to continue to Norfolk,
it is not so conclusive and it is not so easy to shaft him on that.
I have an idea: There should be recorders fitted to these kinds of aircraft, to record what was heard in the crew’s headsets and what the crew discussed and decided to do about what was heard. That way the investigation of an accident or incident could be informed by facts.
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3rd Feb 2015, 00:50 slats11
I have another idea. Lets have a legal requirement for these useful recorders to be obtained by the investigative body whenever possible.
Oh wait, hang on......
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Unread 3rd Feb 2015, 08:05 Fantome
dead right Lookleft .. thanks
It's fair to say the final and exhaustive, credible analysis, will only come from a researcher and writer who -
1. Having taken on the assignment, allows sufficient time to be right across every bit of the story, before drawing any conclusions.
2. Is unrelenting in getting to the bottom of every controversial twist
3. Has runs on the board in air accident investigation
4. Is free of bias
5. Is able to distinguish between fact and assumption, however finely nuanced, and
6.ideally, comes to the task afresh, with no prior knowledge or interest
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