Review: CASA Accident Investigation Report 09/3

CASA investigative team details:

Synopsis reference:

See here for MOU reference:

History constructed from taped transcript:

1 From 4 corners transcript:

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.

That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.

MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...

GEOFF THOMPSON: So it might be a mistake.

MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.

GEOFF THOMSON: And he did.

Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.

DOMINIC JAMES: If I'd been told that there was cloud at 600 feet, even given the fact that I suspected the automatic system was overstating the weather at Norfolk, I would've gone to Fiji.

This clearly shows that not only did the ATSB make a mistake but the CASA investigators neglected to include what the “0801 UTC NADI ATC” actually reported for the 0630 METAR, instead skipping to the 0800 Auto SPECI details. This discrepancy appears to have again been overlooked further on in the CASA report:

And again here:

Excerpt from History summary of transcript:

2 Note: The investigators do not make it clear if the pilot had acknowledged receipt of either the 0803 UTC amended TAF or the 0800 UTC auto SPECI. Nor does the above indicate what was the validity period of the amended TAF.

Confirm this time based on an estimate from the passing FL240 call, it is interesting to note that given 3.5 hrs (210 minutes) originally estimated for the flight plus VR of 10% gives 231 minutes.

Captain interview:

The following excerpt is extracted from 1.5.6 ‘Fatigue’:

Note: How could any professional pilot accept that (a) 4 hrs sleep was enough and (b) that 30 minutes was an acceptable time to flight plan a fairly complex flight, given no software/operational support etc? This is the first indication of a normalised deficiency. This ‘accepted practice’ is further highlighted in the final paragraph of 1.5.8 ‘in flight decision making’:

What is quite revealing is the difference between the Captain interview summary, which is some two and a half pages long, versus the Co-pilot the sum total of 2 paragraphs (ref 1.5.11):

3 Notes and observations up to 1.5.11 page 14:

 The fact that the 2nd Pilot is referred as ‘Co-pilot’ and not ‘First Officer’ is significant. The evidence also shows that although the Westwind is a Multi- crew aircraft the accepted culture within the Pelair Westwind Operation was that the 2nd Pilot was little more than a ‘Safety Pilot’ or essential passenger.  This culture appears to be also accepted as SOP not only by the company but also by the CASA investigators and the CASA special audit team. There is scant mention of the 2nd Pilot responsibilities and/or duties. Here is one of very few examples where the CASA auditors/investigators refer to the 2nd Pilot’s involvement with the operation:

 Which is one of few references to ‘First Officer’ by CASA and does draw attention to there being no supportive documentation/SOPs/COMs for a Multi-crew operation. It would also appear that neither the CASA investigative nor audit teams have picked up on this apparent anomaly, which it could be argued was a very real causal factor in this accident.  The Special Audit team went through the crew’s training records and picked up the following non-compliance:

 What the above highlights is that the crew were in fact not properly checked to line in all facets of a multi-crew cockpit. In a risk mitigating ‘airline world’ the crew should never have been rostered together, the term used would be ‘green on green’. In a true Multi-crew environment the First Officer is essentially the 2nd in command, who should be trained and checked to essentially be able to ‘take command’ at a moments notice if the Captain becomes suddenly incapacitated. However it could be argued that due to company culture and various ‘normalised deviations’ that this First Officer was so far out of the ‘risk mitigating’ loop her role simply played out as more of a hindrance rather than a help.  There was no apparent evaluation of the company approved CRM course and from previous experience the value of such courses is limited by the engagement of the TCS Captains with what it is they’re trying to teach or reinforce. Mostly the CRM courses are largely generic in nature and do not reinforce the principles of Multi-crew discipline.  What is also apparent is that this status quo is an accepted ‘normalised deviation’ within the CASA ranks.

Summary of Special audit by CASA investigators:

The following is an extract from section 1.17 ‘Organisational and management information’ page 19-20 of the CASA report:

4 5 Note: This summary is directly contradictory to the findings, causal factors and conclusions put forward by the investigators in this report. There seems to be a total disconnection between what was investigated/explored as being causal to the accident and what the CASA investigators actually believe was the reason for the accident i.e. an inept, incompetent and reckless Pilot in command.

From the CASA report into the ditching re Chief Pilot interview, reference 1.18.1-1.18.2 ‘Chief Pilot interview’ page21-22:

6 Note: Most of the above is a fairly standard response for a Chief Pilot. However the last paragraph is quite revealing in terms of “any updates to the FAID score based on actual sleep or use of the IFLS” or in fact the use of a FAID score of 75.

Definition IFLS: Individual fatigue likelihood score.

This issue with the FRMS was also highlighted in the following couple of paragraphs from the CASA report:

Section 1.18.3 ‘Fuel Planning’ summary:

This section deals with the flight/fuel planning conducted prior to and during the event flight. Although reasonably comprehensive it tends to be more of a lecture in basic flight/fuel planning/management i.e. how it should have been done.

7 There is no real assessment in this section on why the PIC failed to adequately comply with his obligations under both the company AOC and the CASA regulations i.e. how this ‘normalised deviation’ came about?

The following excerpts from section 1.18.3 and 1.18.4 again skips over the initial METAR information that had been given to the aircraft at 0801 UTC from Nadi ATC:

Section 1.18.5 deals with the legislation applicable to this event:

This is a reasonable summary of the legislative restrictions/obligations pertaining to this event. This section also highlights some of the ambiguities contained within the regulations and orders. However what is glaringly obvious is if you try to differentiate between different levels of operation (i.e. charter vs airwork) as acceptable minimum standards of safety for a particular operation there is no incentive for an operator to strive for a higher standard i.e. the minimum requirements will do.

Section 1.18.5.4 deals the PIC deficiencies in knowledge, skill and competency:

Note: It is interesting to note that all of these so-called deficiencies could and should have been picked up and addressed by an effective, robust Training and Checking department. But again the investigators focus solely on the PIC and his apparent deficiencies.

Excerpt from section 1.18.5.4:

8 Summary from section 1.18.5.4:

Section 2.0 is the investigator’s analysis:

This section gives the investigator’s short analysis of this event and has various sub-headings including 2.1 ‘The Captain’ and 2.2 ‘The Company’. What stands out is there is no mention of the First Officer or indeed the medical crew, both of which could have been potential risk mitigators in this event but weren’t.

The following paragraphs from the CASA investigation report appears to be in direct conflict with the findings from the CASA special audit:

The following paragraph appears to show a very submissive approach to the glaring deficiencies highlighted in the CASA special audit report:

Section 2.3 Causal Factors page 33:

The following list of causal factors seems to be limited or cautionary in the area of ‘task or operating environment’ i.e. the operator. It is also interesting to note that the crew causal factors can be quite obviously also be attributed to a poor TCS culture, a poor Multi-crew (CRM) disciplined environment and poor operational support to a tasked crew. These are all Operator/AOC holder responsibilities and therefore should be highlighted as such:

9 Section 3.0 deals with the ‘Conclusion’ and ‘Findings’:

Section 4.0 deals with the safety/enforcement actions:

The following is a list of the ‘Safety Actions’ enforced by CASA, again it is very devoid of ‘actions’ perpetrated on the Operator. It would appear that CASA was very reluctant to ‘show cause’ on the Operator, maybe this was because it could highlight that CASA was also deficient in it’s oversight of this AOC holder?

11 END