If you talk to someone who's been involved in a serious aircraft accident long enough, they'll eventually get around to two things: The accident constantly intrudes in the daily thought process and any external description of itan official accident report or news reportswon't ring quite true. Experiencing something so traumatic isn't the same as reading someone reporting it.
I thought of that when I interviewed Dominic James over the weekend. James was the Captain on that Westwind that ditched off Norfolk Island on November 18, 2009. At the time, I blogged that the accident report on this one is going to be interesting. Now that the report is complete, I got what I wished for. It's interesting alright, but for the wrong reasons. This accident appears to be a classic example of the linked chain, but the ATSB's report simply ignores many of the links, speeding apace to its conclusion: The crew was responsible.
And so it was. The flight crewJames and First Officer Zoe Cupithad the final vote and sole ability to sunder the accident chain. They failed to do that, but the report itself fails to explain that in some ways, the company, the system and CASA set James up for an accident and left him to his command authority to avoid it. When a perfectly competent pilot throws away a perfectly good airplane, it's often the result of a mindset patterned by past success and both external and internal pressures. This accident seemed to have all of that. As we reported in today's news, James is challenging the ATSB report and an Australian Senate hearing on it is planned for early next month. He says he's not ducking fault or responsibility, but believes the report simply doesn't give an accurate picture of all the factors involved in the accident.
To refresh, the flight was a Westwind medevac mission with a stable patient from Apia, Samoa to Melbourne, Australia. To save you the trouble of hauling out your atlas, that's some 2800-nautical miles, almost all of it over water. It's the distance from New York to Los Angeles, plus another 700 miles. Norfolk Island was the planned fuel stop, a distance of 1600 miles. James said the Westwind had the legs for trips like this, but only if everything went to plan.
For James and Cupit, it didn't. With good VFR forecast for Norfolk, neither the company's policy nor Australian regulation required a named alternate, so none was contemplated. In any event, it's doubtful that one could have been reached. The closest was Noumea in New Caledonia, 400 miles north of Norfolk Island. The Westwind departed with 83 percent of full fuel; mains full, tips empty. Even with the tip fuel, Noumea was unlikely, given the fuel required for climb. When the weather tanked at Norfolk, the crew had no option other than to land there. It couldn't and ditching was the only survivable option other than a desperation, homemade, below-minimums approach. The airplane simply lacked the capability to do the trip with contingency fuel.
The number of links in this accident chain not covered in the ATSB report are too numerous to cover here. But as James explains it, they're obvious to him in retrospect. In hindsight, it is clear how this chain of events led him to the decisions he made. On a previous trip, James had been told Norfolk's automated weather reports were notoriously pessimistic and forecasts for the island were iffy. Other similar aircraft routinely made such trips with no drama, despite Norfolk's exceptional remoteness. Pel-Air seemed to have a loose relationship with regulatory adherence and CASA failed to oversee the company aggressively, as evidenced by an internal report only recently made public. ATSB never mentioned this report.
Pel-Air airplanes routinely operated in or through RVSM airspace, but the Westwind wasn't RVSM equipped, according to James. Controllers would give the flight a bye on RVSM if they could climb to FL390, which the Westwind could do only if light, thus the decision to leave tip fuel behind. Noumea was potentially a paper alternate, but James said the local authorities there didn't want Pel-Air airplanes arriving because they lacked TCAS II and GPWS, not to mention RVSM. The accident airplane had just had TCAS and GPWS installed, but James and Cupit had never seen it and hadn't been trained in its use.
The ATSB made a great deal of discussing James' fuel planning, especially the oceanic technique that routinely requires points of no return and/or critical points, which are continuation decision thresholds when few or no alternates are available. The ATSB conceded that based on the forecast, an alternate wasn't required and that the crew had enough fuel for a flight that proceeded normally, but no contingency for a de-pressurization event that would force the airplane to lower, less fuel-efficient altitudes. If the drift down happens in the wrong place, the range can dwindle to the point of neither being able to return to the departure nor reach an alternate. James insists his fuel load covered this and when he asked the ATSB for its fuel calcs, they declined the request. He had the data reviewed independently to confirm his calculations.
Even with the good forecast, James got an updated METAR for Norfolk from Fiji ATC. The controller misstated the ceiling as 6000 feet rather than 600 feet. A later corrected METAR relayed via HF was garbled in poor atmospherics at dusk. James couldn't explain why he didn't receive it, but he knows he didn't. Fiji refused to release the audio tape of the transmission. "There's no way you sit on your hands for an hour after getting a METAR like that," James said. "You'd have to be a suicidal maniac."
That missed METAR may have been the final or most critical link in the accident chain. Once the Westwind passed Fiji, it was committed to Norfolk, save for a brief diversionary window to Noumea. I like to think if I'd been in that cockpit, I'd have surely had the threat and error management thing going on and would have diverted sooner, just as any competent pilot should. Maybe you think the same thing. The reality is that given the circumstances, I can imagine myself being sucked down the same dark hole James and Cupit found themselves in. For me, personally, that's a creepy truth, but a truth nonetheless.
Later in the week, I'll take a look at another accident that is eerily similar to this one. It occurred 42 years ago in the Caribbean.
Link to the ATSB report. (PDF)