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An Inspector Pel Mystery -When Chief Inspector Pel accepts a drinks invitation at the house of a big shot, Deputy Claude Barclay, he doesn't realise how.
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Dom is making a number of these decisions at a critical time: the afternoon window of circadian low WOCL — a fancy name for that time later in the afternoon where your body experiences a natural degradation in performance. At this time, Dom also makes a decision that is not consistent with his normal thought processes: he only fills up the main fuel tanks but not the tip tanks.
AA archive. The crew conducts a combined brief, loads the patient and her husband into the aircraft and departs for Norfolk Island. There remains another layer of Swiss cheese that further exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all. This, combined with the relaxed and inconsistent company-wide approach to fuel planning, means a number of critical decision gates have been missed, exacerbated by lax regulatory oversight. Many factors have now combined to set this crew on a doomed path and one that will expose them to outcomes they will carry with them for the rest of their lives.
These are the random thoughts facing the crew. Yet right now, the pilots are solely focused on landing a small jet onto the ocean. Where did this weather come from — the forecast looked good when we left? What did I miss? How could this happen? From a human performance perspective, it would be ideal to still be under the influence of the parasympathetic nervous system PNS , which for most parts of this flight has been responsible for sitting back, comfortable, warm, sometimes bored, but mostly helping keep the body in a relaxed state storing energy as the aircraft cruises towards Norfolk Island.
His bronchial tubes within his lungs and his heart vessels have dilated, allowing more oxygen to flow around the body and tensing his muscles. With about three-and-a-half hours of broken sleep, Dom should be experiencing a response similar to combat veterans, such as stress diarrhoea or loss of fine motor control. File image of a Westwind night flight. No time for other random thoughts. Concentrating, time feels like it has slowed down, and Dom can clearly hear the first officer calling the altitude to the water. The aircraft is around ft above the water and the first officer instructs the passengers to brace.
Below ft the aircraft is established in a stable descent and airspeed, a pretty impressive outcome under such trying conditions. For many this stress would cause fixation and loss of fine motor skills.
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Yet Dom has airspeed almost constant, at a constant rate of descent, 80ft to go descent stabilised at ft per minute, airspeed kt ; 50ft to go airspeed kt and decreasing ; the first officer calling out the final descent heights, 40ft, 30ft, 10ft …. Landing on water at such speeds is like landing on concrete, but somehow the aircraft is still right side up.
The fuselage separates into two sections soon after coming to a stop, with the tail section afloat. The primary sound is water flowing very quickly into the aircraft. Fight and flight drugs are still pumping through the bodies of the crew.
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And for the patient — at one stage happily on her way to a medical facility — strapped on a bed, unable to release herself, in an aircraft sitting on the ocean and flooding with water; her stress and panic is likely unbearable. Right now, in a small aircraft cabin quickly filling with water, with a sick patient strapped to the medical bed, Karen, briefly knocked unconscious, has opened her eyes with water already half way up her shins.
She feels no pain due to her own release of fight and flight chemicals , allowing her to immediately collect her thoughts and respond with the flight doctor to get the patient and her husband out of the aircraft. The severe impact has torn muscles and nerves that will result in lifelong damage and severe pain for Karen.
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Dom has already reacted instinctively and exited the rear door, which has been partially damaged by the impact and is also flooding with water. The first officer, initially knocked unconscious, has also quickly recovered and is the last to leave the aircraft. Six people are now out of the aircraft, all huddled together and a few miles off the coast of Norfolk Island.
Reality will set in not long after the rescue boat picks them out of the water. This aerodrome operator contacted the Norfolk Island emergency services coordinator ESC to advise him of the situation, who then called out the other members of the airport rescue and firefighting services, including coordination to contact the owners of two fishing charter vessels that could be used for a search.
One of the firefighters responding to the call-out elected to travel via some cliffs west of the airport. He stopped his vehicle to check the sea to the west of the island, believing that it was possible the aircraft had ditched there.
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After looking for a few minutes, he was convinced the light was real and at about This initial information was critical and helped deliver a quick response. At about Interestingly, Norfolk Island locals had recently completed emergency response scenario training, further enabling them to respond quickly and efficiently.
So where were you on Thursday 19 November when the news broke across the country that an Australian aircraft had ditched into the ocean off Norfolk Island? When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills? In this case, Dom had to make small and fine inputs to aircraft controls one- or two-degree changes in pitch and power. He had to almost subconsciously control the fine line between muscle tension that could cause paralysis and a complete loss of control.
I know personally, having flown aircraft to Norfolk Island many times, that my first thoughts were very critical of the organisation and the pilots. Like thousands of aviation professionals within corporate culture, Dom was doing the best he could aligned to the normal practices, and positive reinforcement, of more senior pilots around him. Certainly, Dom accepts he could and should have done some things differently.
The combination of bias and strong egos can adversely influence an aviation accident investigation, ultimately leading to breakdowns in communication, assumptions, inadequate collection of critical investigation evidence and, in the worst case, a re-write of a preliminary investigation to align with possible political agendas this will never be proven. This only makes the suffering worse for survivors and destroys the careers of seasoned and competent ATSB investigators.
For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents — that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Most importantly, getting to the cause of what happened and implementing processes to address these is vital for the crew, the passengers, and their families and friends, to get some closure.
No surprises but there is talk of a future movie based on this scenario.
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If you thought the movie Sully the story about the ditching on the Hudson River was interesting, some of that content was not factual but rather Hollywood hype. Our local version has the trademarks of a great documentary, including extracts such as the following made by the Transport Safety Board of Canada after completing an independent review of the ATSB:.
So why should you trust my interpretation of the events in a series of upcoming articles? First and foremost, I have one strong belief: we all need a better balance around organisational issues and pilot culpability to genuinely learn some lessons from this accident.
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If nothing else, the survivors deserve a more balanced understanding as to what caused this accident. In the most tragic of circumstances, the patient, suffering heavily from post-traumatic stress disorder and fighting for basic medical compensation, lost her will to fight and lost her life to an overdose in February Dom and Karen are continuing to battle with a basic need to feel the system has learnt lessons from the tragedy. Just a glimmer of hope will help them get on with their lives and to feel the real story is known.
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