In the drink

James’ pilot’s licence was suspended pending an investigation. Two passengers aboard the flight disputed operator Pel

Air’s description of a controlled ditching, describing the incident as a “bloody plane crash” and blaming James for failing to carry enough fuel.

That verdict – though much expanded upon – was essentially confirmed on August 30 with the release of the ATSB’s final report on the ditching. Focusing on the pilots, the ATSB said the Pel-Air crew had failed to make an adequate flightplan, didn’t carry enough fuel for an emergency, didn’t have a current weather forecast before deciding to fly on to Norfolk Island, and didn’t tell air traffic controllers where they were ditching the plane.

But if the ATSB’s thorough investigations typically provide the last word on air accidents, that hasn’t proven to be the case this time. Just after the report was released, ABC TV’s Four Corners aired an investigation raising serious questions about CASA’s oversight of Pel-Air and, by extension, the integrity of the ATSB’s findings. In a special audit of Pel-Air’s operations following the ditching, Four Corners revealed CASA had found the Regional Express subsidiary in breach of 20 different civil aviation regulations. Yet none of that turned up in the ATSB report placing full blame on the crew.

The deficiencies turned up by the CASA audit of Pel-Air make for uncomfortable reading. CASA cited Pel-Air’s “inadequate

fuel policy” for Westwind aircraft and said Pel-Air pilots “use their own planning tools” with “no control exercised by Pel-Air Aviation Pty Ltd to ensure the fuel figures entered are valid. ” The list goes on: Pel-Air had no policy to ensure cross-checking of flight and fuel plans, no specified alternate requirements for remote area and island operations, no specified criteria to obtain weather updates, and no operational decision-making tools to support crew in balancing aviation and medical tasks.

The operator did not provide domestic charts for its pilots or ensure that pilots maintained a complete and current set, did not maintain required flight records and in many cases provided inadequate flight preparation time.

In sum, according to CASA: “The special audit identified significant deficiencies within the Westwind operations in Pel-Air.

These deficiencies existed and had not been identified or rectified which is indicative of broader organisational failures. The company’s executive management relied upon the Westwind standards manager to apply company policy and procedures to ensure the standard of operations were conducted to the appropriate regulatory and safety levels. It was evident that this had not taken place to the regulatory or safety standard required. ” That damning conclusion raises serious questions both about the ATSB report and CASA’s oversight of Pel-Air. First, why wasn’t information from the CASA audit included in the ATSB’s final report, which instead focused on crew errors? The answer, ATSB chief commissioner Martin Dolan told the ABC, is that the deficiencies identified by the audit weren’t judged to have contributed to the Pel-Air ditching.

That may be so, but given the close correlation between the audit’s findings and the circumstance of the ditching – particularly with regard to inadequate fuel planning and inaccurate weather forecasts – the audit would seem at minimum to provide some highly relevant context.

It also points to a larger question – why didn’t CASA make the audit’s findings in some way public before they were obtained by the ABC? Surely clients might have had some interest in the “broader organisational failure” indicated by the audit’s findings.

This also leads one to wonder how Pel-Air could have ended up so far afoul without having previously attracted CASA enforcement action. If previous CASA audits of Pel-Air didn’t turn up the “organisational failure” identified in the special audit – as appears to have been the case – why not? With all this in mind, it doesn’t take much of a conspiracy theorist to start putting the pieces together. By placing blame for the incident on the pilot – and by not revealing the extent of Pel-Air’s organisational safety breaches – has the ATSB distracted attention from a history of inadequate oversight by CASA? As has been noted, these are questions we are fortunate to be asking in the context of an aeromedical ditching that cost no-one their lives. But if the ATSB’s report was designed to provide the final word, in this case it appears to have raised more questions than it has answered.

THE PILOT’S PERSPECTIVE Even if it wasn’t with his dream employer, Dominic James had his dream job.

“It was superb,” James says. “We flew these beautiful jets to these amazing, exotic locations. We were landing on grass runways, on crushed coral. We absolutely loved what we did. ” But it all came crashing down around him on November 18 2009, when he piloted the Pel-Air ditching off Norfolk Island. Actually, it didn’t all come crashing down exactly then – everyone survived the ditching, and James was briefly hailed as a hero – but it all came crashing down soon enough.

First, CASA suspended his pilot’s licence as it investigated the accident, a fact that quickly leaked to the news media – despite, James says, only he, his lawyer and CASA

VH-NGA (title pic & above) File images of the ill-fated Westwind.

knowing about the suspension.

“I know I didn’t go to the media about it and I know my lawyer didn’t,” James says.

From that moment, James says, he realised the blame for the crash was going to fall on him. “It was pretty horrific because I was dealing with CASA being fairly vindictive without any appreciation of what type of flying we were doing,” he says. “It became very punitive and personal. ” As he sees it now, CASA’s decision to come down on him stemmed from a thenongoing audit of the Australian air safety regulator by the US FAA. CASA had failed a preliminary audit required to maintain its top tier status under the International Civil Aviation Organisation. According to US law, failing the final audit would have left Australian flag carriers facing severe restriction on their operations to and from the United States.

CASA would go on to pass the final audit the following year, but that was still an open question when James’ Westwind went down off Norfolk Island.

“At the same time that they had to deal with the FAA, they had this Pel-Air audit,” James says, referring to CASA’s special audit of the aeromedical operator that turned up a litany of problems with PelAir’s operations. “They could not possibly have had a worse thing in their hands than that audit, because there was no way they could be critical of Pel-Air without raising questions about their oversight. ” Thus, James says, CASA decided not to blame Pel-Air, but to blame him – a decision reflected in the ATSB report released on August 30. “The ATSB just took all of CASA’s information and relied on that,” he says. “You won’t find any criticism of CASA by the ATSB. They’re wholly in lock-step. ” James also says pilots were becoming disgruntled with Pel-Air at the time of the incident and had formed “a sort of mini-union” to express their concerns over work conditions.

This was not received well by the operator. In the aftermath of the ditching, he says, Pel-Air essentially broke contact with him.

“They never sacked me, they just left me to wither on the vine for a few months,” he says. “Their attitude is that they don’t return phone calls and don’t respond to summons letters. They don’t want to know, don’t want to deal with it. They weren’t interested. ” As for his own regrets, James acknowledges that he likely missed a weather report prior to heading for Norfolk, though he questions why the report he had was so badly incorrect and why none of the air traffic controllers tracking his flight warned him of the storm. “If a missed weather report is all it takes to create an accident, then something is wrong with the system,” he says.

Another regret: having agreed to take part in Cleo’s Bachelor of the Year contest earlier in 2009, a star turn for which he would later be panned as a “glamour pilot. ” James says he agreed to the photo only under “persistent pressure” from a friend in the publishing industry.

“I did it as a bit of fun,” he says. “I felt fairly uncomfortable with it at the time, and in the end it made me look like a f-wit. ” James has since returned to flying for another charter company and has stayed quiet about the ditching – due, he says to a gag order. But he’s got plenty to say now, and with questions still swirling around the incident, he’s likely to have many opportunities to say it.

“I just want a fair accounting,” he says. “If CASA can’t surveil an operator and keep them on the straight and narrow, then what does that say about them as a regulator?”