An aviation researcher, writer, aviation participant, pilot & agricultural researcher. Author of over 35 scientific publications world wide.


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PelAir and adjacent History

PelAir and adjacent History:

AVWEB has a couple of incicive reports in it’s pages [reproduced below] that are well worth a further read in light of the Supreme Court hearings this week [6th February 2015].

The early reports and press releases at the time, said that the six occupants escaped without injury. The Supreme Court hearing tells us a completely different story, with the flight nurse in fact suffering injuries to the point where, not only will she not work again, but has not worked since  November 2009. The Doctor was a little more fortunate, only having his earning capacity seriously compromised, but within 20 years will be seriously compromised in his ability to work a full work load as a specialist. He is likely to forced into retirement ten years early.

Not a good outcome for a flight which was transporting a patient and her husband from Samoa to Melbourne: With the ditching occurring at a point for a routine fuel stop. The later inquiry, raised serious doubts in the Senate [not by the investigator – ATSB] inquiry as to whether the flight ever recieved a warning [or whether it was given] on deteriorating weather. The weather issued for the stop initially would not have alerted the flight of any weather issues that were up-coming.

Paul Bertolli says:

“….the regulations and op specs—was functionally non-existent, which is the core of the scandal here, in the Senate’s reasoning. The Civil Aviation Safety Authority knew all this because it had investigated Pel-Air in depth. Yet it scape-goated pilot error as the primary cause of the accident.

The pilot was hardly blameless; you can decide for yourself how to apportion responsibility. As is the case with so much in flying, survival—or at least accident avoidance—turns on pilot instincts and skills and all the regulations and cockpit gadgets do is provide entertaining diversion and, okay, some helpful data. If all that stuff fails to keep you from extremis in the first place, you fall back on your lowest level of training and hope it’s high enough….”

Interference with the ATSB investigation by the Regulator [CASA], still raises the hackles of the Aviation industry as a whole. This was to the extent that nearly 250 people made individual submissions to the following Forsyth inquiry [ASRR]. These submissions were less than complimentary of both CASA and the ATSB.

CASA probably fared worse, but seems to be “fighting back” to regain it’s previous situation.

This is of great concern and the compromising of the new CEO Skidmore is of great concern.

The following are from AVWEB:


Australian Senate: Norfolk Island Crash Investigation Could Lead To Criminal Probe

In a scathingly critical report (PDF) of Australian safety investigators and regulators, the Australian Senate last week found that an investigation into the 2009 ditching of a medical evacuation flight off Norfolk Island was so incompetently handled that it could be referred to authorities for criminal prosecution. The Senate investigation, which began last September, found that during the crash investigation, Australia’s Civil Aviation Safety Authority failed to provide the Australian Transport Safety Board with critical documents and findings concerning the Pel-Air ditching. That information would have revealed, according to the Senate probe, that CASA knew of ongoing systemic shortcomings in Pel-Air’s operation that directly contributed to the accident. CASA’s action, says the Senate report, may have violated Australia’s Transport Safety Investigations Act. “It could be seen as a breach of the Transport Safety Act in terms of obstructing an investigation,” said Sen. David Fawcett.

The accident occurred in November 2009 when the twin-engine Westwind ditched off Norfolk Island en route from Samoa with a critical but stable patient. The Westwind’s ultimate destination was Melbourne, with a scheduled fuel stop in Norfolk Island. The flight’s captain, Dominic James, departed with legally sufficient fuel into a forecast of good VFR. En route, the Norfolk Island weather tanked and after three unsuccessful approach attempts, James ditched the Westwind near the island. All six aboard survived, albeit some with injuries. The ATSB’s accident investigation, which took some 1000 days to complete, faulted the crew for not planning the flight in accordance with Australian regulation and Pel-Air operations specifications. It blamed James for not aggressively seeking updated weather reports and for failing to divert to Noumea, New Caledonia, which the Westwind initially had fuel to do.

Following the ATSB’s findings, James challenged some of the investigator’s findings but his queries were dismissed by the ATSB. The Australian Senate took up James’ case last year and its probe revealed widespread flaws in the ATSB’s investigatory work. Among numerous findings by the Senate was a report on a CASA review of Pel-Air that “unequivocally concluded … that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention strategies.” Yet no mention of this report appeared in the ATSB’s findings blaming the pilot. “In other words, Pel-Air was lacking, CASA’s oversight of Pel-Air was lacking, and the accident occurred in an environment of serious aviation safety deficiencies,” the Senate report said.

Although the Senate investigation stops short of saying the ATSB and CASA colluded to suppress information, it does conclude that the two agencies narrowed the accident investigation focus in a way that excluded larger safety issues. “This inquiry has shaken my confidence in the CASA and the ATSB to the core. I no longer have confidence in them. That’s why I think we need an inspector general of aviation,” Sen. Nick Xenophone told Australia’s ABC News. “This goes beyond Dominic James, which I regard and many regard as a scapegoat for the failings of CASA and the ATSB,” he added.

The Senate report makes numerous recommendations to improve the ATSB investigation process, ranging from additional training for investigators, to requiring the ATSB’s chief commissioner to have extensive aviation safety experience, to establishing an oversight board for investigations. In one of its sub-conclusion, the Senate pulled no punches in criticizing CASA. “CASA’s internal reports indicate that the deficiencies identified would have had an effect on the outcome of the accident in several areas. It is inexplicable therefore that CASA should so strongly and publicly reject witnesses’ evidence that they did not think surveillance was adequate, when CASA’s own internal investigations indicate that CASA’s oversight was inadequate,” the report said.


Accidents: The Pilot as Last Defense

For a number of months now, I’ve been reporting on the November 2009 Norfolk Island ditching of a Westwind jet. The Australian Transportation Safety Board’s investigation of this accident has been widely regarded as a mess, criticized equally by the Australian pilot community, the press and lately, by the country’s Senate. As we reported over the weekend, the ATSB’s report (PDF) was cited for numerous omissions related to how regulators oversaw Pel-Air, the company that owned the Westwind.

Thorough as the Senate report is, I found one phrase in it that suggests it wasn’t written by pilots. Or maybe by pilots with a different view of PIC responsibility than I have. In citing numerous deficiencies in how regulators oversaw Pel-Air, the report said these failings left the pilot “as the last line of defense against an accident.”

I found this utterly jarring and the report repeated it several times. The gist of it is this: It’s the regulations and operations specs that make flying safe, the pilot is only there if those don’t cover all exigencies or novel situations otherwise arise. It’s not quite the dog-and-autopilot concept, but it’s close. To a degree, it’s a semantical distinction, but an important one, nonetheless. To take it to an extreme, when you put on your PIC hat, you are the first thing and the only thing between you and your passengers and an accident—not instruments, not traffic boxes, neither radar nor datalink weather, GPWS, glass panels or BRS parachutes or ATC. And definitely not regulations and ops specs, although they undeniably play a critical role in safety.

Those things provide a basic structure by which to frame decisionmaking, yet they don’t help with the novel situations which are perfectly legal, but, if not entirely unsafe, are only safe with no margins worthy of the name. The Pel-Air flight fit that latter description to a T. Given the weather forecast, fuel loads and distance, it was legally dispatched to a remote island with notoriously difficult-to-forecast weather, at night, with the closest airport some 400 miles away and hopelessly beyond fuel range. There was no legal requirement for an alternate, thus one wasn’t filed or planned. The pilot had little or no dispatch support from his company and the weather reporting system was sketchy at best.

So at the outset, what the Senate calls the first line of defense—the regulations and op specs—was functionally non-existent, which is the core of the scandal here, in the Senate’s reasoning. The Civil Aviation Safety Authority knew all this because it had investigated Pel-Air in depth. Yet it scape-goated pilot error as the primary cause of the accident. The pilot was hardly blameless; you can decide for yourself how to apportion responsibility. As is the case with so much in flying, survival—or at least accident avoidance—turns on pilot instincts and skills and all the regulations and cockpit gadgets do is provide entertaining diversion and, okay, some helpful data. If all that stuff fails to keep you from extremis in the first place, you fall back on your lowest level of training and hope it’s high enough.

What informs the skill and instincts in part is knowledge of previous accidents. That’s where many regulations come from, too. It’s no exaggeration to say the rules were written in blood. Systemic safety evolves from unbiased understanding of accident causes and on this point, the ATSB dragged the entire safety edifice backwards. In blaming the pilot for the accident, it failed to account for known failings in CASA’s oversight that, in an ideal world, might have shaped or at least informed his judgment or simply flat-out prohibited the flight in equipment suited to the task only if everything went just right but profoundly inadequate if it didn’t. This kind of flawed accident investigation sows mistrust and is an absolute menace to advancing safety based on documented experience.

I suspect the Australians will have their hands full fixing this because the Senate report gives the impression that it’s a cultural shortcoming within the agencies themselves. At least the investigation into the investigation gives them a good start.

Comments (19)

This actually folds quite well into Mary Grady’s most recent article about the lack of enthusiasm in the pilot community. Now agencies and governments view pilots as a problem and see automation and more regulation as a solution. It’s chilling to think that indeed everyone IS out to get you if you exercise your own best judgement in a situation.

Posted by: Mark Fraser | May 28, 2013 9:17 PM    Report this comment

Seems the Senate are keen to take the pilot out of the cockpit but find they cant because the pilot is “the last line of defense against an accident.”!

A question during the UK Morning Breakfast was would you fly in an airplane knowing there is no pilot? The consensus was that only about 10% might.

Posted by: Bruce Savage | May 29, 2013 4:23 AM    Report this comment

I wouldn’t get too excited about Paul’s take on things “first and only” in this context. As a pilot, I know, absolutely and without any damage to my ego, that I am the last line of defence against an accident. In the world of risk management and defences/mitigators in depth, the final step in the chain of things that can change an outcome is me.

In the case at hand, everything that prepared the ground for that flight failed to identify and mitigate the risks. When the pilot launched, he launched in ignorance of the risks that he was facing and without the situational awareness to change the outcome. How did he get that way – the system failed him.

There is absolutely nothing, repeat nothing, in that report that comes close to justifying any thoughts of “agencies and governments view pilots as a problem” or that anybody is “keen to take the pilot out of the cockpit”.

Posted by: Dick MacKerras | May 29, 2013 6:23 AM    Report this comment

“I wouldn’t get too excited about Paul’s take on things “first and only” in this context. As a pilot, I know, absolutely and without any damage to my ego, that I am the last line of defence against an accident.”

I guess that somewhat depends on the type of operation at hand. In Part 91, I’m certainly the first line of defense, since I’m the only one who makes the decision to go or not to go. I don’t have a dispatch department planning my route of flight and checking the weather, so that’s up to me. I also don’t have a maintenance department telling me if the aircraft is legally ready to fly, or ops specs saying, for example, that I can’t fly SPIFR if the autopilot is down.

As for commercial flights, sure, one can argue that maybe the pilot really is the last, rather than first, line of defense.

Posted by: Gary Baluha | May 29, 2013 9:25 AM    Report this comment

This really is a semantic argument if we want to make it one. Let’s just not do it.

What I hear Paul saying is that we need to guard against bureaucracies getting the idea that their regulations can create safety in spite of the pilot rather than by supporting the pilot. Certainly, there has to be some regulations discouraging bad behavior and undue risk taking by everyone involved. However, the focus needs to be on creating a framework that helps everyone, primarily the pilot, maintain safe operations.

The FAA seems to have been going the wrong direction for a while now, but that seems to be a trend of all bureaucracies.

Posted by: Eric Warren | May 29, 2013 10:32 AM    Report this comment

Paul, I am not able to rise to state of indignance over the wording ’The Pilot as Last Defense’. Perhaps it’s that English takes on many forms; UK, US, & AU. However, my Safety background supports the Senates lead to address the weaknesses in the ATSB accident assessment. The Senate document reads like the ‘Challenger’ accident report where systemic issues were investigated and addressed in detail, while the technical cause of the accident was clear. In this investigation, the choice to launch or not is the Pilot’s responsibility. Having read previous accounts of the flight, the pilot’s focused attention to the destination prevented planning for alternate destinations or decision / turn around points. There existed a longer, northerly route that could have been chosen as well. HIS SINGLE CHOICE ALONE led to the concluding circumstance. However, the other contributing factors of poor weather service, poor communications, bad or no information at departure are systemic elements that can be improved via the implementation of improved services. These were missed by ATSB. Last year, there were no fatal accidents by US carrier service. It is because the NTSB / FAA identified and addressed the systemic issues that were the major risk factors which caused major accidents. I comment all the efforts of these organizations for these significant improvements.

Posted by: PHILIP POTTS | May 29, 2013 4:02 PM    Report this comment

Paul, you’re great, but you’re being a bit sensitive here.

There was an accident chain. There were people and processes in that chain, other than the pilot and flight crew and their processes. If those other people and processes (the “system”) had performed their advertised function, the accident might have been averted. The Senate is asking why that did not happen – especially reasonable since the “system” is expensive to operate.

The Senate is working with the given fact that the pilot was the last line of defense, and failed to prevent the accident. It is not calling for the system to replace the pilot, or have precedence over the pilot. It is simply recognizing that, in this particular accident chain, knowing that the pilot failed to prevent the accident, there may have been other opportunities to prevent it, and is asking why the investigation did not look for those, but simply blamed the pilot.

Pilots place reliance on others – from the designer to the dispatcher and ATC – when operating their aircraft, and it in no way dis-empowers the pilot, to ask whether those others could have done better. For example, if an aircraft had a mechanical failure that rendered it difficult – but possible – to control, the pilot would be the last line of defense. But, if the pilot should fail to prevent the crash, I think people would ask about the design, manufacture and maintenance of the aircraft.

Posted by: Thomas Boyle | May 29, 2013 4:07 PM    Report this comment

I agree with Paul on this. Most non-flyers think that ATC is virtually “controlling” us at all times and we are just along for the ride. It’s not surprising that bureaucrats (probably non-pilots) think the same or even worse.

Barry Schiff was writing in his recent Pilot column about the day when pilots are no longer needed. He said the crew will be a Pilot and a Dog. The Dog’s job will be to bite the Pilot if the Pilot ever tries to touch the controls! I’m sure the pilot will be blamed in this case as well 🙂

Posted by: A Richie | May 29, 2013 4:28 PM    Report this comment

I think it is reasonable to protect a commercial pilot with rules that minimise risk. Otherwise employer pressure may cause him to take chances he really should not take.

That said, US readers should understand the broken nature of Australian Aviation regulation and regulators. At last someone is taking these people to task over their actions or lack thereof. The ATSB, unlike the NTSB, does not investigate all aircraft accidents. They have a certain budget and start at international airlines and work down from there. They run out somewhere around the top end of private operation, if we’re lucky. Sport aviation is ignored beyond a mention in the accident summaries by the ATSB. Sport aviation in Australia is in a situation where CASA delegates to various private bodies(10 at last count), the administration of their activities while claiming the right to set the rules. In reality there is little oversight and some of the bodies work reasonably well, while others like the body “running” soaring, the Gliding Federation of Australia may do internal accident investigation but don’t ever release the results to Australian soaring pilots. So the unnecessary carnage continues with many accidents and fatalities where an “instructor” is on board. I know several Australian soaring pilots who also professional pilots who would not let their sons/daughters/loved ones learn to fly in the Australian gliding system.

Posted by: Mike Borgelt | May 29, 2013 6:02 PM    Report this comment

Well written article, which points to the real problems that face Australian aviation, with a run-away regulator and a safety investigator who has been influenced by the regulator.

Surveillance of operators and approval by the regulator [CASA] of operations, with known issues has been going on for some time. The most notable is the TransAir [may 2005], Lockhart River metro crash with 15 fatalities. At other times, the investigator [ATSB] – Whyalla, just got it wrong. And unfortunately, there are others.

Well done the Australian senate inquiry for getting on with the job and working to the bottom of this one.

Posted by: R advocate | May 30, 2013 5:13 AM    Report this comment

It is not just the folks involved in this report who are leaning toward airplanes where the pilot is replaced by computer systems. Many young people think computers are more reliable than people and hope the day will arrive soon where computers fly the airplanes instead of pilots. I guess this is all part of the insanity found in current academia that is quick to adopt future thinking without the required testing and validation.

We saw in the Air France disaster what happens when even two complete air crews don’t include anyone who can fly an Airbus without the automation online. This should warn everyone who is not living in a sci-fi movie that the notion of pilotless airliners is faulty. How many more full planes must we lose before the general public discovers pilots will always do a better and safer job flying planes than even the smartest electronics?

Posted by: PAUL MULWITZ | May 30, 2013 6:32 AM    Report this comment

To Mr. Mulwitz:

Paul – politely – you have no idea what comprises “insanity.” What you fail – or refuse – to consider is that the Airbus technology in question is fatally flawed BECAUSE it attempts to introduce humans into the control loop. (Of course, I could go off on never wanting to hear the words “French” and “software” in the same sentence, but let’s stay focused here.)

When designing an autonomous control system (call it an “un-tended” system if it makes you feel better), no account is made for human intervention – because it is precluded. Believe it or not, that makes the design job easier and increases the chance of success. (Full disclosure: I’ve spent a great deal of my 4-decade-plus engineering career designing autonomous control systems for mission-critical applications. In this case, MC means that if the control system fails, somebody is likely to die.)

In the Airbus incident, the software did what it was designed to do – and the entire aircrew screwed up. Bad software? Well, to the extent that the design of the software includes intentional “You’ve got its” to the crew, yes – THAT’s bad software. But that’s what they were told to design.

A well-designed autonomous control system (that’s not an oxymoron) will provide a huge increase in reliability and safety. It also will offend some human egos. But it will be shameful if we let anthropomorphic hubris shunt aside science in a fit of denial.

Posted by: Tom Yarsley | May 30, 2013 7:03 AM    Report this comment

Mr. Yarsley,

I’m afraid you misinterpreted my comment. I never suggested there was a design flaw in the Airbus software. Indeed I believe it was a hardware failure (icing of all the pitot tubes) that led to the fatal accident.

I too spent many years designing both hardware and software for fault tolerant environments. In my case it was mostly communications gear rather than life threatening applications such as the ones you engineered.

Airbus design philosophy puts the pilot in the background and expects the planes to always be flown by the automation. This works just fine until the automation fails. The pilots SHOULD have been able to fly the plane satisfactorily with no automation, but in the dark of night and middle of a thunderstorm and no usable airspeed indications they all failed to notice that the plane was stalled. I understand other crews handled the same scenario just fine in simulators.

My point was to suggest pilots cannot be completely replaced by automation. I have no problem with Boeing’s approach which is to consider the PIC to be the primary source of control and the automation to be there to assist him.

I’m glad I don’t travel on routes where only Airbus equipment is used. I don’t feel their approach is safe enough for use by the general public.

Posted by: PAUL MULWITZ | May 30, 2013 7:25 AM    Report this comment

Mr. Mulwitz:

We agree about Airbus technology. And we disagree about the prudence of fielding autonomous control systems in aircraft. Criticisms of autonomous systems are fine – as long as they don’t use the shortcomings of non-autonomous systems (like Airbus’) as their foundation. Such comparisons simply are not valid.

With regard to the failure mode of the Airbus system, I do consider that to have been the result of flawed software design. In a properly-designed system, critical information is derived from multiple sources – and those sources always are different in kind, rather than merely being redundant in count. A well-designed control system would include real-time calculation of groundspeed, based on data provided from disparate sources, and cross-checked for “sanity.” Concurrent variance of airspeed and groundspeed also would be derived. Coupled with sanity-checked derivable heading and altitude data, the control system would have all of the information that it needs to provide usable (that’s the key criterion) airspeed and AOA information – even in the absence of any pitot-static information. In short, that airplane had access to more than enough valid information to determine its airspeed well enough to keep flying safely with its pitot tubes iced over. It just wasn’t designed to use that information or to share it with the flight crew. Call me hyper-critical, but I consider that to be a freshman-quality flaw.

Posted by: Tom Yarsley | May 30, 2013 10:34 AM    Report this comment

Mr. Yarsley,

It appears we will just have to disagree on the subject of autonomous system safety as compared to pilot skills. I doubt I will ever be convinced that any automatic system can come even remotely close to the safety of Darwinian system derived self preservation skills. I certainly have never heard of any system that would satisfy me in the role of keeping an airliner full of paying passengers safe.

I appreciate your point of view. It is shared by many people. I hope it makes you feel safe when you climb aboard a commercial plane with no pilot.

As I understand it, the big problem with Airbus planes is the “Fly-by-wire” system treats the pilot’s input “Stick” like a video game controller with no feedback given to the pilot. I think the French disaster would have been quickly diverted if the pilot who was holding the stick in the full aft position all the way to the sea had to assert more force in that position than one which allowed the plane to attain flying speed. The Airbus paradigm of pilots being mostly excess baggage prevented that feature in the design.

Posted by: PAUL MULWITZ | May 30, 2013 11:19 AM    Report this comment

“Call me hyper-critical, but I consider that to be a freshman-quality flaw.”

Good point, who in their right mind would want to get on a plane flown by a computer whose software is written by humans who make freshman-quality mistakes?

Posted by: Richard Montague | May 30, 2013 1:14 PM    Report this comment

There are many systemic design flaws (imo) of the Airbus system. One as mentioned is the lack of an interconnection between the two side-sticks, such that one pilot could be applying full aft and the other full forward, and neither will have any feedback on this. Another is the lack of throttle movement when the auto-throttle is controlling it. And yet another is how the pilots had to know to look at a completely different display to see the backup readings, while the primary display will still showing a (largely incorrect and useless) value. This is all poor user interface design, regardless of the rest of the systems flaws.

The goal should either be complete removal of the human element (a bad idea in my opinion, and not just because I like to actually control the craft), or always let the human override the system (even if it requires either additional force or the use of some override system that is obvious to activate). In the case of the former, it really would turn the human pilot(s) into the “last line of defense”, and I’d rather it not be that way (as AF447 shows).

Posted by: Gary Baluha | May 30, 2013 1:35 PM    Report this comment

I am surprised that no one has quoted chapter and verse. 91.3 dates back to wind powered sailing vessels. (If anyone can tell me what 91.2 was, I would love to hear the story.) ATC cannot control the airplane. About all they can do is to provide information and clear the airspace. “Destination plus alternate plus 45 minutes” does not account for plan C being 400 miles away. Society as a whole has serious issues about we who actually do make risk management decisions. Many people are scared of general aviation but do not hesitate to pull in front of a semi truck on the freeway and stomp on their brakes. Peter

Posted by: peter koza | May 30, 2013 2:58 PM    Report this comment

A recently released Australian Senate report into the ditching of a Westwind aircraft off Norfolk Island portrays both the Australian Transport Safety Bureau and the Civil Aviation Safety Authority (CASA) in a poor light. We are very concerned that the report is going to become nugatory and swept under the political carpet. The CASA have begun a public media campaign attempting to make the damning 176 page report appear as the ramblings of a small, disillusioned group; clearly the Senate committee and some 445,000 viewers of the Pprune thread disagree.

For those interested in the comments and opinions of the Australian aviation industry and perhaps care to voice an opinion, the following link will take you there. We suggest starting from page 20. The Pprune webpage is freely available here.


PAIN_net. (Professional Aviators Investigative Network).

Posted by: PAIN NET | May 30, 2013 8:08 PM    Report this comment


Before Norfolk Island, There Was ALM980

By Paul Bertorelli | September 19, 2012Reading the ATSB accident report on the Norfolk Island ditching I blogged about on Monday gave me a case of déjà vu about another eerily similar accident in 1970. Being a student of aircraft ditching and survival, I’ve known about this accident for years as the “National Airways” ditching near St. Croix. But I never researched the details until I chanced upon an excellent book on the subject: 35 Miles from Shore: The Ditching and Rescue of ALM Flight 980 by Emilio Corsetti III.

Like the Pel-Air accident, the ALM ditching was the result of a long string of errors, but the fundamental one was flying an airplane for a route for which it wasn’t suited. ALM—Antilliaanse Luchtvaart Maatschappij, the Dutch Antilles National carrier—had wet leased a DC-9 from Overseas National Airways to fly the route between New York and St. Martin, in the Leeward Islands, a direct distance of 1650 miles—coincidentally the same distance the Pel-Air Westwind had to cover between Samoa and Norfolk Island.

At the time, Douglas had broken into the mid-haul market with the DC-9 and while it was suitable for flying city pairs up to 1000 miles apart with profitable load factors, it was never envisioned as a long-haul, oceanic airplane. Recognizing that the DC-9 could fly the route with the thinnest of margins if everything went right, the FAA approved the ALM/ONA routing if Bermuda was used as a waypoint, meeting the-then required one-hour drift-down limits in the event of an engine failure. Bermuda required a jink in the route that increased the flying distance, but it also offered a contingency fuel stop. But as is always the case, adding a fuel stop would mean the flight would lose money, so the crews tried to avoid it. ONA had also arranged with Douglas to add a fuel tank to the DC-9, but it never got done because the airline put it off until the end of high tourist season.

Another problem never addressed was significant inaccuracy in the DC-9’s fuel gauge and totalizer systems for its two main and one aux tank. Douglas said the system shouldn’t show errors greater than 800 pounds, but on the ONA DC-9, errors were in the plus or minus 2000-pound range. This was thought to be due to condensation on the fuel probes. In any case, the ONA airplanes continued to burn more fuel than the Douglas charts said they should. Just two weeks before the accident flight, an ONA airplane landed on St. Martin with minimum fuel, flown by the same captain who would later perform the ditching.

As Dom James did following the Pel-Air ditching, ONA’s pilot, Balsey DeWitt underwent intense investigatory scrutiny about his fuel planning, especially given the fact that he had landed with barely 30 minutes of fuel two weeks before. Why, investigators asked, had he chosen FL290 when passing Bermuda rather than a higher, more fuel-efficient altitude? He later descended twice more looking for a turbulence-free altitude, increasing the fuel burn and encountering unfavorable winds.

What finally did ALM980 in was weather substantially worse than forecast. Apart from daily thunderstorms and occasional tropical storms and hurricanes, the Leewards enjoy mostly fair weather, so much so that the only instrument approaches in those days were non-precision VOR or NDBs. There simply wasn’t much need for anything better. The forecast called for 2500 scattered to broken, 10,000 overcast and 6 miles in haze. Nothing in that forecast would raise concern for most instrument pilots with experience in the islands. What the forecast didn’t say, says Corsetti’s book, is that the haze was caused by a Saharan dust cloud, providing rich condensation nuclei for all that Caribbean moisture.

And that’s exactly what happened. When ALM980 came in range of the St. Martin’s tower, the controller reported 1000 broken, 5000 overcast and 2 to 3 miles in showers. It was marginal for an NDB approach, but legal. Moments later, San Juan Center advised ALM980 that St. Martin was below minimums and Captain DeWitt turned for a diversion to San Juan. Then the tower called again, reporting a slight improvement in the weather to 1000 broken and 4 to 5 miles in rain, well above the 600-foot MDA and 2 miles needed for the NDB approach.

ALM980 turned back toward St. Martin, but DeWitt believed they would land with 4400 pounds of fuel, 100 pounds more than the required 4300. When the airplane arrived over the beacon for the procedure turn, the weather turned out to be far worse than reported and when it broke out, it was too close and too poorly aligned to try to land. The airport’s short runway—5200 feet—left no margin for error. After two circling attempts, the crew gave up and struck off for the alternate, St. Thomas, with 3800 pounds of fuel left—about 38 minutes. Minutes later, St. Martin tower closed the airport due to poor visibility and low ceilings.

They never made St. Thomas, or St. Croix, which was deemed a little closer. With fuel dwindling, DeWitt realized he would have to ditch miles short of St. Croix. While all of the occupants of the Pel-Air survived, sadly, that wasn’t the case for ALM980. After impact, the airplane remained on the surface for 10 minutes; 40 of the 63 people aboard survived. It’s almost certain that more would have, but in one those seemingly innocuous twists on which survival can turn, the cabin PA wasn’t working. The flight crew couldn’t warn the cabin crew that touchdown was imminent. Although they used the ONA method of three chimes to warn the cabin, the ALM-trained cabin crew didn’t know what three chimes meant; it was accustomed to only two. Many passengers were standing or were otherwise unsecured during the impact. The ditching occurred in late afternoon light in moderate seas and rain. In a stroke of good fortune, a Navy helicopter ship was anchored nearby and rescue efforts began quickly.

The post-flight investigation revealed some of the same problems James encountered off Norfolk Island. The procedure for handling liferafts was flawed; vests rode too high and blocked the survivors ears, funneling water into their faces. There were unconfirmed reports that the St. Martin tower operator was pressured to report better weather than actually existed. Witnesses varied on what weather existed at the time of the initial approaches, but some said it was as little as a quarter mile. The NTSB took some lumps, too. It was too slow in assembling a maintenance records group and during the ensuring delay, the airline destroyed the DC-9’s records, hiding possible improper work done on the fuel probes, according to Corsetti.

On March 31, 1971, the NTSB issued its probable cause: fuel exhaustion due to repeated attempts to land at St. Martin until not enough fuel remained for flight to an alternate. Mis-reported weather was also a factor.

Some positives emerged from the accident. Captain Dewitt was at least cited for exceptional airmanship in ditching the aircraft in trying conditions. The NTSB also recommended eliminating the old automotive-style metal-to-fabric seatbelts and this was adopted. Today, you fly behind metal-to-metal seatbelt buckles as a result. Also, better communications were installed in parts of the Caribbean to improve flight handling.

In the end, both the Norfolk Island and ALM ditchings owe their origins to aircraft being pressed into missions they simply weren’t able to fly with suitable safety margins. I suspect the management at Pel-Air had never heard of ALM980 and didn’t realize they risked repeating it.

Comments (7)

Methinks this was a get-home-titus condition forced by the airline. The phrase “But as is always the case, adding a fuel stop would mean the flight would loose money, so the crews tried to avoid it.” says it all.

What happened to the seat belt fasten lights? ” Many passengers were standing or were otherwise unsecured during the impact.” Oh I forgot this is dinosaur flying time no such luxury.

Keep it up Paul your doing well

Posted by: Bruce Savage | September 20, 2012 7:06 AM    Report this comment

Any and every airline captain can cause the company to lose money if they don’t “co-operate”. Look at the current AA problems.

However, jet fuel efficiency and management has come a long way as a result of experience and technology. Would the Concord be approved today to go from Europe to JFK with the very minimal fuel reserves it ocnsistently operated with? Doubtful and even then they were given priority handling routinely. The SST is by no means unusual in the course of “learning to fly jets”.

Certainly I am not condoning injury or loss of life as part of any learning curve but it likely will be part of the process, like it or not.

Posted by: William Zollinger | September 20, 2012 8:51 AM    Report this comment

Paul, what are the ‘metal-to-fabric’ belts? I remember that my dad ordered rear seat belts as an option in his early ’60s Ford Falcon. Those belts had a metal-to-metal latch mechanism; you’d click it shut and then pull the end of the belt to tighten it – just as you do today. A bit of a difference was that instead of pushing a button to release it, you had a wide plate which you could tug lightly on to loosen the belt, tug further to disconnect.

Posted by: Rush Strong | September 20, 2012 11:07 AM    Report this comment

OK, maybe this is how they used to be used on aircraft?


Posted by: Rush Strong | September 20, 2012 11:18 AM    Report this comment

The old belts had a cam mechanism in the buckle. You inserted just the fabric from the opposite side of the belt pair, cinched it down, then locked it with the cam buckle.

Worked, but not a great design.

Posted by: Paul Bertorelli | September 20, 2012 2:33 PM    Report this comment

Those belts were not a great design as the cam could be turned so far by the enormous forces on the belt fabric during a sudden deceleration that there was not sufficient mechanical advantage to release them. Same thing happened if one was hanging inverted from one; the force applied to the cam to effect releasing its bite on the belt fabric was now the force required to lift the whole body upwards, an impossible task with the mechanical leverage built into the mechanism…

Posted by: Scott Jackson | September 20, 2012 3:20 PM    Report this comment

“Would loose money”? “Never got done”? Come on, man.

Posted by: JOHN EWALD | September 20, 2012 3:52 PM    Report this comment

3 comments to PelAir and adjacent History

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